Deadly Drug Fentanyl Spikes the Opioid Epidemic.
NY Attorney General Eric Schneiderman
Press Conference, New York, 2016
Prescription opioid overdoses drop, as fentanyl deaths skyrocket.
July 19, 2019
Tom, a 64-year-old male real estate appraiser liked to do home renovation projects after work. He was proud that he saved money by doing his own repairs. Tom adhered to a healthy lifestyle and lifted weights twice a week to try to build muscle for his tall and lean body. After a summer of building a block wall and a brick patio, he twisted to lift another 2x4 of wood and felt a sudden sharp pain down his left leg. Crawling to his bed, he lay motionless for 2 days—hoping it was just a simple muscle pull.
No over-the-counter NSAID medications eased the pain and he finally went to the emergency department, where he received a prescription for muscle relaxants and oxycodone. Without relief days later, he returned to the ED, was given a fentanyl patch from another physician, and was put on a 2-month waiting list for his primary doctor.
For 8 weeks, Tom writhed in pain with any lateral motion and began to lose the feeling in his left leg. Finally, after seeing his primary doctor and an orthopedic surgeon following 2 more months’ awaiting insurance approval, he received back surgery; his collapsed disc and multiple compressed nerves were likely due to the delay in repair. In the meantime, he had become dependent on fentanyl for pain relief.
The Opioid Epidemic
Names of Fentanyl
Per-a-Pop (berry-flavored Fentanyl lozenge)
Fentanyl is a synthetic opioid that represents 64% of all illegal cases of drug abuse (DEA, 2017). Whereas morphine is derived from the poppy plant, fentanyl is completely synthetic and can be manufactured anywhere, including in home laboratories. This synthetic opioid analgesic is 50 times more potent than heroin and 100 times more potent than morphine. It is a schedule I drug often used to manage post-operative pain (USDJ, 2016).
Healthcare professionals who prescribe or administer an opioid need to be aware of appropriate use—and potential for misuse and abuse—of any opioid analgesic. Not only do healthcare professionals need to be well informed about the appropriate use and cautions for opioid misuse but they also need to be able to recognize effectiveness, side effects, overdose symptoms, and abuse in patients as well as in other healthcare professionals.
Opioids are a class of drugs with opium-like qualities that interact with receptors in the brain and spinal cord to block pain and produce a sense of euphoria. Opioids include codeine, fentanyl, hydrocodone, meperidine, hydromorphone, methadone, morphine, oxycodone, and heroin (USDJ, 2016).
Opioid drugs are powerful analgesics used for pain management. Because they are powerful, and powerfully addicting, millions of people use them and can become physically and psychologically dependent or addicted to them. From 2000 to 2015, more than half a million people in the United States alone died from opioid drug overdoses (CDC, 2017).
Opioids are categorized as schedule I or II drugs by the Drug Enforcement Agency (DEA). A schedule II drug (eg, morphine, fentanyl) has been approved for medical treatment as an analgesic but has high potential for strong psychological and physiologic dependence. It has been used for over 100 years as an analgesic. Heroin, which is made by adding a chemical reagent to morphine (from the opium plant) that makes it more potent and potentially dangerous, is a schedule II drug and is not approved for any medical use because it is highly addictive.
So, how did we get to this point of millions of Americans using and abusing opioids?
The documented use of opioids began as early as 3400 B.C. in Mesopotamia with the discovery of the opium plant, which was known as the “joy plant.” Opium was used for every medical malady, including diarrhea, cholera, rheumatism, fatigue, and even diabetes, by early Egyptians. Opium was then regularly traded by Turkish and Arab traders in the sixth century. Opioid use became much more common in the early 1700s after the British refined production of the Asian poppy plant, which they grew in India and sold in China.
What became helpful as analgesia quickly became popular for treating every malady, and it was even used as entertainment—as seen in historical records of opium parties. The Opium Wars began in the mid-nineteenth century as Chinese government officials refused entry to British ships filled with the addictive drug. As we all know, the war against narcotics continues to the present in the United States.
Sadly, the drug culture got a boost from the medical profession’s legitimate interest in addressing pain for patients. Pain was added as the fifth vital sign in 1996 and a movement to minimize all pain increased prescriptions for opioids. Campaigns by pharmaceutical companies, boasting the effectiveness of their drug and claiming they had no side effects, added to the growth of prescriptions for opiates. Pharmaceutical companies even created organizations with persuasive lobbyists to decrease barriers and regulation of opiate use.
Another cause for the increase in the opioid epidemic has been the creation of semi-synthetic and fully synthetic in their laboratories by pharmaceutical companies. Creating heroin from morphine can even be done in a home laboratory, which has increased the availability of street drugs. The demand for heroin by Americans continues to support the illegal supply coming from Central and South America, and now China, into the United States. The desire to make heroin more potent has led to home laboratories creating mixtures of heroin with fentanyl that become unpredictable and lethal.
The Centers of Disease Control (CDC) has estimated that over 20,000 Americans died from fentanyl overdose in 2016, and that rate continues to climb in the United States. Fentanyl production in China has surged due to the high demand for it in the United States, and it has been called the new “nuclear” narcotic in the “Opium War Against America” (Tribune News, 2018).
What You Need to Know
Healthcare professionals need to know the correct and incorrect uses of fentanyl in order to be part of the solution when addressing chronic pain and analgesia. When used as prescribed by someone authorized and medically trained (eg, physician, nurse practitioner, physician assistant) opioids can be a blessing to someone in chronic pain; however, the patient needs to be monitored closely for adverse side effects and correct education.
Although national news appropriately focuses on issues of abuse, opioids—both natural and synthetic—still have a place in pain relief. Fentanyl becomes dangerous when it is mixed with street drugs such as heroin and users are unaware of what they are receiving. The quantity of fentanyl in street products varies widely and can become quickly fatal as doses exceed what would have been carefully prescribed. Illegal street use without guidance, monitoring, and education have created the dangerous opioid epidemic.
Did You Know . . .
Opium comes from the natural Asian poppy plant and is 10 times as potent as cocaine. Heroin is 10 times as potent as morphine, or opium. When we say fentanyl is 100 times more potent than morphine, it is equivalent to saying one pound of fentanyl is the same as 100 pounds of morphine. On the spectrum of potency is cocaine (not an opioid), opium, morphine, heroin, fentanyl and carfentanil, and W-18 (10,000 times stronger than heroin).
- Access to more prescriptions.
- Emphasis on treating pain aggressively.
- Difficulty of producing the drug.
- Its mixture with other drugs that hide its presence.