February 12, 2018
What the data around fentanyl is telling us
Opiates are a class of drug derived from the cultivation of opium poppies. Opiates have been utilised by humans for thousands of years for their medicinal properties, namely pain chronic relief. Isolation of the active chemicals in opium has led to the creation of semi-synthetic forms such as morphine, codeine and heroin. This progressed to the creation of completely synthetic forms such as fentanyl.
Synthetic forms of drugs are often more potent than their naturally occurring ancestors. Fentanyl has been demonstrated to be roughly 50-100 times more potent and 200-500 times more rapidly absorbed than morphine. Easily accessible synthetic ingredients also mean that fentanyl is much cheaper to produce than other semi-synthetic opioids such as oxycodone and morphine. These factors have also lead to the illegal production of Non-Pharmaceutical Fentanyl’s (NPF’s). NPF’s are often referred to as ‘synthetic heroin’, though are now also being sold as a cheaper alternative to authentic prescription medication. 1 2
Fentanyl prescription and risks
Medically, fentanyl is an effective post-operative analgesic and is prescribed for chronic pain. As with other opioid drugs, fentanyl reduces pain while also inducing the feeling of relaxation, euphoria, drowsiness and reduced anxiety. Some of the negative side effects include constipation, nausea and skin itching. More serious symptoms involve reduced blood pressure and urinary retention. Fentanyl overdose is usually the result of respiratory depression.1
Fentanyl is absorbed into tissue roughly 200-500 times more effectively than morphine. Chronic use can cause an accumulation within the tissue, leading to prolonged sedation, increased incidence of respiratory depression and overdose. Information being gathered on NPF overdose is suggesting that most have occurred rapidly, regardless of the route of ingestion.
Factors thought to be responsible for this include:
- increased potency and absorption
- fluctuation in concentrations between batches
- indistinguishable variations between appropriate and lethal dose.
This situation is further compounded by the mounting evidence that drug manufacturers and dealers may be adding illegally produced NPF’s to other drugs to increase their potency, resulting in increased unintentional use of NPF’s.1
Trends in the prescription, use and misuse of Fentanyl
The dangers of the potency of fentanyl were flagged by the US-based regulating agency the Food and Drug Association (FDA) in 1994, when an increase in accidental overdose was observed with the use of fentanyl transdermal or skin patches. Despite numerous warnings since, including the research stating that fentanyl therapy was deemed unsafe in 74% of patients, not only is it still commonly prescribed, prescription use has increased in both the U.S and Australia in the last 10 years. Significantly high levels of dependency on pharmaceutical opioids have been demonstrated in prescription opioid users. An 80% increase in fatal synthetic opioid overdose in the US between 2013-14.
While rates of use have proven difficult to obtain due to non-medical use (NMU), fentanyl-related emergency department visits in the US rose by 104% from 2004-2011. Comparatively, in Australia rates of pharmaceutical opioid deaths were 1.6 times higher in 2012 than in 2001. In 2012 the incidence of fatal overdose from pharmaceutical opioids was 2.5 times high than from heroin; this data correlates with increased prescription of opioids such as fentanyl by roughly 21% between 2010-15 in this time. Research has noted that this significant increase in fentanyl use mortality comparatively to other opioids is also a key indicator of high levels of NMU. 2 3 1 4
Fentanyl misuse in Australia
Non-medical use of pharmaceutical opioids has surpassed the use of heroin among illicit drug users in the US, and NMU of opioids has also increased within the Australian population, though heroin is still the dominate opioid of choice for people who inject drugs (PWID). Fentanyl can be relatively easily extracted from transdermal or skin patches and prepared into an injectable form for use by PWID, though appropriate dosing post extraction can be difficult to ascertain. 2 1 3
Fentanyl fatalities have been seen in Australia among PWID, and a 2016 retrospective review conducted by Sydney’s Medically Supervised Injecting Centre (MSIC).
- Though the use of fentanyl is relatively small compared to heroin, it increased 10-fold between 2012-15. This is an increase consistent with the estimated levels of NMU in Australia and one that is also consistent with US trends within the same time period.
- Fentanyl was responsible for roughly 8% of overdoses at the centre.
- Overdose was twice as likely for fentanyl users comparatively to heroin users and was 8 times more likely than those injecting other pharmaceutical opioids.
This research demonstrates the increased risk of fatal overdose associated with the known use of NPF, and while no recorded illicit drug seizures have reported the presence of fentanyl in Australian drugs, fentanyl-laced heroin is becoming common in the US and Canada, contributing exponentially to the mortality rate. Thus, understanding the current Australian environment and risks factors is essential to reduce the risk of a similar scale public health crisis.3
- A review: Fentanyl and non-pharmaceutical fentanyls. Suzuki, Joji and El-Haddad, Saria. 2017, Drug and Alcohol Dependence, Vol. 171, pp. 107-16.
- Risk of Fentanyl overdose among clients of the Sydney Medically Supervised Injecting Center. Latimer, Julie , et al. 2016, International Journal of Drug Policy, Vol. 37, pp. 111-114.
- Trends in heroin and pharmaceutical opioid overdose deaths in Australia. Roxburgh, Amanda, et al. 2017, Drug and Alcohol Dependence, Vol. 179, pp. 291-298.
- AIHW. Non-medical use of Pharmaceuticals: Harms, Trends & Treatment - 2006-07 to 2015-16. Canberra: AIHW, 2017.
- Gibson, Amy, et al. The extent of diversion of fentanyl for non-medical purposes in Australia: What do we know? NDARC Technical Report No. 265. Sydney: National Drug and Alcohol Research Center, University of New South Wales, 2007