By: Amber Marek, BSN, RN
Fentanyl is a powerful synthetic opioid that has become a major contributor to the ongoing opioid epidemic in the United States. As a registered nurse (RN) in the emergency department (ED) in the California Bay Area, I have seen firsthand the devastating impacts of overdoses from fentanyl, or “fenny” as it’s called on the streets, often multiple times a shift.
Fentanyl, like other opioids, decreases the respiratory drive. Early signs and symptoms of an overdose are pinpoint pupils, slow irregular breathing, and sedation. Late signs and symptoms may include seizures, acute respiratory distress, discoloration of the skin, and coma (Volkow, 2021).
“Fentanyl is a synthetic opioid that is up to 50 times stronger than heroin and 100 times stronger than morphine” (CDC, n.d., para. 2).
· From 2020-2021, death rates caused by overdoses (ODs) from synthetic opioid increased 22%.
· From 2020-2021, heroin ODs decreased by 32%.
· From 1999-2015, deaths caused by ODs increased from 8,050 to 33,091.
· During the months of May 2020- April 2021, over 100,000 people died from ODs in the United States.
Who is at risk from a fentanyl overdose?
Tragically, anyone using any drug is at risk of a fentanyl overdose. Whether a person is using heroin, cocaine, methamphetamine, or even “party drugs” like ecstasy – fentanyl can be present without the user’s knowledge, leading to an accidental overdose. Before the rapid expansion of fentanyl, a heroin OD was only common in heroin users. Now, even people who don’t typically use opioids can experience a life-threatening overdose from a fentanyl contamination. Teens and young adults who experiment with cocaine, methamphetamines, or even psychedelics can potentially OD on fentanyl adulterated substances. Likewise, non-opioid-using individuals who use stimulants like meth, cocaine, or crack daily might OD on fentanyl.
These people are shocked when they wake up in the ED and ask how they got there. They report not intentionally using fentanyl prior to overdosing. They thought they were taking ecstasy, popping some pills their friend gave them, or just using their regular “dose” of meth or crack. Patients have even woken in the ED after an overdose and reported only smoking cannabis.
How is it possible that fentanyl is found in other drugs?
Fentanyl comes in both liquid and powder form, making it exceptionally easy to add to, or “lace”, ANY drug or substance. Sometimes the drug finds its’ way to the streets from the medical industry, but most commonly it is illegally imported from countries outside the US (Pergolizzi et al., 2021). Often the most dangerous ODs I see in the ED, are from opioid-naïve patients, e.g., people who do not normally take narcotics, and they often end up in intensive care on a naloxone drip.
Why are these drugs getting laced with fentanyl?
First off, it’s cheap. According to Volkow, fentanyl is 50-100 times more profitable than heroin, (2021). Secondly, it is very addictive, so the dealer can get their client “hooked” on a drug that otherwise might not be considered as addictive (CDC, n.d.). I have also witnessed cases where people intentionally sell drugs laced with fentanyl, as a means to rob their buyers after they have passed out or overdosed.
What is being done about this crisis?
50 years into the “War on Drugs” has yet to see punitive measure effectively dissuade opioid use or ODs. Yet, numerous states have continued to pass legislation for harsher penalties for dealing or delivering fentanyl (Cole & Barocas, 2023). Harm reduction programs aim to increase distribution of naloxone (commonly referred to by the brand name Narcan), which is the reversal agent of opioids. Overdose prevention sites utilize methadone and buprenorphine to treat opioid addiction. CNN reports the federal government’s State Opioid Response grant program prevented more than 600,000 deaths from ODs through the distribution of 10 million free naloxone kits (Christensen, 2024).
Before Narcan was widely distributed patients displaying signs of overdose would come into the hospital and ED staff would administer the first dose of naloxone. Now, due to more widespread availability and education, naloxone is more commonly first being administered by a friend or other witnesses. The patient then arrives in the ED breathing, alert, and oriented to their surroundings. Because naloxone is shorter acting than opioids the patient may require additional doses if overdose symptoms return.
Fentanyl testing strips are also becoming more widely accessible and utilized by substance users. The strips enable anyone intending to do drugs to quickly test the product for fentanyl contamination.
The Bottom Line:
The rise of fentanyl has made the opioid epidemic even more deadly. While the best
advice is to avoid using any illicit drugs, the reality is that people will continue to use.
Having naloxone on hand and testing drugs for fentanyl contamination can be the
difference between life and death. Education and harm reduction measures are crucial
in addressing this public health crisis.
References
Centers for Disease Control and Prevention. (n.d.). The facts about fentanyl. https://www.cdc.gov/stopoverdose/fentanyl/index.html
Centers for Disease Control and Prevention. (2021, December 14). Trends in and Characteristics of Drug Overdose Deaths Involving Illicitly Manufactured Fentanyls — United States, 2019–2020. https://www.cdc.gov/mmwr/volumes/70/wr/mm7050e3.htm?s_cid=mm7050e3_w
Centers for Disease Control and Prevention. (n.d.). Understanding the Epidemic. https://www.cdc.gov/opioids/basics/epidemic.html
Christensen, J. (2024). Biden administration announces focus on ‘flooding the zone’ with life-saving overdose reversal medicine. CNN Health. https://www.cnn.com/2024/03/13/health/biden-administration-naloxone/index.html
Jurecka, C. A. & Barocas, J. A. (2023). Using evidence to inform legislation aimed at curbing fentanyl deaths. JAMA Health Forum, 4(1), e225202. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2800863
Pergolizzi, J., Magnusson, P., LeQuang, J. A. K. & Breve, F. (2021). Illicitly manufactured fentanyl entering the United States. Cureus, 13(8). https://assets.cureus.com/uploads/review_article/pdf/61656/20210927-7631-1wqnowx.pdf
Volkow, N. D. (2021). The epidemic of fentanyl misuse and overdose: Challenges and strategies. World Psychiatry, 20(2), 195-196. doi: 10.1002/wps.20846 Assessed and Endorsed by the MedReport Medical Review Board