Fentanyl Overdose Deaths Are Touching More Americans Than Ever

The opioid epidemic has had no shortage of coverage, whether in the political arena, the popular press, or in this blog itself. But when we talk about opioids, we are actually talking about a number of different drugs with drastically different risk profiles. Fentanyl is the most vicious of all.

50 to 100 times more potent than morphine and 30 to 50 times stronger than heroin, Fentanyl is a synthetic opioid used in the administration of anesthesia and to manage pain. For medicinal purposes, it is an extraordinarily effective medication that can, in many cases, restore patients’ quality of life, even with severe chronic pain. But with its high potency, rapid onset, and short duration of action, it is also extraordinarily addictive. Initially, Fentanyl was primarily used in general and twilight anesthesia and did not pose a significant addiction risk – it simply wasn’t used in a way that encouraged addiction to take hold. But once the drug was introduced for chronic pain management in the form of transdermal patches, lollipops, and sublingual sprays, however, things changed. Suddenly, Fentanyl wasn’t solely administered within the confines of controlled medical environments, it was available on an ongoing basis for personal use. As of 2012, Fentanyl was “the most widely used synthetic opioid in clinical practice.” It is also widely regarded as the most dangerous drug currently on the market.

The appeal of Fentanyl as a recreational drug was recognized immediately after becoming available for personal use, and it was quickly introduced into circulation in the black drug market, both via legitimate prescriptions and illegal synthesis by major drug cartels. Today, it is sold as a standalone drug as well as combined with other substances like heroin, sometimes without the knowledge of users, creating the perfect storm for overdoses in new and experienced users alike. As Jonah Engel Bromwich writes for The New York Times:

In March 2015, the Drug Enforcement Administration issued a nationwide alert about the dangers of fentanyl. Maura Healey, the Massachusetts attorney general, said fentanyl was the cartels’ “drug of choice.” “They have figured out a way to make fentanyl more cheaply and easily than heroin and are manufacturing it at a record pace,” she said.

Whether people deliberately seek out the drug or take it unknowingly, addiction is rampant amongst recreational drug users as more and more cartel-supplied Fentanyl floods the market, introducing an ever-growing number of users to the drug.

In recent years, much of the press about the dangers of Fentanyl has focused on these recreational users, particularly IV-drug users who accidentally overdose on Fentanyl-laced heroin and sensational stories about addicts sucking the last bits of gel out of other people’s used fentanyl patches. But the addictive power of Fentanyl isn’t limited those who take it to get high.

It is not known what percentage of Fentanyl addicts start out as therapeutic users. What we do know is that Fentanyl doesn’t care if you have a prescription or not; it can take over your life whether you’re using it for chronic pain or to get high on a Saturday night. Even the most responsible of users taking it for serious chronic pain can develop intense physical dependence, requiring more and more Fentanyl to achieve relief. As your body becomes accustomed to the drug, so too does your brain, which shapes itself around its new conditions through neuroadaptation. Without the drug, you go into withdrawal—and withdrawal hurts not just physically, but psychologically. Desperate to avoid the pain, you seek out the Fentanyl you need whatever way you can, whether it’s by begging your doctor for more, spreading yourself between multiple physicians, or turning to that black market. And eventually, you may start inching toward the possibility of overdose.

Contrary to popular belief, pure heroin overdose deaths are relatively rare; typically, what is reported as a heroin overdose is, in fact, the result of mixing heroin with other substances, such as alcohol or sedatives. Or Fentanyl. Pure Fentanyl overdose deaths, however, are not rare, and accidental overdoses amongst users are rising; according to the CDC, “Overdose deaths involving synthetic opioids other than methadone increased by 80% from 2013 to 2014.” In total, 5,500 people died from synthetic opioid overdoses in 2014, and most of those overdoses resulted from Fentanyl.

Fentanyl overdose, however, isn’t an automatic death sentence. If opioid antagonist medications such as naloxone are administered quickly, the risk of death decreases dramatically. The problem is that most Fentanyl users do not have overdose reversal medications available to them at the time of overdose, may not know how to access them, or may not even be aware that they exist; as Dr. Timothy Fong, Associate Clinical Professor of Psychiatry at UCLA, recently noted in a talk at the inaugural Innovations in Recovery Signature Luncheon, many clinicians are reluctant to bring up the topic of overdose reversal medications for fear of insulting the patient. While “the state of California took the remarkable step of passing a law that allows pharmacists to distribute Naloxone to anyone who wants it” earlier this year, this does not help people unless they know about it. This is especially true for therapeutic users, who may be far less likely to identify themselves as at risk for overdose than a recreational user.

To guard against overdose, then, the first step is educating patients about the mechanisms and availability of overdose reversal medications. Including loved ones in this discussion could be critical to the practical application of these medications, as the person experiencing the overdose may not be able to get themselves to the location where the drugs are dispensed or administer them to themselves. According to Zachary Siegel of The Daily Beast, another possible step “would be to prescribe naloxone, the lifesaving antidote, with every bottle of painkillers,” ensuring that all therapeutic users automatically receive overdose reversal medication.