We’re in the midst of an opioid overdose epidemic in the U.S., and the synthetic opioid fentanyl has now surpassed heroin and oxycodone as the leading cause of overdose deaths. In 2016, fentanyl was involved in nearly 30 percent of drug overdose deaths, accounting for more than 18,300 deaths that year. 1 It’s a sharp rise from 2011, when the drug was involved in just 4 percent of such deaths.
In 2011, oxycodone, the active drug in prescription painkillers such as Percodan and Percocet, was responsible for the most overdose deaths. The title then transitioned to heroin from 2012 to 2015, 2 and now fentanyl.
The rate of drug overdose deaths involving fentanyl doubled each year from 2013 through 2016, from 0.6 per 100,000 in 2013 to 5.9 in 2016, according to a report from the U.S. Centers for Disease Control and Prevention's (CDC) National Center for Health Statistics. 3
"Fentanyl is so deadly in the geographic regions where it's been flooding in, deaths soared like we've never seen before,” Dr. Andrew Kolodny, cofounder of Physicians for Responsible Opioid Prescribing, told CNN. 4
What Makes Fentanyl so Deadly?
Fentanyl is a synthetic opioid that’s up to 100 times stronger than morphine. Originally developed as a pharmaceutical drug for the treatment of cancer pain (typically administered in the form of a patch on the skin), fentanyl soon became a drug of choice for abuse.
The U.S. Drug Enforcement Administration (DEA) classifies fentanyl as a Schedule II substance, which means it has a high potential for abuse, and abuse may lead to severe psychological or physical dependence. 5 According to the DEA: 6
“Fentanyl is added to heroin to increase its potency, or be disguised as highly potent heroin. Many users believe that they are purchasing heroin and actually don’t know that they are purchasing fentanyl — which often results in overdose deaths. Clandestinely-produced fentanyl is primarily manufactured in Mexico.”
Fentanyl has a number of street names, ranging from China White and Apace to Great Bear and He-Man, but the ones that are the most fitting are Poison and Murder 8. When fentanyl is ingested, it produces a sense of well-being or euphoria that reduces anxiety and aggression.
The high is intense, but it’s also only temporary, giving way to drowsiness, trouble concentrating and apathy. If too much is taken, fentanyl can also lead to slowed respiration, reduced blood pressure, nausea, fainting, seizures, coma and death.
“As the dose is increased,” the DEA notes, “both the pain relief and the harmful effects become more pronounced. Some of these preparations are so potent that a single dose can be lethal to an inexperienced user. However, except in cases of extreme intoxication, there is no loss of motor coordination or slurred speech.” 7
Psychological and Physical Dependence Are Common With Fentanyl Use
Because of fentanyl’s potency, it’s easy to quickly become dependent. A person who’s physically dependent on fentanyl will experience withdrawal symptoms when drug use is discontinued. At first, this may be in the form of a runny nose and sweating, but it will progress into irritability, cravings for the drug, depression, increased heart rate and blood pressure , chills, flushing and excessive sweating. 8
As for psychological dependence, this can continue even after the physical need for the drug has passed, and may cause the person to think about using the drug and have trouble coping with daily activities without it. 9
Both prescription and “black market” fentanyl are problematic. Prescription varieties, which exist in tablet, nasal spray, patch, injectable and lozenge formulations, may be obtained by patients, physicians or pharmacists distributing them, as well as via theft or fraudulent prescriptions.
Illegally produced fentanyl can also be found, typically in powder or tablet formulations and sometimes in combination with heroin. Fentanyl has also been identified in counterfeit pills meant to mimic oxycodone.
According to the DEA, data from the National Forensic Laboratory Information System reveals increasing reports on both pharmaceutical and illegal fentanyl by federal, state and local forensic laboratories in the U.S., increasing from 5,400 reports in 2014 to more than 14,600 in 2015. 10 The rise in fentanyl usage is a sign that the opioid epidemic may get worse before it gets better.
As Dr. Harshal Kirane, director of addiction services at Staten Island University Hospital in New York City, said in a news release, "It represents an evolution of the opioid crises in which patterns have shifted to a much more potent drug, putting users at a greater risk of overdose and death." 11
Are Doctors Prescribing Fentanyl for Everyday Pain?
The U.S. Food and Drug Administration (FDA) approved fentanyl for treating breakthrough pain in cancer patients — a type of severe pain that occurs despite the patient being treated with other painkillers. Yet, in a complaint filed by the U.S. government, it’s alleged that Insys, which manufactures Subsys, a fentanyl under-the-tongue spray, focused its marketing campaign on treating pain in general.
The complaint is the result of an investigation into five whistleblower cases filed by former Insys sales representatives as well as workers of a pharmacy benefits manager that processed insurance claims for Subsys. 12
Subsys was approved in 2012 and approached sales of $500 million just three years later. This dramatic rise in sales was not happenstance but a carefully orchestrated marketing ploy of a highly addictive drug.
