The United States is in the midst of an opioid drug crisis, and fentanyl is beginning to overtake heroin as the drug responsible for the most overdose fatalities. Fentanyl is 50 to 100 times stronger than morphine, and has a high fat solubility that allows it to enter the brain incredibly quickly. Ninety-one Americans die from an opioid overdose every day, and overdose is now the leading cause of death for Americans under the age of 50. And while many of these opiate overdoses are due to people knowingly taking fentanyl, an increasing number of other drugs, such as heroin and cocaine, are being laced with fentanyl and sold to people who don’t realize what they’re getting.
Fentanyl’s Role in America’s Opioid Crisis
Although fentanyl is usually prescribed for palliative care, especially among cancer patients, and for post-surgical pain, most of the fentanyl found in overdoses in the United States was made illegally in China, and brought into the U.S. by Mexican drug cartels, or sent through the mail. Fentanyl manufacturing requires extreme expertise to set up at first, but thereafter the drug is easy to manufacture at low costs, and it is so incredibly potent that a little goes a long way. Just one kilogram of fentanyl can sell for $3,000 to $5,000 in China, then go on to create more than $1.5 million in illicit U.S. sales.
As a result of this extraordinary profit margin, individuals dealing in illicit drugs attempt to use fentanyl in as many products as possible. They mix it with cocaine and heroin, and use it in counterfeit prescription medications like oxycodone or Valium. Essentially, fentanyl can work as a cheap filler, amplifying the intoxicating and addictive effects of other drugs. Much of the current fentanyl overdose rate can be contributed to dealers selling fentanyl to addicts who had no idea what they were buying.
Between 2013 and 2015, deaths from fentanyl and other synthetic opioids tripled, from 3,105 to 9,580. These numbers are probably underestimates, because many death certificates don’t list specific drugs in the case of overdose, and some medical examiners don’t test for fentanyl. It takes a long time to get exact, official numbers when it comes to drug overdose, but the New York Times estimated that 2016 had over 59,000 overdose fatalities, up 19% from 2015. This is the biggest annual increase ever seen in the U.S., and 2017 is already projected to be even worse.
Highly Potent and Highly Available
Many American opiate addicts became hooked on painkillers that were legally prescribed to them. Eventually, when their physicians were unwilling to continue writing prescriptions, these individuals turned to heroin, which is cheaper and more readily available from illicit sources than prescription meds. Fentanyl is 50 times stronger than heroin, making it even more addictive and lethal, and thanks to the recent rise in illicitly-made fentanyl, the drug is becoming increasingly cheap and available. Many heroin addicts shoot up with doses cut with fentanyl without even knowing that they’re doing so, and some addicts turn to fentanyl as their tolerance to heroin increases.
Law enforcement reports indicate that fentanyl seizures or confiscations increased sevenfold between 2012 and 2014. This reflects the jump in illicitly-made fentanyl, not legally made and prescribed drugs given to patients suffering from severe pain. In 2014, from July to December, 18 U.S. states reported over 20 confiscations of fentanyl. During that same six-month timeframe in 2013, only six states reported over 20 fentanyl confiscations.
The Fentanyl Crisis in Ohio
The horrors of the rising fentanyl crisis can be seen in action throughout Ohio, where heroin abuse has been eclipsed by the abuse of fentanyl or one of its analogues. In the Summit County area—Akron is located here—drug overdose fatalities have skyrocketed. In 2016, the county suffered 312 drug fatalities, which is 46% more than 2015. In fact, the death toll was so severe, that three times last year, the Summit County morgue ran out of room, and the medical examiner’s office had to request refrigerated trailers for body storage.
These deaths are almost entirely related to fentanyl or equivalent drugs, and the problem is statewide in Ohio. In Montgomery County, where Dayton is, three out of 100 drug overdose deaths tested positive for heroin, and 99 of the 100 tested positive for fentanyl or an analogue. The deadliest fentanyl analogue is carfentanil. This literal elephant tranquilizer is 5,000 times more potent than heroin, and a lethal dose can be as tiny as a couple grains of salt.
On the day that carfentanil showed up in Akron in 2016, 17 individuals overdosed and one individual died over a nine-hour span. Through the next six months, 140 overdose fatalities tested positive for carfentanil—fifty percent more deaths than Akron had for all of 2015.
Fentanyl Addiction and Overdose
The signs of fentanyl addiction include:
- Weight loss and loss of appetite
- Nausea and vomiting
- Problems urinating
- Vision changes
- Dry mouth
- Reddening of the skin
- Swelling and sores
- Severe mood swings
- Muscle and bone pain
Fentanyl addiction, or even a one time use of fentanyl or one of its analogues, such as carfentanil, has a shockingly high chance of leading to a fatal overdose. Signs of fentanyl overdose include:
- Blue lips, mouth and hands
- Extreme drowsiness
- Respiratory depression: slowed or ceased rate of breathing
Fentanyl and Carfentanil: Dangerous and Deadly
The DEA issued a public warning about the risks of carfentanil to law enforcement and the public in 2016, explaining that the drug is 10,000 times stronger than morphine and 100 times stronger than fentanyl, which is already 50 times stronger than heroin. Carfentanil is appearing in more communities everyday, frequently disguised as heroin.
