Is ther fentanyl in an epidural?

In this article:

• What is fentanyl used for?
• How do epidurals work?
• How much fentanyl is in an epidural?
• Fentanyl during labor: Is it safe?

In this article

• What is fentanyl used for?
• How do epidurals work?
• How much fentanyl is in an epidural?
• Fentanyl during labor: Is it safe?

Fentanyl is an opioid medication used as an anesthetic in hospital settings as well as a pain reliever (analgesic) both in and out of the hospital. It plays a key role in various medical procedures, including epidurals. An epidural is a method of pain relief used commonly during childbirth that involves injecting medication into the lower back, in the space around your spinal nerves. Fentanyl can be one of the medications in epidural anesthesia, providing effective pain management when administered by trained healthcare professionals. Read on to learn more about the use of fentanyl in epidurals, including safety considerations and how it works for pain management. 

What is fentanyl used for?

Fentanyl injections are approved by the Food and Drug Administration (FDA) as a pain reliever (analgesic) and an anesthetic in the following situations:

• Pain management before a medical or surgical event or procedure, such as a vaginal birth or C-section
• As an add-on to general or local anesthesia
• As general anesthesia
• Pain management after a surgical procedure

Fentanyl is commonly used to sedate people who are intubated, to treat cancer pain, and to treat severe cases of pain in people who have kidney failure. 

Pharmaceutical fentanyl vs. illegally made fentanyl

Pharmaceutical fentanyl and illegally made fentanyl (IMF) can both be misused and dangerous. Pharmaceutical fentanyl, made by drug companies, comes in the form of skin patches or lozenges. “Fentanyl used in healthcare settings is overseen by the FDA. It is manufactured under strict regulations. It always comes in a known, precise dose. Doctors can control exactly how much a patient gets,” explains Sylvie Stacy, MD, chief medical officer at Rehab.com. Although it is effective when used as directed, it can be misused.

On the other hand, IMF is made illegally and is found as a powder or pill. IMF may be combined with other illegal drugs, making them more dangerous and increasing the risk of a drug overdose. “Street fentanyl is made in illegal labs. It is often mixed with other drugs. It is completely unregulated. So you never really know what you’re getting. That makes it incredibly dangerous,” Dr. Stacy says. According to the Centers for Disease Control and Prevention (CDC), IMF was involved in more than 68% of overdose deaths in the U.S. in 2022.

How do epidurals work?

Epidural anesthesia (another term for an epidural) is a type of anesthesia injected into the epidural space, near the spine. It’s also called neuraxial analgesia. Anesthetic medications can be delivered to the epidural space via a tube to block pain and sensation in the lower back, lower abdomen, pelvis, and upper leg areas. 

Epidurals are most commonly used for childbirth. A study published in 2018 found that about 73% (almost 3 in 4) of people giving birth had an epidural. Epidurals can also be used for certain surgeries as well, including surgeries in the abdomen or around the lower spine. 

Anesthesiologists, medical doctors with a specialization in administering anesthesia, typically choose a combination of medications for the epidurals. Epidurals contain a combination of a local anesthetic that blocks pain in the lower body and an opioid to manage pain. Medications commonly used in epidurals include Marcaine (bupivacaine), Naropin (ropivacaine), lidocaine, fentanyl, and sufentanil.

How long does it take for an epidural to work?

How long it takes an epidural to work and how long it lasts depends on the types and doses of the medications used. For example, bupivacaine reaches peak levels in the blood 30 to 45 minutes after injection, though the person may experience pain relief sooner. According to its drug label, bupivacaine reaches very low levels three to six hours after administration. If pain management is still needed, anesthesiologists may deliver maintenance doses.

How much fentanyl is in an epidural?

Epidurals contain a combination of a local anesthetic and an opioid, which may be fentanyl or hydromorphone, for example. Only weak concentrations of fentanyl are used, and it’s typically measured in micrograms per milliliter (mcg/mL). For example, an epidural may contain 0.0625% levobupivacaine, a local anesthetic, and 2 mcg of fentanyl per milliliter of epidural solution. Only a small amount enters the mother’s bloodstream, making it safe for the baby while ensuring the mother doesn’t experience the side effects that oral or intravenous fentanyl would cause.   

Fentanyl during labor: Is it safe?

“When administered by a trained medical professional, fentanyl is generally safe for labor pain relief. It is often included in epidurals and spinal blocks because it provides effective pain relief without causing excessive sedation,” explains Edmond Hakimi, DO, a dual-board-certified internal medicine physician and the medical director at Wellbridge in Calverton, New York. He explains that, unlike opioid medications injected intravenously, “epidural fentanyl works locally, reducing pain without significantly impacting the baby’s breathing.”

In a study of low-risk pregnancies in Thai hospitals, fentanyl given during childbirth through the veins or an injection under the skin did not have any negative effects on the mother or newborn. However, there are some fentanyl side effects and risks associated with epidurals in general. According to the American College of Obstetricians and Gynecologists (ACOG), common side effects of using opioids like fentanyl include itching, nausea, vomiting, and breathing problems. Other side effects of an epidural include lower blood pressure, fever, headache, soreness, shivering, difficulty urinating, and reactivation of cold sores. 

Who is fentanyl not for?

Some people shouldn’t use fentanyl, even in a safe hospital setting. According to its drug label, fentanyl is not for people who are allergic to fentanyl, who have a history of opioid addiction, or who are at risk of slowed heart or breathing activity (cardiovascular or respiratory depression). According to the American Pregnancy Association, an epidural is not an option for people who:

• Use blood thinners or have low platelet counts
• Have an infection on the back, in the back, or in the blood
• Are bleeding or are in shock 
• Are not at least 4 cm dilated, or labor is moving too fast
• Can’t have their epidural space accessed by a healthcare provider

“Fentanyl may not be safe for all women, particularly those with severe respiratory disorders, opioid dependence, or certain heart conditions. In rare cases, high doses may cause temporary breathing issues for the baby, so its use is closely monitored,” Dr. Hakimi shares. 

Fentanyl in epidurals and breastfeeding

In general, fentanyl given during labor and short procedures is not expected to harm newborns. Clinical trials have shown that epidurals, with or without fentanyl, don’t have an effect on starting or continuing breastfeeding after birth. 

Newborns who are breastfed by people on oral opioids such as fentanyl can be at risk of side effects such as sleepiness and possible nervous system depression. If a baby shows signs of sleepiness, difficulty breastfeeding, difficulty breathing, or limpness, get emergency medical help immediately.