by Greg McClenaghan
Drug addicts turned to the prescription drug fentanyl since OxyNeo® was introduced in 2012. Once used mainly to treat patients in palliative care or suffering cancer-related pain who have built up a tolerance to other opioids, it is now finding its way to the street. Fentanyl has been linked to almost two dozen overdoses and deaths in North Bay, Ontario alone.
Fentanyl is a synthetic opioid analgesic used as an anesthetic in operating rooms and intensive care units and clinically to manage chronic pain. When used for pain, it is administered either as a lozenge or through a transdermal (skin) patch that allows for continuous extended release into the bloodstream.
The patch has a backing to protect it from the environment, a drug reservoir, a porous membrane that limits the rate of drug transfer and an adhesive so it can be secured to the skin.
Aside from the drug’s therapeutic applications, fentanyl is a potent drug of abuse.
Commonly referred to on the street as “the patch” and “stickies,” abuse has included illicit preparations of the drug and diversion of clinical preparations. In particular, abuse of the patches has received increasing attention in recent years.
The abuse of patches is not restricted to transdermal application; contents are also injected intravenously, volatilized and inhaled and taken orally.
There are several sources of illicit fentanyl: “double doctoring” (until the centralized prescription tracking system came into effect), prescription forgeries, overprescribing, pharmacy robberies and B&Es and diversions from individuals with legitimate prescriptions.
Although the majority of fentanyl available on the street in North Bay is trafficked by criminal entrepreneurs – patients with legitimate prescriptions who sell part or all to controlled prescription drug (CPD) dealers or users – organized crime involvement is growing.
Misuse of prescription drugs and related harms – including overdose mortality – have emerged as important challenges for the North Bay Police Service (NBPS).
As with other high abuse index drugs, increased misuse and abuse of fentanyl has been associated with acquisitive crime in North Bay (i.e., B&Es, thefts, prescription forgeries, prostitution).
Fentanyl has also been linked to an increasing number of non-fatal overdoses. Since 2008, six people – three males and three females – have been admitted to the emergency department (ED) in North Bay as a consequence of fentanyl misuse and abuse. Four were found without vital signs and required resuscitation.
{Fentanyl-related mortality rates}
Fentanyl is 30 to 50 times more potent than heroin and 50 to 100 times more potent than morphine. It can be fatal, depending on several factors, including a person’s weight and level of opiate tolerance.
Fentanyl acts on and is a Central Nervous System (CNS) depressant. In combination with other opiates, it can be expected to produce more pronounced CNS depressant effects. Signs of overdose include difficult or shallow breathing, drowsiness (the “nods”), extreme sleepiness or sedation, inability to think, talk or walk normally and feeling faint, dizzy or confused.
The transdermal system, the most commonly abused form of fentanyl, is designed to deliver a specific dose at a constant rate based on the initial concentration in the patch. When a patch is altered, a large dose of medication can be obtained in a gel form, resulting in 72 hours worth of the drug being ingested in a single setting.
There are many different methods of altering the transdermal delivery system. All involve separating the release membrane from the patch. Varying temperature extremes will fracture the release membrane, as will biting or chewing the patch.
There have been 13 cases in North Bay since 2007 where fentanyl caused or contributed to death (see Fig. 1) — nine men and four women between 20 to 53 years. Blood concentrations of fentanyl ranged from 2.9 to 81 ng/mL.
A variety of routes of administration were identified, including intravenous injection of patch contents, oral/transmucosal administration and volatilization and inhalation of the patch contents.
The co-administration of other drugs with fentanyl was common, although their presence in many cases wasn’t considered to have contributed to death.
{Initiatives to combat abuse}
{Education & awareness}
In response to the marked increase in deaths, the NBPS, in cooperation with the coroner and medical officer of health, issued a public advisory in October 2009 aimed at increasing awareness about the risks of misuse.
{Targeted enforcement}
Unlike other street drugs, mere possession of synthetic opiates by someone suspected of dealing them is not enough if they have a legitimate prescription. This poses a significant challenge for law enforcement. Investigations require significant time and substantial police resources to build cases and prosecute those involved in trafficking opiates.