In May 2015, the U.S. Department of Justice (DOJ) announced it was intervening in the five whistleblower lawsuits, which accuse Insys of paying illegal kickbacks and defrauding federal health programs in the marketing of Subsys.
The complaint further reveals some of the tactics Subsys used to get doctors to write more prescriptions. Among them, a pain specialist from Florida was taken to a strip club and a shooting range by Insys executives.
Medicare has paid more than $3 million for Subsys prescriptions from this one doctor, since 2012. In another case, sales reps offered another Florida pain specialist a full-time job for his girlfriend, if he could increase his prescriptions of Subsys. He wrote prescriptions for 60 units over the course of just two days, and his girlfriend received the job a month or two later.
Meanwhile, while the drug was only supposed to be used for cancer patients, Insys sales reps frequently promoted the drug for off-label uses to doctors without cancer patients, for treating chronic pain ranging from back pain to headaches. In fact, up to 90 percent of Subsys prescriptions are for off-label uses, 13 even though the potential for deadly overdose is high.
Stat News reported on one such death — 32-year-old Sara Fuller, who was prescribed the Subsys to treat pain from car accidents and fibromyalgia. A year later, she died from a drug overdose, with a toxicology screen showing a lethal level of fentanyl in her blood. 14
Is Your Doctor Paid by Opioid Makers?
Many are not aware that doctors receive payments from pharmaceutical companies, even those marketing dangerous opioid drugs. A study published in the American Journal of Public Health 15 used the online Open Payments Program from the Centers for Medicare and Medicaid Services to reveal opioid-related payments to physicians between August 2013 and December 2015.
More than 375,000 nonresearch opioid-related payments were made to more than 68,000 physicians, totaling more than $46 million. This amounts to 1 in 12 U.S. physicians receiving money from drug companies producing prescription opioids. The top 1 percent of physicians received nearly 83 percent of the payments, and fentanyl was associated with the highest payments.
You can also use Open Payments to search and find out what (if any) payments your doctor has received from the pharmaceutical industry , along with the nature of the payments.
Are Opioids Necessary for Pain Relief?
A case could be argued for giving fentanyl to a terminally ill cancer patient near the end of his life. That case gets much harder to support, however, when the patient is dealing with moderate or even severe pain from other causes, such as backache or fractures or other injury, as the risks are just too high.
What’s more, such drugs may not even be necessary to provide adequate relief. Research published in the Journal of the American Medical Association (JAMA) suggests, for instance, that less risky opioid-free options may work just as well. 16
The study evaluated the effects of four different combinations of pain relievers — three with different opioids and one opioid-free option composed of ibuprofen (i.e., Advil) and acetaminophen (i.e., Tylenol) — on people with moderate to severe pain in an extremity, due to bone fractures, shoulder dislocation and other injuries.
The patients had an average pain score of 8.7 (on a scale of zero to 10) when they arrived. Two hours later, after receiving one of the pain-relief combinations, their pain levels decreased similarly, regardless of which drug-combo they received. Specifically, pain scores fell by: 17
- 4.3 in the ibuprofen and acetaminophen group
- 4.4 in the oxycodone and acetaminophen group
- 3.5 in the hydrocodone and acetaminophen group
- 3.9 in the codeine and acetaminophen group
“For patients presenting to the ED with acute extremity pain, there were no statistically significant or clinically important differences in pain reduction at two hours among single-dose treatment with ibuprofen and acetaminophen or with three different opioid and acetaminophen combination analgesics,” the researchers concluded. 18
Think Carefully Before Taking Opioids for Pain
According to the CDC, the number of drug overdose deaths in the U.S. has never been higher. From 1999 to 2016, 197,000 people have died from overdoses related to prescription opioids alone. 19 It’s not uncommon for a person to start taking an opioid due to an injury, only to become dependent on the drug.
Then, when their prescription runs out and their doctor won’t prescribe anymore, they turn to the black market and may soon start taking heroin, fentanyl or a combination of the two.
Tolerance is also a common side effect of opioids, which means if you take such drugs for a chronic condition, like back pain, you might need to take more and more of the drug to get the same pain relief over time — which also puts you at risk of overdose. If you’re in pain, it can make you feel desperate for relief, but think carefully before resorting to opioids.
Ibuprofen and acetaminophen are generally safer options than opioids, but even these come with risks, which is why I recommend exhausting nondrug options for pain relief first.
Chiropractic adjustments, 20 massage and acupuncture 21 are examples of therapies that can get to the root of your pain, whereas tweaking your diet can also lead to relief from chronic pain conditions. There are even topical options, such as capsaicin cream , which is made from hot peppers, that are proven to decrease pain without the use of drugs. 22
The opioid overdose epidemic has gotten so bad that even the CDC recommends talking to your doctor about ways to manage pain that don’t involve prescription opioids, and admits that some of the natural options below “may actually work better and have fewer risks and side effects”: 23
- Cognitive behavioral therapy “ … to modify physical, behavioral and emotional triggers of pain and stress”
- Exercise therapy, including physical therapy
- Exercise and weight loss
- Other therapies such as acupuncture and massage