Newsflash: The headlines we read would have us all think that fentanyl is so deadly it can kill you with a single use. Or that anyone who ends up with fentanyl in their system — from any source — was trying to buy another drug and simply got something “laced” with it. While this can be quite true, the headlines often miss the bigger picture, and therefore leave many who struggle with fentanyl addiction feeling an extra layer of stigma and loneliness.
We’re not really, as a society, talking about fentanyl itself as an addiction, and we need to be. By definition, addiction is something that someone does repeatedly, regularly, despite all of the harmful consequences. And as the heroin supply has largely disappeared and been replaced by fentanyl in several major metro markets, we now have many individuals addicted to fentanyl. At Ophelia, over 70% of our patients who enter care using opioids are testing positive for fentanyl, whether they realize they've been consuming it or not. This means that drug users in the community are often exposed to fentanyl, if not daily, and yet do not necessarily succumb to a fatal overdose.
Some people are more susceptible to fentanyl overdoses than others. Everyone’s biology is a little bit different which means their response to fentanyl will be slightly different. Fentanyl can cause respiratory suppression in the brainstem just like any other opioid with full activity at opioid receptors. Because fentanyl is so potent, it can lead to fatal overdose with such a small dose, just a few tiny grains, that it would be hard to even see it. However fentanyl comes with other unique dangers that are not as common with other opioids. First, fentanyl acts very quickly on someone’s system because it crosses the blood-brain barrier very fast. This means that an overdose that otherwise could have taken 10-20 minutes to onset can occur much more rapidly, just within a few minutes.
Additionally, fentanyl can cause changes in the lungs and chest wall. In particular, fentanyl is associated with “wooden chest syndrome.” This is something that anesthesiologists who have been using fentanyl in the operating room for decades have been very familiar with for years. The hardening of the chest wall means that rescue breaths from CPR and naloxone reversals are less likely to be effective. In part, this is because the rigidity from wooden chest syndrome occurs so quickly. For instance, a recent study found that nearly half of fentanyl-involved overdose deaths occurred before the body even had a chance to break down fentanyl into its metabolites, something that typically only takes 2-3 minutes to happen. Fentanyl can also cause lung damage, when the air sacs of the lungs become submerged in leaky fluid and can no longer exchange air effectively because of cardiac abnormalities that can rapidly affect blood pressure changes in the lungs. This can cause a drowning effect which further worsens overdose outcomes.
Just like treatment for heroin, the evidence-based treatment for fentanyl addiction is with medications approved by the FDA such as Suboxone or methadone. Yet among the millions of people with an opioid use disorder, upwards of 80% do not receive evidence-based care. Largely this reflects stigma that is pervasive throughout our society and our fractured healthcare systems that often keep addiction treatment inaccessible and unaffordable. Once people enter treatment with FDA-approved medications successfully, the most important thing is long-term retention: patients who drop out early, especially within the first year or two, have much worse outcomes. At Ophelia, we have shown that we can retain about twice as many people in care as usual in-person care settings.
What about people who aren’t addicted to fentanyl but who may be exposed to it in other drugs such as cocaine and pressed pills from the black market or internet (e.g. Xanax)? There has been a push in recent years to increase access to fentanyl test strips to help drug users have more information about what is in their supply. This is especially important for sporadic users of drugs who may think they are using cocaine or methamphetamine without realizing that black market drugs are often cut with dozens of other substances. Typically this is for profit motives by dealers and to evade law enforcement. Unfortunately, this also means that the unregulated drug market contains all sorts of dangers that can lead to permanent injury or death. One piece of advice, if you think you need to use a fentanyl test strip, it’s probably best to avoid the drugs in question. The safest way to know what you are consuming is to only use medications prescribed by a licensed clinician and dispensed by a licensed pharmacy.