By Terry Gotham
I know that sometimes I can seem all doom & gloom about the state of the drug-consuming universe, but once and a while I happen upon something that justifies my concern. This letter by Dr. Leon Gussow, published in the Emergency Medicine News (March 2017) journal is one of those things.
The filtration of fentanyl & fentanyl analogs into the recreational opiate supply has pushed us into a place where the simple “opiate overdose” prognosis in emergency rooms & EMT visits is no longer simple. Previously, treating an opiate overdose involved a single dose of narcan/naloxone, with a few hours of observation before the patient was back on their feet. The patient was then assessed for discharge and removed from the workload of the emergency room if released. This allowed even severe opiate overdoses to be handled in a timely, almost mundane fashion, if the EMTs were timely and the staff was experienced. But as Dr. Gussow explains, this is no longer the case.
Emergency rooms are now being forced to handle overdoses that stem from a massive range of increasingly potent novel opiates. 10-15 years ago, if you presented with a set of symptoms that pointed towards an opiate OD, there were a half dozen drugs that ER staff saw, legal and illegal that could cause it. They were of similar strength and had known toxicology profiles, chemical half-lives and side effects. Today, a patient who claims to have injected or snorted “heroin” or “dope” could have actually taken fentanyl, carfentanil, flurofentanyl, acrylfentanyl. In some cases, even Xanax was adulterated. As you can imagine, this makes diagnosis and rapid treatment difficult. The idea that you could present with symptoms of consuming one drug, while having actually consumed a sister drug that’s 5-10,000x more potent than that drug is mind-bogglingly dangerous. Yet, here we are.
Even when you’re lucky enough to get prescription painkillers, these substances are counterfeited as well. As Dr. Gussow sadly reminds us. Prince thought he was taking a legitimate prescription painkiller when he overdosed on fentanyl & U-47700. Some believe that Philip Seymour Hoffman injected himself with fentanyl-laced heroin, those reports are still being challenged. This problem is hitting emergency rooms across the country like a ton of bricks. The lethality of the drugs, combined with the fact that there is no good guidance on how to differentiate between these substances, including novel drug tests, leaves ERs fighting blind.. For many of these substances, one dose of naloxone is insufficient, with even the CDC declaring that multiple naloxone doses may be needed for fentanyl overdoses.
This has taken emergency medicine staff by surprise. Not only are previous tactics almost totally ineffective, but these new patients need continual monitoring to ensure they don’t get worse without warning. Dr. Gussow mentions a patient who experienced respiratory depression 8 hours after naloxone infusion completed. That’s a novel risk to users that present for treatment at hospitals that aren’t familiar with the recent shifts in adulterants in their community. A problem this big won’t go away because of a border wall or even the Fentanyl export ban recently levied by China. This has fundamentally changed how emergency medicine interfaces with opiate users.
I’ve spoken about the growth on novel psychoactive substances, but when it comes to novel psychedelics like NBOME or even novel stimulants like Alpha-PVP/Flakka, there seems to be some collective memory surrounding those substances. Novel psychedelics are being seized significantly less often, with fewer overdose reports than we saw in years past. One of the last bastions of novel psychoactive substance use outside of Fentanyl is synthetic cannabinoids, which were responsible for a rash of non-responsive states at a Brooklyn bodega in the summer of last year. People seem to understand which drugs prove problematic, especially when they’re doing them only at parties. But fentanyl is uniquely dangerous for a few reasons.
Opiate dependent individuals can consume truly startling quantities of opiates. This is the case whether they have done heroin for decades, or have chronic pain and have been prescribed increasing doses of painkillers by their general practitioner for the same amount of time. Fentanyl used to be available for a very narrow band of painkiller users, who had exceptionally high tolerance and were being carefully supervised. One of the most reassuring things about classical opiates like morphine, opium and heroin is that when found on the street, they were most likely cut and not very strong. This has all changed now. People using fentanyl are not only unlikely to know they’re using it, they probably don’t even know how much they took. Add to that the proliferation of fentanyl analogues and the spikes in overdose death that America is currently wrestling with becomes more understandable. Not only are more people consuming opiates, but they’re consuming dangerous ones that might kill them before emergency medicine can arrive, assess and treat them.
On a macro level, wave after wave of heroin overdoses, buffered by fentanyl & fentanyl analogues, rapidly deplete naloxone stores. Just look at what happened in Louisville two weeks ago. 151 overdose calls in 4 days. This is the equivalent of a multi-alarm fire overwhelming a single fire department, requiring backup. We currently have no strategy to deal with this. Either in the emergency room, as Dr. Gussow reminds us, or on the national level, with states continuing to tread water in this flood, with 50,000 people dying from drug overdoses in 2015 (the most ever).
We need to stop pretending that walls or prisons or bans of drugs from China will put a dent this problem. Banning carfentanil from our shores will save some lives in the next 3-12 months (which should be celebrated) , but we cannot ignore the need to ensure non-adulterated opiates are being used by those in chronic pain, dependent or using recreationally. Safe injection sites provide an environment that allows for medical monitoring, clean needle use and hopefully, expanded testing of substances. Safe injection sites create an opportunity to stamp out a significant chunk of new HIV, Hep C, & STD diagnoses, and to guarantee people aren’t injecting fentanyl, carfentanil or the cornucopia of problematic substances adulterating the drugs in the USA, Canada, Mexico and across Europe. Legalization may be a long way off, but there are ways we can save lives and prevent extreme added cost & capacity to our emergency medicine systems. Those costs tend to be ignored during arguments about treatment and insurance, but as Dr. Gussow illustrates, if opiate users require 40 hours of naloxone, that’s going to explode our costs, and very few healthcare systems are up to that challenge.