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ST. LOUIS - Justin Knox bit down on the bitter-tasting wafer, probably not realizing the medicine in his mouth was more powerful than morphine and strong enough to kill pain for three days.
As the gel on the fentanyl pain patch dissolved on his tongue, his craving for pain drugs was relieved. But the overdose of the prescription drug slowed and eventually stopped his breathing. The 22-year-old construction worker in the southeast Missouri town of Farmington died before he could get to a hospital.
Emergency rooms visits by people misusing the pain relieving opiate fentanyl shot up nearly 14-fold nationwide from 2000 to 2004 to 8,000, according to U.S. Department of Health and Human Services' figures. The survey of hospitals does not estimate what proportion of the ER visits were because of the patch.
Prescription sales of the fentanyl pain patch reached the billions last year. More than 5.7 million prescriptions were filled in 2003 for the brand name Duragesic patch, according to IMS Health.
"I cannot tell you the amount of people I've seen and the creative ways they abuse this drug," said Dr. Scott Teitelbaum, director of the Florida Recovery Center in Gainesville, Fla. "Fentanyl has been abused for years. But recently there's been an increase. I've seen more chewing, squeezing of the drug off the patch and shooting it up."
About a week after Knox's death in March, a second man in the same county was prescribed the patch legally and died after injecting himself with the gel that he scraped from it.
Both men joined a list of people across the country who have died abusing the prescription pain patch. A least seven have died in Indiana, and four in South Carolina, since 2005. More than 100 deaths in Florida in 2004 were blamed on pain patch abuse.
The Food and Drug Administration has an ongoing investigation into deaths and overdoses related to both Duragesic and generic fentanyl patches.
Burl Washington, accused of illegally selling the fentanyl patch to Knox, has been charged with second-degree murder. Knox left behind a 2-year-old daughter and his mother, who wants to warn others about fentanyl.
"The awareness is just not out there. I had never heard of this patch," Rose Marler said. "There's a new generation of drugs and people just need to be aware."
Fentanyl is at least 80 times more powerful than morphine and doctors say a single patch releases a three-day dose of pain medication through the skin.
Last summer, the FDA released a health advisory on the fentanyl pain patch in response to deaths related to the drug. The advisory was related to legitimate use - warning about symptoms of accidental overdose, that people with asthma shouldn't use the drug, and to flush used patches down the toilet because they still contain enough drug to poison a curious child digging through the trash.
Other warnings have said to avoid exercise while wearing the patch to prevent a faster release of the drug.
Sales of the patch more than tripled from 2000 to 2004, according to the Pacific Law Center in La Jolla, Calif.
Duragesic was developed for cancer patients and people with chronic pain. Last year, the first generic versions of the patch hit the market.
The Duragesic pain patch, made by Johnson & Johnson, exceeded $2 billion in sales worldwide in 2004, and half of that was in the U.S., according to investor information on the company's Web site. Sales of Actiq, made by Cephalon, increased 19 percent to $412 million in 2005. The lolipop-like dose of fentanyl is known on the streets as a Perc-O-Pop.
"We track for adverse events, unexpected outcome from use of the drug and report the information with the proper authorities, including the FDA," said Mark Wolfe, spokesman for PriCari, the company that oversees Duragesic.
Wolfe said the product information gives warnings of the potential abuse and misuse of Duragesic.
There have been reports of fentanyl being made in clandestine labs, according to the U.S. Drug Enforcement Agency.
Recently, numerous deaths have been highlighted among heroin users from Chicago to Philadelphia who are overdosing on fentanyl laced heroin. It's unclear exactly where that fentanyl is coming from.
The DEA does not discuss its role in cracking down on fentanyl's misuse or how common it has become on the street, DEA spokeswoman Rosean Waites said. The DEA's Web site lists fentanyl next to other "drugs of concern."
One belief for the increase in sales and availability of the drug is a trend of doctors steering away from prescribing another strong pain opiate, oxycodone.
"The abuse of oxycodone and the fear of litigation is enough to scare doctors from prescribing it. Duragesic is in vogue as we've seen over the last year and a half and two years," said Dr. John Brandt, a chronic pain specialist at the University of Florida.
Brandt said the DEA cracked down on the illicit sale and use of oxycodone about five years ago and that sent a chill through doctors in the pain prescribing community.
There were more than 35,000 non-medical oxycodone ER visits in 2004 compared to the 8,000 fentanyl visits.
Marler, Knox's mother, said her son tried to get help for his addiction to pain killers, but he checked out of treatment after less than a day.
"Even after Justin died, he (Washington) continued selling this drug," Marler said. "It's like it didn't faze him what so ever. Without him on the streets, there's lives being saved."