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The Age of Fentanyl

The Age of Fentanyl

Ending the Opioid Epidemic
edition:Paperback
also available: eBook
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Excerpt

DRAFT

Introduction

The nurse on the phone told me Amber had been eating breakfast an hour earlier, she had seemed well, but now she was hardly breathing. She wouldn’t wake up. When I entered the room she looked so peaceful, somnolent, her long black hair spread across the pillow. I placed an oxygen meter on her right index finger and saw the blue sapphire glow under her nails, the sign of hypoxia I had seen in my textbooks. The oximeter beeped into life and confirmed what we could see with our own eyes. Amber was dying.

The most accurate sign of an opioid overdose is when a person takes less than twelve breaths a minute. Try breathing only once every five seconds. If you wait too long your brainstem takes over and forces you to breathe. Amber was breathing once every ten seconds. She was twenty-five years old. She had been admitted two days earlier to the third floor of the Toronto hospital where I was a fourth year medical student on the internal medicine ward. It took another sixty seconds to push a syringe of naloxone into the IV in her left arm.

Amber had come to the emergency room with a fever on Sunday night. Every part of her body hurt, her chest felt heavy, she thought she had the flu. Her doctor knew she was using needles. It was 2009 and more men and women like Amber were walking into emergency rooms across North America with track marks, abscesses, and infections deep in their bodies. More had been coming in by ambulance after overdosing as well. Amber was anxious, especially when she was told she had a murmur in her heart. She said no one had told her that before. Not that she’d been to the doctor in a while. Her mother drank and her father was long gone. Her teachers cared about her but she had left school and home at sixteen.

The first time Amber snorted heroin she forgot, for a while, about her mother, her absent father, the men who had hurt her and the small room where she lived with her latest boyfriend. The heroin travelled to opioid receptors in every part of her central and peripheral nervous system. The opioid molecules spurted into the narrow alleyways of the mesolimbic system, flooding her brain with the pleasure molecule, dopamine. She felt no pain. It was like floating in a pool of warm salt water.

She had only been injecting for a month when her fevers started. The heart murmur and the red sores on her arms, quickly identified as track marks by her doctor, led to the diagnosis, which took her some time to understand, of endocarditis; an infection in her heart. A mass of bacteria coalescing on her tricuspid valve sending waves of bacteria and debris ricocheting through her body with every heartbeat. We could see the mass, called a vegetation, using an echocardiogram, an ultrasound of the heart. We gave her penicillin and treated her fever.

The naloxone entered her IV, pulsed into her vein then filtered through to all the opioid receptors in her body. The tiny molecules displaced any opioids they found and blocked the receptors. In a few seconds she sat up with a start, eyes wide, startled, her black hair whipping around.

“Shit!” she exclaimed. She looked around in anger. “What did you do to me?”

The naloxone had put her into immediate opioid withdrawal but after a few minutes she calmed down. We explained that she had stopped breathing. We had needed to give her oxygen, put a mask and squeeze air with an Ambubag to help her breathe. She had overdosed. She had been using heroin in her room again, her boyfriend had smuggled it in, they couldn’t stop using. As we reminded her, she nodded, yes, it was true, that was what had happened. She had never been given naloxone before, so she had never been quite so rudely awakened from a drug slumber. It would still be a few years before naloxone would enter every paramedic’s bag and every pharmacy, before it would be pressed into the hands of people who used drugs across the continent.

It was 2009 and Amber was the first patient I had ever treated for an opioid overdose. She was the first patient with whom I discussed going to addiction treatment, trying methadone, something she said she had been thinking about more, especially now that she had this thing growing in her heart.

I had no special interest in addiction medicine at that time. I had done my masters thesis on tobacco control and I was interested in infectious diseases like HIV and hepatitis, but if someone had told me I would end up an addiction doctor, working on the front lines of the OxyContin then heroin then fentanyl waves of the opioid epidemic I would not have believed it.

But the epidemic called my name.

