Fentanyl, the killer

Here’s what you need to know about fentanyl and how to avoid being killed by it.

Bold Ideas - Dorothy Dobbie
Bold Ideas –
Dorothy Dobbie

There’s a vicious killer stalking our streets and he wears a variety of disguises. Sometimes he looks like OxyContin, other times he hides in heroin or cocaine or methamphetamines such as crystal meth – even in marijuana. This killer is the deadly drug, fentanyl.

A Naloxone Kit. Photo by James Heilman, MD.
A Naloxone Kit. Photo by James Heilman, MD.

Where it came from
Fentanyl is a synthetic opioid that was developed way back in the 1960s by a guy named Paul Janssen, Baron Janssen to be exact. A Belgian born in 1926, he was the founder of Janssen Pharmaceutica, a company responsible for the development of treatments for schizophrenia, menstrual pain, cardiovascular disease, allergies, mental illness and diarrhea, among a long list of others. His development of fentanyl was focused on pain management and marketed as the anesthetic, Sublimaze. It is chemically similar to Demerol (meperidine). Derivatives include sufentanil, alfentanil, remfentanil and lofentanil.

Janssen Pharmaceutica was the first Western company to set up manufacturing in the People’s Republic of China. Now the expertise earned there through that early factory is coming back to haunt us as most of the fentanyl entering Canada is coming from China. And not only is the drug being shipped in, but so are pill presses and other manufacturing aids.

How fentanyl works
Like all opioids, including the poppy-based ones and other synthetics such as heroin, fentanyl binds in the brain to opioid receptors that control pain and emotion. In doing so, it drives up our natural dopamine levels which gives us that sense of euphoria and relaxes us and creates a feeling of well-being. The problem is that fentanyl also binds to the receptor in the brain that controls breathing.

Fentanyl acts rapidly, delivering a shot of rapture to the brain, but this lasts very briefly – not even as long a time as that induced by heroin. This is followed by deep relaxation, slower breathing, lower heart rate, loss of focus and concentration and, finally, mellowness and even sleep. The danger is that the tiniest amount too much (perhaps one grain, the size of a sugar crystal) can cause breathing to stop. The result is death.

At the outset, the euphoria and relaxation and (for those taking it medically) the cessation of pain makes it worthwhile. But tolerance and addiction build rapidly – sometimes within days. Those who are susceptible to the “highs” it induces at the outset need ever larger amounts to get the same reward and this is compounded by an irresistible craving. Medically, the doses are 12.5, 25, 50, 75, and 100 mcg per hour, but for even a habitual user, a dose of 200 mcg used within an hour will kill.

Fentanyl can be taken into the body in many different ways, including through simple skin absorption, which is why drug control officers are so concerned about encountering the stuff in powder form. Illegally distributed, it might appear on a spiked blotter to be taken by mouth. Tablets disguised as OxyContin are common and often the drug is mixed with heroin, morphine or other opioids and the user may not know it is even there.

The fentanyl crisis is forcing first responders to rethink their strategies.
The fentanyl crisis is forcing first responders to rethink their strategies.

How long does it take to get addicted?
It is very hard to pinpoint an average amount of time or usage that indicates ultimate addiction to any opioid. People vary considerably in their physical and psychological make up and that means so do the effects of opioids. For some individuals, however, becoming dependent on fentanyl takes a very short time: days rather than weeks.

And the impact of the drug is powerful. Perhaps that’s one reason why drug pushers are willing to risk killing their clients – it is so easy to create new addicts. People dependent on other opioids are also often not aware that they are being fed fentanyl because our killer may be introduced in one of its many disguises, the favourite being the preferred prescription opiate, OxyContin. As mentioned, fentanyl-laced products are created to look like Oxy – the pills are the same shade of green and are stamped with an “80”, the most frequently prescribed dose of OxyContin pill sold on the street. The fentanyl pill even has a name: Shady 80. Unsuspecting users can be quickly hooked on the more deadly, and less-expensive-to-produce, drug.

The problem is that controlling the dosage of fentanyl is very hard. It is 80 to 100 times stronger than morphine and hundreds of times stronger than heroin. The tiniest bit extra can mean the end of a life.  Click here to read more about how easy it is for a pusher to create an overdose.

What to do if someone overdoses
You have probably heard about naloxone or Narcan, the antidote that knocks the opioid off the brain receptor. It is also used to overcome overdoses of other drugs such as heroin, morphine, etc. Narcan is delivered via intramuscular injection or through a nasal spray. It takes about two to five minutes to work and its effects last 30 to 90 minutes. Fentanyl, on the other hand, stays in the system for up to 72 hours, even though the “high” lasts only three to six hours. Indeed, after 17 hours, the drug in your bloodstream will have decreased by only 50 per cent. For this reason, it is important that users of Narcan be monitored after naloxone intervention in case the treatment has to be re-administered.

As well, the patient may require additional oxygen for a time and body temperature and hydration must be monitored. Habitual users may suffer withdrawal symptoms – perhaps acutely – after being treated with Narcan and will require continued help and observation for some hours.

(Note that overweight people keep the drug in their systems longer.)

Here’s a video on how to use Narcan:

Administer the antidote and call 911 immediately.
But how come some people use fentanyl for long periods?

Fentanyl is sold legally in many forms in strictly controlled doses. It can be prescribed as a patch (Duragesic), as a lollipop or lozenge (Actiq), as a sublingual (under the tongue) tablet (Fentora) as a mouth spray (Subsys) and as nasal spray (Lasanda).

Under a physician’s care, the doses are carefully monitored. However, the patient can still become addicted as tolerance builds and higher doses are required to have effect. Patients do become addicted.

Longer term, controlled fentanyl use can include such symptoms as confusion, depression, difficulty walking, swelling in hands and feet, muscle stiffness, slowed/altered heart rate, laboured breathing, weakness, dizziness, light-headedness, and fainting, shaking, sleepiness, slurred speech, weight loss, visual hallucinations, nausea and vomiting, itching and scratching, itchy nose, sniffles, severe sneezing attacks, and pinpoint pupils. But for chronic pain relief, people are willing to put up with a lot of “inconvenience”.

It is also used in palliative care where the users are not expected to live long enough to suffer these side effects. I am pretty sure it has helped speed many dying patients to their final rest even before the new laws were put in place.

Withdrawal and detoxification
Withdrawal symptoms can include sneezing fits, chills, dizziness, yawning, sweating, restlessness, tears, runny nose, chills, backache, stomach cramps, nausea and diarrhea, joint , back and muscle pain, hair bristling, rapid breathing, rapid heartbeat, nervousness, irritability, shivering, confusion, general weakness, loss of appetite, tremors… all compounded by mental anguish as your brain is flooded by the compulsion to get another hit. It is not advisable for people try to withdraw on their own or cold turkey. Get help.

What if you are prescribed fentanyl?
Canadian doctors push this stuff and other opioids more than in any other country. In 2016, it is reported by the Globe and Mail that at least 655 Canadians died from fentanyl. The real total is probably much higher.

Fentanyl is not the only opioid that is over prescribed in our country. Hydromorphone and oxycodone are two other offenders that are frequently dispensed. About 20 to 30 percent of opioid addicts got started through prescriptions according to Ontario’s Bellwood Health Services which treats addiction.

Many others become addicted during prolonged hospital stays then have to go through withdrawal at home because the medical systems avoids admitting that this is happening.

If you are prescribed any opioid, think long and hard before agreeing to take it and ask for alternatives. Pain management can take many forms; the answers don’t all come in a pill.

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