Fentanyl’s path of death and destruction

Fentanyl is a prescription drug and its use represents a growing public health crisis in some parts of our country. Reports of use and overdose deaths occur at regular intervals, with British Columbia declaring a public health emergency after overdoses killed 200 people in the first three months of 2016.¹ Between 2009 and 2014, there were at least 655 fentanyl-related deaths in Canada, with an average of one death every three days – and this figure is probably an underestimate.² During this period, the number of fentanyl-related deaths increased close to 7-fold in BC and 20-fold in Alberta, while in Ontario and Quebec the rates increased by 1.7-times and more than two-times, respectively.² Many of these victims, however, were not people who use substances in a problematic way but people who occasionally use substances who did not recognize the drowsiness, difficulty breathing and slowed heartbeat that occur with fentanyl overdose.³ The vast majority (73%) of study participants that tested positive for fentanyl did not report its use, indicating that many people who occasionally use substances may be unknowingly exposed to fentanyl.⁴

In the United States, fentanyl overdose deaths (47,055 people in 2014 or 125 Americans every day) are reaching levels similar to the number of HIV-related deaths reported at the peak of that epidemic.⁵ The US Centers for Disease Control and Prevention (CDC) estimates that for every overdose death, there are 10 treatment admissions for use, 32 emergency department visits for substance use, 130 people who have substance use disorder and 825 people who occasionally use substances.⁶

Fentanyl is a powerful synthetic opioid pain reliever that is chemically similar to morphine, but 50 to 100 times more potent.⁷ It was initially used for cancer patients and others suffering debilitating pain, but its use has been broadened to include those needing moderate to severe pain management.⁸ Canada is now the second-largest per capita consumer of prescription opioids (exceeded only by the US).^9,10 This trend coupled with an increasing level of use was recognized and opioids have been reformulated to reduce the likelihood of use.¹¹ These actions made it difficult for long-term users and they started looking for alternatives, including counterfeit pills.¹¹ Fentanyl enters the black market by diversion of pharmaceutical fentanyl products (primarily transdermal patches) from domestic supply channels, or more importantly, by the illegal importation of the drug via internet sales,¹² notably from China.²

Steps are being taken to address fentanyl use, including the “Take Home” naloxone program which was initiated in British Columbia in 2012 and is currently available at 62 sites in that province.¹³ In addition, Canada’s Minister of Health has highlighted several steps she will take to address this issue. These include providing Canadians with better information about opioid risks; improving medical practices to support better opioid prescribing practices; reducing access to unnecessary opioids; expediting regulatory approval and importation of naloxone nasal spray; supporting improved treatment options for patients with addiction; and improving the evidence base.¹⁴ These actions can be contrasted with the steps being proposed in the US where new opioid prescribing guidelines were released in March 2016 that focussed on rationalizing prescribing practices and patient education.¹⁵

Whether these approaches will be sufficient remains to be seen. What is clear, however, is that Canada’s ongoing opioid crisis requires immediate and collective action aimed at reducing harm through a public health approach.