The Center for Disease Controls and Prevention (CDC) reports that the rate of fentanyl-related overdose deaths dramatically increased in 2017. This increase is notable because 2018 saw the first significant decrease in opioid medication overdoses – a 5% drop – since 2015. Policy makers now consider the misuse of fentanyl – notably a chemical variation called carfentanil – to be the third wave of the opioid crisis.
Fentanyl: A Highly Potent Synthetic Opioid
Fentanyl and synthetic opioid medications with very similar chemical structures, known as analogs, are typically prescribed to address severe, chronic pain that’s associated with cancer, and in some cases, not associated with cancer (NCP). NCP conditions include osteoporosis, neuropathic pain (associated with medical issues like diabetes, thyroid problems, spinal surgery), and chronic back pain.
This medication is administered either by a transdermal patch, sublingual tablets, oral spray, or lozenges. Fentanyl, and its analogs, are considered highly addictive because of their potency. For example, carfentanil – a well-known fentanyl analog – is 50-100 times more potent than morphine.
Health care providers calculate the potency of opioid pain relief medications on the morphine equivalent dosing (MED) scale. Synthetic opioids – those synthesized in a laboratory as opposed to naturally occurring ones, such as morphine – are calculated in milligram morphine equivalents (MME). Given this scale, to take an example, if one were prescribed 50 mg of fentanyl, this would be equivalent to 120 mg of morphine.
Because the potential for misuse and the sharp increase in overdose-related deaths for prescription opioid medications, new CDC guidelines advise prescribers to be very cautious before increasing doses above 50 MME. Evidence shows that dosages higher than 50 MME double the risk of overdose.
One reason, in addition to its potency, that fentanyl presents a serious overdose risk is because this medication dramatically affects breathing – a basic function controlled by the central nervous system (CNS). In fact, the ability to survive an overdose typically depends on one’s ability to breathe oxygen. Narcan – a.k.a. naloxone – is an especially effective medication to reverse overdose symptoms by binding to the opioid receptors on cells in the CNS and essentially kicking fentanyl off those sites. By blocking the action of fentanyl, normal breathing returns, and fatal overdose can be avoided.
Possible Explanations for the Increases in Fentanyl Overdose
Part of the explanation for the increase in fentanyl-related overdose deaths is its potency, and how quickly small increases in dosage can lead to respiratory failure. Another important piece of this story is the increased market for illicit made fentanyl (IMF). Law enforcement officials and public health scientists have identified and begun to track the influx of IMF in street drug sales. Illegal distributors (drug dealers) often mix IMF with heroin, which means individuals purchasing street drugs may not know they’re buying a drug that’s far more powerful than what they’re accustomed to. IMF is 50 times more potent than heroin, making street heroin mixed with IMF extremely dangerous.
Sarah Wakeman, a member of the medical faculty at Harvard University, offers a useful analogy for explaining the danger of IMFs being mixed in street drugs when the purchaser is completely unaware:
“It would be like ordering a glass of wine and instead getting a lethal dose of pure ethanol.”
That puts it in perspective: street heroin, because of Fentanyl, is now more dangerous than at any time in the past.
Cause for Optimism
While the increase in fentanyl-related overdose deaths is cause for concern, the larger trend – a significant drop in opioid medication-related deaths – should be reason for optimism. Awareness campaigns, prescribing guidelines, law enforcement efforts and investments made by government agencies, such as the Department of Health and Human Services (HHS), in access to treatment are showing positive results.
These combined efforts promise to reverse the trend of fentanyl-related deaths. A greater understanding of how IMF is getting into the hands of individuals turning to illicit markets for opioids will also help. Furthermore, innovations in the treatment of opioid substance use disorders – including effective pharmacological treatments that alleviate craving and thus fentanyl drug-seeking – indicate that, while it’s not yet time to sit back and declare victory, we may have turned a corner with the opioid crisis.
Overall opioid overdose deaths are down: next, we can focus on the new wave of challenges presented by fentanyl.