Dr. Melissa Anderson and Dr. Cheryl McClain host a discussion about the fentanyl crisis: treatment, recovery, and solutions. Illicit fentanyl has become the leading cause in the increase of overdose deaths in the US. This deadly drug now contributes to more young deaths than heroin, cocaine, meth, benzos, and Rx medications combined. How can we prevent this from happening? What are the options for recovery? Are there any solutions for fighting this epidemic?
What is Addiction?
Contrary to the stigma and incorrect belief that addiction is a choice, addiction is a treatable, chronic disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. Addiction can happen to anyone. A person’s choice may lead to the first use but contributes minimally to addiction development. Trauma, genetics, environmental factors, presence of other psychiatric illnesses, early age of first substance use, drug and drug metabolism, and cultural influence are all risk factors that can increase the likelihood of someone developing an addiction.
Addiction “hijacks” the brain’s reward system by altering pleasure signaling, otherwise known as dopamine. Essentially, dopamine is released in our brains when something we do makes us happy, like partaking in your favorite hobby. When someone takes an opioid, there is a large release of dopamine, which usually is felt in the feeling of euphoria or pain relief.
Individuals then become dependent on the opioids, but repeated use leads to a decrease in dopamine signaling. Decreased dopamine then leads to difficulty with attention, short-term memory, decision-making, and feelings of loneliness and low self-esteem. This decrease in dopamine draws individuals into taking more and more doses of opioids. Higher doses will be needed for a person to feel “normal.” This feeling leads to addiction.
So how successful is prevention and treatment for addiction? Dr. McClain says,
“Prevention and treatment approaches for addiction are generally successful, and we don’t think about that sometimes. We don’t think about [someone with an addiction] being able to recover. Sometimes we kind of stereotype them, so let’s open that up and think about that. It’s just like any other chronic disease. You think about folks with diabetes and how constantly their sugars go up, they’re better, and then it goes back down. Well, [addiction/substance use disorder] is the same way.”
What is Fentanyl?
Fentanyl is a synthetic, or man-made, opioid used to treat severe pain. It is an opioid with extremely high potency, meaning that it is incredibly strong in its ability to bind to opioid receptors and produce effects. It is 50 times more potent than heroin and 100 times more potent than morphine.
There are two different broad categories of fentanyl: illicit fentanyl and pharmaceutical fentanyl. Dr. Anderson explains how it is vital for people to understand the difference between the two:
“With fentanyl in the news and different media sources, everyone just kind of throws out the term fentanyl, but I don’t hear a lot of people delineating whether we’re talking about illicit fentanyl or legal pharmaceutical fentanyl or illicit street fentanyl, and obviously there are some major differences there. When you’re talking pharmaceutical grade, you’re talking [about a drug that is] highly regulated and coming from legitimate legal labs. It has been tested in terms of concentration and purity, versus something that you’re going to be getting from a street lab or a street purchase. Then you’re never sure as to what analog you have or what concentration you have, so they are wildly different.”
More than 107,000 Americans died from a drug overdose in 2021. Synthetic opioids, primarily illicit fentanyl, were in involved in 66.5% of those deaths. Therefore, illicit Fentanyl is currently the leading cause in the increase of overdoses in the US, making it the leading cause of death in Americans ages 18-45. Unfortunately, it is also the fastest growing cause of death in young Americans, ranging from ages 14-23 years old. In fact, it contributes to more deaths in the US than heroin, methamphetamine, cocaine, benzos, and Rx medications combined.
Fentanyl: Who, What, Where, and How?
Most illicit fentanyl is manufactured in China and enters through the US and Mexican border. There has been a rapid increase in the amount of fentanyl that has been smuggled into the US because it is such a small, highly potent drug, that smugglers can bring over a large amount. They can “cut and batch” the fentanyl prior to distributing it, making it difficult to know the starting analogue of the fentanyl. This makes drugs laced with fentanyl extremely dangerous.
Dr. Anderson provides fascinating insight into how these batches are created in labs through Mexico and Latin America:
“A common thing [that DEA agents] will see is the Nutribullet. In the street lab or in the street world, they’re taking their base fentanyl and throwing it in the Nutribullet with the cutting agent, and then making their big batch for distribution. Unfortunately, we don’t know what fentanyl they’re starting with; fentanyl has a number of different analogs, or what I would call siblings, and all of those have different potency, different ability to cause effect, and different risk of causing death…And then we’re adding different cutting agents, and throwing that all into the Nutribullet, so we have no idea what that smoothie is going to look like. It could be when you batch it out that these 10 pressed tablets have all of the fentanyl and the rest have all the cutting agent, or it could be dispersed. This creates a high and higher risk of those that we call the deadly batches.”
The Real Risk of “Fake” Medication
Unfortunately, today there are several deliberately and fraudulently manufactured medications that can be mistaken as legitimate pharmaceuticals. These “fake” medications may appear to be nearly identical to their legitimate counterpart, while also often containing methamphetamine or fentanyl. In fact, 4 in 10 of over 20 million counterfeit pills that were seized by the DEA this year contained fentanyl. These counterfeit pills are becoming prominent on college campuses. Dr. McClain goes on to explain how this is a real, serious danger to college students,
“So you know, with college kids for example, we are seeing this more and more. In some of these college towns, they think they’re getting Adderall to stay up at night and study, and in fact it’s pressed fentanyl, and there has been some deaths from that.”
