Fentanyl and the Opioid crisis
The relationship between fentanyl and the opioid crisis is unmistakable. The spectacular increase in the consumption of fentanyl in recent years and its consequences in certain countries acquires the rank of a pandemic. This is reflected in a recently published report (Provisional Drug Overdose Death Counts) by the US CDC. Some 100,000 people died in the United States in 2020 from drug overdoses (30% more than in 2019). Approximately 70% of deaths are related to synthetic opioids, primarily the use of fentanyl also called "synthetic heroin."
The opioid crisis
The opioid crisis refers to the marked increase in the use of opioids (mainly prescription) and its consequences. To understand this phenomenon, we must first know that fentanyl is a drug 50 times more powerful than heroin. As little as two milligrams of fentanyl can be a lethal dose in most people. Therefore, the risk of a fentanyl overdose is relatively high when the use is non-medicinal. In 2020, 1,580 people died in New York City from fentanyl use. More than half of all overdose deaths involve any other drug. Here in Spain, and saving the differences, a similar effect has been produced concerning the consumption of fentanyl and other synthetic opioids such as tramadol.
Two milligrams of fentanyl can be a lethal dose for most people.
Most fentanyl overdose deaths are due to the use of other drugs (mainly cocaine, heroin, benzodiazepines, and ecstasy) that have been adulterated with this potent opioid. Therefore, to better understand the opioid crisis, two aspects must be kept in mind: on the one hand, the use of fentanyl by medical prescription and, on the other, the use of fentanyl and its derivatives from the illicit market. Finally, we explain the implications that the opioid crisis is having in Europe, in Spain, and of course, in Valencia.
Fentanyl prescription and the opioid crisis
Opium-derived drugs have been used for medicinal purposes since their discovery. These are natural (opiate) or synthetic (opioid) compounds from opium or morphine. They are drugs like heroin, buprenorphine, fentanyl, or codeine. At the same time and for various reasons, the recreational or non-medicinal use of these substances has always been present. Morphine was extracted from opium in 1803, and fentanyl was synthesized in 1960. In 2017, fentanyl was the most widely used opioid globally for medicinal purposes.
The prescription of fentanyl, along with that of other opioids, has experienced a marked increase in recent years. It is a highly effective drug as an analgesic and is widely used to treat cancer pain, among other indications. The truth is that an essential part of the origin of the opioid crisis has to do with an excessive prescription of these drugs. In other words, for years, fentanyl has been prescribed at will for acute non-cancer pain, migraine, back pain, or fibromyalgia, to name a few examples.
Today we know that opioids as powerful as fentanyl should only be indicated for breakthrough cancer pain. We also know that immediate-release forms (aerosols and dispersible tablets) can become addictive more quickly than sustained-release forms such as transdermal patches.
Immediate release fentanyl and addiction
Fentanyl has a powerful analgesic and sedative action. Its main indication is pain treatment, but it is also used in anesthesia and veterinary medicine. Fentanyl presentations include a solution for injection, sublingual tablets, nasal spray, and transdermal patches. Nasal sprays and so-called "fentanyl lollipops" are immediate-release formulations that can become addictive very quickly. So much so that the Ministry of Health attached a specific security note for these presentations. In the Valencian Community, the health authorities published in 2016 a mandatory resolution for fast-release fentanyl drugs.
The high potential for addiction to fentanyl is associated with the euphoric effect that characterizes all opioids. Rapid-release fentanyl can produce a very powerful sudden feeling of well-being. Absorption through the buccal mucosa is immediate, and as the effect diminishes rapidly, a new use is likely. In addition, the tolerance generated by opioids is high, and we quickly need a higher dose to achieve the same effects. In this way, fentanyl addiction can be triggered.
Fentanyl lollipops
"Fentanyl lollipops" were designed in the United States in 1985 for use in children undergoing surgery. They looked similar to conventional "lollipops." Fentanyl applied in this way is absorbed as rapidly as injected and enters the central nervous system without being metabolized. Its effect is practically instantaneous.
Fentanyl lollipop In USA
Recently, the US has admitted overprescription of opioids and non-recommended practices. "The FDA had approved Actiq ® only for cancer patients with acute uncontrolled pain, a tiny market. However, Cephalon (a pharmaceutical company) went after a much larger one. They eventually marketed it for patients with low back pain and migraines."
Synthetic fentanyl derivatives and the opioid crisis
As health authorities establish new laws that regulate the use of drugs, new psychoactive substances such as alpha-PVP flood the illicit market. In the same way that the overprescription of these drugs can be established as the cause of the opioid crisis, we can also say that one of its consequences is the appearance of fentanyl on the black market. That is, illegally manufactured fentanyl without any health control. As many people tried to solve different pathologies in the consultation, they developed an addiction that caused them the repeated use of opioids. In a certain way, this can be conditioned by each country's health system. Fortunately, in Spain, we have a universal health care system that has defended us from this pandemic.
Opioid withdrawal test
If someone develops a dependence on opiates and finds it impossible to access them through legal channels, they will probably try to obtain them through other means. In this way, fentanyl has flooded the black market. It is easier and cheaper for mafias to synthesize and distribute fentanyl than heroin. It is more profitable. Today, in cities like New York, any drug purchased on the street is highly likely to contain fentanyl. This poses a high risk to community health and has put health authorities worldwide on alert.
And not only this, as the laws restrict, prosecute and punish the possession of this drug, new synthetic derivatives of fentanyl continue to appear. Some of them are extremely dangerous. For example, carfentanil is 10,000 times more potent than morphine. In this way, new synthetic opioids arise that are more toxic than fentanyl. Something similar occurs with benzodiazepines, cathinone, and cannabinoids.
Updated health regulations on fentanyl
We have already mentioned the decrees that regulate the prescription of rapid-release fentanyl in Spain and the Valencian Community. Recently (July 2021), a new decree has been approved. This is the need for an inspection visa to access immediate-release fentanyl. It's like an additional filter. To dispense these drugs in a pharmacy, the medical inspector must previously validate the rapid-release fentanyl prescription. Otherwise, it cannot be dispensed to the patient.
"Immediate-release fentanyl-containing medicinal products are indicated exclusively for the treatment of breakthrough cancer pain in adults who are already chronically receiving other opioid maintenance treatment. Patients receiving opioid maintenance treatment are those taking at least Oral morphine 60 mg daily, fentanyl 25 micrograms transdermal hourly, oxycodone 30 mg daily, hydromorphone 8 mg oral daily, or an equianalgesic dose of another opioid for one week or longer."
This provision is included in the " Optimization Plan for the use of opioid analgesics in chronic non-cancer pain in the National Health System. " In this report, the Valencian Community appears among the 3 autonomous communities with the highest consumption of opioid analgesics in Spain. Fentanyl is the most used in them, particularly in the Valencian Community.
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