Fentanyl--Details We All Should Know
Synthetics vs. Plant-Based
Last week my partner and I were made aware of the death of a third young person in our mutual acquaintance, another young, vibrant life snuffed out quietly in an apparent accident—no suicide note, no evidence of actual suicidal intent—and—importantly—the result of simply swallowing a pill.
That last detail is, at least for me, the major eyeopener—the thing that brings the much talked about fentanyl crisis home to roost. Most of us are accustomed to imagining that drug induced deaths are mostly the result of intravenous drug use—a death one could therefore avoid simply by avoiding recreational drug use administered with a needle. Given the squeamishness most of us have around needles, especially poking ourselves, it seemed a good dividing line. No longer.
It is tempting slip by endless media clips on the topic of drugs, fentanyl in particular, but when the bodies start to pile up around you and you realize this epidemic will eventually touch someone you know, someone dear to you, someone you didn’t even know was using, it takes on new significance. I recently came upon two articles in the Washington Post that I found enlightening:
One, entitled “Cause of death: Washington faltered as fentanyl gripped America”, is a long narrative woven around Ed Byrne, a man who has been on the scene in the aftermath of nearly 500 fentanyl deaths since 2018. It is a gripping story. I highly recommend it.
The other, entitled “Why is fentanyl so dangerous?” I recommend for its plain English explanations. Hats off to these investigative reporters. If you don’t have a subscription to the Washington Post, these two articles are each worth expending some of your monthly free reading allotment.
Even as a retired physician reading these two articles (and some of the links contained in them)—and talking with a few people who have recovered from narcotics addiction—re-oriented my thinking. What follows, in no special order, are just a few of my takeaways. I urge to to read, study, and follow the links in these articles I just mentioned. Your takeaways may be different than mine.
Fentanyl and all opiates, when they kill by overdose, do so by suppressing or stopping breathing. Within five minutes of cessation of breathing the brain begins to die and eventually the heart stops. It follows that if, in time, breathing is supported (mouth to mouth, Ambu Bag, artificial respiration) and/or if the drug effect is pharmacologically reversed (naloxone, brand name Narcan) the overdosed patient can totally recover. Apart from the very nasty consequences of physical and psychological addiction, opiates generally don’t otherwise ruin the body the way cocaine and methamphetamine often do.
Fentanyl is synthetic opioid. The opiate class of drugs (see below) historically derived from plants, but thanks to “the wonders of modern chemistry” fentanyl decouples production from the need to engage in agriculture. Instead of the legal exposure of growing acres of plants, fentanyl is produced in what might be a make-shift laboratory using chemicals that have other, mundane uses. (Note that there aren’t any farmers whose livelihood is dependent on producing growing the raw material—a fact that reduces risk and probably further increases the profit margin.)
Fentanyl (and its hundreds of variants) may be lethal in unbelievably small doses, around 2 milligrams, 2 thousandths of a gram. For reference, that’s about the weight of a small mosquito or about 20 grains of fine table salt. (In contrast, a lethal dose of heroin [a plant-based but chemically manipulated opiate] is 50 times that.)
a typical intravenous dose of fentanyl for relief of discomfort in the context of surgery is a mere 50 micrograms, that is, effects are felt from the drug in weights (and volumes) that even tinier (1/40 of that small mosquito).
Several things follow from this level of potency:
Even tiny, very hard to detect amounts of fentanyl produced and smuggled across the border can be massively attractive and profitable for the folks engaged in this trade. The high value of even small amounts of pure fentanyl smuggled into the country—once it is peddled in tiny doses to those who those who want it (the “demand” side of the equation), is a powerful incentive. The opportunity for profit is just too tantalizing—especially when those orchestrating manufacture and distribution are relatively insulated from arrest and prosecution.
The difference between a pleasant dose and a lethal dose of fentanyl is dependent on demanding, highly accurate measurement of tiny quantities of the drug prior to the sale to the consumer. People die from unintentional overdose of fentanyl probably because of failure in measurement and quality control somewhere along the illicit drug pipeline. This is likely not intentional. Killing one’s customers is maladaptive and unprofitable.
Chemical variants of the basic molecule of fentanyl vary in potency, making dose adjustment even more dicey.
The supply side of this scourge of death due to fentanyl, a problem that is in the public mind intertwined with the “Border Wall” and immigration, won’t be usefully tackled by Congress until either 1. Republicans become convinced that shouting about walls and talking about Replacement Theory won’t buy them votes—or 2. There is a large Democratic majority in both houses of Congress.
Money spent on interdiction of fentanyl as it crosses our borders (in the form of technology and hiring more border agents—and even some improvement in border walls) will never totally solve the problem—but it can help.
What can we do then?
Elect Democrats who understand the issue to Congress
Educate, educate, and do so realistically. Make clear the danger of addiction. Understand the physiology that can lead to death. Understand that the risks are not limited to intravenous use. A counterfeit pill purchased on the street inevitably carries a risk of death. We need to understand and admit past glaring lies, for example, the “this is your brain on drugs” ad suggesting that marijuana was inherently addictive and destructive—an ad that nearly everyone since my generation knew was a sad, blatant lie. There is an analogy here to the honest, medically accurate sex education that equips young people to understand the problems and pitfalls, rather than relying on ignorance and scare tactics.
Keep to the high ground,
A few more notes:
The name for this whole class of drugs is “opiates”, a word that comes from a There are two plants with which humans have had complicated relationships for thousands of years and from which most of the drugs we broadly call “narcotics” have been derived. The opium poppy (Papaver somniferum), a native of the Old World, is the source of the raw material for opium, morphine, codeine, and the inspiration for semisynthetic (e.g. heroin) and full synthetic (e.g. fentanyl) opiates. Cocaine comes from an entirely different plant, Erythroxylum coca, native to South America. Cocaine is not an opiate. Indeed, in many ways it is the opposite of an opiate. Cocaine is fundamentally a stimulant. When cocaine is overdosed it typically kills by stopping the heart. Opiates, in contrast, kill by depressing breathing. Both classes are lumped together as “narcotics” (derived from a Greek verb that means “to make numb”)
Methamphetamine is (broadly speaking) a potent stimulant with some similarities to cocaine—except that, like fentanyl, methamphetamine production is entirely synthetic. No plants, no agriculture needed. “Meth” is often and rather inaccurately and confusingly lumped under the term “narcotic” along with cocaine and most of the opiates, especially the illegal ones.
All of these drugs classified and regulated under the Schedules established by the Comprehensive Drug Abuse Prevention and Control Act of 1970 (aka the Controlled Substances Act [CSA]) and signed into law by President Richard Nixon at the beginning of the “War on Drugs”. The history of attempts at legal control in the United States is fascinating—and far beyond the scope of this blog.