She continues to explain that when buying drugs from any place other than a pharmacy, you just never know what you might be getting into. Xanax, Percocet, Adderall, Oxycodone, and Marijuana are all drugs that are commonly laced with fentanyl or duplicated to look like the original pill when they really are full of fentanyl. Dr. Anderson adds on by saying,
“I know a lot of graduate students who have purchased street Adderall because they want to do better on their boards. They have no opioid tolerance, and no one has ever told them ‘Hey, you could be buying fentanyl…’ There is no group that is immune to this risk if you purchase outside of a pharmacy. That’s why I think it is so important to educate and to also talk about fentanyl testing strips. If you buy medication outside of s pharmacy, it is really easy to stop and utilize a fentanyl testing strip and know for certain that that is not what you are going to encounter when you take that medication.”
Myths and Facts: Exposure to Fentanyl and Naloxone (Narcan)
Many people believe that touching even the smallest amount of fentanyl will cause a person to overdose, fall into a coma, or die. This is 100% not true. Incidental skin exposure to fentanyl is extremely unlikely to immediately harm a person. However, inhaling, or transferring fentanyl from skin to mucous membranes, such as eyes, mouth, or nose, can cause incidental exposure and are the most common causes of accidental exposure. Fentanyl and other synthetic opioids may appear as a powder, tablet, capsule, or in solution.
If someone is experiencing a suspected overdose, utilize all PPE, have naloxone on hand and use safety precautions. Make sure to wash your hands and all exposed surfaces with soap and water as soon as possible to remove any trace residue. Do not ever user alcohol-based hand sanitizers, wipes, or products because they can increase absorption of transferred drug residue.
Some people falsely believe that naloxone cannot reverse a fentanyl overdose because of fentanyl’s strength. This is not true. Naloxone, or NARCAN, safely and effectively counteracts the effects of an opioid overdose, including fentanyl. Naloxone’s treatment is time limited, so if you suspect someone is overdosing, call 911 immediately.
How To Recognize an Opioid Overdose
One of the most described characteristics of a fentanyl overdose is the rapid speed of onset, with 75% of 60 respondents, who have their own firsthand accounts of overdose, describing symptoms of an overdose occurring within seconds to minutes. These symptoms can include pale face or clammy to touch, limp body, blue or purple fingernails and/or lips, vomiting or gurgling sounds, inability to wake up, inability to speak, slow breathing or no breathing, and a slow or stopped heartbeat.
Nearly 40% of overdose deaths occur when a bystander is present. There are several ways that overdose can be prevented from happening. Naloxone is a huge component in preventing overdose. Increasing community availability to naloxone would greatly impact a decrease in overdoses. It is also important that we educate ourselves and others by informing each other of local resources. For persistent users, respectfully advise them about information they should know like being aware that substances could possibly be laced with fentanyl, being alert to different responses or tastes in a substance, starting with a small amount, never use alone, not combining with other substances, and knowing where to find naloxone.
What Happens After an Overdose in the Community? Here are Some Helpful Intervention Steps
Dr. Anderson says, “Anytime someone experiences an overdose, that is a moment of crisis. However, moments of crisis are often what prompts the opportunity for change. That is the positive light of an overdose; if an overdose is reversed and that patient survives, they have the opportunity to recover.”
Overdose can be extremely serious and life-threatening, but it can also provide a new chance for people to get better.
When you are in the presence of someone overdosing, there are some factors you should be prepared to experience. The individual who is going through the overdose may have anger, agitation, or severe sickness after an overdose is reversed because Naloxone can cause rapid onset of opioid withdrawal. After administering naloxone, stay with the person for at least 20 to 30 minutes in order to assess if a repeated dose is needed. In the forum, Dr. McClain explains how sometimes an individual who has been administered Naloxone during an overdose will feel defensive towards the people helping them.
“Folks don’t want to go to the emergency room; they don’t want to get help. They want to go use again, but the ‘why’ of why they want to go use again is because they feel miserable [in that moment].”
In other words, patients may become aggravated with first responders and try to escape because they are feeling the urge to relieve the withdrawal symptoms of Narcan. However, continued support afterwards is important in a person’s recovery journey.
What Does Recovery From Fentanyl Addiction Look Like?
Anyone can fully recover from fentanyl addiction and go on to live a healthy, happy life. Everyone’s road to recovery looks different; what seems like a small accomplishment to some could be an end goal for others, and vice versa. Some of these achievements can include mending relationships, picking up old hobbies and healthy habits, re-gaining custody of children, becoming employed, expunging criminal records, serving probation or parole and being released, exercising, paying off bills, opening a savings or checking account, and being present with family.
Does Harm Reduction Work?
Harm reduction involves the provision of non-judgmental and non-coercive services designed to educate, empower, reduce risk, and improve the lives of people who use drugs. Common services that are offered as harm reduction include abscess and wound care, SUD treatment referral, HIV and HCV testing/PEP/PrEP, naloxone distribution, and syringe exchange. Abstinence should not ever be a requirement for participation. As Dr. Anderson says,
“I don’t know any other health condition that we require perfection…Usually early on someone is the most vulnerable. They need the most support, they need the most grace, they need the most compassion.”
Although abstinence is not required, harm reduction does not encourage drug use either. Harm reduction is incredibly helpful because it reduces non-fatal overdose, overdose death, transmission of viral illness, and increases entry into treatment.
