On Friday, June 2, 2016, Prince died of a self-administered opioid overdose. The culprit was none other than fentanyl, a drug rising in popularity with the country’s addict population. While discovery of the cause of Prince’s death answered one question, it raised another: where did he get fentanyl?
Prince had a prior prescription for Percocet to treat hip pain sustained from performing on stage over the years. According to his friends and family, the use, or misuse, of the Percocet prescription led to a dependency and then an addiction. So was this fentanyl obtained from a “street pharmacist?” If so, it was most likely synthesized in an underground lab by someone unqualified to make it. Since manufacturing of the drug requires relatively little technical knowledge, illegal synthesization labs have sprung up across the nation.
Fentanyl is a synthetic opioid that is 80 times more potent than morphine and most often used for cancer or hospice patients. With such a high potency, a small dose of fentanyl produces a similar effect to a normal dose of other opioids. The high potency of fentanyl also means smaller amounts are needed for trafficking, making border smuggling easier. Just one gram of fentanyl can produce approximately 7,000 doses for street sale. One kilo of fentanyl will generate $1.2 million in profit, whereas the same volume of heroin would only bring in $80,000.
Fentanyl is available in a wide variety of dosage forms. It most commonly comes in a transdermal patch but is also available as an injectable, a dissolving film or tablet, nasal/sublingual sprays, or lozenges/lollipops. These are the legal, regulated dosage forms, but there are a multitude of other dosage forms that can be found on the internet’s black market, including gel-tabs and Pez candies. Powerful opioids disguised as candy are particularly dangerous for children.
Fentanyl is often passed off as a different controlled substance, such as Xanax, or combined with another illegal drug like heroin. This is especially dangerous with fentanyl, where the risk of entering into opioid-related respiratory depression is relatively high. During respiratory depression the brain is slowed by the opioid so much that it forgets to tell the body to breathe, leading to death without medical intervention. The risk is higher with fentanyl pills synthesized in illegal labs, which are not regulated and may contain uneven amounts of fentanyl in each tablet. This makes safe dosage difficult to determine and increases the likelihood of an opioid overdose.
Just last week, one West Virginia town recorded 27 overdoses in the span of four hours due to heroin laced with fentanyl. There have been more deaths in Delaware due to opioid overdose in the first six months of 2016 than in the entire last year—a statistic that has been mirrored in most other states. According to a CDC report from January 2016, both the rate of heroin overdoses and those due to synthetic opioids like fentanyl have increased between 2013 and 2014. The rise in heroin overdoses was 25%, but the increase in fentanyl-related overdoses was almost 80%. This statistic shows that even one dose of fentanyl is much more likely to be fatal, especially to an unknowing user.
There is no simple solution to the growing opioid crisis. Tightening up prescribing laws has thus far done little to solve the problem. Barry Ulmer, Executive Director of the Chronic Pain Association of Canada, states, “The guidelines will make it much harder for pain sufferers, but will do absolutely nothing to discourage abuse and addiction.” The threat of overdose deaths have failed to act as a deterrent, and more stringent laws have led to an increase in illegal sales. When doctors face severe restrictions while lawfully prescribing pain medications, patients may seek it elsewhere.
Instead of causing practitioners to fear prescribing pain medication due to increased scrutiny, axialHealthcare identifies those healthcare professionals who have aberrant prescribing patterns and offers intervention and education. Flagging poor opioid prescribing patterns is essential to improving the quality of life for patients in pain and reducing the negative outcomes that result from opioid abuse. Education and prevention is key to reducing the nationwide rise in opioid overdoses.
Vinny Cavaliere, Doctor of Pharmacy & Master of Management Intern