Fentanyl: The Untold Part of the Story

Dr. Joseph Alton’s recent piece in AT—“What You Need to Know About Fentanyl”—is best represented by his comment, “I’ve known of fentanyl my entire medical career.” He’s a medical preparedness specialist, and in that field, I defer to him. But my career was spent in Anesthesiology, where we don’t know “about” fentanyl, we know it intimately. I have personally administered gallons of the stuff. For that reason, I can pick up the discussion where he left off, which is the “show me the money” issue.

Anesthesiologists know about all the other opiates. It does not matter whether they are natural (opium, morphine), refined and modified natural (Heroin, Dilaudid), semisynthetic (codeine, hydrocodone, oxycodone), or fully synthetic (meperidine, pentazocine, fentanyl, sufentanil, remifentanil, and so on). If I give a patient an appropriately measured dose of any of those drugs, they will all produce basically the same desired effects and undesired side effects. 

In short, while hair-splitters will argue, the fact is that they’re all basically the same drug. You read that right. Opiates all do the same things. They just do it via different routes of administration and for different durations. Of course, with continued dosing, all sorts of multiple-compartment pathways of distribution and elimination lead to changes in duration, and receptors become tolerant, requiring higher doses.

Now that I’ve impressed you with my knowledge of pharmacodynamics (effects) and pharmacokinetics (uptake, distribution, and elimination), (insert snarky comment here), let’s tackle the question Dr. Alton did not ask: “Why, given that all these drugs cost almost nothing to manufacture, have they made criminals immensely rich?”

Image: Fentanyl from a United States Sentencing Commission publication.

As Hamlet said, “Ay, there’s the rub.” If heroin and fentanyl are as cheap to make as aspirin (and they are), why aren’t they sold for pennies at your neighborhood pharmacy? If they were, the Mexican drug cartels would go broke, because there wouldn’t be any profit in it. This economic question points us to the Pure Food and Drug Act of 1906 and its descendants. Those laws made possession of opiates for non-medical use a crime. And there are people who want those intoxicants, come Hell or high water.

Roughly a third of the population throughout history has wanted intoxicants. Fermented beverages like beer are universal. Other intoxicants such as marijuana, psilocybin, khat, and coca leaf are nearly as prevalent. The key in all of them is that, as commonly used, they generally provide some sort of buzz, but without causing the inability to function. Overused, all lead to problems.

Opiates can cause a much more profound “high” in some people. This leads to a desire for more. However, continued use causes receptor tolerance, which requires more and more of the drug for the same effect. Before long, this tolerance prevents any high from the drug. All that’s left is the abstinence syndrome, commonly shown in movies as a horrific withdrawal. That may be a bit overblown but still leads the addict to search for more drugs to avoid its unpleasantness.

Only a small fraction of one percent of addicts starts with prescription drugs. The rest are introduced in non-medical locations with the purveyor intending to cause addiction. It is that addiction that finances the Mexican cartels. And those profits can only exist because the drugs are illegal.

When a person wants an intoxicant drug, he realizes that it’s illegal. In turn, that means he must surreptitiously interact with a curbside pharmacist. Since it’s illegal, the pusher demands a high price to compensate him for the chance of arrest and prosecution he’s taking. In economics, that’s a “risk premium.” If the user must pay a high price, he demands higher quality. It’s a vicious cycle that leads to more drug merchants entering the neighborhood. 

When competing criminals appear on the same turf, two outcomes are possible. The first is a turf war, similar to Chicago’s daily sonic footprint. The other is competition to reformulate the drugs to be more attractive to users. This typically involves adding fentanyl to heroin. Heroin is essential because it lasts hours, while fentanyl lasts minutes. The fentanyl can give a “hit” to overcome tolerance while the heroin postpones withdrawal. Both are needed. This creates an economic problem.

Fentanyl is very easy to smuggle because it’s a hundred times as potent as heroin. Cartels can send smaller parcels through more routes with a higher chance of success than heroin. But they still need both. However, when the local druggists mix up the street drugs, there’s no standardization whatever, unlike Double Uoglobe Heroin in Vietnam.

This brings us to a point that that Dr. Alton made. “This practice of ‘cutting’ drugs with fentanyl causes the user to inadvertently be given a dose much stronger than ordinarily expected…” 

Take special care to understand this. Overdoses are not a result of fentanyl’s potency. They are a result of the unknown potency of the street drug combination. If the bag you just bought has double the pop of the bag you bought earlier from the guy who just assumed room temperature due to high-velocity acute lead poisoning, then you are likely to forget to breathe.

Addicts don’t deliberately overdose very often. They just suffer from the predictable pharmacological consequences of drug prohibition. Al Capone made lots of money because alcohol was illegal. El Chapo got rich from the same set of economics. When you make drugs illegal, the people who want them will commit crimes in order to get them. This collateral damage then lines the pockets of the cartel criminals. It is a completely predictable consequence of the laws. There are only two possible ways to fix this.

First, we can keep doubling down on failed policies, heading toward the Singapore model. There, mere possession or consumption has a ten-year prison sentence. Trafficking can lead to a death sentence. This is what Senator Rubio wants to see for fentanyl. Put bluntly, this will only increase the police state. More money will be wasted on militarized SWAT teams, jail cells, and ineffective rehab centers.

The alternate approach is decriminalization with harm reduction. Notice there are two elements. Decriminalization has already shown benefits, but more can be done. Portugal decriminalized in 2001, adding various treatment facilities and drug maintenance programs. It started with overdoses and drug use roughly similar to the rest of Europe. Since the policy change, Portugal has had less than half the rate of O/Ds in the rest of Europe. Crime has fallen, and the number of people in prison with it.

Insanity can be defined as doing the same thing over and over again while expecting different results. Punitive laws against drug use have been in place since the Chinese emperors in the eighteenth century. They didn’t work then, and none of the laws since then have ever reduced drug use. All they have done is increase misery and deaths.

Perhaps it’s time to question our sanity…

Ted Noel MD is a retired Anesthesiologist/Intensivist who podcasts and posts on social media as DoctorTed and @vidzette. His DoctorTed podcasts are available on many podcast channels.

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