Fentanyl / Opiate Overdose

 

What is Fentanyl?

Fentanyl has been in the forefront of the news lately, but it's nothing new. I used to use it (properly) as an ER doc for what is known as "conscious sedation." That's where you need to knock someone out for a painful emergency procedure without putting them completely under with a general anesthetic. I'm talking procedures like putting a dislocated shoulder back in place, setting a broken bone, or looking into someone's stomach with a scope. Fentanyl was a great choice because it is used at extremely low doses due to its potency, because it works very quickly, and because it has a short "half-life'" meaning that it wears out quickly. A doctor can quickly knock somebody out with Fentanyl, and 20 minutes later it's worn off, and an hour after they walk out of the ER.

However, the very properties that make Fentanyl useful in the ER are the same properties that make it so lethal as a drug of abuse.


Fentanyl's great danger, the reason it causes so many deaths on the streets, is because it has a very narrow "therapeutic index." That means that the gap between an effective dose and a lethal dose is very small. This is compounded by the fact that we use very small doses of it (it is 100 times more potent than morphine), so even a small mistake in measuring it out can easily be fatal. In the powder form an amount the size of two grains of salt can kill a healthy adult.

Fentanyl is an opiate, meaning it is derived from the opium poppy. However, unlike many other opiates (such as heroin, morphine, methadone, oxycodone, etc - which are natural or semi-synthetic) it is entirely synthetic.

Why is Fentanyl on the street?

Fentanyl is so potent that even a tiny amount of the powder form can have thousands of doses contained in it. Therefore, it is much easier to smuggle into a country. Most of the illegal Fentanyl is coming from China, and often arrives in envelopes small enough to not arouse suspicion.

Dose-per-dose, Fentanyl is much cheaper to produce, import and package than is heroin. Therefore it can be used to "cut" heroin, or even make fake heroin. The user still gets high, and is none the wiser. I was recently involved in the case of a young man who was brought to the ER after being resuscitated from a heroin overdose. Or at least that's what he thought. His blood test showed not a trace of heroin... it was all Fentanyl. He thought he was using heroin.


With Fentanyl, dealers have a cheap way to rip off their customers. The problem is that the Fentanyl powder they are using comes from amateur labs and therefore nobody knows how potent or dilute it is. Therefore the dealers cutting their heroin (or making fake heroin) have no idea how much Fentanyl is actually going into their "product." Because even a small amount of Fentanyl is lethal, it is very easy for lethal doses to end up on the street, and the users don't even realize there is Fentanyl in it.

I have seen a news report saying that some heroin dealers in New York actually brand their "product." The report said that once in a while they will purposely spike a few doses with lethal amounts of Fentanyl. When the news announces that their brand recently caused a number of ODs, their sales increase because users think their heroin is really potent. Ouch!

While I don't agree at all with the criminalization of the medical problem known as addiction, such as we see in the United States and elsewhere, I am less inclined to protest a new legal trend that has arisen in Canada in the fall of 2017. Canadian prosecutors have started charging dealers who taint their narcotics with Fentanyl with manslaughter. While it is true that many dealers are simply desperate people whose addiction has driven them to deal in order to support their own habit, Fentanyl spiking represents pure profiteering and exploitation with full knowledge of the deceit of customers and the deadly potential. However, I am a physician, not a lawyer so I will leave the legal debate to others.

It's not just Fentanyl that's the problem

Any opiate can cause an overdose death. Fentanyl is just the most potent, so it is the easiest to OD on. The problem is that many other opiates that are sold on the street - oxycontin, dilaudid, codeine - are also laced with fentanyl for the same reasons as heroin: fentanyl is cheap and easy to import.

There is yet another problem to Fentanyl: it has a chemical cousin that is far more potent: Carfentanyl (sometime spelled Carfentanil). Carfentanyl is 10,000 times more potent than morphine. It is so toxic that it is being investigated as a military weapon. Its toxicity is similar to that of military-grade nerve gases. Carfentanyl has only one purpose: anesthesia for very large animals. In fact, it's usually only used in elephants. Even in elephants the doses used are so small that it is easy to kill the animal with even the slightest slip-up.

