The opioid Fentanyl has been increasingly dominating headlines these last few years, as the “opioid epidemic” grew to the point of capturing public attention, and by extension politicians and the press. Unlike heroin, which is made from opium poppies, Fentanyl is synthetic, meaning it’s made in a factory. The media and political buzzing mistakenly treats the two as interchangeable, but Fentanyl is a game-changing evolution in the arms-race nature of the drug war.
One recent 911 call I had illustrates why. We arrived at the lobby of an apartment building, where firefighters were performing CPR on a young woman. We administered high-dose Narcan and returned her to her natural dimension. First, she said she was extra sleepy. “Let’s not play this game,” I responded. “A person will not sleep through CPR. You were dead.” After complaining of how disrespectful it was that we cut off her favorite dress (I found little fish-scale flashies in my “office” for days thereafter), she finally fessed: she licked up something from her boyfriend’s mirror and shower curtain. “Licked, mmmm, interesting, where is this boyfriend now?” “He died last month.” “Mmm, died, interesting choice of words, overdosed maybe?” Then she got too upset to talk rationally. Turns out, the apartment had been sealed by the police and she convinced the super to let her in by herself for a while, Where she did her licking. She said she thought the shower might have been the last place he was, and… something, something, “memorial, feel him,” something.
This was likely my first in the wild encounter with Carfentanil. She might have been lying (Q: how can you tell an addict is lying? A: their lips are moving), but if just contact absorption of the substance dropped her dead (as opposed to bloodstream absorption of IV injection, or mucosal absorption by snorting), it was likely a highly concentrated form of the opioid – concentrated beyond what is possible naturally. The misadventure is also an “in the wild” example of the Iron law of Prohibition: “the harder the prohibition, the harder the drugs.”
Vancouver recently concluded a study meant to find out exactly what their addicts were using. They found that the vast majority of the samples recovered from their junkies were Fentanyl, not heroin. It would be hard to imagine an American disciple of the molecule trusting authority enough to offer such a specimen, and it would be illegal for the clinician to take it. This is because America’s legal framework of drug prohibition is a paradox of making drugs into a schedule 1, which recognizes a high potential for abuse with no known clinical use, awkwardly alongside the illegality of ever finding out anything of a Category 1 drug’s clinical use. Physicians in the United Kingdom know that at least one legitimate use of heroin is in treating heroin addiction safely. The therapy is called Heroin Assisted Treatments (HAT), and it is known to work all over the world.
Addicts don’t prefer Fentanyl, though we know that’s what they are getting. From an addict’s POV, Fentanyl fails because it is quite short-acting (which brings them back for more). They are getting Fentanyl because the illegal drug markets push it over heroin. They push it over heroin because it’s easier to make in a factory than grow in a field, and because it can be concentrated, making it easier to smuggle and transport. It is made clandestinely in China and travels hidden amid the millions of packages shipped into America every day.
Distribution of the drugs then depends on the dealers to subdivide the Fentanyl into individual doses. Fentanyl doses are measured in micrograms, with 1,000 micrograms equal to 1 milligram. It’s up to a criminal not to mislay one of those teeny, tiny decimal points. Carfentanil adds another three decimal points to the complication. Another menacing reality is that they are not diluting the Fentanyl with industrial consistency. with all of my mandatory training as a front-line soldier in this crisis, I had to take to the Internet to learn of Fentanyl’s “hot spot” problem: since it’s so concentrated, a grain can clump and remain concentrated, like a pellet of hot chocolate mix in the bottom of a cup. So, a dealer can sell a thousand correct doses, and then have a customer felled dead by a hot dose. Amazing, what you can find on the internet, amazing we can’t treat it as a distributed form of study (my favorite from the druggie forums: their recommendation of using a CPAP machine when they “push off”).
An order-of-magnitude overdose of Fentanyl is possible, and likely fatal, whereas a ten-fold OD of heroin is not. Actually, and astonishingly, this happens far less than one might think, given the infrequency of overdoses. This says a lot about how safe these drugs really are, and how much safer they would be if caged in a medical environment. I apply Fentanyl safely and routinely at work, it’s not plutonium.
Consideration of the ecosystem of the underground drug economy reveals why 10-fold ODs are rare: drug dealers, despite being criminals, are far from unaccountable. And if they misplace ten doses for ten customers, consequences will ensue. The consequences will not involve a court, and here we get to the ecosystem of violence as the inevitable form of conflict resolution with all illegal markets.
Medicine can know what factors keep an addict alive by studying the habits of live junkies, whereas prohibition looks at autopsies and can know only what makes addicts dead. This would not surprise Keith Richards, who accounts his junkie-longevity to never using low quality “street junk.” Another great example is how we are learning the degree to which opioids synergize with [prescription psychiatric drugs, to multiply the effects (and dangers) of both. This is the true story of Phillip Seymour Hoffman’s death, which was reported as a heroin overdose, but would be categorized by a clinician as a “multi-substance OD.” Since no clinician wants the DEA investigating them, it’s safe to say that a communications barrier between patient and clinician is built into our ideas of drug scheduling, which will synergize the synergizing risk. A more medical approach would involve a medical culture’s ability to individualize a problem and its specifics. It’s laughable to suggest our bi-polar political process can do this amid our all-out partisan war. Medicine is an evolutionary process, adaptive and dynamic, and the law is, well, not.
To a large extent the opioid problem in general, and the fentanyl evolution in particular, is the same as the atomic bomb problem: the information is out, the genie is out of the bottle. Fentanyl (or methamphetamine, LSD, MDMA, XTC) cannot be un-invented. Communication at the speed of light on how to make them all in a lab cannot be undone. Hell, like everything else, the hard parts of chemistry and lab manufacture will gladly be handled by the Chinese, where new evolutionary drug beasts are released into the wild every day.
I’ve been on the street level of this problem for a generation, and I can’t decide if I feel the sudden interest in the issue is “better late than never,” or anger at the irony that the only new factor seems to be the upscale addresses. But that’s not the whole story, the whole story is: the factory Fentanyl threat is an entirely new ball game, and we can’t counter it using the methods that put us in this situation. The solution to a problem is rarely the same as its cause. The bitterest part of the irony comes from the suddenly open solution space in searching for alternatives. The karma of it is that if we had a humane approach to the disease eating the least of us from the beginning, we might have alternatives to the evolutions we can’t control. We could have forged the treatment tools we need a generation ago.
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Thanks, Ed! Keep safe and clear headed.