Understanding the Opioid Crisis in the United States: Part 3

Fentanyl and why restricting opioid prescriptions is not the solution.

Posted Oct 07, 2019

Hello again to everyone – this is the third post in a multi-part series on the opioid crisis in the United States. Our first two entries (first one here, second one here) covered the current state of the opioid crisis and the evolution of the crisis, respectively. For this post, it will look into fentanyl, which has become the major contributor to opioid overdose currently.

For those of you who need a refresher (or first look) at what an opioid medication is, please see my second post. Assuming you know what opioids are, it is safe to say that prescription fentanyl is simply an opioid. It is, however, a very, very potent opioid—the teaser picture of a few grains next to a penny illustrates what would typically be a lethal dose. This guide from the Centers for Disease Control and Prevention is a great explainer. 

The summary of that guide, with other key points on fentanyl, is:

1.       Fentanyl is 50 to 100 times more potent than typical opioids, including heroin.

2.       Prescription fentanyl is administered as a patch or lozenge, and it is important for control of severe pain, including surgical pain. It is so important that it is on the UN’s list of essential medicines.

3.       Nearly all of the harm from fentanyl is caused by illicit fentanyl, not prescription fentanyl. (I led a recently published research study on prescription fentanyl misuse that agreed – prescription fentanyl is not commonly misused).

4.       Illicit fentanyl seizures have increased, at least through early 2018, suggesting increased supply.  These seizures have been most common along the East Coast and in the Appalachian states.

5.       Fentanyl is often mixed with other drugs, like heroin or a stimulant, to increase the high from drug use. Sometimes, the person using the drug is unaware of the fentanyl, which can lead to severe consequences.

6.       Regardless, most individuals who use fentanyl or fentanyl-laced drugs do not have sufficient tolerance to the effects of such a potent opioid medication. This often leads to overdose.

These six points would be concerning enough, but the key additional point is that fentanyl supply seems to have increased (#4, above) and the use of illicit fentanyl also seems to have increased.

As a result, fentanyl-related overdoses have increased dramatically since the beginning of 2015, according to the overdose numbers I referred to in the first two posts. They started out causing a little over one in six of opioid overdose deaths, and as of February 2019, they are projected to cause over two in three such deaths. Many of you may have heard that the illicit fentanyl behind nearly all of these deaths originated in China, but most of it is actually brought into the US by drug cartels from Mexico, though fentanyl originating in China contributes significantly. This summary of a RAND Corporation report highlights how fentanyl arrives in the US and ominously notes, “Evidence from abroad suggests synthetic opioids may be here to stay: the study found no instance where fentanyl lost ground to another opioid after attaining a dominant position in drug markets.”

At the same time, a key part of the initial response to the opioid crisis was to urge providers to prescribe opioids much less often and in lower and fewer doses than before. This was a key part of the updated CDC guidelines on opioid prescribing for chronic pain, released in 2016. The problem, though, was that many individuals did not receive adequate pain relief from other treatments – or worse, they were dropped from treatment entirely. Besides the cruelty of forcing someone to live with untreated or undertreated pain, there is significant evidence that some of these individuals then entered the illicit market, using heroin or other illicit opioids to relieve pain. That exposed them to a variety of potential harms, including fentanyl-laced drugs and the overdose risk that accompanies that.

Simply making opioid medication harder to obtain has not reduced opioid overdose, as evidenced by the fact that overdose numbers have only very recently (and hopefully permanently) declined, despite efforts to restrict medication for years. Illicit fentanyl was a major contributor to the lack of a decline. On the other hand, when prescription opioid access was reduced, many people suffered. Personal experiences from some of those individuals will be our next topics in the series.