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Fentanyl overdoses present a unique problem to Canadian provinces and US states *.

While few want to return to Nancy Reagan's "just say no" **, it seems to me that the extremely deleterious long term effects and the very low probability of long term recovery would make it worthwhile for governments to try to dissuade prospective users to try, or risk mistakenly using, fentanyl specifically.

Akin to maybe the no-smoking messaging that was put out for decades. Or even alcohol-moderation messaging (this could even be enhanced by a tacit messaging to divert to other, illegal-but-less-deadly, drugs).

I recall hearing, 10-15 years ago, anecdotes about a supposedly successful US anti-meth campaign that played to teens' body image concerns by showing crumbling meth-addict teeth. Now, the thing is I never heard any hard stats about how well that worked.

Aside from an - unlikely - law enforcement supply-side suppression, it seems that a demand-side reduction would yield benefits, if successful.

Many different approaches have been, or are being, tried with regards to fentanyl harm reduction, so I wonder if pre-use messaging has been attempted.

* No, Europe doesn't have fentanyl large scale yet, so please don't trot out Portugal, that was for heroin, a related, but due to toxicity and especially cost, quite different class of drugs. So far, the only significant fentanyl crisis in Europe seems to have been Estonia (2007-2017?) and its resolution is unlikely to be repeatable: large scale arrest of the conveniently concentrated supplier base.

** My position on drug use is mostly on the libertarian end of things, where people get to decide for themselves (at least until they become a burden to society). No need to answer based on explaining the failures of the US "War on Drugs" and this is not what I was asking about.

p.s. In Vancouver, Canada we are all too familiar on the streets with the long term outlooks for addicts. They are not necessarily that dangerous to bystanders either - many are too messed up to be a threat. My partner works in that field, and the bleak long term prognostics are something her medical community is all too well aware of.

p.p.s. Not against harm reduction per se, as long as one recognizes there is no way to "fix" serious users permanently: "All the king's horses and all the king's men Couldn't put Humpty together again."

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  • I don't think convincing people to not take painkillers prescribed to them for a good reason will ever work. Most people's opioid addiction starts in that way (as opposed to meth, which isn't a legitimate medicine).
    – littleadv
    Mar 8 at 1:30
  • "there is no way to "fix" serious users permanently" Not true. France is a good counterexample. Opiate addiction is treatable on a permanent basis with the right kind of treatment.
    – ohwilleke
    Mar 8 at 2:40
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    @ohwilleke "Opiate addiction is treatable". Yes, and no. First, dragging my poor partner into this again, she was already prescribing methadone to heroin addicts in NYC 10 years ago. Her, direct, professional experience, is that, no methadone does not work well on fentanyl users. It's not strong enough. Those NYC addicts could function and hold minor jobs, on methadone. Again, not the case here. Europe still doesn't have a fentanyl problem so comparing their, heroin-based, situation is like comparing beer to grain alcohol. Same family, different class of drug. Mar 8 at 19:22
  • @ohwilleke Second, how do you fix, my word, not treat, someone who has had both legs amputated due to passing out in a snowdrift? How do you fix a 35 yr old with a spine befitting a 90 yr old woman with advanced osteoporosis? How about someone w brain damage from repeat oxygen deprivation from ODing? Out of 5.5M pop, BC loses about 2500/yr, each year to overdoses, about as much as we did in total to covid. That's not old-school levels of heroin deaths and we need to be very careful when prescribing solutions inspired from older, even if related, problems. Mar 8 at 19:45
  • I'd note that the "war of drugs" has been successful in countries that refused to pull their punches. China and Singapore don't have (and won't have) a fentanyl problem because they execute anyone caught dealing drugs. Mar 8 at 22:00

1 Answer 1

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Demand reduction only works if people know what they are buying

The basic problem with demand reduction strategies is that lots of people who overdose on fentanyl don't know that they are taking it. As the CDC explains:

Powdered fentanyl looks just like many other drugs. It is commonly mixed with drugs like heroin, cocaine, and methamphetamine and made into pills that are made to resemble other prescription opioids. Fentanyl-laced drugs are extremely dangerous, and many people may be unaware that their drugs are laced with fentanyl.

