The Opiate Overdose Crisis: An Experiment in Vancouver Suggests a New Approach

Across North America, first responders and hospitals report a deluge of overdoses among heroin users whose drugs are mixed with fentanyl, a strong synthetic opiate or the even more powerful carfentanil, which is used in veterinary anesthesia. Word from Vancouver is that public health workers have used a reagent test for the presence of fentanyl in other street drugs for the clients that they serve.

In addition to the dangers posed by heroin itself, these additives make street doses unpredictable in strength.  By volume, the synthetics are much more powerful, and street users depend upon illicit manufacturers and distributors to supply semi-predictable products. Although many street users now expect that the heroin they buy (and sometimes, the cocaine) will contain synthetics, they also have little or no way to know how carefully compounded these drugs are. Judging from the rapid rise in overdoses in recent weeks, the answer is that dosage chaos reigns.

Why Vancouver first? First, British Columbia is treating it as the emergency it is. It declared it as such in April 2016, with the CBC reporting that by June, 71 overdose deaths had taken place and 60% involved fentanyl.  But uniquely, the city has a government-funded organization called Insite, a supervised injection site for drug users. Nurses and other clinic workers staff the place, and it is the only program like it right now in North America. Insite also has some health care services, provides clean needles and can respond to overdoses on site.

Drug users bring in their own drugs, and they are free from the risk of arrest while they are there. This also provides an opportunity for drug testing. Consumers of the drugs can learn about the composition of the drugs they are about to inject, while the clinic can gain information about, and report on, trends in purity and composition of street drugs.

Which brings us to the potential of fentanyl test strips. Francine Diep reports in Pacific Standard magazine that fentanyl testing may – emphasis on may – provide some benefit to drug users by detecting its presence. Insite ran a pilot testing program this summer, using the strips for a month on as many samples as they could. 90% of the heroin samples contained fentanyl, and some of the cocaine samples did, as well.

There are two key issues here. First – how accurate the tests are from a strictly scientific viewpoint: what are the rates of type I and II errors, and what is the specificity to the problem of an adulterant like fentanyl as opposed to cross-reactions to other less deadly ingredients? The strips were originally designed to test urine, and in lab settings it has a 6% false positive rate and a 0% false negative rate. Most of the medical consultants on Insite’s project felt that it might do just as well in water-dissolved samples at the clinic. In the abstract, the low false negative rate is good news. The test strip doesn’t react to carfentanil, however.

It should be kept in mind that some users actively seek out synthetic opiate pills, either preferring them to injecting heroin or using them as a bridge at times when heroin is hard to come by.  People who buy hydrocodone illegally may be getting fentanyl instead, or a mixture, and again, the unexpected strength can be deadly. It appears that fentanyl in a hydrocodone preparation is what killed legendary musician Prince at age 57 in Minnesota this past spring.

Also, to what extent does a positive result for fentanyl discourage a user from injecting the drugs? Diep notes that few people at the Vancouver site seem willing to throw away contaminated drugs altogether. But staffers suggest they may be willing to lower their intake if they know the powerful synthetic is present.  The clinic reports that 86% of the drug samples they tested contained some fentanyl, which implies that at least for the population that uses that clinic, it may be hard to avoid.

Fentanyl is now everywhere. It can be purchased on cryptomarkets online, where either tablets or ingredients can be obtained. Making it is not that difficult, and mid-level distributors can move into manufacture. It can also be diverted from legitimate medical use, as it is often prescribed to people with cancer.

Similar ideas for other cities have been stymied by an insistence on abstinence and prohibition-based approaches and legislation which inhibits or quashes altogether such harm-reduction opportunities, in both Canada in the US. The only recent harm-reduction initiative that hasn’t been aggressively and routinely blocked is overdose-reversal medication like naloxone, which many communities distribute to first responders or make available to the public by prescription.

But as synthetic mixes hit the streets, naloxone is less effective. Reports from Indiana suggest that when carfentanil is present, even five or six doses of naloxone may not reverse the effect. Carfentanil is also powdery and light, posing risks to police and EMTs who respond to places where the drug is present just by touching or inhaling it, in a similar way that methamphetamine making can expose others to risk.

So, the way to think of the new synthetic adulterant problem is: a mess we don’t know how to handle, situated on top of a mess that we do know more about than we are willing to do.  You’d think decades of a failed War on Drugs – drugs won, in case you haven’t been keeping up – would demonstrate the need for greater humility and innovation in policy making. The pilot project in Vancouver can save lives and prevent injury, and similar programs could also tell us a great deal about drug adulteration, and how best to protect public health.

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