Report by Terry Gotham

Enough people sent me the NY Times article about Fentanyl overtaking Heroin that I had to say something about it. If you’ve not seen it and the plurality of think pieces surrounding it, the only piece you need to read on it is by the person who runs The Dose Makes The Poison, Kevin Shanks. He’s been one of my go to sources on novel psychoactive substances for years now, and he, along with a handful of others have been yelling as loud as they possibly can. The point he raised almost a month ago is one I’ve not seen a single mainstream medical journal begin to grapple with in any kind of meaningful way.

As I’ve said for a while now, this ain’t your father’s heroin. At what point do we stop calling it heroin and refer to the standard “heroin” product on the street as fentanyl?
~Kevin Shanks (9/2/17)

While drug overdose deaths are up 22% from 2015 alone, fentanyl deaths doubled. That’s not including the fact that cases are severely under counted, given the volume of fentanyl analogs in circulation right now. I previously reported on the report coming out of Ohio with 24 analogs & active metabolites being identified. That, combined with the increased cost in testing for analog substances, we’ve arrived at a place where medical staff have no idea how many chemicals they’re not testing for. How many rural communities are testing for acrylfentanyl or butyrylfentanyl? How many rural communities are seeing analogs that we don’t even know about yet? Communities along the migratory arc that fentanyl takes from China into Western Canada or Mexico into border communities, that see these substances first, are they still getting the same analogs, or is there already something new? At this point, it’s likely the unknown unknowns are already on the ground and slowly being consumed for the first time.

This means that every day, the number of people who are doing heroin that hasn’t been spiked with fentanyl or a fentanyl analog dwindles a little more. Traditional opiates simply cannot compete on price, potency or ease of transportation. Why would anyone choose to associate with the Taliban or the Zetas when you can just buy 100g of some fentanyl analog off the Dark Web and wholesale it to low level dealers who adulterate their street morphine or heroin? Zero tolerance policies continue to force the market to provide, even after obliterating traditional supply lines for heroin, so dealers find a way. Montreal and Quebec found out the hard way that you can’t just take opiates off the streets and expect dependent users to disappear.

The crisis we are witnessing, although it started as a crisis of over-prescribing opioids, has  shifted — and actually gotten worse — because of the introduction of illicitly manufactured fentanyl, which is a consequence of law enforcement focusing on the supply side of drugs without adequately addressing the needs of people who have become addicted.
~Eugenia Socias, University of British Columbia, BC Center on Substance Use – to the Montreal Gazette, 10/5/17

To be clear, Canada’s fentanyl problems (2800 Fentanyl overdoses last year) are minuscule compared to ours (20,145 deaths attributed to synthetic opioids, compared to 15,466 for heroin, or 14,427 for prescription opiate related deaths). To the point where we, collectively as a society, need to reframe our thinking about heroin, opiates, overdoses, and legalization. The CDC declared that 300,000 people had died since 1999 from opioid overdoses. How many of them have died because of the “third wave” of fentanyl? Enough that the DEA flagged them as a “Global threat” in a brief submitted to the Department of Justice.

Motivated by enormous profit potential, traffickers exploit high consumer demand for prescription medications by producing inexpensive, fraudulent prescription pills containing fentanyls. The equipment and materials necessary to produce these counterfeit drugs are widely available online for a small initial investment, greatly reducing the barrier of entry into production for small-scale drug trafficking organizations (DTOs) and individual players.
~Drug Enforcement Administration: Counterfeit prescription containing fentanyls: a global threat

We need to accept that the calculus on the black market has changed, potentially irrevocably. 35 years ago, during the peak of the classic heroin crisis, the dystopians predicted that we’d not only still be doing heroin, but a plurality of other deadly drugs that emergency personnel would have no idea how to identify when they presented in the emergency room. Cole & Nelson published a brief in the American Journal of Emergency Medicine a month ago that spoke to this problem and our total inability to cope with it.

For the foreseeable future emergency physicians, EMS personnel, epidemiologists, law enforcement, and even drug dealers, should not think about heroin, fentanyl, carfentanil, or any specific opioid overdose; rather they will need to consider all issues under the generic rubric of opioid overdose,” forcing us to each learn new tactics even as we approach a decades old problem.
~Controversies & carfentanil: We have much to learn about the present state of opioid poisoning.

With cocaine on the rise and the growing body of evidence documenting cocaine adulterated with fentanyl, we’ll be seeing non-opiate users starting to overdose and land in the hospital in even greater numbers. Not only because the price will continue to fall as more fentanyl analogs enter the market, but because more and more drug users will try cocaine for the first time, potentially without testing it. This led to the OD in the Hamptons that was captured on snapchat earlier this year. There’s no reason for me to believe this will change in the near future, but hopefully, as discussed on The Poison Review, those in charge of Emergency Medicine & Response teams across the country will adjust the initial dose of naloxone, or potentially extend observation periods that dependent users are held for. If implemented, we could potentially mitigate some of the problems I explored in my article The Elephant in the Emergency Room. If not, areas that have seen explosions in fentanyl overdose rates will soon see their emergency room systems totally overwhelmed.

As more and more people risk their lives using synthetic opiates of questionable purity and content, I am asking for your help, personally, to get the word out. Many of us know opiate users, some of us know people struggling with opiate dependence. Educate them, make sure they have naloxone, show them how to use it, maybe even buy a test kit for them if you’re of reasonable means. While it’s not our job to keep people from destroying their lives with drugs, we might be able to keep some people from dying with a needle in their arm, or overdosing when they weren’t planning to, as dark as that sounds. Even one person saved from this scourge is a victory.