The incentive to use fentanyl is the black market for drugs is driven by the fact that fentanyl delivers more doses per kilogram than almost any other drug on the market, making it more attractive to smuggle, because the difficulty involved in smuggling drugs is basically proportionate to the mass and volume of drugs smuggled. From the same CDC link:

Fentanyl is a synthetic opioid that is up to 50 times stronger than heroin and 100 times stronger than morphine. It is a major contributor to fatal and nonfatal overdoses in the U.S.

There are two types of fentanyl: pharmaceutical fentanyl and illegally made fentanyl. Both are considered synthetic opioids. Pharmaceutical fentanyl is prescribed by doctors to treat severe pain, especially after surgery and for advanced-stage cancer.

However, most recent cases of fentanyl-related overdose are linked to illegally made fentanyl, which is distributed through illegal drug markets for its heroin-like effect. It is often added to other drugs because of its extreme potency, which makes drugs cheaper, more powerful, more addictive, and more dangerous.

Put another way, fentanyl use is surging because the wholesale price per dose is much lower, because the cost of smuggling drugs dwarfs the cost of synthesizing it, and fentanyl is much cheaper to smuggle.

So, someone may think that they are buying heroin, but actually be buying sugar or chalk cut with a much smaller volume of fentanyl, providing a comparable dose to that amount of heroin.

But without medical laboratory class equipment and technician skills, it is much easier to err by overdosing or underdosing something cut with fentanyl than it is with a less potent drug, because a seemingly trivial fraction of a gram can be the difference between the intended dose and a fatal overdose.

Fentanyl is even routinely cut into non-opiate illegal drugs, because it gives the user a potent effect and is addictive.

But, demand based efforts only work to prevent people from buying fentanyl when they know that they are buying it. For example, PR efforts like the "One Pill Kills" campaign in Texas haven't had any appreciable positive impact.

Indeed, anecdotally, it appears that lots of people are skeptical of using fentanyl in medically prescribed settings because of the bad press that the drug has gotten from the abuse of illegal fentanyl. I am personally aware of several people who have either declined fentanyl treatment, or only agreed to it after extensive discussions with health care providers, in cases where it was appropriate, who prior to widespread publicity related to fentanyl wouldn't have given it a second thought. So, if anything, demand reduction approaches are currently backfiring.

Pharmaceutical fentanyl abuse

Some people do know that they are taking fentanyl and prefer it, but this is the exception rather than the rule.

But people who are getting fentanyl when they are intending to get fentanyl are often getting product diverted from legitimate hospital supplies where the dosage is trustworthy and the drugs are pure. This isn't the population that is experiencing the lion's share of the harmful consequences of taking fentanyl, however. The people who are diverting pharmaceutical fentanyl are not really significantly worse off that people who illegally take less potent opiates.

Other harm reduction measures

There are generalized harm reduction measures, like supervised injection/drug use sites, and widespread distribution of narcan (an opiate antidote) along with immunity from civil and criminal liability for those who help respond to overdose situations. But many jurisdictions are uncomfortable with affording any legitimacy to conduct that they've made a serious crime otherwise.

Distributing test strips for fentanyl so people know what they are doing, can help, but this approach hasn't really been rolled out on a big scale yet.

A lot of the larger opiate addiction problem in the U.S. comes from a failure to make drug based (mostly methadone and buprenorphine based) treatment options widely available from low cost, easily access providers. Requiring primary care doctors to make this kind of opiate addiction treatment widely available is, for example, the main reason that the opiate addiction problem was curtailed in France, starting in 1996, while it continued to surge in the U.S. where such treatment is frowned up and hard to get. Cold turkey is the norm in the U.S. and causes lots of jailhouse withdrawal deaths. As discussed below, however, in December of 2022 the U.S. passed legislation intended to shift U.S. policy on opioid addiction treatment in the French direction.

In France, overdose deaths are now concentrated in methadone users, because the addiction program has been controlled with general practice drug based treatments, so widely availability of narcan there is the current focus.