Opioids, like fire, like disease, like the hand that holds the knife, have been killing for millennia. There have been surges and waves and moral panics about drugs in the past. What is different this time is the durability of the epidemic. If we trace it back to the early 1990s, then we see how it has been with us, first hiding, lurking below public awareness, now frightfully obvious, for a quarter century. The other thing that is different is the scale, displacing all other causes of accidental death, reaching into every strata of society, pushing down life expectancy. The final thing that is different is fentanyl.

 

We have ridden three waves, so far, of the North American opioid epidemic. As more doctors prescribed more opioids, patients in the 1990s began to die from those medications. That was the first wave. The second wave began in 2010 as heroin became increasingly competitive with prescription opioids in terms of cost and purity and new heroin networks spread across the continent. The third wave began only a few short years later in 2013. We are in the third wave now, and it’s much worse than the 1990s, worse than 2010. The third wave is being driven by fentanyl (CDC 2018).

On February 13th, 2017 Ottawa Public Health and the Ottawa Police released an alert entitled "Potential Risk of Overdose from Counterfeit Prescription Pills". The notice warned that "illicit fentanyl has been detected in counterfeit pills manufactured to resemble prescription pills like Percocet. The presence of illicit fentanyl significantly increases the risk of overdose; it is fatal in very small amounts." I began to hear about the fake Percocet tablets from patients around the same time. The full force of the third wave was about to crash down on the continent.

The next day, February 14th, 2017, Chloe Kotval died of an overdose. She was 14 years old and in a photo her shoulder length brown hair frames her brown eyes, a subtle smile brightens her oval face. Two weeks later the Ottawa police confirmed that pills found near her body tested positive for fentanyl. More teens died in the same neighbourhood, parent groups demanded action, some parents got a naloxone kit and had that agonizing discussion with their children.

Sam Quinones writes of the epidemic in his powerful book Dreamland: “This epidemic involved more users and far more death than the crack plague of the 1990s, or the heroin plague of the 1970s; but it was happening quietly… Via pills, heroin had entered the mainstream. The new addicts were football players and cheerleaders; football was almost a gateway to opioid addiction. Wounded soldiers returned from Afghanistan hooked on pain pills and died in America. Kids got hooked in college and died there…They were the daughters of preachers, the sons of cops and doctors, the children of contractors and teachers and business owners and bankers” (Quinones 2015).

When first setting out to write Dreamland Quinones was sitting in a tavern in Covington, Kentucky when he fell into conversation with an elderly woman. He told her he was just beginning a book about the epidemic. She bade him to sit down and introduced herself as Carol Wagner: “Carole went on the tell me of her handsome, college-educated son, Chad, who was prescribed OxyContin for his carpal tunnel syndrome, grew addicted, and never got unstuck after that. He lost his home and family and five years later lay dead of a heroin overdose in a Cincinnati halfway house” (Quinones 2015). Quinones was “stunned that so random an encounter in America’s heartland could yield such personal connections to heroin.”

The opioid epidemic has spread across North America like spilled ink across the page. In April 2018, Evan Wood, a pioneer in addiction and harm reduction research in Canada, wrote that “Every indication is that North America’s opioid-overdose crisis is not abating, and experts have recently estimated that overdoses could kill more than half a million Americans over the next decade (Wood 2018). In 2017, almost fifty thousand Americans and four thousand Canadians died from opioids. Every year has seen big increases, in recent years these increases were driven by fentanyl.

In October 2018 all twenty one samples of drugs tested at my clinic in Ottawa which were sold on the street as heroin contained fentanyl, zero samples contained heroin. Of the fifteen samples thought to be speed or crystal meth, five contained fentanyl. In that unusually warm fall of 2018, without any prompting from me, patients were talking about the power of this synthetic opioid.

"The down has got a real hold on me now, I didn't even like down before, but the purple stuff, I think it's the fentanyl, I can’t stop. Whenever I see someone doing it, or someone offers it to me, I have to use." Clara told me one afternoon. “It’s so easy to get, it’s cheap, only twenty bucks for half a point.” She looked away for a moment then continued. "I can't expect anyone to help me, I'm not helping myself. I've been so fucked up since I started on fentanyl. Yes I was using before, but now all I can think about is getting my next point of fentanyl, the first thing I have to do is stop using"

Even people who weren’t using fentanyl were affected as my next patient told me. "I missed my appointment yesterday because I went to a wake, my friend overdosed on one of those new kinds of fentanyl, the kind you can't come back from"

The idea that there was a kind of fentanyl that you could not come back from had entered the minds of people who used drugs in towns and cities across the continent. The world was changing.

