T

he opioid crisis just keeps getting worse, in part because new types of drugs keep finding their way onto the streets. Fentanyl, heroin’s synthetic cousin, is among the worst offenders.

It’s deadly because it’s so much stronger than heroin, as shown by the photograph above, which was taken at the New Hampshire State Police Forensic Laboratory. On the left is a lethal dose of heroin, equivalent to about 30 milligrams; on the right is a 3-milligram dose of fentanyl, enough to kill an average-sized adult male.

Fentanyl, according to the Centers for Disease Control and Prevention, is up to 100 times more potent than morphine and many times that of heroin.

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Drugs users generally don’t know when their heroin is laced with fentanyl, so when they inject their usual quantity of heroin, they can inadvertently take a deadly dose of the substance. In addition, while dealers try to include fentanyl to improve potency, their measuring equipment usually isn’t fine-tuned enough to ensure they stay below the levels that could cause users to overdose. Plus, the fentanyl sold on the street is almost always made in a clandestine lab; it is less pure than the pharmaceutical version and thus its effect on the body can be more unpredictable.

Heroin and fentanyl look identical, and with drugs purchased on the street, “you don’t know what you’re taking,” Tim Pifer, the director of the New Hampshire State Police Forensic Laboratory, told STAT in an interview. “You’re injecting yourself with a loaded gun.”

New Hampshire, like the rest of New England, has been particularly hard hit by the opioid epidemic. The state saw a total of 439 drug overdoses in 2015; most were related to opioids, and about 70 percent of these opioid-related deaths involved fentanyl. The state has seen 200 deadly opioid overdoses this year so far, said Pifer.

Fentanyl was originally used as an anesthetic. Then doctors realized how effective it was at relieving pain in small quantities and started using it for that purpose. In the hands of trained professionals — and with laboratory-grade equipment — fentanyl actually has a pretty wide therapeutic index, or range within which the drug is both effective and safe.

The difference in strength between heroin and fentanyl arises from differences in their chemical structures. The chemicals in both bind to the mu opioid receptor in the brain. But fentanyl gets there faster than morphine — the almost-instantaneous byproduct when the body breaks down heroin — because it more easily passes through the fat that is plentiful in the brain. Fentanyl also hugs the receptor so tightly that a tiny amount is enough to start the molecular chain of events that instigates opioids’ effects on the body.

This tighter affinity for the opioid receptor also means more naloxone — or Narcan — may be needed to combat a fentanyl overdose than a heroin overdose.

“In a fentanyl overdose, you may not be able to totally revive the person with the Narcan dose you have,” said Scott Lukas, director of the Behavioral Psychopharmacology Research Laboratory at McLean Hospital in Belmont, Mass. “Naloxone easily knocks morphine off of the receptor, but does that less so to fentanyl.”

Matt Ganem, a former addict, explains the excruciating process of opioid withdrawal. Alex Hogan/STAT

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  • I used Vicodin for 10 yrs, it helped me function like a normal person. I stopped when a few people in my DR’s office treated me like an addict. I also wondered how many of my friends thought I was an addict. My body was dependent but I weaned my self off at the end in 10 days. I cannot do simple things like I used to, oh well. I do use Gabapentin , it helps some. The way I see things is that MANY people have no idea they have addictive issues UNTIL they come across their “poison” . I assume people that have never had a drink do not know they are or could be an alcholic. People like myself that never abused their medication, never ever snorted it or injected it , should not have to pay for those that do. Once you cross that line…… you are an abuser. My DR thinks the gov wants to push people to medical cannabis because it is a whole new source of revenue. I tried it, it did not work for me.

    • guess what…if you were on Vicodin for 10 yrs you were an addict and your Dr. was your dealer…………….been there done that

    • I’m living with chronic pain for years Because of the stupidity of some. I can’t get the mediation I need to manage my pain. Nobody wishes death on some one But how many of these over doses are people that went through treatment and where not told that if they relapse they can’t use the same amount they used before treatment. This is why some are overdosing.

    • @Randy, you make an excellent point. Rehab, life changing moments, trauma, chronic auto immune disorder or disease, is part of many layers why people over dose. We are humans that are different in DNA exposed to who knows what, when or how.
      Some don’t know that Vietnam agent orange changed the the DNA coding in their children. Their children ended up with auto immune diseases.
      Opioid is a class of pain management. The black market opioids supported and watched by former CIA since Vietnam say the problem is not the addiction it’s the addiction to US cash flow.

