Here we go again! Another round of deaths here in Alberta related to opioids. Just one more trial for the legitimate chronic pain patient and those of us who persist in being willing to prescribe opioid trials to seek those who benefit from opioids and willing to be vigilant to detect side-effects, abuse and diversion in those patients. In our clinic the absolute numbers of opioid patients who benefit significantly exceeds those who do not.
In a normal year we discharge three to five patients for selling their medication or using illegal drugs with their prescribed opioids. As long as the demand for illegal mind-altering drugs and human beings exist in large numbers this will remain an issue.
Ignorance(to not know) is probably not as much of a problem as stupidity(to know and still do) but ignorance is wide spread. The recent epidemic of deaths from fake oxycodone 80mg tablets(sometimes called ‘greenies’ on the street) is a case in point. Most of these patients were found with high level of fentanyl in the blood at autopsy(that should be a hint of a poor outcome!). What is going on here?
Well, technically it is quite simple. Oxycontin was replaced by Oxyneo because it cannot be easily crushed and snorted or crushed, filtered and injected. The technique is the way illegal users can get the fastest and most aggressive ‘high’. When drugs are snorted or injected they enter the blood without being changed by the liver and the time it takes for the drug to get from the mouth to the stomach and intestine for absorption is eliminated as well. So we have a group of people who know how to perform this piece of moronic magic. This is the first part of the perfect storm.
The second part goes way back to 1960 when Paul Janssen created fentanyl, a derivative of meperidine(Demerol), revolutionising the use of opioids in anesthesia. Demerol, like fentanyl is best given by injection(poorly absorbed in the gut) but has toxic breakdown products and in large doses is toxic to the heart. Fentanyl became rapidly the commonest drug of the opioid class used in anesthesia and the drug of choice for open heart surgery anesthesia.
The third part happened more recently. Fentanyl was a good pain drug but could not be given by mouth because it was not well-absorbed when swallowed and was also destroyed by the liver. If you held it in your mouth or nose it would be absorbed much better but that wasn’t very useful for chronic pain patients. Things changed when a research company in California in the 1990’s figured out the technology to put fentanyl in a patch delivery system that would get the drug into the blood through the skin, bypassing the liver metabolism and creating stable blood levels for three days from one patch. This created a useful product for patients with cancer pain and patients whose guts were not working well. As the shift occurred where doctors were encouraged to try opioids for chronic non cancer pain fentanyl patches became widely used and widely known. The original patches were called Duragesic by their manufacturer. These patches made it very difficult for illegal extraction of the fentanyl and very little absorption if the patch is swallowed. Much higher blood levels could be achieved by chewing the patch, but this is extremely dangerous because there is more than enough fentanyl in a patch to kill from overdose. Later, when the original patent expired, generic companies began making patches and sadly some of them are quite easy from which to extract the fentanyl for illegal purposes.
Fast forward to today. The illegal drug community is well aware Oxycontin pills can be crushed and snorted or injected. They are also aware that Oxyneo(the replacement for Oxycontin) is almost impossible to crush, snort and inject(ingenious methods have been proposed on the internet, however). The Canadian Government has, in a very questionable decision, allowed generic drug companies to produce the old crushable formulation. Of course a prescription is required.
Enterpreneurs who prey on the stupid, illegal and ignorant have devised a brilliant plan. They put fentanyl in a pill that looks like Oxycontin 80mg(the ‘greenie’) and sell it on the street. The enterpreneurs knew these morons would snort or inject the drug so it would work(fentanyl when swallowed does very little). What the unsuspecting morons did not understand was how potent fentanyl is compared to oxycodone-if your body is not used to huge dose opioid doses, the result is a guick overdose death and that is precisely what we are seeing today!
Personally, I feel anyone who dies from an overdose of an illegal counterfeit pill should qualify for a Darwin Award.
Foy you math lovers. 10 milligrams of fentanyl injected intravenously is about the same same as 500 to 1000 milligrams of morphine. Just ten milligrams of fentanyl in a fake Oxycontin 80mg(a ‘greenie’) would kill all but a very few even seasoned addicts with high tolerance and everyone else!
This new product may remove more than a few by death by ignorance.
gcwardell 