Not only is carfentanil deadly for fentanyl addicts, it can be deadly to first responders, medical professionals, drug dogs, and laboratory personnel. It can appear as tablets, spray, blotter paper, or powder, all of which can be absorbed through the skin when touched. The powder can also be accidentally inhaled in tiny but fatal amounts. Law enforcement are urged to never test suspected fentanyl or carfentanil on the scene, but carry it back to the laboratory where it can be safely handled. Anyone who suspects they have been exposed to carfentanil should seek immediate medial attention. EMTs will most likely administer naloxone, which is an antidote to opioid overdose.
The Downside of the War on Drugs
Getting tough on drugs seems like a good idea in abstract, but in practice, the “War on Drugs” has only worsened the problem. Acres of South American poppy fields were wiped out to cut off the supply of heroin to the U.S., but this only made space in the illicit marketplace for fentanyl labs in China and Mexico to respond to demand—and much more profitably, as well. For the cost of several kilograms of heroin, smugglers can transport a few grams of fentanyl, with much less chance of getting caught.
Fentanyl is so potent that those few grams can be diluted into an extremely large amount of product, but irregular methods and imperfect dilutions result in street drugs with widely varying degrees of potency. To make it worse, fentanyl can be ordered from an online pharmacy in China, then sent through the mail, because a powerful amount of the drug is physically small enough to fit in an envelope.
This negative consequence of the War on Drugs is often referred to as the “iron law of prohibition,” referring to a phenomenon observed during the American prohibition of alcohol in the 1920s, which resulted in far less consumption of beer, and much higher consumption of stronger liquor, which produces greater intoxication via a smaller amount. When it comes to the fentanyl crisis, this phenomenon is seen as follows: you crack down on prescription opiates like oxycodone and hydrocodone, you increase the demand for heroin, you crack down on heroin, you increase the demand for fentanyl.
The fact is, there are at least two million opiate addicts in the United States today, and law enforcement crack downs will not deter an addict from doing whatever they can to avoid the incredibly painful and debilitating withdrawal symptoms they experience as the level of opiates in their system begins to wane.
What Can Be Done to Help?
When it comes to saving lives from fentanyl overdose, naloxone needs to be made as available as possible. This opioid-overdose reversing medication can make the difference between life and death in minutes. But we still need to prevent fentanyl addiction before it gets that far.
If criminalization and large-scale attacks on drug smugglers and producers can’t fix the fentanyl crisis in America, then what can? As long as there is a demand for strong opiate drugs, there will be criminals willing and able to supply them. Therefore, the answer lies in solutions that help prevent and treat addiction at the individual level.
First off, we need to advance the science and practice of pain management to reduce our reliance on opioid drugs. There are many people with legitimate medical conditions, injuries, or surgeries that result in severe levels of pain. Left untreated, chronic pain results in significant declines in mental and emotional health, driving many to serious depression and thoughts of suicide. There need to be more options for the treatment of chronic pain—options that don’t so easily result in addiction.
Second, the public in general, and especially young people, need to be educated about opiate drugs. Telling someone to “just say no,” won’t work; you have to explain to them why it is in their best interests to say no; you have to help them understand all the misery and tragedy that can result from a little prescription drug misuse, or a little opiate drug experimentation. Most people in the general public have no idea how opiates work on the brain, causing physical changes that swiftly train users to become addicts.
And third, we need to increase awareness of and access to opiate addiction treatment. Widespread treatment interventions for opiate addicts will directly reduce the demand for opiate drugs and thereby reduce the development and distribution of more and more potent opiates.
Treatment for Fentanyl Addiction
Anyone addicted to opiates, and especially individuals lucky enough to have survived an overdose, should be connected to a treatment program that provides Medication-Assisted Treatment.
Medication-Assisted Treatment is an approach to opiate addiction that integrates various therapeutic interventions to treat all sides of the problem. Patients are given medications such as buprenorphine and methadone, which allow them to resume normal functioning and apply their energies to recovery. Once stabilized, patients can undergo therapy to explore the various issues in their lives and within themselves that prompted and perpetuated their use of drugs, making changes where necessary. Because the opiate replacement medication is suppressing the intense drug cravings and symptoms of withdrawal they would otherwise experience, they have the necessary physical support through this challenging emotional process.
Most Medication-Assisted Treatment programs also utilize Cognitive Behavioral Therapy and/or relapse prevention services to teach recovering addicts practical ways to deal with life stressors, conflicts, and trigger situations. Behavioral counseling prepares patients to effectively deal with in the moment challenges that would have pushed them to use in the past.
Another useful medication in opiate addiction treatment is naltrexone. Patients taking naltrexone are discouraged from relapsing because the drug will make them experience withdrawal symptoms instead of intoxication if they use opiates again. The only issue with this drug’s effectiveness is compliance, but there are extended-release forms of the medicine that can be injected monthly at treatment centers, thereby avoiding this problem.
Reasons to Hope
The fentanyl crisis in America is a serious issue that has no easy solution. But with more widespread drug prevention education, better and safer options for dealing with chronic pain, and easier access to quality addiction treatment programs, the situation can be improved, person by person, over time.