Archives for posts with tag: epidemic

In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers, and healthcare providers began to prescribe them at greater rates. This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive.

National Institute on Drug Abuse[1]

 [This is Fred and I’m here with more bad news about heroin and the other opioids now destroying us, plus some cheerful speculation. Note the paragraph quoted above. Apparently in the 1990s we didn’t understand that opium and its relatives are highly addictive, even though it was obvious 200 years earlier. See our recent blog[2] on Thomas de Quincey’s Confessions of an English Opium Eater.[3] So I guess our great planners didn’t expect patients to start abusing opioids once those drugs became plentiful by prescription. And once more people became addicted certainly no one expected the criminal class to fill the increased demand with their own, informal products. Who would ever dream such a thing?

Also, we still don’t know if opioids actually treat pain when they are used in the long term. According to one recent study: “Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose dependent risk for serious harms.”[4] Translation?  The long term benefits are unclear, but the dangers are obvious.

Not to worry, the National Institutes of Health [NIH], and their parent, the Department of Health and Human Services [HHS] have swung into action. Today society has a problem with opioid addiction and they will solve it by:

  1. Improving access to treatment and recovery services;
  2. Promoting use of overdose-reversing drugs;
  3. Strengthening our understanding of the epidemic through better public health surveillance;
  4. Providing support for cutting-edge research on pain and addiction; [and]
  5. Advancing better practices for pain management.[5]

So what could go wrong? Well, think about it. If we’re going to improve access to “treatment and recovery” services [Point 1], what does that mean? Do we have some magic cure that will wipe away addiction? I don’t think so. It’s very difficult to ween an addict from his [or her] opioid of choice. It was that way for Thomas de Quincey, and the situation hasn’t changed.  And if the weening process takes a long time, that sounds expensive. Taxpayers beware!

OK, but surely it would be a good thing to promote “overdose-reversing drugs.” [Point 2] Yes it would, because those drugs prevent death by overdose and it’s always good to do that. But overdose drugs don’t cure addiction, so we still have the problem of treating the survivors.

All right, then what about Point 3? NIH wants to know more about the size of the problem, how many addicts there are, and so forth. Again, who can quarrel with that? “Knowledge is power,” we’re told;[6] and why rent a rowboat for addicts if we really need a passenger liner? So yes, by all means study the problem, but not at the expense of making progress elsewhere. And by the way, the early returns are in. See Crappy News, the next section.

How about “cutting edge research” [Point 4]; is that a good idea? Practically always, say I. If our scientists research pain, perhaps they’ll develop new ways to treat sufferers without dosing them with addictive substances. That’s got to be a “better practice” [Point 5] than what we’ve been doing.

Then what about “cutting edge research” on addiction itself? Should we work on that as well? Yes, and we’ll discuss that later, under Vaccines.]

The Crappy News, or Why One Should Avoid the Drudge Report Early in the Morning

So the other day I was minding my own business, checking the Drudge Report, when I happened on a piece from Reuters that said: “More than third of [all] U.S. adults [were] prescribed opioids in 2015.[7] [Drudge is my substitute for a morning tabloid; feel free to pick a different service if you want; but definitely we all need something to read at breakfast.]

Ugh? Looking further I found the original data, or at least an abstract of it.[8] Officially the study is called the 2015 National Survey on Drug Use and Health [NSDUH]. So let’s sketch the findings. What else can you do with an Abstract?

