Co-Medical Director / Founding Member
Dr. Ehab Abdallah is the Managing Partner and MD Psychiatrist at Legacy Recovery Center bringing a wealth of expertise to his role. He obtained his medical degree from Alexandria University in Egypt and completed his residency in psychiatry at West Virginia University. Dr. Abdallah is triple board-certified in General Psychiatry, Consultation-Liaison (Psychosomatic) Psychiatry, and Addiction Psychiatry and Medicine.
With a specialized focus on addiction medicine, Dr. Abdallah has extensive experience treating individuals facing complex medical and psychiatric conditions. His dedication to high-quality care and genuine commitment to his patients’ well-being make him an invaluable member of the team.
In addition, Dr. Abdallah is a Fellow of the American Psychiatric Association and serves as a clinical assistant professor of psychiatry at the University of Arizona, where he educates and mentors medical students and residents.
Fentanyl, one of the most effective and potent painkillers, is a primary method for managing severe spinal pain following surgery, injury, or conditions such as spinal stenosis. However, there is also a well-known public health addiction crisis with fentanyl.
Fentanyl is often prescribed for severe spinal pain. However, if abused, it carries significant risks to spinal health, including neurological suppression, bone deterioration, and the potential for devastating addiction that can further injure the spine.
Fentanyl impacts the spine mainly through its effects on the spinal cord’s pain-processing areas. While it can provide quick relief, it can also lead to complications such as heightened pain sensitivity over time, a big concern in addiction recovery.
In this article, I look at the complex relationship between fentanyl and the spine, examining its therapeutic effects, its direct and indirect physiological impacts, and the long-term consequences of use and addiction.
Fentanyl’s Primary Action: Quieting the Spinal Alarm System
Fentanyl interacts with the spinal cord’s pain pathways in several ways, including:
- Fentanyl binds to mu-opioid receptors in the brain as well as certain regions in the spinal cord’s dorsal horn. This is where pain signals travel from nerves to the brain.
- This binding blocks the release of neurotransmitters like Substance P. This “short-circuits” the transmission of pain signals from the body to the brain.
For acute, severe postoperative pain or traumatic injury, this suppression of the pain signals is vital for healing and quality of life. It allows patients to participate in physical therapy and movement essential for spinal recovery.
Why Pain Can Worsen with Ongoing Use
Long-term use of fentanyl can trigger “opioid-induced hyperalgesia” (OIH). In this condition, circuits in the spinal cord become overly sensitive, and, despite using the drug, this makes pain feel worse.
OIH results from changes in brain chemicals, including NMDA receptors in the spine. This leads to tolerance, creating a cycle that fuels addiction, in which more of the drug is needed but with less relief. With the aim of resetting these spinal pain pathways, recovery programs that offer them can incorporate therapies such as NMDA blockers and counseling [1].
For people in recovery, knowing this helps explain why stopping fentanyl often brings intense pain flares as the body adjusts. Chronic abuse dysregulates the pain pathways. This prolongs hyperalgesia during detox. When treating addiction, using NMDA antagonists or anti-inflammatory methods can reduce withdrawal pain.
Sudden weakness or paralysis after fentanyl use usually points to other issues, like infections from injection, not direct fentanyl toxicity.
3 Direct Neurological Effects on the Spine and Nerves
Fentanyl depresses the central nervous system. Beyond pain relief, there are three implications for spinal function:
- Suppression of Protective Reflexes: Since fentanyl slows reaction times and dulls awareness of body position, there is an increased risk of falls or improper movement. This can lead to new or worsened spinal injuries, such as herniated discs and fractures.
- Impact on Nerve Function: Fentanyl can cause or worsen sedation, dizziness, and confusion. In overdose, it can lead to respiratory depression, where the breathing control center in the brainstem is suppressed. Due to oxygen deprivation, this is indirectly linked to spinal cord health.
- Opioid-Induced Hyperalgesia (OIH): This is a paradoxical effect where prolonged use can make the nervous system more sensitive to pain. This can worsen the perception of back pain and create a vicious cycle of increased dosing [2][3].
Fentanyl impacts the spine mainly through its effects on the spinal cord’s pain-processing areas. While fentanyl can provide quick relief, it can also lead to complications such as heightened pain sensitivity over time. This is a big concern in addiction recovery [4].
Indirect and Long-Term Structural Impacts
Fentanyl use can affect the very structure of the spine.