Serious efforts to reform prescriptions of opiate pain killers to prevent people from becoming addicted have had only modest success so far

Lots of changes in how medical providers prescribe opiates were made to address the opiate addiction problems in the twenty teens. As the Kaiser Family Foundation explains at the link:

The opioid overdose epidemic, characterized by the rapid rise in opioid-involved overdoses and overdose-related deaths, began in the late 1990s, driven by increased prescribing of opioids to treat pain. In subsequent years, the epidemic evolved, and is now largely driven by synthetic opioid-involved deaths, including illicitly manufactured fentanyl. Medicaid enrollees have been particularly impacted by the opioid epidemic, with higher rates of substance use disorder (SUD) and prescribed opioids among Medicaid enrollees compared to people with other types of insurance. To combat the opioid overdose epidemic, policymakers have enacted legislation to reduce opioid prescriptions for pain and increase access to treatment for opioid use disorder (OUD), and the Consolidated Appropriations Act, passed in December 2022, vastly increased the number of providers authorized to prescribe controlled substance medication treatment to treat OUD.

This analysis builds on previous KFF work by using Medicaid claims data, administrative data on Medicaid enrollees’ health care utilization, for 2016-2019 to explore how prescriptions for opioids used to treat pain and those used to treat OUD or rapidly reverse overdose changed across states and enrollee demographic groups over time leading up to the COVID-19 pandemic. A full description of the data and methods can be found in the Methods section. Key findings include the following:

  • Opioid prescriptions declined overall from 2016 to 2019, driven by a 44% decline in the number of prescriptions for opioids used to treat pain. At the same time, prescriptions for medications used to treat OUD or rapidly reverse opioid overdose doubled, driven by an increase in buprenorphine prescriptions.

  • The share of enrollees receiving at least one opioid prescription for pain declined from 11.3% in 2016 to 7.2% in 2019, which drove the overall declines in utilization of opioids to treat pain. The magnitude of declines varied by state, eligibility group, and race/ethnicity.

  • The share of enrollees receiving at least one medication used to treat OUD or reverse opioid overdose doubled from 2016 to 2019. Compared to Black and Hispanic enrollees, White enrollees were more likely to receive at least one treatment prescription and saw the largest increase their share over the period, suggesting racial disparities in access to prescription medication to treat OUD or reverse overdose.

But the problem of opiate overdose deaths has continued to grow, and illegally manufactured fentanyl products have continued to be a severe and growing problem. See the chart below (from here):

enter image description here

Why are European comparisons relevant?

Examples like France, Switzerland and Portugal that have taken a less punitive approach to drug addiction are relevant, contrary to the OP, because this less punitive approach has reduced the intense pressure to make smuggled drugs more potent per volume/mass that exists in the U.S. and Canada, reducing the market pressure to introduce fentanyl into the black market for psychoactive drugs.

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  • You are far from getting to the root of the problem. The root cause lies in the government's mismanagement of painkillers. Today's hospitals rely too much on painkillers, and their solution to a minor cold is usually just a few bottles of painkillers, although these are obviously too many. This has led to civilians also lacking a correct understanding of painkillers and over-reliance on painkillers. It all adds up to the truth of the matter.
    – Jack_here
    Mar 8 at 2:22
  • 3
    @Jack_here Those considerations are important in the overall problem of opioid addiction, but aren't that relevant to the particular harms caused by fentanyl relative to other illegal opioid use, which is what the question is asking. Opioid addiction is a bigger problem, but this is looking at one particular facet of it. This particular set of harms isn't caused to any great extent by overuse of prescription pain killers.
    – ohwilleke
    Mar 8 at 2:24
  • Your reasoning is completely wrong. Why do the results caused by the parent class have nothing to do with the subclass? This is obviously unreasonable. The general environment has caused civilians' misunderstanding of painkillers to spread to careless use of drugs. This series of effects is the root of the problem. The abuse of drugs by civilians is not something that comes from heaven. The medical complex’s capital expansion at the expense of health and the inaction of government supervision are the fundamental reasons.
    – Jack_here
    Mar 8 at 2:34
  • 3
    @Jack_here Feel free to post your own answer if you think this is completely wrong. Lots of the prescriber side reforms have already been implemented in the U.S. but haven't been effective at curbing the trends. There is some truth in the pharma company greed driven narrative, but that is only one modest part of the whole and one that is increasingly less important.
    – ohwilleke
    Mar 8 at 2:36
  • 2
    @Jack_here The over prescription of painkillers for minor illnesses is true and is a problem especially in the US were a lot more painkiller are available over the counter. That doesn't make ohwillikes answer wrong in any way.
    – quarague
    Mar 8 at 8:06

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