Fake Heroin

W hen buying drugs on the street, “Let the Buyer Beware” has always been good advice. Recent experience suggests that in 2018, failure to heed this warning could not only be dangerous, but fatal. I treat patients with opioid use disorder, primarily using Suboxone (buprenorphine with naloxone), which is taken under the tongue daily. The […]

The need for effective treatment of opioid addiction is even more urgent

By David M. Novick, MD

When buying drugs on the street, “Let the Buyer Beware” has always been good advice. Recent experience suggests that in 2018, failure to heed this warning could not only be dangerous, but fatal.

I treat patients with opioid use disorder, primarily using Suboxone (buprenorphine with naloxone), which is taken under the tongue daily. The patients come to the office every 1-4 weeks, submit a urine sample, are interviewed and examined, and receive their prescription. Their urine is submitted directly into a specialized test cup, which can quickly detect the presence or absence of 12 drugs and also measures the urine temperature, which documents that the specimen is fresh and has originated from the patient who is being seen. In May or June, four different patients acknowledged a relapse to heroin use, but their urine tests were negative for opioids (heroin tests positive for opioids). All patients tested positive for methamphetamine, a powerful stimulant, and some specimens also tested positive for cocaine.

These urine samples were sent to a reference laboratory for confirmatory testing, and we also requested testing for fentanyl. All specimens tested were positive for fentanyl and its metabolite, norfentanyl, neither of which is assessed by the test cup. Some of the samples had levels of fentanyl or norfentanyl greater than 90,000 picograms per milliliter, i.e. the levels exceeded the upper limit of what the lab usually measures.

The high death rate due to the opioid epidemic in recent years has been caused in large part by the use of fentanyl and related compounds. Fentanyl is a synthetic opioid which is 50 times more potent than heroin and 100 times more potent than morphine. Some derivatives of fentanyl are even more potent: carfentanyl, used as a tranquilizer for elephants and other large mammals, is 10,000 times more potent than morphine. Fentanyl is manufactured legally in the United States and used in anesthesia for humans as a patch or other forms for treatment of chronic pain. Fentanyl and related drugs are increasingly manufactured illicitly outside the United States and smuggled in. They are mixed with heroin by drug dealers to increase the potency, leading to overdoses which may be fatal or may respond only to multiple doses of the drug-reversal agent naloxone. Drug dealers lack the ability to reliably measure the amount of fentanyl in each sample, or they may not care to do so. Overdose deaths of their customers have not been harmful for business because of the high demand, and some people reportedly seek out the dealers of those with fatal overdoses, in order to acquire the most potent substances.

These “fake heroin” episodes are different because the recipients were not seeking fentanyl, and they were surprised to learn that their urine contained fentanyl. Whether the realization that they could have died will lead to better adherence to treatment remains to be seen. But these episodes highlight the risk of buying any drug on the street, as you never know what you are getting.

Some people who inject opioids are using fentanyl test strips to test their drugs before using them. If positive, they may take steps to modify their behavior, such as not using the drug, injecting more slowly, or having someone present who has naloxone. Further information is available on the Harm Reduction Coalition website, www.harmreduction.org. Overdoses, however, can still occur despite these measures or even with a negative test.

The significant risk of death from opioid use, as well as the many other medical, legal, and social consequences, makes it imperative to provide treatment of opioid use disorder to all who need it. The most effective treatment is with the long-acting opioid medications Suboxone or methadone, or the extended-release form of the opioid antagonist naltrexone (known as Vivitrol). Suboxone and methadone are effective because their duration of action is greater than 24 hours, so that when taken daily there is a stable level of drug in the blood and other tissues; this prevents opioid withdrawal symptoms and reduces drug craving. Vivitrol works by prolonged blockade of opioid receptors. These medications are most effective when combined with counseling and other social services.

The accidental overdose death rate in Montgomery County has decreased significantly in the second half of 2017 and even more in the first half of 2018, though the 2018 numbers are preliminary and subject to change. There were 378 such deaths in the first half of 2017, 188 in the second half on 2017, and 132 in the first half of 2018 (source: phdmc.org). This decline is not necessarily a result of fewer overdoses, but may reflect the effective use of naloxone by first responders. This positive change does not detract from the need for treatment expansion. People who survive an overdose urgently need treatment, and a recent study showed that starting buprenorphine or methadone treatment quickly after an overdose reduced the death rate at one year by 40-60%. The Spring 2018 Buprenorphine Prescriber News, published by SAMHSA, a division of the Department of Health and Human Services, indicates that Ohio is the state with the third greatest need for additional physicians who can prescribe buprenorphine (an 8-hour course is required). There is still much to be done in order to get the opioid epidemic under control.

David M. Novick, MD is board-certified in Gastroenterology and Addiction Medicine and practices both specialties in the Greater Dayton area. He sees patients for addiction at Mahajan Therapeutics and practices Gastroenterology at Digestive Specialists, Inc. He has published extensively on substance use issues. His first book, A Gastroenterologist’s Guide to Gut Health, was published in 2017.

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