- Opioid-Induced Endocrinopathy: Long-term use of fentanyl lowers testosterone and estrogen levels. This may result in accelerated osteoporosis (bone loss) and weakening of the bones in the vertebrae. This increases the risk of compression fractures, particularly in the thoracic and lumbar spine.
- Muscle atrophy and weakness: Sedation and reduced activity from fentanyl use lead to muscle deconditioning. As a result, muscles that support the spine weaken, placing more mechanical stress on spinal discs, ligaments, and joints. This potentially leads to chronic instability and pain.
The Cycle of Addiction and Spinal Trauma
Fentanyl abuse and addiction can change the spinal cord in ways that make pain feel worse. This manifests as increased pain sensitivity and alterations in the dorsal horn due to long-term use or withdrawal.
This is caused in part by changes in brain chemicals such as NMDA receptors in the spine, leading to tolerance. More drugs are needed for less relief—a cycle that fuels addiction. Some recovery programs use NMDA blockers and counseling to reset these spinal pain pathways.
Fentanyl substance use disorder carries multiple risks to spinal health:
- Impaired Judgment: There is a higher risk of high-impact trauma, such as car accidents and falls. These can hurt the spinal cord, break vertebrae, or damage discs.
- Neglect of Health: Underlying spinal conditions are ignored or self-medicated, leading to disease progression, such as worsening degenerative disc disease.
- Financial and Social Costs: Individuals who use fentanyl have challenges finding and maintaining proper medical care, such as physiotherapy and surgery.
Legitimate, short-term, medically supervised use of fentanyl can be appropriate. Nonetheless, it’s important to be aware of risks to bone health. It’s important to regularly monitor and consider multiple methods of pain management.
The Fentanyl Fold
The “fentanyl fold” or “fenty fold” or “fenty lean”—a rigid forward bend at the waist in unresponsive users—is a neuromuscular sign of overdose. Heads are bowed, knees are bent, and the person is often unable to respond or move. It is linked to fentanyl-induced muscle rigidity in trunk muscles via opioid receptor effects on the brain and spinal cord.
It stems from central nervous depression, muscle stiffness restricting respiration/posture, and disrupted brain-muscle signaling, though not direct spinal toxicity. This posture often happens right before or during an overdose, making it a critical warning sign that emergency help is needed immediately.
However, spinal structural damage from the fentanyl fold has not been medically observed and confirmed. Yet the fentanyl fold does involve severe rigidity, which impacts mobility during heavy abuse. Unlike direct spinal toxicity, this is a reversible neuromuscular effect, treatable with naloxone (though risking withdrawal).
Key Takeaways
For non-prescribed use of fentanyl, the impact on the spine is just one part of a profoundly dangerous threat to life and health. It’s important to seek appropriate addiction treatment. And during treatment, watch for breathing issues or sudden pain spikes during detox. Speak with your provider about non-opioid options to protect spinal pain circuits.
It helps to develop awareness of the impact of tolerance. Many treatment programs combine meds, therapy, and lifestyle changes to break the hyperalgesia cycle for lasting relief.
Integrated Mental Health and Addiction Support at Legacy Recovery Center
Legacy Recovery Center is a highly rated, premier addiction and mental health treatment center in Arizona. Legacy is owned and operated by two psychiatrists with over 40 years of combined experience, as well as a robust therapeutic team.
We’re unique among residential treatment centers thanks to our ability to help people suffering from mental health and/or substance abuse issues. Our expert psychiatric team is equipped to treat multiple issues concurrently, focusing on your specific needs.
Sources
[1] Uddin O, et al. Divergent profiles of fentanyl withdrawal and associated pain in mice and rats. bioRxiv 2020.11.16.384818; Pharmacology Biochemistry and Behavior
[2] Jin D, et al. mGluR5 from Primary Sensory Neurons Promotes Opioid-Induced Hyperalgesia and Tolerance by Interacting with and Potentiating Synaptic NMDA Receptors. J Neurosci. 2023 Aug 2;43(31):5593-5607.
[3] Lewandrowski, K., et al. (2025). Opioid-Induced Hyperalgesia and Inflammaging in the Management of Spine Pain: The Case for Genetically Directed Dopamine Homeostasis. International journal of spine surgery, 19(4), 459–484.
[4] Laboureyras, E., et al. (2022). Fentanyl-induced hyperalgesia and analgesic tolerance in male rats: common underlying mechanisms and prevention by a polyamine-deficient diet. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 47(2), 599–608.
