Why is fentanyl so deadly?

Pittsburgh rapper Mac Miller had just released his fifth full-length album, Swimming, before he died at age 26 earlier this fall.

A coroner recently declared his death an accidental overdose involving fentanyl, a fast-acting opioid drug that’s 100 times more potent than morphine.

Miller joins a staggeringly long list of people who have been unknowingly exposed to the potentially deadly substance, which is one that has Canada in the midst of a crisis.

There were more than 8,000 apparent opioid-related deaths in Canada between January 2016 and March 2018, according to the federal government. Between January and March of this year, there were at least 1,036 apparent opioid-related deaths, of which 94 per cent were accidental; 73 per cent of those involved fentanyl.

“Fentanyl is extremely toxic,” says Vancouver Coastal Health medical health officer Dr. Mark Lysyshyn. “A small amount has a powerful effect. It’s a very dangerous product.”

ALSO SEE: Rapper Mac Miller’s death ruled accidental overdose of fentanyl, cocaine and alcohol

Fentanyl has a legitimate use in medical settings: it’s used for anesthesia and for the management of severe, long-term pain, often in cancer patients. When prescribed by a doctor, it’s administered via injection, transdermal patch, or lozenges. Carefully monitored in a clinical setting, it can be effective and safe.

It works by binding to the body’s opioid receptors, which are found in areas of the brain that control pain and emotions. Like heroin, morphine, and other opioid drugs, when fentanyl binds to those receptors, dopamine levels in the brain’s reward centres rise, leading to a state of relaxation and euphoria, according to the National Institute on Drug Abuse.

However, here’s why it’s so dangerous: Opioid receptors are also found in the areas of the brain that control breathing. High doses of opioids, especially forms as potent as fentanyl, can cause breathing to stop completely, which can cause brain damage or death.

Two milligrams of pure fentanyl — about the size of four grains of salt — is enough to kill an average adult.

Fentanyl that’s sold on the street can be mixed with heroin or other drugs, significantly driving up its toxicity and potential dangers.

It is odourless and tasteless and therefore hard to detect, according to the RCMP. It can be found in powder, liquid and blotter form. Fentanyl is also often stamped into pill form and sold on the street as oxycodone, a popular painkiller. In Canada, these counterfeit pills are often green in colour and stamped “CDN 80.”

Fentanyl goes by all sorts of nicknames, including apache, China girl, China white, dance fever, friend, goodfella, green beans, jackpot, murder 8, shady 80s, TNT and tango and cash.

A single kilogram of fentanyl, worth a few thousand dollars, can be cut down into more than 100,000 pills, which are worth millions on the street, according to the U.S. Drug Enforcement Agency.

According to the U.S. Drug Enforcement Agency, the primary source of illicit fentanyl is China. Organized crime and independent dealers are able to buy the drug online and have it shipped across the border; the RCMP says that many Chinese manufacturers even offer free replacements if the first shipment is seized.

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Drug-testing projects in use in Vancouver — including fentanyl test strips and infrared spectrometers that scan drug mixtures to detect fentanyl — have led to greater understanding of contamination of illicit substances. Lysyshyn says that fentanyl is most commonly mixed with opioids, such as heroin. Recent tests showed that less than five percent of cocaine and crystal meth are contaminated, and even lower rates were found in MDMA and ketamine.

“It’s a completely unregulated market, and as a result there are variety of things that can happen,” Lysyshyn says. “People can intentionally contaminate drugs—add it to heroin—or substitute one drug for another and sell fentanyl instead of heroin. If someone wants to buy cocaine but you have a different white powder, you can sell it because you want to make money. Or you can make an error. You might think you’re giving someone cocaine but because you’re under surveillance by police and you have to do the transaction quickly, you give them fentanyl. People are now using more dangerous drugs than before. It’s a crisis of contamination.”

Many users begin with legitimate prescriptions to manage pain but end up addicted and turning to the opiate black market to feed their addiction. A recent United Nations report found that Canada consumes the most prescription opioids per capita of any country in the world.

Canada is in desperate need of far more doctors who are trained in addiction medicine, says Dr. Evan Wood, director of the British Columbia Centre on Substance Use at Vancouver’s St. Paul’s Hospital. He points to the case of B.C.’s Jordan Miller, who died in 2014 at age 25 of an accidental overdose. His mom, Leslie McBane, has gone public with his story, sharing with media that he was prescribed oxycontin for pain stemming from a workplace injury and became addicted to it. He repeatedly told his doctor he needed help getting off the painkiller, but didn’t receive any help.

The College of Physicians and Surgeons later found that the doctor failed the young man, by “prescribing combinations of opioid(s)” and “not taking definitive action when presented with evidence of opioid misuse.” McBane went on to cofound Moms Stop the Harm to work for harm-reduction changes to drug policies.

ALSO SEE: Fentanyl is linked to thousands of deaths a year, so why do doctors still prescribe it?

“Most health-care providers who should be diagnosing and treating addiction are not and do not know how to do so,” Wood says. “In a situation where family doctors can prescribe opioids for pain, they need training to prescribe medication for opioid addiction, like Suboxone. We have pathologists, respirologists, gastroenterologists, cardiologists, but we haven’t invested in training health care providers in evidence-based addiction care.”

Drug-checking, where people can get drugs tested for the presence of fentanyl, needs to be more widely available, Wood says, as do recovery services. “Treating this disease as a criminal justice issues makes it very difficult for people to come forward and get help.

“Treatments like heroin prescription needs to be scaled up for people who are street-entrenched; we know it’s cost-effective,” he adds. “Recovery services helping people with employment, helping them get out of a life of addiction, needs to be brought to scale Why isn’t it happening? Because there isn’t a skilled workforce of care providers.”

To prevent overdose deaths, it’s crucial for people who use street drugs to not use alone and to go to a supervised-injection site or an overdose-prevention site if possible, Lysyshyn says. People should never mix opioids with alcohol or other substances. Users or those who are in contact with them should also carry naloxone kits so they can use it if necessary; the medication quickly reverse the effects of opioid overdose. And he says people should know what an overdose looks like so that they can get emergency medical care when needed.

“People need to know that it’s safe to call 911, that they’re not going to be arrested if there’s drugs on scene or if they admit to using drugs,” Lysyshyn says. “With an opioid overdose, people become drowsy; they may fall asleep or lose consciousness. Their lips can become blue, skin can become grey if don’t get enough oxygen to the brain. They might be short of breath.”

“This very dangerous product is still out there, people are still using it and they’re still using it in high-risk situations, alone behind closed doors,” he says. “The solution is ultimately to get rid of stigma by decriminalizing drug use, by regulating the drug supply so that this dangerous drug is not out there.”

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