But there was also good news that day.

“Doc, I haven’t used in a month”

I was surprised. Joel had been my patient for 3 years and I’d never seen him go more than three days without smoking, injecting, swallowing or snorting an opioid.

“That’s amazing. How did you do it?”

“I was tired of fucking up, I just woke up the other day and I didn’t feel like using” he grinned.

I looked at his matted blonde hair, his pale cheeks marked with a few days of stubble and then back at his smile. It was different. That smile had been driven away by terrible withdrawal symptoms, sleepless nights smoking crack and injecting heroin, the police pounding on his door and jail time. It wasn’t rueful, ironic or self-deprecating. It wasn’t the smile I had seen a few months earlier when he told me “I’ve gotten very good at crime, I’m not proud of it.”

This new smile changed his face.

Amongst the daily assault of dark news and pessimism about the epidemic, I see the light of such small successes almost everyday. In the safety of my office, face to face with a huge photo of a traditional rehab scene – a tranquil mountain lake just as the sun is about to set – a patient will unwrap layers of shame and trauma and share their fragile victories.

I have seen how exquisitely delicate these periods of recovery can be so I treat them with great care. We talk about how to nurture their success, how to incubate this newfound freedom from opioids.

But each time I see some light, I am reminded that the tragedies have not stopped. At meetings of physicians this reminder is a simple line on a graph labeled “Overdose Deaths.” The line points up as the death rate continues to climb, dragging down life expectancy for entire swathes of the population and destroying families and communities in the process. Life expectancy in the U.S. went down for two years in a row because of the rising death toll. One morning I opened a journal to see a simple statistic: one hundred and fifteen lives are ended by opioid overdoses every day in the U.S.

The news is filled with overdoses, but death is only the final frame in a life filled with scenes of lost careers, ruined relationships, sickness, jail time and secret misery.

“I haven’t told my dad that I relapsed, I was doing so good. He keeps asking why I’m losing so much weight, I think he knows” Carl told me recently, as sweat poured down his angular face and he looked at me through swollen pupils.

We talked about increasing his dose of buprenorphine and we booked a follow up visit in a week to reassess his use. I looked at his urine drug screen which was positive for heroin, fentanyl and cocaine and thought about our visits two years earlier when Carl had celebrated a whole year without drug use.

“Why do you want to stop using this time?” I asked.

"I'm getting tired of watching all my friends die. I look around to all the people I got into this mess with and they're all gone. Why should I wait to quit when I’m fifty, when the damage is already done?”

The next week Carl came back to share his success. “My cravings are much better now. I started reading this book. It’s the first time I’ve read a novel”

Carl told me he went 3 days without injecting fentanyl. I noticed he wasn’t sweating as much as at our last visit and his pupils weren’t as big. I increased his dose of buprenorphine again and we made a plan to meet in another week. Carl was on the first rung of the ladder. We talked about his supports. His girlfriend was still using heroin and cocaine, but she was also trying to quit. His dad supported him, but he was keeping the truth from him. He had recently seen a psychiatrist and was on a mood stabilizing medication. His sleep was getting better as his opioid withdrawal symptoms were treated by his buprenorphine. He hadn’t missed an appointment with me for several months. Things were starting to come together for Carl.

The next day Pamela sat down in front of me with a strained smile which then transformed into a face of agony. “I need to get out of this city, I just found out another friend of mine died. We were supposed to meet up yesterday but she never came. I called her like ten times yesterday but it went to her voicemail. Then today I heard she was found in the stairwell across the street from my place”

The tears streamed down her face and I felt her raw emotions wash over me. In the hallway that leads to the drop in area of our clinic, there is an overdose memorial wall filled with names and photos. Sometimes people write messages of farewell next to the faces. I knew that Pamela’s friend would be one more name on the wall, one more face.

