Understanding The Synthetic Opioid Overdose Epidemic
In the midst of a global pandemic the United States is also dealing with an epidemic. The devastating synthetic opioid (primarily fentanyl) use and overdose epidemic is taking lives at astounding rates.
For starters, let’s do a quick review of the 4 categories of Opioids commonly seen in Opioid overdose:
- Natural Opiates (including Morphine and Codeine) and semi-synthetic opioids (drugs like Oxycodone, Hydrocodone, Hydromorphone, and Oxymorphone). Commonly prescribed as an analgesic (pain reliever).
- methadone, a synthetic opioid. Typically used for medication assisted treatment of opioid use disorder and also pain management.
- Synthetic opioids other than methadone (drugs like tramadol and fentanyl). Commonly prescribed as an analgesic (pain reliever). Fentanyl is a synthetic and short-acting opioid analgesic that is 50-100 times more potent than morphine.
- heroin, an illicit (illegally made Schedule I) Opioid synthesized from Morphine that can be a white or brown powder, or a black sticky substance. Schedule I substances under the Controlled Substances Act have a high potential for abuse and no currently accepted medical use for treatment in the United States.
For most of my 30-year career in the field of substance use treatment, I have seen the impact of this epidemic morph, grow, and just like the disease of addiction itself, it has become insidious and progressively worse.
The Opioid epidemic predates the pandemic with the first wave beginning in the 1990’s with increased prescribing of Opioids. Most overdose deaths during this time involved prescription opioids (natural and semi-synthetic opioids and methadone).
In 2010, the second wave began with rapid increases in overdose deaths involving heroin.
The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids, particularly fentanyl manufactured illicitly in clandestine ways. Fentanyl was initially developed in 1959 and introduced to the United States in the early 1960’s as an effective anesthetic to be used during medical procedures.
As a foreshadowing of sorts, my first introduction to the potency of fentanyl was even earlier than 2013 when I worked for health practitioners’ monitoring program from 2003-2007. I had anesthesiologists on my caseload whose drug of choice was fentanyl. I recall one instance where the anesthesiologist, during surgery, had one IV line going into a patient and another line going into themselves under the table; they overdosed during surgery.
It was during this time frame when we would say that the first sign that someone had relapsed on fentanyl was death. Meaning, most people did not have the same progressive use and tolerance leading to overdose and subsequent revival stories we would typically see with other Opioids/Opiates. Instead, their first return to fentanyl use was immediate overdose and death.
Deaths From The Synthetic Opioid Epidemic
The market for illicitly manufactured fentanyl continues to grow and change. Fentanyl can be found mixed in heroin, pain killers, and cocaine. Synthetic opioids, illicitly made fentanyl in particular, are the primary driver of the increases in overdose deaths.
According to the Center for Disease Control’s (CDC) National Center for Health Statistics, there was a decline in heroin overdose deaths 4.1% from 2017 to 2018; however, the fentanyl related overdose deaths continued to increase as heroin users were introduced to the more potent fentanyl. Sometimes they unknowingly had fentanyl mixed in their heroin as drug dealers sought more profit. Other times Heroin users abandoned Heroin for what they thought and hoped was Fentanyl which led to their demise.
The number of overdose deaths increased 18.2% from the 12-months ending in June 2019 to the 12-months ending in May 2020.
Overdose death estimates indicate that the largest monthly increases in drug overdose deaths occurred in the 12-month ending in April 2020 (77,842 deaths) to the 12-month ending in May 2020 (81,230 deaths). These one-month increases of 2,146 deaths and 3,388 deaths, respectively for the 12-month periods, are the largest documented monthly increases since 12-month estimates began to be calculated in January 2015.
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Where Is The Synthetic Opioid Use And Overdose Epidemic Now?
As stated above, the increases in drug overdose deaths appear to have accelerated during the COVID-19 pandemic. We are learning that many variables during the pandemic are the cause of this increase (eg social isolation, decrease in healthcare insurance for substance use treatment, waiting list for substance use treatment, increase in untreated mental health disorders, changes in access to medication and subsequent drug supply, financial strain, stress, pre-existing medical conditions exacerbated, poor coping skills, etc.).
Data from the CDC National Center for Health Statistics indicate that there were an estimated 100,306 drug overdose deaths in the United States during the 12-month period ending in April 2021, an increase of 28.5% from the deaths during the same period the year before.
Overdose deaths from psychostimulants such as Methamphetamine also increased in the 12-month period ending in April 2021.
Official CDC Health Advisory Recommendations
The CDC has generated many health alerts and health advisories related to the pandemic and the epidemic as they both are significant public health concerns. Below is an abbreviated sample of the Emergency CDC Health Advisory #CDCHAN-00438 entitled, “Increase in Fatal Drug Overdoses Across the United States Driven by Synthetic Opioids Before and During the COVID-19 Pandemic.”
- Expand the provision and use of Naloxone, a medication that can immediately reverse an overdose to an opiate, and overdose prevention education by:
- Increasing awareness, access, and proper administration of the general public through the use of public health departments and community-based organizations.
- Increasing awareness about potency of drugs, consequences of mixing drugs and using drugs alone.
- Healthcare providers:
- Talk to patients about the changing illicit risks for overdose and exposure to highly potent opioids such as illicitly manufactured fentanyl.
- Prescribe Naloxone to individuals at risk for Opioid overdose.
- Co-prescribe Naloxone to patients with high Morphine milligram equivalents and those receiving Opioids and Benzodiazepines.
- Expand locations in which overdose prevention education and take-home Naloxone are provided.
- Counsel patients that multiple doses of Naloxone may be needed for a single overdose event because of the potency of illicitly manufactured Fentanyl and Fentanyl analogs.
- Harm reduction organizations:
- Increase the provision of overdose prevention education and take-home Naloxone to people who use drugs, their friends, and others likely to witness or experience an overdose.
- Ensure that individuals have sufficient doses of take-home Naloxone to account for the potency of illicitly manufactured Fentanyl and Fentanyl analogs.
- Call 911 immediately after recognizing an overdose or resuscitating a patient. Naloxone available in the field may not be sufficient to reverse the overdose.
- Prioritize Naloxone distribution to people who use drugs following periods of abstinence and during transitions where Opioid tolerance may have waned. There is a higher risk of overdose during these periods.
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A Look Ahead
March 28, 2022, President Biden called for increased funding to address addiction and the overdose epidemic. “A core component of President Biden’s Unity Agenda is beating the opioid and overdose epidemic that claims an American life every five minutes,” said Dr. Rahul Gupta, Director of the White House Office of National Drug Control Policy (ONDCP).
“The requested increased funding would support the expansion of evidence-based prevention, treatment, harm reduction, and recovery support services, with targeted investments to support underserved communities, reduce the supply of illicit drugs like fentanyl and stop drug trafficking,” says the March 28, 2002 press release.
If you or someone you love is using illicit drugs, there is no guarantee for safety. Illicit drugs can contain dangerous levels of fentanyl that is unrecognizable by the human eye. Ceasing drug use is the only real way to protect yourself from an overdose. As the synthetic opioid epidemic continues, take advantage of free resources available to you, and reach out to a treatment provider here. A treatment provider may have a confidential conversation with you about the admission process into a licensed treatment facility.