  • In 2015 72,600 eligible civilian, noninstitutionalized adults were selected to participate in the study, and 51,200 completed the survey interview.
  • Based on these inputs, NSDUH estimated that, in 2015, 91.8 million (37.8%) of U.S. civilian, noninstitutionalized adults used prescription opioids.
  • 11.5 million people (4.7% of all adults) misused opioids; and 1.9 million (0.8%) had an opioid use disorder.
  • Among adults with a prescription, 12.5% reported they misused it; and of these, 16.7% reported a “prescription opioid use disorder.”
  • Most commonly people who misused opioids did so to relieve physical pain (63.4%). Does that sound familiar? Check out Thomas de Quincy’s story, referenced above.
  • Misuse and use disorders were most common with adults who were uninsured, unemployed, had low income, or had behavioral health problems.
  • Among adults who misused opioids, 59.9% reported using them without a prescription, and 40.8% obtained prescription opioids – for their most recent episode – for free from friends or relatives.[9]

So there you have it. Lots of doctors prescribe opioids; more than one-thired of U.S. adults had prescriptions in 2015; and some of those also used opioids without a prescription. Thank you, NSDUH, for that insight.

And some patients get violent if their doctors refuse to write prescriptions.[10] The states are upset; they argue over-prescription and the resulting addictions are impacting state resources;[11] and they’re beginning to sue the drug companies [and others] they think are responsible. Congress is alert, and will hold hearings on the matter.[12] Mexico is producing more and more opium to satisfy the demand growing in the U.S.[13] [Frankly, I didn’t know Mexico produced any opium; I thought most of the world’s supply came from our dependency, Afghanistan.] And, of course, our medical establishment is studying the problem that, one could argue[14], it created.


None of this is good, but is there sunlight behind the clouds? A month or so ago a friend[15] sent us an article about medicines that fight opioids and other addictive substances.[16] Apparently this has been researched since the 1970s, although without much recent success. Right now therapists have only three medications – methadone, buprenorphine, and naltrexone – to use to help the opioid addicted “get clean” and stay drug free. They work, but “not perfectly.”[17]

Current research is directed toward finding vaccines to directly counter opioid addiction. Most foreign substances are blocked from entering the brain by something called the blood-brain barrier. Opioids are an exception to that. They are very tiny molecules; can penetrate the barrier and enter the brain; and then do their damage unopposed. Opioids may lose their advantage – of small size – if they are attacked by antibodies “that bind to the drug molecules, creating complexes that are too large to cross into the brain.”[18] If the brain isn’t accessed, “there’s no high.”[19] And, one might add, there’s no corresponding brain damage to reinforce later addictive behaviors.

So the research is directed at triggering the human immune system to directly attack opioids. To (i) convert opioids to larger things that will not pass into the brain, or (ii) flush them out of the body before they reach the brain, or (iii) to do both. The Scripps Research Institute in La Jolla, CA, and the Walter Reed Army Institute of Research in Silver Spring, MD, have promising lines of study, and may have vaccines ready to begin human trials in the not too distant future. There are other candidates out there as well.


The situation with opioids is grim and looks worse every day, but perhaps there really is sunlight behind the clouds. The important thing for Congress to remember is that, when they’re throwing oodles of money at law enforcement to chase bad guys with drugs, they shouldn’t forget the scientists who, with funding and a bit of luck, may solve this problem for everybody.

Until the next one comes along, of course. Humans are weak, and our criminals are very ingenious. Didn’t you know?


[1] This is from the website of the National Institute on Drug Abuse, an organization within NIH. You can find it at . It was last updated in June of this year.

[2] That’s the blog of 07/16/2017, Opium Portrayed, at

[3] That’s Confessions of an English Opium Eater, Being an Extract from the Life of a Scholar. It’s currently in print from the Oxford University Press.  It was first published in 1821 in London Magazine, and was picked up in 1886 by George Routledge and Son. You can find the hard copy on Amazon. However, in keeping with blog policy, we found an alternate, free source for the text, this time in an eBook from Project Gutenberg.  Go to .

[4] See Annals of Internal Medicine, The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop (February 17, 2015) at Abstract, available at .

[5] See n. 1.

[6] See Knowles, Oxford Dictionary of Quotations (6th Ed., 2004) at Proverbs, p. 624, n. 45.

[7] It’s at Reuters Health News, Seaman, More than a third of U.S. adults prescribed opioids in 2015 (July 31, 2017), available at .

