[Note: This one is for Dave Feagles, who helped me understand fentanyl and its problems.  That’s not to say that he agrees with all or any of my conclusions. No friend of mine should have to do that.]

[There was a brisk response to our last post, some of it about my personal habits and obvious failings as a copy editor, but some of it also on substance. Please, you all know Jeremy Bentham didn’t accept name calling and personal attacks as legitimate tools of debate. They’re usually irrelevant to the issues of the day, and are intended to distract listeners from the real stuff. And there’s no truth to the rumor that our story was a cheesy effort to drive down real estate values in my locality, West Virginia. The facts might do that, but I haven’t made up anything. And, by the way, I live here too. What we have here is simply a very dismal situation.

So I’ve picked the best of your comments, edited out the obscenities, etc., combined them with others on the same subject, and will now deal appropriately with what remains.]

All right, Mr. Sallust, you’ve done it this time! There you were, playing with words at the beginning of the last post, and you completely bollixed it up. You left out a key word, you ninny, and spoiled whatever effect you were trying to achieve! That’s a poor performance for someone who pretends to be educated. What have you done to make sure it doesn’t happen again? Have you fired the secretary?

Actually, you’re right, at least about the preposition.  The commenter is talking about the introduction to the last piece – you know, the part in italics – where I jokingly quoted myself, and described that as possibly a “ridiculous case unbridled narcissism.” Of course, that should have been a “ridiculous case of unbridled narcissism.” A reader caught the mistake soon after publication, and I speedily corrected the published version. It was too late to change drafts that already had been circulated. So what? They were drafts, you know; not final copy.

The rest of the comment is mistaken. We don’t have a secretary here at Elemental Zoo Two. Everyone does his own typing so, I guess, for that piece I was the secretary [as I am for this one]. As a matter of policy, I will not fire myself. I’m too important to the health of the blog. Also, I need something to do on off days.

You have opinions about fentanyl, but don’t tell us much about it, except that it’s synthetic. Do you know anything more, or were you just pretending?

Now that’s a good question. I didn’t say much about fentanyl last time because I knew the subject generally but didn’t have a lot of detail. After the first couple of comments it was obvious that people wanted to know more; so I went back to the books, and here’s what I found.

The Drug Enforcement Administration [DEA] identified fentanyl as a problem drug just last year.[1] The drug had been around for a long time[2], but incidents and overdoses involving it were on the rise in 2015 and “occurring at an alarming rate throughout the United States.” As such they represented “a significant threat to public health and safety.”[3] Fentanyl and fentanyl derivatives are “often laced with heroin,” and that sort is up to “100 times more powerful than morphine, and 30 – 50 times more powerful than heroin.” [4]

The euphoric effects of fentanyl are the same as heroin[5], but “[i]ngestion of [fentanyl] doses as small as 0.25 mg can be fatal.”[6] Also, last but certainly not least, fentanyl is dangerous to law enforcement and “anyone else who [might come] into contact with it.”[7] It can hurt people who take, touch or breathe it.[8]

So – and this is my opinion – combining fentanyl with heroin doesn’t sound like a particularly bright move unless a dealer is out to exterminate his [or her] clientele, and possibly law enforcement as well. Addicts may disagree, and probably do.

Where does fentanyl come from? Is it, like heroin, a product of the opium poppy grown in Afghanistan?

The drug is synthetic, you know, and the chemists – amateur and professional – seem to be hard at work on it. At last count there were 15 versions – the so-called “fentanyl analogues” – in addition to the basic compound.[9] It’s not clear to me whether the opium poppy is necessary, or useful, to create synthetic fentanyl,[10] but I suspect it isn’t.

Fentanyl abuse is growing around the world, in Russia, Ukraine, Sweden and Denmark, for example, and Mexican authorities have seized fentanyl laboratories in their own country. Back in 2006, the U.S. found one in California.[11] So where one can be built, many are possible. Apparently the precursor chemicals for fentanyl are sold by companies in Mexico, Germany, Japan and China. Right now Afghan poppies don’t seem to be on any list of precursors.

Of course, my opinion is based only on information that’s currently public.[12] No doubt there’s a lot going on in the world that we don’t know about. One article reports, for example, that fentanyl is cheaper to make than heroin[13]; if that’s the case why wouldn’t customers, and dealers, migrate in that direction? So perhaps there are illegal fentanyl laboratories all over the place, not just in Mexico and California. Perhaps heroin from Afghanistan will be driven off the market by a newer, more potent [and deadly] synthetic. Of course that’s not necessarily a good thing, is it?

There’s an anti-overdose medication that police forces in some jurisdictions are authorized to use. Do you have it in your area, and, if so, is it effective?

I think you’re talking about naloxone [also called Narcan] which is highly recommended[14] as a treatment for opioid overdoses.[15] In an overdose the victim’s respiratory system is severely depressed, to the extent that he or she may stop breathing. Death follows. Naloxone reverses that, and can save the victim’s life. “The earlier the treatment the better the result,” or so I’m told.

