September 19, 2016 | Continuing Ed with Ed Baker
"Continuing Ed" with Ed Baker: Fentanyl Alert
By Ed Baker, LICSW/LADC
Burlington Labs Addiction Education Specialist
This blog post will focus on the current and alarming crisis we are facing regarding fentanyl use and overdose deaths in America.
We are in the midst of a fentanyl crisis. Hundreds of thousands of counterfeit pharmaceutical pills, some containing lethal doses of fentanyl or fentanyl analogs, have been smuggled into the USA. Fentanyl is more lethal to potential users than other opioids due to its extreme potency (approximately 100x more potent than heroin). And because these pills are being inconsistently mixed and disguised as less powerful opioids, people with opiate addictions who purchase fentanyl may have no idea what’s in their next hit, making overdose much more likely.
That’s the crisis in a nutshell. Let’s take a closer look.
What is Fentanyl?
Fentanyl is a synthetic opioid, manufactured completely from pharmaceutical ingredients, and engineered molecularly to initiate a very high activity at mu receptor sites, thus mitigating intense pain. Oral transmucosal lozenges, or “lollipops”, are prescribed for cancer “break-through” pain, as are effervescent buccal tablets. Fentanyl injections are administered for potent analgesia or anesthesia. Transdermal patches are used for patients with chronic pain needing constant analgesia. It is the most powerful class of opioids, and effective at very low dosage.
The DEA Intelligence Brief, “Counterfeit Prescription Pills Containing Fentanyls: A Global Threat” (July, 2016), reports that there were “eight times as many fentanyl exhibits (seizures) in 2015 as there were during the 2006 fentanyl crisis, clearly demonstrating the unprecedented threat and expansion of the fentanyl market.”
Why are we in this crisis right now?
For probably the last decade or longer, illicit-drug producers and dealers have been known to mix acetyl fentanyl with heroin to increase potency, which has contributed to overdose death rates. But the scale of fentanyl-related overdose deaths has increased exponentially in the last 3 to 4 years. What’s driving this?
Recently, criminal enterprises have expanded the practice of mixing acetyl fentanyl with heroin into also producing counterfeit pharmaceutical pills, mainly Oxycontin and Xanax, with some form of fentanyl being the only opioid contained in the counterfeit pills. As noted earlier, a lethal dose of fentanyl is very small, compared to other opioids.
In March of 2016, 10 overdose deaths occurred in Sacramento, California. One sample of counterfeit pills related to these deaths contained between 0.6 and 6.9 milligrams of fentanyl per pill: 6.9 milligrams being more than three times the lethal dose of fentanyl for a person without opioid tolerance. The wide variance in fentanyl content between these pills was due to faulty and inconsistent ingredient mixing and pill pressing procedures carried out in clandestine, criminal “labs.”
Which brings us to one of the key differences between the fentanyl crisis of 2006 and the one we’re seeing today. The fact that fentanyl is now being disguised as less potent opioids -- and the fact that the amount of active ingredient contained in one “dose” is not always the same -- greatly increases the danger, since a user may not know what substance, or what amount, he or she is taking – making overdose much more likely than ever before.
Left: Fentanyl powder.
(Source: Michigan State Police Situational Awareness Bulletin, 9/14/16.)
Right: Counterfeit 30mg Oxycodone pills containing fentanyl.
(Source: TN Bureau of Investigation.)
Additionally, there have been numerous overdose deaths attributed to carfentanyl, a member of the fentanyl family. Heroin laced with carfentanyl was the cause of 174 overdoses, with 8 deaths resulting, in Ohio recently. Carfentanyl is 10,000 times more potent than morphine, and 100 times more potent than fentanyl, making it one of the most potent known opioids. It is used as a general anesthetic for large animals, and is inappropriate for human use. A dose the size of a grain of salt could kill a person, even if absorbed through the skin.
So what’s motivating producers and dealers to turn to fentanyl? Money, of course; a brief look at the economics of the fentanyl business is eye-opening. The DEA estimates that one kilo of illicit fentanyl, purchased from a Chinese source, at $3,500 USD, will produce one million one-milligram pills. Pill presses can also be purchased in China for approximately $1,000, as can die molds for pressing counterfeit pharmaceutical products (Oxycodone, $115; Xanax, $130).
Pill presses used to manufacture counterfeit pharmaceutical products.
Sold at $15 per pill, the “street value” of this investment is $15 million – for an up-front supply cost of less than $5,000.
Clearly, organized criminal enterprises have identified a market opportunity with a huge profit margin. They are capitalizing on a reduction in the supply of pharmaceutical opioids in America – ironically, due to the recent progress that’s been made on moving to more conservative opioid prescription practices, the creation of prescription drug take-back-programs, the disruption of pill mills, and so on. Like a balloon that’s squeezed in one area and pops out in another, the reduction in these sources of illicit opioid supply has created an unmet demand – and new opportunities for criminals to capitalize on addiction.
An example of this dynamic was seen in Canada a few years ago. The Canadian government removed Oxycontin from its legitimate market in 2012. Between 2009 and 2014, a six-year period, there were 1,019 fentanyl-related overdose deaths. Fully 50% of those deaths occurred during 2013-14, immediately following Oxycontin being taken off the market.
In addition to acetyl fentanyl and the fentanyl analogs, another deadly synthetic opioid has made its appearance in the US market: U47700, known on the street as “pink” or “pinky.”
According to the Utah Statewide Information and Analysis Center, “The synthetic opioid… is growing in popularity with recreational drug users throughout the United States…[and] is readily available for purchase on the internet, primarily from Chinese suppliers.” Because this drug is so new, it is not yet illegal to purchase (though the DEA filed in early September to schedule U-47700 as a Schedule 1 Controlled Substance, citing at least 15 confirmed overdose deaths involving the substance in several states).
What’s next, and what can we do?
What all this amounts to is the potential for yet even more tragic deaths over the coming months among this most vulnerable population. The DEA Intelligence Brief warns, “Overdoses and deaths from counterfeit drugs containing fentanyls will increase as users continue to inaccurately dose themselves with imitation medications.”
These users may be our clients, our patients, our neighbors, and in some cases, our family members.
It’s advised that those of us with direct contact with people with Opioid Use Disorder begin educating them to these new risks immediately. Below is one school district’s proactive measure to raise consciousness regarding U-47700.
In light of these new overdose risks, we should also all advocate for more widespread availability of Narcan, on the harm-reduction side – and for the quick expansion of MAT programs, on the treatment side.
As this new crisis illustrates, reducing the supply of opioids (via drug take-back programs, tighter prescription controls, and so forth) is only half of the solution. We also need to reduce demand through education, prevention, getting more people into treatment, and making treatment programs more successful.
If you have thoughts to share or questions to ask regarding fentanyl, please contact me at [email protected]. And if you have suggestions for future blog post topics, those are always appreciated!