Fentanyl, Toxicology, Healthcare Costs & Estate Planning: Strange Bedfellows in 2017

Report by Terry Gotham

This week’s edition of “Why We Can’t Have Nice Things” is a look at a couple of different secondary effects of the opiate overdose epidemic that I don’t think are being given enough scrutiny. With Donald John Trump Jr. declaring a “state of emergency” but not promising any tangible resources, I thought it would be best to do the opposite. Dive into the nitty-gritty of two facets of the opiate epidemic that are so far out into the policy weeds that our president has probably never thought about them.

One of the more complex problems caused by the flood of fentanyl and fentanyl analogs is the difficulty in investigating overdose deaths. This is somehwat related to the explosion in complexity that ER staff are forced to cope with when it comes to determining what someone is overdosing from exactly. I spoke about this a while ago but only touched on the difficulties Emergency Rooms and hospitals are dealing with while working with the patient in vivo. But the work doesn’t stop there.

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Shockingly, People Don’t Actually Throw Out Drugs.

In what is the biggest “I can’t believe we have to prove this academically” story of the year, three Johns Hopkins researchers showed that 66-92% of people who got a pile of prescription opioids, didn’t use them all. Not only did 67-92% of patients report unused opioids (92!) but up to 71% of opioids obtained even by surgical patients weren’t consumed. This review of 6 different studies drives home the need for much of the mainstream addiction/treatment community to modernize their thinking when it comes to harm reduction and human behavior. Unsurprisingly, 3 out of 4 people didn’t secure their opioids properly (yes, the FDA legitimately believes that people should store pain pills in locked containers). Even more unsurprisingly, no more than 9% of patients in any study “disposed” of their drugs “properly.” What does disposing drugs properly look like? This:

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Prohibition, Jake Leg, Methanol & Jamaican Ginger: Adulterants 100 Years Ago

Report by Terry Gotham

Picture New York City, Christmas Eve night, Bellevue Hospital. 60 people hospitalized over the course of the evening, with another 23 hospitalized from drug poisoning within the next 48 hours. With 8 dead by the time the smoke cleared, it sounds like a news story you’ve heard every week this year coming out of some distraught community in Ohio or Connecticut or Georgia? It’s got to be a bad batch of fentanyl? Maybe some spiked heroin or morphine that no one saw coming. It was actually alcohol and the year was 1926. As the Chicago Tribune editorialized in 1927:

“Normally, no American government would engage in such business. … It is only in the curious fanaticism of Prohibition that any means, however barbarous, are considered justified.” Others, however, accused lawmakers opposed to the poisoning plan of being in cahoots with criminals and argued that bootleggers and their law-breaking alcoholic customers deserved no sympathy. “Must Uncle Sam guarantee safety first for souses?”
~The Chemist’s War (Deborah Blum, 2/19/2010 Slate.com)

Returning to the History of Addiction series this week, I’m going to be exploring one of the lesser known eras of adulterated drugs in world history, Prohibition-era America. While it’s widely known that alcohol was still available during Prohibition, we have a romanticized idea of what this was like, with the speakeasy culture, Al Capone and flappers dominating our vision of it. The reality of bathtub gin and moonshine had some dangerous facets that we don’t talk about, that even continue to this day in places like Russia. This ties directly to the continued prohibition/unaffordable nature of scheduled substances.

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Cocaine, “Narcan Resistance” & the Grey Death: Fentalogs in 2017

By Terry Gotham

If you follow the news about adulterants in the recreational drug supply, it’s easy to get overwhelmed with the news breaking every day. Last Friday, the medical examiner’s office of Cuyahoga County in Ohio disclosed that they’re on track to obliterate their overdose record from last year. With 187 heroin/fentanyl overdoses on the books since Jan 1st, if things don’t change substantially, they’ll blow past their 2016 total of 660 overdose deaths by over a hundred people. If you missed my last article, multiple types of fentanyl are now being found in overdoses & drug seizures. And I don’t mean one or two. 24 fentanyl analogs & metabolites were found in blood/urine in Ohio overdoses alone:

1-3-Methylfentanyl; 4ANPP; Acetyl Fentanyl; Acetyl Fentanyl 4-Methylphenethyl; Acryl fentanyl; AH7921; Alfentanil; Beta-Hydroxythiofentanyl; Butyryl Fentanyl/Isobutyryl Fentanyl; Butyryl Norfentanyl; Carfentanil; Despropionyl Para-Fluorofentanyl; Fentanyl; Furanyl Fentanyl; Furanyl Norfentanyl; Norfentanyl; ParaFluorobutyryl/4-Fluoroisobutyrylfentanyl; Para-Methoxyfentanyl; Remifentanil; Remifentanil Metabolite; Sufentanil; U-47700; Valeryl Fentanyl
~Research Update on Fentayl Outbreaks in the Dayton, OH Area, Boonshoft School of Medicine, Wright State University, 4/28/17

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Do No Harm: Safe Injection Facilities in Fentanyl’s World

Analysis by Terry Gotham

But until recently, politicians dismissed the idea of a safe-injection site as being too controversial. More controversial than people dying in libraries and babies picking up needles on the beach? Please. San Francisco has essentially become one big unsafe injection site.
~Heather Knight, SF Chronicle “Safe injection sites offer hope in scourge of discarded syringes”

I wasn’t sure how to start this piece, a feeling I think mirrors the paralysis many policymakers feel when it comes to moving away from puritanical, expensive & needlessly harmful criminalization of controlled substances. In the case of the city policymakers, the opioid overdose epidemic has gotten so bad, they may be getting over it.  The SF Department of Public Works collected 13,333 syringes in San Francisco. In March. That’s 430 a day. In Ohio, there were 100 accidental drug overdoses in Mongomery County, Ohio in January & February alone, with an average age of 40. Here’s the kicker, 99 tested positive for fentanyl, and, 56% tested positive for acryl-fentanyl, 3 carfentanil cases, and 24 total fentanyl analogs and metabolites were found in total. 24. The majority of the cases tested positive for more than one “fentalog.” But of course, straight from the report:

All acryl fentanyl and furanyl fentanyl cases also tested positive for fentanyl; about 45% of acryl fentanyl cases also tested positive for furanyl fentanyl.
~Research Update on Fentanyl Outbreaks in the Dayton, OH Area: Acryl Fentanyl & Furanyl Fentanyl Commonly Found in Overdose Death Cases.

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