The NBPS successfully concluded an undercover operation dubbed Project HOPE in late 2013 to identify and prosecute street level individuals involved in supplying and/or trafficking controlled prescription drugs, specifically fentanyl, and reduce the supply through targeted enforcement. The operation resulted in 20 individuals facing 93 drug and drug related charges.
A key objective was to collect information and intelligence with a view to providing a strategic level overview of the controlled prescription drug abuse issue.
Street drug prices are not static. The perceived inexperience of the buyer, availability, current supply and even the time of the month (before or after the issuance of social assistance cheques) were all felt to influence the street value. Prices for controlled prescription drugs varied based on brand name and strength. Weak opioids such as Percocet sold for as little as $5 per pill while the more potent opioids sold for as much as $100 per pill
Percocet, morphine and oxycodone were the most commonly available controlled prescription drugs in North Bay. Fentanyl was also available, albeit at significantly lower levels than previously thought when compared to other controlled prescription and illicit drugs. This was attributed to the number of new users. The increasing popularity of fentanyl among young people, as evidenced by the age of those arrested during the project, was a concern.
Given that fentanyl was more difficult to obtain on the street, it was therefore much more expensive. A 100 microgram ratio®-fentanyl patch worth $12.05 (in the pharmacy) sold in North Bay during the project for between $400 and $450 on the street.
{Patch exchange program}
Even after the prescribed application time has elapsed, enough fentanyl remains in a patch to provide a potentially lethal dose. Up to 60 per cent of the medication can remain so discarded patches are a sought-after commodity by some abusers and can pose a risk to young children who may come into contact with them. Proper disposal is crucial in preventing both intentional and accidental misuse.
The NBPS, in cooperation with local physicians and pharmacists, introduced a fentanyl “Patch 4 Patch” exchange program in December 2013. Patients with prescriptions are now required to return their used patches to a pharmacy for proper disposal before receiving new ones.
The program is not meant to disrupt or otherwise complicate pain management treatment. Rather, it guarantees the responsible provision of a powerful and potentially lethal drug and ensures its proper disposal to avoid accidental misuse and outlines the responsibilities of both physicians and pharmacists.
Prescribing physicians are discouraged from writing large prescriptions and pharmacists are required to reconcile and inspect used patches for any signs of damage (tampering) and to report any suspicions or concerns to the prescribing physician. Pharmacists are allowed to initiate a contingency dispensing protocol – one patch every 72 hours – should the patient fail to return all patches.
Since its release in December, the policy has been revised to address issues that have arisen. To avoid the program, patients with legitimate prescriptions have their fentanyl dispensed by pharmacies outside of North Bay. To prevent this, physicians are now identifying on the prescription the actual pharmacy and location where it is to be dispensed and, whenever possible, faxing the prescription to the pharmacy.
{Complex challenges}
Regulations for the use of prescription opiates and the related harms they can cause poses distinct and complex challenges for law enforcement. These drugs are essential therapeutic tools in pain management, especially for severe and chronic pain. Any initiatives must not affect or compromise access and their ability to manage pain.
Any strategies or initiatives to reduce or counter the negative impact of prescription drug abuse should engage stakeholders and include four key elements:
• Reduce drug related crime
• Reduce the supply of illegal drugs through targeted enforcement
• Prevent young people from becoming drug users
• Reduce drug use and drug-related offences through treatment (i.e. detoxification centers) and support (i.e., counselling).
Because prescription drugs are legal, they are easily accessible. Police and the medical community (doctors and pharmacists) have a role to play in reducing abuse. Police need to engage and form partnerships with community partners and other stakeholders to reduce abuse.
The fentanyl patch exchange program is the result of such partnerships and includes the following components:
• Education: A crucial first step in tackling the problem of abuse is to educate parents, youth and patients about the dangers of abusing fentanyl drugs. Prescribers also need to be taught the appropriate and safe use and proper storage and disposal of fentanyl.
• Proper disposal: Patients are required to return used patches for safe disposal by pharmacists.
• Enforcement: Police are notified when a patient fails to return all their patches.
The highly addictive nature of Fentanyl and the steady increase of misuse and abuse represent a serious threat to Ontario communities. A lack of understanding of its effects when abused, coupled with wider availability on the street, means more overdose deaths and acquisitive crimes committed primarily by drug addicts.
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