Fentanyl Fact and Fiction: The Rise of America s Narcotic Crisis Dan Batsie daniel.batsie@vermont.gov @danbatsie
"Opium Throughout History". PBS Frontline. Retrieved 22 October 2006
Jim Edwards for Business Insider. 17 November 2011 Yes, Bayer Promoted Heroin for Children Here Are The Ads That Prove It
Pain Stress Temperature Respiration Endocrine activity Gastrointestinal activity Mood Motivation Williams, J. T. et al. Regulation of μ-opioid receptors: desensitization, phosphorylation, internalization, and tolerance. Pharmacol. Rev. 65, 223 254 (2013).
Tolerance Demand Brooks M. FDA clears hydrocodone with abuse-deterrent properties. Medscape Medical News. November 20, 2014
Discontinuation Syndrome Rhinorrhea, sneezing Yawning Lacrimation Abdominal cramping Nausea/vomiting/diarrhea Leg cramping Piloerection (gooseflesh) Dilated pupils
Havens J.R. et al. The impact of a reformulation of extended-release oxycodone designed to deter abuse in a sample of prescription opioid abusers. Drug Alcohol Depend. 2014 Jun 1;139:9-17.
Muhuri P, et al. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. (2013).
https://www.dea.gov/divisions/hq/2015/hq031815.shtml
https://www.dea.gov/divisions/hq/2015/hq031815.shtml
1981 $3,620 Today $622 https://www.dea.gov/divisions/hq/2015/hq031815.shtml
Number of Fentanyl Exhibits in NFLIS, 2004-2015
Retail 1981 10% Today 40%
Massachusetts, Maine, New Hampshire, Ohio, Florida, Kentucky, Maryland and North Carolina. Fentanyl seizures up 426% Fatal OD up 174% http://health.usnews.com/health-care/articles/2016-08-25/synthetic-fentanyl-fueling-surge-in-overdose-deaths-cdc
2013-2014: 79% increase in deaths related to synthetic opioids U.S. Department of Justice, Drug Enforcement Administration, DEA Investigative Reporting, January 2015. Centers for Disease Control, National Center for Health Statistics, Number of drug-poisoning deaths involving synthetic opioids: United States, 2013 2014, December 2015.
What percentage of the liquid market do we really have?
2014 and 2015 China-based fentanyl sold for $3,500 per kilogram. Counterfeit Prescription Pills Containing Fentanyls: A Global Threat www.dea.gov.
March and April 2016 Sacramento, CA 52 overdoses and 10 deaths from counterfeit pills. Lab showed pills contained fentanyl doses between 0.6-6.9 mg/pill 2 mg of fentanyl is lethal dose for non-opioid users)
March 2016 Lorain County, Ohio PD seized 500 pills that visually appeared to be oxycodone. Laboratory analysis indicated that the pills did not contain oxycodone, but were instead the research chemical U-47700
carfentanil acetyl fentanyl beta-hydroxythiofentanyl W-18 U-47700
Gas 'killed Moscow hostages', BBC News, 27 October 2002 Modest Silin, Hostage, Nord-Ost siege, 2002, Russia Today, 27 October 2007
The lethal dose range for carfentanil in humans is unknown; however, carfentanil is approximately 100 times more potent than fentanyl, which can be lethal at the 2- milligram range (photograph), depending on route of administration and other factors.
Opioid epidemic s hidden hazard: SWAT officers treated for fentanyl exposure during drug raid
Opioids #1 cause of pharmaceutical death in US Mortality = Respiratory ARDS Cardiac toxic
Narcotic Toxidrome Opiate Triad Altered mental status Decreased respiratory rate Pinpoint pupils (miosis)
Miosis
Opiate/Narcotic Toxidrome Hypotension Decreased Bowel Sounds nausea & vomiting Flushed skin and pruritus Local histamine release Urinary Retention Hypoglycemia Hypothermia
Unresponsive and known or suspected to have used narcotics End goal of adequate oxygenation and ventilation
Support Respirations Naloxone
Naloxone (Narcan) Blocks opiate receptors Clinical half-life of naloxone is roughly 20-60 minutes Can elicit withdrawal symptoms Should not be used in neonates
Intranasal Medication Administration Equipment Small syringe Atomizing device (preferred)
Intranasal Medication Administration Precautions: Beware damage to the nasal mucosa that may effect absorption of medications Vasoconstrictors (EG cocaine) prevent absorption Bloody nose, nasal congestion, mucous discharge Destruction of nasal mucosa from surgery or cocaine abuse
Insert in nostril and rapidly compress the syringe plunger. Brisk brief compression results in controlled atomization. Gently pushing the plunger will not result in atomization Consider pinching nose shut
Reversal Reaction
Long Lasting Opioids Methadone Propoxyphene Norpropoxyphene Normeperidine
Barbiturates Benzodiazepines Alcohol GHB Rohypnol Sleep agents Chloral Hydrate Ethchlorvynol (Placidyl) Sedative-Hypnotics
Sedative-Hypnotic Toxidrome CNS depression Ataxia Nystagmus Slurred speech Hyporeflexia
Questions? daniel.batsie@vermont.gov @danbatsie
The U.S. heroin user population is slightly smaller than the estimated methamphetamine user population and significantly smaller than the population reporting current use of marijuana, prescription pain relievers, or cocaine. However, the heroin user population is increasing in size at a much faster rate than any other drug of abuse. The number of people reporting current heroin use nearly tripled between 2007 (161,000) and 2014 (435,000), according to the Substance Abuse and Mental Health Services Administration (SAMHSA) annual National Survey on Drug Use and Health
heroin seizures in the United States increased 80 percent over five years, from 3,733 kilograms in 2011 to 6,722 kilograms in 2015.