Special Topics in Pain: Opioids

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Addressing the Fentanyl Threat to Public Health.

Author(s): Frank R G, et al.
Journal: N Engl J Med. 2017; 376(7):605-607. 5 references.
Reprint: Richard G. Frank, PhD, Department of Health Care Policy, Harvard Medical School, Boston, MA.
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids

Editor’s Note: To reduce the cost of Heroin, if is being “cut” with Fentanyl because of lower costs of Fentanyl and the dosage may be uncertain as the drug is produced illicitally. The effects are more rapid leading to more overdoses representing a burgeoning public health problem. Fentanyl's low production costs and high death toll pose a distinctive challenge that requires a concerted response.  

Class: Pharmacology: Addressing the Fentanyl Threat to Public Health. 

Fentanyl, which is a powerful synthetic opioid, has a low production cost which encourages suppliers to use it to "cut" heroin and as an active ingredient in counterfeit oxycodone tablets. It poses a serious overdose risk because it can rapidly suppress respiration and cause death more quickly than do other opioids.

Even with declining prices, heroin costs about $65,000 per kilogram wholesale, whereas illicit fentanyl is available at roughly $3,500 per kilogram. Producing precise fentanyl doses also requires specialized equipment and knowledge. Street-drug suppliers who are unwilling or unable to provide precise dosing create an especially acute overdose risk.

Governments are struggling to determine how to deploy the tools at their disposal to address wide spread fentanyl-related deaths. Some believe there is merit to a harm-reduction approach involving increased transparency for users and public health and public safety organizations, harm-reduction policing, expanded naloxone use, and targeted treatment.

Harm reduction involves channeling the use of heroin, OxyContin, and other products toward the least risky formulations. That means using policy tools to make illicit markets more transparent, strengthen incentives for drug suppliers to avoid introducing fentanyl into their products and increase the likelihood that overdoses can be reversed. On the transparency front, law enforcement and the health care delivery system provide opportunities for surveillance and development of an early-warning system about fentanyl's presence in various drug products. Data from systems such as Arrestee Drug Abuse Monitoring and laboratory-informed epidemiologic surveillance tools that reach hidden or vulnerable populations can form the platform for an early-warning system like those recently adopted in Europe.  

Harm-reduction technologies may also help redirect user demand away from products containing fentanyl, though their effectiveness is unproven. Pill-testing technology could be provided to clubs, festivals and safe injection sites to detect the present of fentanyl. These efforts, while promising, have yet to be carefully evaluated.

Within the policing arena, traditional drug-enforcement approaches emphasize use reduction. Simple use reduction aims to decrease the volume of illicit-drug consumption. Use reduction can benefit public health by deterring distribution, sale, and use. Cracking down on illegal laboratories and other links in the supply chain would probably help disrupt the fentanyl market. However, law-enforcement policies can aggravate public health harms. For example, intensive policing interventions--particularly those targeting buyers caught with syringes--increase needle sharing and raising the risk of HIV transmission.

Harm-reduction policing seeks to place the burden of reducing unintentional fentanyl consumption on the individuals and organizations that can most effectively reduce the risk. It may prove most effective to assign liability (through enforcement attention) to individuals and organizations (e.g., gangs) that supply illicit drugs containing fentanyl. A more measured response would impose harsher penalties on distributors and sellers found to have sold drugs containing fentanyl, even if these drugs did not cause immediate harm.

Health care delivery has a key role in reducing the likelihood of death when overdose occurs, and preventing overdose through opioid-use disorder treatment. Naloxone can reverse fentanyl overdoses, but it appears to require more rapid administration (and perhaps escalation to additional doses) than is needed for heroin or other opioids.

These facts have three implications: naloxone kits need to meet higher dosage requirements for fentanyl; user-friendly formulations (intranasal and auto-injector) should be rapidly available, which means equipping first responders with appropriate kits; and naloxone should be made available to users by provision of take-home kits. Take-home kits for users would require altering pharmacy regulations in many states. It would also mean encouraging users not to use it alone, and teaching them how to respond if they encounter a likely fentanyl overdose. Timely availability of naloxone could also be provided by creating so-called safe bases for taking drugs--an approach that has been used with some success in Canada and Europe.

Expanded access to evidence-based substance use disorder treatment--particularly medication-assisted therapy--would also help. Health care providers should recognize that treatment itself can pose overdose risks by reducing tolerance in drug users who continue to use at some level.

Important Points:
Fentanyl's low production costs and high death toll pose a distinctive challenge that requires a concerted response. A full package of prevention, treatment, and harm-reduction interventions is the best bet for reducing a frightening public health threat and saving lives.

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