News about the accelerating rise in death by drug overdose hits the headlines in our country almost weekly. A report from the CDC, which was released on May 11, 2022, indicates that one drug overdose death occurred every five minutes in the US in 2021, an increase of 15% from 2020, and the year’s death toll crossed the 100,000 mark for the first time.
What is behind this, and what can be done?
The spread of synthetic opioids is, in large part, to blame. Produced in celandine laboratories, these highly potent drugs are quite deadly. Fentanyl—one of the more popular synthetic opioids—caused more overdose deaths than any other drug last year. It is highly potent, and therefore even small amounts can cause rapid respiratory suppression and death, especially in people with little prior experience with opioid use.
One reason for the recent spread of synthetics is that drug trafficking patterns have changed. Increasing difficulty getting drugs across the border has led drug producers to switch from farming opium poppies to drug production in laboratories. Cartels are finding it easier to produce and distribute synthetic opioids without getting caught as compared to plant-derived drugs like heroin. Drug control officials are calling the spread of synthetics a “nightmare.”
The pandemic has fueled the spread of synthetic opioids also. For one thing, isolation from quarantine led more people to seek comfort in drugs of abuse. Secondly, it made border crossing more difficult, favoring illegal drug production locally.
Why the synthetic opioid problem is so hard to treat
People who develop an addiction to synthetic opioids have a unique set of obstacles to face when they want to stop.
- First, it can be harder to get started on relapse prevention treatment. Medication-assisted treatment (MAT) is a primary treatment for opioid use disorder (OUD). There are three primary medications that help promote recovery: extended-release naltrexone (Vivitrol), buprenorphine (ie, Suboxone), and methadone. When fentanyl is someone’s drug of choice, it can be harder to initiate buprenorphine and naltrexone because fentanyl stays in the body longer than other opioids, like heroin, and these two treatments have some opioid-blocking effects. If opioids are still in the system when someone takes their first dose of either, people can go into opioid withdrawal, which can be extremely uncomfortable. Unfortunately, buprenorphine and naltrexone both have advantages over methadone, the third option, because they have reduced overdose risk and potential for abuse.
- Second, synthetic opioids are often mixed with stimulants like methamphetamine. Therefore, these days addictions to both opioids and stimulants are common. People who use more than one substance have a harder time staying in recovery when they try to quit. Animal studies show that exposure to one of the two drugs will trigger drug-seeking behaviors for both drugs; relapse to one may trigger relapse to the other.
- The third obstacle is more speculative. Could fentanyl be more addictive than some of the other opioids as a result of its high potency? Does it have more powerful effects on the reward circuitry, and could it, therefore, be more reinforcing and harder for people to quit? So far, few studies have been done to answer this question. Clinicians report that people with synthetic opioid problems have a harder time staying in recovery. More research in this area is needed.
There are several novel approaches under study or available today that specifically target the synthetic opioid problem.
- Fentanyl test strips: Many of the people who overdose on fentanyl are never even aware that they are taking fentanyl at all. Counterfeit pills containing synthetic opioids are marketed as other opioids, like oxycodone, or sedatives, like alprazolam. High-schoolers are at particularly high risk of taking fentanyl without knowing it and overdosing. Fentanyl test strips allow people to test whether fentanyl is present in a drug they have just purchased to know what they are taking. States across the country are legalizing the tests so that harm reduction programs or schools can distribute them. However, not all states are on-board with legalization. For example, Florida’s legislature maintained the test strips’ status as drug paraphernalia and therefore illegal.
- Fentanyl vaccines: Drug vaccines have been under study for several decades for nicotine and cocaine. The concept behind a drug vaccine is that it will induce the body to produce anti-drug antibodies so that upon use, the existing antibodies would bind to the drug, rendering it inert and preventing both the high and the overdose. However, despite this, vaccines haven’t found their way to the market due to somewhat disappointing results in human studies. However, there is a growing interest and research into this kind of product again for synthetic opioids with some promising findings in some animal studies.
- Low-dose buprenorphine inductions: Individuals who use fentanyl are afraid of starting buprenorphine due to the higher-risk precipitated withdrawal. A buprenorphine rapid overlap initiation (ROI) protocol (also known as “rapid micro-dosing”) utilizing small, escalating doses of buprenorphine may be able to overcome this barrier, early studies say, allowing people to reach therapeutic doses in 3 to 4 days without excessive amounts of withdrawal.
- Methadone take-homes: Recall that methadone is one of three primary opioid use disorder medication-based treatments. It is a long-acting opioid and is only dispensed in specially-licensed clinics. When starting out, most patients receive their doses under supervision, with daily visits to these clinics. Over time, with more time abstinence from illicit opioids, they are allowed to have more and more take-home doses. With the pandemic, many methadone clinics have loosened the restrictions for take-homes and found it was surprisingly uncommon for people to sell their methadone or overtake it and overdose. Since naltrexone and buprenorphine are more difficult to start in people who have a problem with synthetic opioids, methadone might be a better option, especially if quicker transitions to take-home doses make a methadone regimen more practical.
Ongoing efforts that benefit treatment for all types of opioid use disorder, such as increasing access to treatment in underserved and rural areas and making naloxone, a life-saving overdose antidote, available, should be prioritized, too.
Synthetic opioids, including fentanyl, are an increasing problem. Likely the drug overdose epidemic is here to stay for a while. Much work still needs to be done to determine how to best combat it at the research, public policy, and treatment levels. But, despite the dire statistics, there has also been progress, and there is reason to hope.