Recently the Food and Drug Administration asked industry to develop a phone app to help “opioid users and their friends” locate naloxone when they need it.[16] That may be a good idea but, more to the point, today naloxone is used by doctors and in emergency rooms, etc., to treat the cases that come in the door. In some states it’s also included in kits issued to emergency responders [including law enforcement] and some drug users.[17] My state, West Virginia, does that.[18]

My personal opinion is that, while the kits are a good idea in today’s environment, and hopefully will reduce the death rate from overdose, they probably won’t reduce the rate of addiction. Addicts who die automatically drop out of the pool of current users. Those who survive have a second chance, but not all of them will enter treatment, abandon drugs, and get their lives back. Some will, and some won’t. At the same time new addicts reveal themselves every day, [19] lining up to pour money into the illicit drug trade. So my point is, without other changes, drug interdiction, better enforcement and so forth, the addiction rate may well go up even as overdose deaths decline.

Of course, that little speculation assumes we know how to count the addicts hidden in our society.

I don’t mean to be macabre, but how is the 2006 heroin death rate shaping up in your area? Is it rising or falling?

It looks like the final numbers come out about 12 months after any year ends. There are anecdotes, but they lead nowhere. Let’s wait and see. “Time destroys the speculation of men, but it confirms nature.”[20]

[Will there be more questions and answers next week? Probably. If not next week, then soon.]

[1] See DEA, Headquarters News, DEA Issues Nationwide Alert on Fentanyl as Threat to Health and Public Safety (March 18, 2015), available at https://www.dea.gov/divisions/hq/2015/hq031815.shtml Henceforth this will be cited as DEA 2015 Alert.

[2] Since 1960, if you’re curious. See the Wikipedia entry on fentanyl at https://en.wikipedia.org/wiki/Fentanyl

[3] See DEA 2015 Alert.

[4] Id. “In the last two years, DEA has seen a significant resurgence in fentanyl-related seizures. According to the National Forensic Laboratory Information System (NFLIS), state and local labs reported 3,344 fentanyl submissions in 2014, up from 942 in 2013.  In addition, DEA has identified 15 other fentanyl-related compounds.”

[5] Id. “Its euphoric effects are indistinguishable from morphine or heroin.”

[6] Id.

[7] Id.

[8] Id. “DEA has also issued warnings to law enforcement as fentanyl can be absorbed through the skin and accidental inhalation of airborne powder can also occur. DEA is concerned about law enforcement coming in contact with fentanyl on the streets during the course of enforcement, such as a buy-walk, or buy-bust operation.” See also The Washington Post, Bever et al., Opioid epidemic’s hidden hazard, SWAT officers treated for fentanyl exposure during drug raid (September 14, 2014), available at https://www.washingtonpost.com/news/post-nation/wp/2016/09/14/eleven-swat-officers-treated-for-exposure-to-fentanyl-and-heroin-in-drug-raid/

[9] See n. 4. So far DEA has identified 15 other fentanyl-related compounds.

[10] I’ll try to answer that another day.

[11] See the Wikipedia piece on Fentanyl, under recreational use, available at https://en.wikipedia.org/wiki/Fentanyl

[12] See DEA 2015 Alert. “Globally, fentanyl abuse has increased the past two years in Russia, Ukraine, Sweden and Denmark. Mexican authorities have seizure fentanyl labs there [i.e., in Mexico], and intelligence has indicated that the precursor chemicals came from companies in Mexico, Germany, Japan, and China.”

[13] See New York Times, Seelye, Heroin Epidemic Is Yielding to a Deadlier Cousin: Fentanyl (March 25, 2016), available at http://www.nytimes.com/2016/03/26/us/heroin-fentanyl.html?_r=0 . “’For the cartels, it’s their drug of choice,” Ms. Healey said. “They have figured out a way to make fentanyl more cheaply and easily than heroin and are manufacturing it at a record pace.’”

[14] See CDCHAN-00350, Health Advisory, Recommendations for Laboratory Testing for Acetyl Fentanyl and Patient Evaluation and Treatment for Overdose with Synthetic Opioid (June 20, 2013) at p. 3 of 5, Recommendations, available at https://emergency.cdc.gov/han/han00350.asp

[15] Id. “We recommend that emergency departments and emergency medical services treat suspected opioid overdoses according to standard protocols. In addition, larger doses of naloxone may be required to reverse the opioid induced respiratory depression because of the higher potency of fentanyl and acetyl fentanyl compared to heroin.”

[16] See Los Angeles Times, Healy, FDA asks coders to create an app that matches opioid overdose victims with lifesaving rescue drug  (September 19, 2019), available at http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-naloxone-app-20160919-snap-story.html

[17] See the Wikipedia discussion at Naloxone; available at https://en.wikipedia.org/wiki/Naloxone#Opiate_overdose    “[Naloxone is included as a part of emergency overdose response kits distributed to heroin and other opioid drug users and emergency responders. This has been shown to reduce rates of deaths due to overdose…”

[18] Metro News, Kercheval, Life-saving naloxone approved in WV (March 11, 2015), available at http://wvmetronews.com/2015/03/11/life-saving-naloxone-approved-in-wv/  “Hughes was on hand Monday when Governor Tomblin signed into law SB 335, authorizing the first responders to carry the opioid antagonist and allowing doctors to prescribe naloxone to relatives and friends of a person at risk of overdosing.”

[19] They can be anywhere. See USA Today, Bowerman, Sheriff’s candidate charged with heroin possession in West Virginia (August 3, 2013), available at http://www.usatoday.com/story/news/nation-now/2016/08/03/sheriffs-candidate-charged-heroin-possession-state-police/87998338/

[20] That’s from Marcus Tullius Cicero, a Roman dude I was once forced to translate. You can find it on Brainy Quote, at: http://www.brainyquote.com/quotes/keywords/speculation.html