  • Around 15 years ago I had excruciating pain and I cannot eat when I have pain because I vomit my food up. My weight dropped to 70 pounds & I looked like I had just walked out of the Auschwitz concentration camp. I could not get a doctor to prescribe a opioid. And I cannot take anti-inflammatory drugs because I almost died of a bleeding ulcer. I had 3 blood transfusions. I was put on fentanyl’s lowest dose. The doctor who put me on the fentanyl & he saved my life. I was on fentanyl (without going up on dose) for 11 years. This allowed me to work another 7 years before I retired. I gained 35 pounds and I was able to become more healthier than I had for so many years. I have several serious diseases. That doctor not only saved my life but he gave me a better quality of life. There is not a opioid epidemic. We have 328 million people in this country. 67 million senior citizens & 71 million baby boomers. Those two may overlap each other. By the way if 420,000 people died of a opioid overdose that is under one percent of the population. So, if 50,000 people die of opioid overdoses that is very low on the one percent. So, we do not have a opioid epidemic and the pill mills have been shut down and people who do doctor shopping will be put in prison. We have the largest older population in the history of our country. When a person buys illicit drugs on the street they know that it is very dangerous and so they need to take responsibility for their own health & they may die as well. I have decided to write a book on the fraudulent activities of our government, their altering of data to say we have a epidemic. This is big money for the federal government – or should I say the money is going to some people in the federal government as well as private contractors. Not all people who work for the federal government are deceitful and they are being fooled into what they believe is that there is a epidemic. I do statistics and the numbers do not show a epidemic. If a person dies of 2 opioids (oxycodone & hydrocodone) that one person is counted as two people dying from a overdose. The federal government admits this in their data. I assume nobody reads the information they have put out there. So your tax dollars are being used to make people rich. The American people have been told a lie. Fentanyl patch is a drug that is safe if we can get the drug addicts to stop ruining it for people in excruciating pain. I have not seen anyone stick up for the people in pain & their suffering. I will die if my pain medication is taken away from me. In fact, the pain sufferers are probably going to die much sooner because of this deception & the people who have abused opioids, and the individuals who are protesting against opioids as well, are going to be the ones who are going to be responsible for people in pain taking their own life. All because a love one died of a opioid overdose. I don’t care that this supposed epidemic has killed more people in auto accidents. Did you know that over 400,000 people have died in hospitals because of errors they made. No one says anything about that. So, stop comparing data to auto accidents. I was a whistleblower before I retired and all the individuals were found quilty. I am in contact with President Trump and Governor Christy and there will be a reckoning because people in pain do not deserve to suffer or commit suicide. I have all the evidence to prove my case. The CDC has altered death certificates as overdoses of opioids. And there is a interview with a individual who works for the CDC who admits that they do alter death certificates.

    • Your callous indifference to the deaths of 50,000 people suffering from the disease of addiction, not to mention those who suffer with addiction on a dialy basis, makes it very difficlt to simpithize with your suffering as an individual. Good luck.

    • My position based on the CIA explaining the war on drugs is a cash flow addiction not the “opioid.”
      As I agree, pain management still needs to be in place for people with different chronic health issues, rehab should be equally funded.
      Don’t blame a very minority of physicians that opened up pill clinics because of this problem. As there is plenty of blame to go around for the death of opioid overdose. At the same time the human genome / brains are all different and can not be one size fits all for big pharma conventional medicine.
      If you need proper prescribed with proper medical history pain management to function daily, I say make it happen.
      The stigma is coming from the street drugs that have more quantity in opioids than any pharmacy. This is the data we need.
      Since the Vietnam era, the CIA had been delivering heroin, cocaine, and opium to the USA in large quantities. The United States Coast Guard missed over 500 drug traffic incidents in 2016 because of man power / equipment not available.
      Trump just slashed the USCG budget therefore paving the way for more illegal drugs to pipeline into the USA.
      Call it war on drugs, call it a crisis, truly if we legalized everything like Portugal the jails would empty and the use would drop 60 percent. Why? Cash flow.
      This is not going to go away unless we drop the laws.
      Have I seen the dead drug overdoses in real time, yes. 23 years on the streets in emergency services.
      I also see people responsible to pain management and you couldn’t tell they were on it because they behaved normally to function.
      Remember it’s a cash flow problem first with addiction second as the result in death if it’s tainted, over used, or mixed with other drugs or alcohol.
      Fix the cash flow. Fix the problem. For now rehab, is all anyone has if it’s addiction based vs managing a chronic illness that pain management is all anyone has.

    • Thank you, you’re correct in saying that no one sticks up for the people in severe pain. I’ve been dealing with severe pain for almost 9 years now. The first 5 with doctors that would not even prescribe me ibuprofen 800s. I’ve finally found a doctor that prescribes me just enough medication to live a normal life, able to work and provide for my family. The “opioid epidemic “ in this country is more political than most people know. Yes, there are people dying from overdoses of prescription drugs, and they are making it very difficult for people with painful disorders or diseases to live a normal life. I’m not saying it’s not tragic, it is. But some of this blame has to be accepted by the addict as well. I know parents always want to see the best in their children, that’s understandable. What they don’t want to realize is that some of their children, prior to their overdose, would lie, steal, cheat, rob and many other things in order to get their drugs. And now, the politicians get involved. Reaching out for money to help combat the epidemic in their state. Just another way for someone to get paid. I know quite a few recovering addicts who are fine, upstanding members of society. The addiction has to want to quit, those who don’t end up a stastistic. In turn, making life more difficult for the rest of us. Anyway, enough of my rant, thank you again for sticking up for those of us who need treatment, it’s very much appreciated.

    • Thanks, N. Ingraham, Im one of those in chronic pain and the Dr. here in Minnesota have me on tramadol and will never put me back on fentanyl which I had been taking 50mg every 72 hours. One Dr. said she was worried about her reputation.
      PLEASE tell every body you can because their are many elderly suffering

    • That is an incredibly misguided statement and all my dead friends and dead sons and daughters of people I know could tell you how real the epidemic is.

    • Thanks, Im one of those in chronic pain and the Dr. here in Minnesota have me on tramadol and will never put me back on fentanyl which I had been taking 50mg every 72 hours. One Dr. said she was worried about her reputation.
      PLEASE tell every body you can because their are many elderly suffering.This is my first posting. Do say this is a duplicate posting

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