Decoding the Fentanyl Crisis

Navigating Complex Medical Realities

Apr 06, 2024

First, a quick apology. I haven’t been around for a while. Professional reasons held me back from doing what I love! But here I am, and I hope to stay. I can’t promise consistency, but I can promise a full effort to do so! Happy reading :) P.S- If you’re curious as to why I have been missing for a year, feel free to send an email/message and I’ll spill the tea ;).

NOW- Back to business…

Some of you may have heard of the Fentanyl Crisis in the news. For those who haven’t, the US is grappling with an opioid overdose crisis which is killing 150 people A DAY in the United States.¹ This is 30 points higher than the number of people who are shot and killed in the US per day.²

The word Opioid comes from the opium poppy plant. In the 1950s, a class of drugs emerged that resembled opium, but wasn’t quite the same- thus opiOID.

During med school, we were made to learn about all sorts of drugs and anaesthetic agent, opioids being one of them (we had a whole chapter on them in a classic book called the KDT). We were taught to classify opioids based on how they were made:

The flow-chart above shows that opioids can be divided into three main categories, based on how they were made.

One, the natural type- morphine and codeine. Morphine is a natural derivative of the opium poppy plant. Two, the semi-natural- Heroin. Heroin is usually made from chemically processed morphine. Three, the completely unnatural- fentanyl. This drug is completely derived and synthesised in the laboratory.

Fentanyl

Now that we know what Fentanyl is, let’s talk about how it’s used. It is primarily used in the operating room and is an extremely popular anaesthetic that knocks patients out quickly, and for a short time.

In the 1950s, anaethesiologists were looking for an agent that was highly potent and had the potential to provide analgesia and sleep for a short duration. A doctor and pharmaceutical expert in Belgium, Dr. Janssen, began experimenting with a molecule called meperidine in the lab. Meperidine was great because it was easy to experiment with- but was not potent enough. He was able to tweak things to create Fentanyl.

Dr. Janssen went on to establish Janssen pharmaceuticals which was later bought by Johnson and Johnson. The Janssen division is currently the most profitable division of the company! ³

Almost 70 years later, Fentanyl remains as the most popular anaesthetic agent in the operating room. I have seen it live in action and it is extremely fascinating to watch as the patient, nervously chatting away, begins to drift off and slur within seconds of injecting the drug.

This drug is also used to manage pain. I worked as a house officer in an orthopaedic set-up, and we would, occasionally, see patients who were on fentanyl patches to manage their pain if Codeine and morphine proved to be insufficient.

So, as you can see, fentanyl is very useful, and a common medicine prescribed by doctors for the good of patients. Its abuse, though, looks very different.

Illicit Fentanyl

Fentanyl is abused in many forms. Apparently, you can mix it with heroin which makes it far more potent. This is what dealers are doing to sell fake heroin on the market and earn a profit. It can be mixed with other drugs like cocaine, or laced into regular pain tablets and it is extremely difficult to tell the difference!

To understand why fentanyl is so dangerous, its useful to look at it as a comparison to morphine. Fentanyl is 50-100 times more potent than morphine. This means that extremely small doses (sometimes as small as 0.25milligrams) is potentially fatal (Depends on the person’s body size, weight, and previous exposure).⁴

Why Now?

In 2021, the overall death toll in the US climbed to over 80,000 people. That’s 10 times more than the number of military personnel killed during the wars after 9/11.

This graph below illustrates the death toll due to fentanyl compared to other drugs⁵ :

A graph of a number of drugs

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See how the graph exponentially travels upwards after 2020? Most researchers understand that the COVID-19 pandemic was a significant driver of this change. Disruption to supply chains of other routine illicit drugs forced abusers to turn to unknown sources or new substances. Coupled with social-distancing measures, people were consuming unknown substances alone leading to higher instances of overdose related deaths.

What makes Fentanyl so terrible if abused is the extremely high potency and fast action makes it extremely addictive, and easy to die from. Most overdose incidents occur with 2 milligrams, which is basically close to 20 grains of table salt!! (I didn’t count, but you can ;) )⁶

In a podcast on spotify by the BBC, I learnt that most of the Fentanyl seems to be coming from drug traffickers in Mexico with materials sourced from China. You can listen to that podcast here-

What next?

The efforts to contain the crisis are on-going with the CDC seemingly working hard to track overdose incidents, advancing research, and building awareness.

Public awareness of the dangers of Fentanyl is extremely important. I have never believed that using substances that have the potential to kill to have a good time is a very wise idea. Most people I know who do so are either encouraged by their group of friends who are unaware of the potential harmful effects or choose to ignore it as the fun is tempting in the moment. If you yourself do this or know someone who does- there is no room for judgement! However, it is your responsibility to educate. Make sure you know as much as you can about the substance you wish to consume- especially how much can kill you. Find out what the antidote is and what the easiest way to acquire it is! Be assured that if you ever come across someone who might have overdosed and is afraid to visit the hospital, most countries have laws that do not allow prosecution for consumption.

Now that my mini lecture is over, lets learn about the signs of overdose and what you can do to help someone in this situation.

Signs of Fentanyl overdose

Fentanyl is an opiod, so it looks like heroin when it wants to kill. I like to remember things by going top to bottom:

Brain- makes it very slow. The person will start to fall asleep or lose consciousness.

Pupils- They may become very small, or pin-point. Which is contrary to cocaine!

Throat- The persons voice box may constrict producing gurgling or choking sounds.

Chest- Breathing becomes very slow. Eventually, the person will stop breathing. This is because opiods inhibit the centre in your brain which controls respiration.

Skin- may turn blueish or ashen, as the oxygen in the body depletes due to lack of breathing.

Muscles- become limp and loose.

If you come across someone like that, here is what you can do:

1. Keep them awake. Walk them around, slap them, do what you have to do! OD NOT leave them alone.

2. Alert emergency services. Take them to the hospital yourself if necessary.

3. Naloxone, the antidote to opiods, may be available over the counter as a nasal spray in your local pharmacy.

A little side note about Naloxone- it is an exceptional antidote for opiods as it works at the level of the receptors that the opiods work on and basically kicks them out. However, because fentanyl is so potent, you need a lot more naloxone for fentanyl and it doesn’t always work! Did we need any more reasons to fear fentanyl?

That’s it from me. See you next week! Happy reading :)

Decoding the Fentanyl Crisis

Navigating Complex Medical Realities

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