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The relationship between fentanyl and the opioid crisis is without a doubt. The spectacular increase in fentanyl consumption in recent years and its consequences, acquires the status of pandemic in certain countries.
This is reflected in a report recently published (Provisional Drug Overdose Death Counts) by the US CDC. About 100,000 people have died in the United States in 2020 from drug overdoses (30% more than in 2019).
Approximately 70% of deaths are related to the use of synthetic opioids, mainly to the use of fentanyl, also called "synthetic heroin".
1. The opioid crisis
The opioid crisis refers to the marked increase in opioid use (mainly prescription) and its consequences.
To understand this phenomenon, the first thing we need to know is that fentanyl is a drug 50 times more potent than heroin. Only two milligrams of fentanyl can be a lethal dose in most people.
The majority of deaths due to fentanyl overdose are due to the use of other drugs (especially cocaine, heroin, benzodiazepines and ecstasy) that were adulterated with this potent opioid.
Therefore, in order to better understand the opioid crisis, two aspects must be taken into account:
- on the one hand, the consumption of medically prescription fentanyl and
- on the other, the use of fentanyl and its derivatives from the illicit market.
2. Prescription of fentanyl and opioid crisis
Drugs derived from opium have been used for medicinal purposes since their discovery. These are natural (opiaceous) or synthetic (opioid) compounds, derived from opium or morphine.
They are drugs such as heroin, buprenorphine, fentanyl, or codeine. At the same time and for various reasons, recreational or non-medical 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 in the world 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 for the treatment of cancer pain, among other indications.
That is, for years fentanyl has been prescribed at its discretion for acute non-oncological pain, migraine, back pain, or fibromyalgia, to name a few examples.
Today, we know that opioids as potent as fentanyl should only be indicated for oncological rash pain. We also know that forms of immediate release (aerosols and dispersible tablets) can cause addiction more quickly than forms of sustained release, such as transdermal patches.
3. Instant-release fentanyl and addiction
Fentanyl has a powerful analgesic and sedative action. Its main indication is the treatment of pain, but it is also used in pre-anesthesia and veterinary.
Fentanyl presentations include:
- solution for injection,
- sublingual tablets,
- nasal spray and transdermal patches.
Nasal sprays and so-called "fentanyl pills" are immediately-release presentations that can generate addiction very quickly.
Absorption through the oral mucosa is immediate and as the effect decreases rapidly, a new use is likely. The tolerance generated by opioids is high, and we easily need a higher dose to achieve the same effects. This can trigger fentanyl addiction.
The "fentanyl surgeons" were designed in the United States in 1985 to be used in children who were going to undergo surgery. They looked similar to conventional "Chupa Chups".
Fentanyl applied in this way is absorbed as quickly as injected and reaches the central nervous system without being metabolized. Its effect is practically instantaneous.
Recently, the United States has admitted that there was an over prescription of opioids and undesirable practices.
4. Synthetic derivatives of fentanyl and opioid crisis
As health authorities establish new laws that regulate the use of drugs, new psychoactive substances such as pink cocaine or alpha-PVP flood the illicit market.
That is, fentanyl manufactured illegally, without any sanitary control. As many people tried to solve different pathologies in the office, they developed an addiction that caused them to use opioids repeatedly.
In a way, this can be clearly conditioned by the health system of each country.
If someone develops dependence on opioids and finds it impossible to access them through legal channels, they will probably try to obtain them by 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 itself. It's more profitable.
Today, in cities like New York, any drug purchased on the street is likely to contain fentanyl. This poses a high risk to community health and has put health authorities around the world on alert.
And not only that, as the laws restrict, persecute and punish the possession of this drug, new synthetic derivatives of fentanyl continue to appear. Some of them are extremely dangerous.
Carfentanil is 10,000 times more potent than morphine. In this way, new synthetic opioids emerge that are more toxic than fentanyl itself. Something similar happens with benzodiazepines, cathinones, and cannabinoids.
5. Updated health regulations on fentanyl
In order to dispense these medications in a pharmacy, the inspecting physician must first validate the prescription for rapid release fentanyl. Otherwise, it cannot be dispensed to the patient.
Medicines containing immediately-release fentanyl are indicated exclusively for the treatment of oncological inflammatory pain in adults who are already chronically receiving another opioid maintenance treatment.
Patients receiving opioid maintenance treatment are those who take at least 60 mg of oral morphine daily, 25 micrograms of transdermal fentanyl every hour, 30 mg of oxycodone daily, 8 mg of oral hydromorphone daily or an equianalgesic dose of another opioid for a week or more.
This provision is included in the "Plan to optimize the use of opioid analgesics in chronic non-oncological pain in the National Health System".
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