Fentanyl – Understanding the Crisis: Why information is our best defence

Does it seem like every time you turn around, there’s another story about fentanyl? You’re not mistaken. Just a year ago, Health Minister Sarah Hoffman described fentanyl as Alberta’s leading public health problem. Since then, the fentanyl problem has become a crisis. In the first nine months of 2016, 193 Albertans, including one St. Albert resident, died from fentanyl-related overdoses.

The emergence of fentanyl has been so sudden and so staggering that the media coverage is often sensational, even hysterical. And fentanyl is frightening. A fatal dose is almost unthinkably small: as little as 2 mg, roughly the size of two grains of sand. Fentanyl and its analogues, including carfentanil (which is a hundred times more potent than fentanyl), are being manufactured in clandestine labs and mixed into various street drugs. Even dealers may not know what’s in their product, nor how potent it may be.

This information is not meant to frighten you. Instead, with some basic facts and resources, you can feel informed, empowered and less afraid.

What Are Opioids?

Fentanyl is an opioid. At their most basic, opioids are medications we take to relieve pain. They imitate the body’s own endorphins by binding to opioid receptors found in the brain, spinal cord, gastrointestinal tract and other organs. There they either inhibit the transmission of pain signals or produce an excess of dopamine, a chemical we associate with rewards and pleasurable feelings. Some opioids you may have heard of include codeine, morphine, heroin and oxycodone (OxyContin).

Beyond reducing the perception of pain, opioids produce side effects such as drowsiness, mental confusion, nausea and constipation. Depending on the amount of drug taken, opioids may also significantly slow down respiration. Some people experience a euphoric response to opioid medications because these drugs affect the part of the brain involved in experiencing pleasure. Others feel numbing or a sense of relaxation, a lessening of anxieties.

Over time, people who take opioids of any kind need more of the drug to achieve the same effects. This process is called developing tolerance. Tolerance diminishes after a person stops taking opioids, so over time a once-tolerable dose could be toxic. Because of their pain-relieving effects, however, opioids may quickly become addicting, creating strong dependencies that require complex, long-term treatment.

What Is Fentanyl?

Fentanyl is a synthetic opioid, meaning it is chemically similar to morphine and heroin, but does not occur naturally. Like other opioids, fentanyl acts rapidly in the body to relieve pain and reduce feelings of anxiety. It is up to 100 times more potent than morphine, and its euphoric effects may be profoundly addictive. Its strong, physically depressive qualities, however, can be fatal.

Pharmaceutical fentanyl has been available since the early 1960s, when its primary use was as an anesthetic. Today, pharmaceutical fentanyl is more often used with patients managing acute or chronic pain—cancer patients in palliative care, for instance. Most of these patients take fentanyl through patches applied directly to the skin. Although pharmaceutical fentanyl may be abused, illicit fentanyl is the form most commonly found in western Canada.

Illicit fentanyl is produced in illegal home labs (often called clandestine labs) from chemicals that are readily available overseas. According to Sgt. Layne Wakefield, until recently a member of St. Albert’s RCMP Drug Unit, much of the fentanyl in Canada comes from China and Russia, where it is not illegal to manufacture. It is shipped to Canada as a nearly pure powder, then mixed with other substances and formed into pills (or, less commonly, sold as a diluted powder). These other substances, called adulterants, may include caffeine, heroin and even xylazine, a powerful veterinary tranquilizer. The ease of manufacturing fentanyl and fentanyl analogues (chemicals that are similar to fentanyl in their makeup and effects), alongside the small dose required to produce effects—one kilogram of fentanyl powder can yield 500,000 or more pills, depending on how it is cut—means the drug has become widely available across Canada.

The biggest problem with illicit fentanyl is quality control. The type and quantity of fentanyl in a pill or mixed into another substance may vary considerably. Batches often have “hot spots,” meaning some pills contain more fentanyl than other pills. A batch of chocolate chip cookies provides a visual analogy. Although the cook may put one cup of chocolate chips into the batter, any one cookie could contain more or fewer chips: no two cookies are alike.

Depending on how the fentanyl is cut, it may be contaminated with substances that resist treatment in the case of an overdose, and the strength of fentanyl analogues is unpredictable. Some are many times more powerful than fentanyl itself, and new analogues emerge frequently.

When fentanyl or an analogue is mixed with another drug, the fentanyl is virtually undetectable. And it is when fentanyl is mixed with other drugs, or is presented as another drug—most commonly oxycodone—that the risk of overdose becomes acute. The user may unwittingly take too much and die of fentanyl poisoning.

Another major problem with fentanyl is users who are “opioid naïve”—that is, who have not taken opioids before or do not know they are taking opioids. For a user with no tolerance for opioids, a two-milligram dose may be fatal.Here’s where the fentanyl problem becomes a crisis. In western Canada, fentanyl is known by various street names, including street oxy or fake oxy. Other names include greenies, green monsters, beans or green beans, apples or green apples, eighties or shady eighties. Now that oxycodone, a much less potent pain-reliever, is carefully regulated, some recreational drug users, and many novice users, have started buying street oxy as a replacement. Buyers may think they’re actually buying oxycodone; the pills are often pressed to look like OxyContin (light green with CDN stamped on one side and 80 stamped on the other). But if the pill is actually fentanyl and that pill is “hot” or the consumer takes more than one, the effects might be fatal unless an antidote is administered immediately.