Carfentanyl is so toxic to humans that even handling it can be lethal. In June 2016 the Canadian Border Services seized a shipment of one kilogram (2.2 lbs.) of Carfentanyl. That small amount contained 50 million lethal doses, enough to kill the entire population of Canada, with 15 million lethal doses to spare.

What happens when we overdose?

Opiates cause death by "respiratory suppression:" They suppress the part of the brain that regulates breathing. Our brain stops telling the body to breath, and breathing slows or stops. If we take enough of an opiate we will simply stop breathing, and die.  Because the victims are heavily intoxicated or unconscious, they do not realize what is happening or have no ability to do anything about it.

Often the user who has OD'd is alone or with other people who are high and incapacitated, or afraid of the law coming, so do not help or call for help. Often their addiction drives them to rob the person who has OD'd and leave them to their fate.

Alcohol when taken with opiates can increase the risk of respiratory suppression and death; if we drink and use we can OD much easier. The same effect can happen with other brain depressants, such as benzodiazepines, muscle relaxants, etc.

Even if the victim survives the OD, if they go too long without breathing damage to the brain and other organs can leave the person unable to walk or function normally, even if treatment with naloxone is given. They may end up in a vegetative state (living as a "vegetable") or otherwise mentally impaired.

Overdose symptoms

Prior to death, opiate overdose symptoms are referred to as the "opiate overdose triad": 1) decreased level of consciousness, 2) pinpoint pupils, and 3) respiratory depression. Other symptoms include seizures and muscle spasms. Usually the decreased level of consciousness is such that the victim won't even wake up to their name being called or being shaken.

What to do in an overdose

If you think someone has overdosed, you should try to wake them by calling out to them, shaking them, and rubbing your knuckles on their breast-bone (sternum). Call 911 immediately if they are not responsive. Supporting their breathing and administering Naloxone are the mainstay of first aid.

For details, I recommend the WebMD section on first aid for overdose (Click Here).

What is Naloxone and what does it do?

Naloxone (brand name Narcan) is a medication that can reverse the effects of opiate overdose. It attaches to the same parts of the brain that heroin and other opiates attach to, blocking them from the brain for 30-90 minutes. This reverses the respiratory suppression that would otherwise lead to death from overdose.


Note that Naloxone is not the same as Naltrexone. Naltrexone is made of Naloxone but is a much longer-lasting slow-release version. It is sometimes used in the treatment of drug or alcohol dependence.

Naloxone only reverses the effects of opiates, such as heroin, methadone, morphine, codeine, or hydrocodone. It does not counter the effect of other types of drugs, including alcohol, cocaine, and amphetamines. But if the person is not breathing and we don't know what they took, it will not hurt to administer naloxone. If there is an opiate involved they will likely start breathing again – though they will still be sedated from the other drugs. Many overdoses happen due to mixing opiates with other drugs, which is a common practice. In the worst case scenario, naloxone will simply do nothing, but in the best case scenario it will save a life.

Serious side effects of Naloxone are rare. The most common side effect is opiate withdrawal, since Naloxone removes the opioids from their receptors in the brain. The risk of withdrawal increases with larger doses of Naloxone as well as the degree of the victim’s drug dependency. Common opiate withdrawal symptoms include body pain, irritability, profuse sweating, diarrhea, nausea, and vomiting.

When the Naloxone takes effect, the overdosing patient should start breathing and may regain consciousness, or it may be possible to wake them up. However, Naloxone only lasts for about 30-90  minutes. If the body hasn’t processed all the opiates by then, the overdose symptoms may return. Even if the patient seems to be recovering after the Naloxone, it is still important to call 911. If someone is sick enough to receive Naloxone, a trip to the hospital is a must. The ambulance carries Naloxone in case the first dose starts to wear off.

Bottom line

People who have suffered an OD are in a dangerous place, even when the crisis is over. It is urgent for help to be offered so that they can deal with their addiction and substance use, and the mental effects that do with it. Unfortunately, many are still facing barriers to accepting help (see "Barriers to Recovery" Click Here).

The Fentanyl crisis has added a new urgency to the need for those of us who are addicted to substances of abuse to seek help and recovery. It's more life and death than ever before.



To learn more about the science and psychology of addiction and recovery, and to understand why alcoholics and addicts behave the way they do, see the author's book The Alcoholic / Addict Within.

Available for sample or purchase in paperback and ebook editions at amazon.com (Click Here).