A Week in the Life (aka Fentanyl, Heroin & Elephant Tranquillisers)

I read the news today, oh boy

59,000 deaths from opioids

And though their lives were rather short

We had to count them all,

Now we know how many scripts it takes to fill the mortuary hall…

There’s a risk when reading repeatedly the horrifying statistics associated with opioid harms that, like a dose of fearsomely potent fentanyl, a certain spreading numbness can ensue – deadening the pain made manifest in the numbers. But the opioid epidemic, crisis, scourge… pick your label, continues in the news. And well it should  – the US (consumers of 80% of the world’s opioid supplies) is facing the deadliest drug epidemic in its history and the numbers from the UK, Canada, Australia, amongst others, show worrying signs of mimicking the trend.

The grim ‘new normal’

When the Pill Mills stopped churning, many addicted to prescription opioids turned to heroin resulting in a seemingly never-ending tsunami of death and tragedy. In a powerful recent piece on cincinnati.com, over 60 reporters, photographers and videographers were ‘sent out to chronicle an ordinary week in this extraordinary time’:

Seven days of heroin

This is what an epidemic looks like:

“Ali walks along McMicken Avenue in Over-the-Rhine, looking for someone willing to pay her for sex.

It’s what she does to get money to buy fentanyl, and to keep a roof over her head. She’s 25 and addicted to the synthetic opiate. She used to take heroin, but now she prefers the more powerful and more dangerous synthetic…

“The taxpayers are paying for this crisis, but they didn’t create this crisis.” – Clermont County Commissioner David Painter, announcing a lawsuit that claims wholesale pharmaceutical distributors fuelled the heroin epidemic…

Elliana, who turns eight months old today, is here for a checkup at Cincinnati Children’s Hospital Medical Center. She’s a patient at a special clinic that treats babies for neonatal abstinence syndrome, which occurs when babies are born to mothers addicted to heroin…” (emphasis added)

Rising faster than ever

Josh Katz in The New York Times on June 5 2017

AKRON, Ohio — Drug overdose deaths in 2016 most likely exceeded 59,000, the largest annual jump ever recorded in the United States, according to preliminary data compiled by The New York Times.

Early data from 2017 suggests that drug overdose deaths will continue to rise this year. It’s the only aspect of American health, said Dr. Tom Frieden, the former director of the C.D.C., that is getting significantly worse. Over two million Americans are estimated to be dependent on opioids, and an additional 95 million used prescription painkillers in the past year — more than used tobacco. 

Current estimates suggest that upwards of 100,000,000 Americans experience persistent pain.

Huntington’s disease

Huntington, West Virginia has been labelled America’s overdose capital. A recent Netflix documentary followed three women – a fire chief, a judge and a street missionary as they try to save lives and save the community

“Once a bustling industrial town, Huntington, West Virginia has become the epicenter of America’s modern opioid epidemic, with an overdose rate 10 times the national average. This flood of heroin now threatens this Appalachian city with a cycle of generational addiction, lawlessness, and poverty.”

It’s difficult to watch, but you should.

Andrew Joseph back in August 2016 writing about the situation in Huntington for statnews.com:

The heroin problem emerged about five years ago when authorities around the country cracked down on “pill mills” that sent pain medications into communities; officials here specifically point to a 2011 Florida law that arrested the flow of pills into the Huntington area.

As the pills became harder to obtain and harder to abuse, people turned to heroin. It has devoured many communities in Appalachia and beyond.

It’s possible that the rash of overdoses was caused by a particularly powerful batch of heroin or that a dearth of the drug in the days beforehand weakened people’s tolerance.

But police suspect the heroin here was mixed with fentanyl, a synthetic opioid that is many times more potent than heroin. A wave of fatal overdoses signaled fentanyl’s arrival in Huntington in early 2015, and now some stashes aren’t heroin laced with fentanyl, but “fentanyl laced with heroin,” said Police Chief Joe Ciccarelli. (emphasis added)

Another possibility is carfentanil, another synthetic opioid, this one used to sedate elephants.

A crowd of people stood and stared*

Not every person who takes prescription opioids will become addicted, and not every addict started on the road to devastation with a prescription for Oxy for chronic low back pain, but amongst the shattered lives in both groups are our patients, and former patients, and no health care professional can belong to a crowd that stood and stared and wondered if we’d seen the latest face, cold, blue and lifeless, of the opioid epidemic before, perhaps in our clinic. One of the best bits of writing I’ve read for a while was a call to action in a forthcoming paper – I know the authors wont mind me paraphrasing this bit:

“It’s time to stop watching and being too timid to act. It’s time to really awaken, rise up and use our skills to do something about the problem of pain – it’s time to lead our communities out of this opioid crisis.”

If you’re not a prescriber, maybe this means picking up the phone and calling whoever signs the prescription for the opioids and asking some (hard, unpleasant, uncomfortable even) questions about the plan to stop them – you’re backed by now overwhelming evidence that persistent pain is made worse, not better, by opioids. If you are a prescriber, if you haven’t already, this may mean considering not even starting people on opioids to begin with for persistent pain, and investigating other options for pain treatment.

Standing and staring is not an option.

-Tim Cocks

*Of course, I owe a debt to Lennon and McCartney and their greatest ever, and most poignant, work.