Naloxone

Naloxone, also known as Narcan, is the only antidote for fentanyl poisoning. Naloxone is an opioid-antagonist. That means it counteracts the effects of opioids such as fentanyl, heroin and oxycodone. Naloxone is used in emergencies to keep a person who has overdosed on opioids alive until full medical attention is available; it is not a replacement for emergency care.

Naloxone reduces harm by interrupting or reversing an opioid overdose and preventing brain damage or death. Most importantly, it restores respiration, which means the user continues to breathe and his or her heart continues to beat. Naloxone has no other effects and does not produce a high. It is effective only within a very brief window before an overdose becomes fatal.

Although normally available only by prescription, naloxone is being distributed freely across Alberta (as well as in British Columbia) in kits for drug users and their friends and families, as well as for emergency responders. Naloxone kits are crucial to Alberta’s overall strategy of harm reduction. The availability of naloxone is not tacit permission to use drugs. Rather, it is an acknowledgement that people are dying from using fentanyl.

How We Got Here

Although pharmaceutical fentanyl has been used clinically for decades, the appearance of illicit fentanyl in Canada is fairly recent. In mid 2013, members of the Canadian Community Epidemiology Network on Drug Use, a national network of community partners who share information about emerging local trends in substance use, began to report illicit fentanyl showing up in pill and powder form. Since then, its circulation has skyrocketed, primarily in British Columbia and Alberta, although fentanyl is a Canada-wide problem.

In 2014, Alberta reported 120 fentanyl-related deaths; in 2015, that number rose to 272. Experts predict the toll for 2016 may reach 300 deaths. And although most deaths are concentrated in urban centres such as Edmonton and Calgary, month by month the picture is changing. Fentanyl is showing up frequently in suburban communities and small towns. No community is immune.

In a resource produced for Alberta Health Services, Dr. Hakique Virani, who works out of the Metro City Medical Clinic in Edmonton, says many users of fentanyl are young—often high-school age—and come from upper-middle-class families. Virani attributes the arrival of fentanyl to a gap in the drug market. When oxycodone disappeared from the Edmonton area, the initial response was a spike in the heroin trade, then the appearance of fentanyl, followed by fentanyl analogues. Virani’s observations don’t blame or point fingers, but do speak to a community-wide problem of silence and misunderstanding surrounding drug use and addictions.

A Harm-Reduction Strategy

To combat the fentanyl crisis, Alberta Health Services has adopted a harm-reduction strategy. That means the first priority is to keep fentanyl users alive. Then specialists can work with an individual to find appropriate follow-up actions. A major component of harm reduction is information. One of the best resources for current information about fentanyl and fentanyl analogues is the Alberta Health Services website (www.albertahealthservices.ca). It provides straightforward information for people with addictions as well as health professionals, teachers and families, including downloadable instructions on how to recognize and handle an opioid overdose and how to use a naloxone kit.

You may also have noticed public-service communications about fentanyl—on Edmonton city buses, for instance. The key messages may be uncomfortable because they directly address the potentially fatal consequences of fentanyl use: Don’t use alone. Test a small amount of a drug before using. Don’t mix opioids with other depressants (“downers”). Carry a naloxone kit. Learn rescue breathing. Educate yourself and others. But this is not a topic to shrink back from, no matter how uncomfortable we may feel, because a person’s first experience with fentanyl could also be the last.

Public health officials are uniformly emphatic: making people aware of the risks of fentanyl is not an endorsement or an encouragement to take drugs. Peter Churchill, an addictions advisor at Alberta Health Services, says, “Information doesn’t lead to exploration. Information doesn’t lead to experimentation.” This message is particularly important for teachers and parents of teens, who are often opioid naïve. One of the most important things adults can offer the young people they care about is communication. Open, honest conversation—about what kids are curious about, what they believe they know, what they don’t know—is an important element of harm reduction.

Safety in Conversation

The fentanyl crisis is not something that’s happening somewhere else to someone else. It’s a problem in affluent, suburban communities, including St. Albert, and it’s affecting people you know, work with, coach or teach. Part of the conversation around safety involves acknowledging that fentanyl is available in St. Albert.

Ignoring this issue will cost the lives of hundreds, perhaps thousands, of young people, some of whom have no idea how risky so-called recreational drugs can be. This is especially important right now because fentanyl is being cut into ecstasy (“X”) and MDMA (“Molly”). At a recent public meeting held in St. Albert in conjunction with National Addictions Awareness Week, the presenters had one resounding message: talk. No community can afford to be quiet about drug use, mental health issues and addictions awareness, not when the stakes are so high.

This is an issue on which there is no moral high ground. We need to be honest about the problem and face it together. Communication and awareness are our best tools.  t8n

What To Do for an Opioid Overdose

1. Call 911.
2. Stay with the person, and keep the person conscious and as engaged as possible.
3. Use naloxone if it’s available and you know how to give the injection. More than one injection may be necessary, depending on the severity of the overdose. Naloxone will have no effect if the person has not taken opioids.
4. Do not give the person any other drugs.

Signs of An Opioid Overdose

1. Extreme drowsiness—the person may be unable to stay awake or may not respond to communication
2. Breathing is very slow or stopped, or breath may sound like gurgling or snoring
3. Pulse (heart rate) is slow or absent
4. Pupils are very small, like a pinpoint, or the eyes may be rolled back
5. Skin is very pale and feels cold
6. Nails and lips may look blue or purple
7. Body is limp and the person is unresponsive