As the death rate climbed stories like Pamela’s became commonplace. She was the last person to talk to the recently deceased, he was texting at the time, they had used the same heroin. Pamela reflected on her own life that day, wondering why she hadn’t died, exuding classic survivor guilt that is seen in every epidemic or natural disaster. There but for the grace of God go I.

“I must have tolerance, I must have, because I’ve been using the same fentanyl as everyone that died” she told me through her tears.

Overdose deaths ricochet through the community, impacting everyone differently, adding to the burden of fear, guilt and trauma. They affect people in many ways such as when Julian tried to resuscitate a teenager who had overdosed in the lobby of the hotel he worked in using a naloxone kit and the rudimentary CPR he had learned in high school. “We were trying to resuscitate a dead kid, he was like only nineteen. It was fucking terrible” he told me afterwards

Other times the consequences are more unexpected.

“A guy at the shelter overdosed and set the bed on fire, now I've got nowhere to sleep" Larry told me when I asked him where he was living. This time there was no death as the fire alerted the shelter workers and they dragged the young man out of the burning room and were able to administer naloxone before calling both the paramedics and the fire department.

Sometimes, weeks will go by without anyone mentioning an overdose and everyone relaxes a little, maybe gets a little complacent about where they are getting their drugs from or how much they use in one shot, until there is another death.

How did we get to this point in history, this line on a graph? The Ancient Egyptians cultivated poppies and wrote prescriptions for opium on medical papyri. The word opium itself comes from the Greek word for poppy juice opion. We have engineered the poppy to make powerful medicines to control pain. Opioids make people feel euphoric, tranquil, free. They calm people living with ceaseless anxiety or sadness. As our bodies become tolerant to opioids we need to use more and the more we use the more the opioids quiet our level of consciousness, even our will to breathe.

Pamela told me that heroin is like an abusive lover, he gets under your skin and into your mind. Opioids make you feel high then bring you down. They make you feel calm and safe and then smother you in your sleep. All you can think about is your next point of heroin or your next pill of Percocet, but more than anything you want to stop using. You want to get away, you fight, but the opioid fights back. It gives you chills and drenching night sweats, it makes you vomit, it makes you want to jump out of your skin, it makes you crazy with revulsion and desire. It is the perfect biological weapon aimed at the pleasure centers of the brain. People from every walk of life have stepped into the boiling sea of opioids filled by doctors and dealers and pilfered from medicine cabinets across the continent.

A friend told me that when he took opioids for 2 days after an injury “I’ve never felt better in my life, I was so happy and I got so much done.” Another doctor told me she wasn’t going to stop prescribing opioids “Because they work, I’m careful with them and they help people.” People feel good when they take them and doctors feel good when they can relieve their patients’ suffering. It has proved to be the perfect storm.

Sandra, a thirty year old veteran of the street, looked at me and asked a simple question. “What’s going on? Why is this happening?” Like Sandra I wanted to understand why opioids work so well and kill so easily. I wanted to understand the history that brought us to this point. Finally I wanted to lay out and inspect the weapons we have against this scourge – treatment, prevention, harm reduction – and make a battle plan, a call to arms, to beat this thing. We are in a race against death. Every day we do not solve the epidemic more lives are lost.

Opioids are the catalyst of a story that is as complex as the lives it touches. We will travel into darkness with patients like Carl and Pamela, but we will also see their light. I will open the door into clinics and hospitals, into needle exchanges and safe injection sites across the continent. We will look together into the past of America’s addiction to opioids, into the deep past of the poppy seed then follow heroin and OxyContin as they are born and spill across the continent. We will see the moment on December 8th, 1960 when fentanyl was first built from solvents and reagents in a lab in Belgium. We will see that science can be a weapon for good as hope emerges in the form of methadone, buprenorphine, naloxone and new treatments to come, technologies we cannot even imagine. And we will meet the champions fighting the disease; the nurses, the social workers, the doctors, the people who use drugs and the visionaries. This is a story of hope.

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