Fentanyl Folly

Fentanyl has been in the news quite a bit in 2016:

• In 2014, it began being reported on the U.S. East Coast that heroin was being laced with fentanyl, creating a combination that is "untenably addictive"
• The Sacramento Bee reported in April that 51 overdoses including 11 deaths had been reported thus far in the Sacramento area in 2016; 8 of the deaths were tied by toxicologists directly to fentanyl (watch the 34 second video that describes "death as collateral damage" to the drug dealers interested in market dominance)
• Later in April, the L.A. Times reported the issue had migrated to the San Francisco area, with "false advertising" that fentanyl pills made to look like Norco as a primary culprit
• The Chief Health Officer in British Columbia proclaimed a Canadian public health emergency because of more than 200 overdose deaths during the first three months of 2016; a large portion of them involved "greenish pills purporting to be OxyContin 80 mg tablets"
• In June it was confirmed that Prince died from an accidental overdose of fentanyl, unbelievable because he was an outspoken advocate of clean living (from having a "swear jar" to not consuming alcohol)

One of the common threads throughout these stories is China's involvement. The Wall Street Journal published a front-page article on June 23 entitled "China's Role in U.S. Opioid Crisis". The opening paragraph sets the stage:

Last spring, Chinese customs agents seized 70 kilograms of the narcotics fentanyl and acetyl fentanyl hidden in a cargo container for Mexico. The synthetic opium-like drugs were so potent that six of the agents became ill after handling them. One fell into a coma.

The article goes onto describe how fentanyl often is disguised as hydrocodone and Xanax on the black market - dangerous drugs by themselves but not nearly as potent or fatal as fentanyl. Since China does not regulate fentanyl or analogs used to create fentanyl, there is a significant financial incentive for the drug dealers - $810 of materials can create 25 grams of fentanyl and yield up to $800,000 in pills sold on the black market.

According to the Canadian Globe's expose on the issue (an excellent look at the black market), accessing fentanyl can be as easy as "Sign up for an account, choose a method of payment, and receive the package in three to four business days." And reinforcing the financial model ... "A kilogram ordered over the Internet – an amount equal in weight to a medium-sized cantaloupe – sells on the street in Calgary for $20-million, making it a drug dealer’s dream."

So, fentanyl is a problem. It's 25-50 times more potent than morphine. It's highly addictive. It's available fairly easily on the black market. And it is prescribed by doctors. Way too often. Approved by the FDA and on script pads supplied by the DEA, it's Federal legitimacy adds to the lack of stigma associated with use. Which is one reason why I think Prince could rationalize his use because a doctor likely prescribed it for his chronic pain - and other patients fall into that same trap (with fentanyl and other dangerous Rx drugs).

According to the FDA's own warnings (as reported on drugs.com):

Because of the risks of addiction, abuse, and misuse with opioids, even at recommended doses, and because of the greater risks of overdose and death with extended-release opioid formulations, reserve Fentanyl Transdermal system for use in patients for whom alternative treatment options (e.g., non-opioid analgesics or immediate-release opioids) are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain.

Per Official Disability Guidelines, "Due to the significant side effects, not for use in routine musculoskeletal pain." In my opinion, fentanyl should be used to help people die with dignity during end of life care. Period. It's that dangerous. And yet we see it being prescribed, used, and paid for. Month. After. Month.

If you are prescribing fentanyl - Why? If you are being prescribed fentanyl - Why? If you are paying for someone's fentanyl - Why? Too many people are overdosing and dying not to ask a simple question ... Why?