An explosion of fentanyl deaths should motivate—not absolve—the medical community

      Opioid use and abuse garnered a whirlwind of attention from the media and medical community last year when updated government prescribing guidelines set off reactions around the country. Since then, the narrative of the opioid epidemic has taken a series of dramatic turns as the scope of the problem comes into focus.

      Among the more shocking developments in the public health saga is the emergence of synthetic opioid deaths. Drugs like fentanyl and its synthetic cousins are many times more potent than common street drugs like heroin. Unlike natural opioids like morphine, they don’t require fields to grow and harvest poppies, which makes them easy to manufacture and cheap to obtain. On the street, dealers have combined them with or laced them into other drugs, often without disclosing this to buyers.

      Swapping the more predictable street-grade heroin with illicit synthetics has led to a surge in overdose deaths. They often come in clusters when a particularly potent batch hits a community, overwhelming local medical resources and sometimes even triggering mass casualty events. A trend of mixing meth with the synthetic opioid carfentanil (a large animal tranquilizer) forced Ohio coroners to deploy special morgue trailers to hold the surge of bodies.Injection, heroin, overdose, drugs, opioids

      Data released by the Centers for Disease Control (CDC) last week illustrates the trend in chilling figures. Synthetic opioids have now surpassed every other type of opioid in terms of body count. And the ascent has been lightening-fast.

      But there has been another effect of fentanyl’s emergence that will not show up in the statistics. The shift of deaths to the synthetic opioid column also threatens to shift the focus of our attention to the downstream effects of the epidemic and away from its root cause. It may also create a convenient excuse to further deflect blame from medical and pharmaceutical stakeholders.

      Take, for instance, an editorial published in the June issue of Emergency Medicine News. In it, Dr. Mark Mosley, MD writes that the opioid epidemic has been unfairly cast as a problem with prescription drugs and the clinicians that prescribe them. He cites a 5-year downtrend (2010-2015) in deaths from natural/semi-synthetic opioids (like oxycodone and hydrocodone) and a general decrease in overdose deaths in his home state of Kansas as proof that legally-produced opioids are a diminishing threat and not responsible for a rise in overdoses.

      “Fentanyl made in China… and other illicitly made synthetic opioids are the main culprits in these ‘opioid deaths,’” he wrote. Physicians, he concludes, should not feel pressured to change their practice based on a problem that essentially has little to do with them.

      Of course, Dr. Mosley is correct that a huge proportion of overdose deaths are caused by synthetic opioids. But that is not the whole story.

      Those who inject heroin and street fentanyl are not magically conjured by rubbing a DVD box set of The Wire. They are real people whose addictions began somewhere. And according to the CDC, three-fourths of those who use heroin started with a prescription opioid (several observational studies have shown between 39% and 86%).

      Since there is no evidence of a significant demographic difference between those who overdose on heroin and fentanyl, it stands to reason that a majority of those overdosing on fentanyl also began with prescription opioids.

      Here is what that means in hard numbers.

      According to the CDC, from February 2016 to February 2017, 14,465 people overdosed on natural and semi-synthetic opioids, 15,549 people overdosed on heroin, and 21,163 died from fentanyl and other synthetics. All of these figures increased from the previous year, but synthetics recently made a massive leap.

      However, if you consider approximately 40-80% of heroin and fentanyl users likely began their addiction with prescription drugs, prescribed opioids directly and indirectly account for somewhere between 29,149 and 43,834 deaths in that single year.

      So yes, illicit fentanyl may have been the gasoline poured on the overdose fire. But those flames were already burning bright on the kindling of prescription pads. If anything, fentanyl’s lethality merely unmasked a problem that has existed all along: America’s widespread dependence on opioids.

      Rather than deflect our responsibility, this surge in synthetic deaths should heighten the desire of medical providers to participate in solutions.

 

The Contralateral:

      Despite attention and press coverage, few cohesive, effective plans exist to combat the opioid epidemic. Curbing opioid prescriptions alone will do little to reverse the burden of addiction that already exists. Even if the pendulum swings back toward stingy prescribing patterns—which is almost certainly will—we still have a responsibility to those left in its wake.

      That means a focus on rehabilitation—and not stigma.

Author: Harrison Reed

Harrison Reed is an emergency medicine and critical care physician assistant (PA-C) in Baltimore, MD. He is the Associate Editor of the Journal for the American Academy of PAs (JAAPA) and regularly contributes to the New England Journal of Medicine's In Practice blog. He is the creator and editor of The Contralateral.

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