[8] The Abstract appears as Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health (August 1, 2017). You have to pay for a copy if you want to read the underlying article. I don’t know why that’s the case, since the study apparently was funded by our government. Anyway, the abstract is available at .

[9] These findings are paraphrased or directly quoted from the Abstract.

[10] See, e.g., Fox 5, Hundreds mourn doctor slain after denying opioids to patient (August 2, 2017)), available at .

[11] See Reuters, Raymond, State attorneys general probe opioid drug companies (June 15, 2017) available at

[12] See Clair McCaskill speaking to the DNC on July 28, 2016, available at finance.html&form=EDGEAR&qs=PF&cvid=59500fa1e8204d0a8a8906e8292f9679&cc=US&setlang=en-US&elv=AXXfrEiqqD9r3GuelwApuloTP6wVwkOjONBqpuAMtOReD2p9Vv8km70BwEANJJDGrbYQZQruLL%21jduPgTqpAT%212GMOjDF0L2w7LKJr4QVFIa

[13] See RT, US offers to help fund Mexico’s heroin eradication efforts – report (22 April 2017) available at

[14] In fact, there doesn’t really seem to be an argument about this. See n. 1 and the quote that accompanies it.

[15] That’s Dave Feagles. Many thanks, Dave!

[16] See Science News, Gaidos, Vaccines could counter addictive opioids, Vol. 190, No. 1, p. 22 et seq. (July 9, 2016), While we have this article in our library, we don’t have a web  address for it, so we’re citing to the hard copy magazine.

[17] Id. We’re citing to the print version of the article, but don’t have the printed pages before us. We estimate that this information appears around p. 23.

[18] Id. at around p. 24.

[19] Id.



In the final analysis, however, the implication that there is a decision to be made (seek medical care or not) or a ‘spreader’ to be found is merely a cognitive convention that has been imposed on the PPE-bereft care nexus by western philosophy.

Eugene T. Richardson and many others, in The Ebola suspect’s dilemma[1] 

[Hi everybody, this is Fred. You might be wondering what epidemic I’m talking about, and what that quote means. Frankly, I don’t have a crystal ball; I don’t know what the next epidemic will be. We’ll discuss the quote later.

Of course the last really scary epidemic was Ebola; there are multiple varieties of that, and one or another of them could break out at any time. But there are other possibilities as well: hemorrhagic fevers that have yet to imitate Ebola’s success; Zika, a virus spread through common varieties of the mosquito, that horribly damages the unborn; or things we don’t know about, hiding in the nooks and crannies of the planet. Nature is tenacious, and evolution is one of her weapons. When silly humans poke into areas they don’t normally invade, the local flora and fauna adapt, and their parasites do as well. Then, perhaps a new epidemic!

I don’t know what the next epidemic will be, but definitely there will be one. There always is.

So if there’s another plague coming, how do we prepare for it without a crystal ball? Well, the other option, I guess, is to look to the past to see what it tells us about the future. Learn from experience?

So let’s talk about how and why Ebola spread so rapidly the last time it broke out. It just so happens that the Washington Post recently put out an article on that very subject.[2] It seems that, according to the Post report, Ebola was spread mostly by a few people who just wouldn’t go to the hospital. “If super spreading had been completely controlled, almost two-thirds of the infections might have been prevented, scientists said.”[3] So problem solved! Just confine the people who have Ebola and you confine the disease!]


Let’s back up for a minute. If you followed the outbreak of two years ago – I did – you were told at the time that there was no known cure for Ebola; only “palliative” care, if any, could be provided at local hospitals; the disease was spread by personal contact with Ebola victims; and that fatality rates were ranging from 53 to 64%[4]. So let’s say that you lived in one of the infected areas, and you developed symptoms. You had fever, vomiting, muscle pain and headache. Those are signs of Ebola for sure; but they’re also symptoms of malaria, and that also was prevalent in your area.[5] So which did you have?

Governments and doctors knew that the best way to contain Ebola was to isolate the people who had it. The problem was there was no easy way to tell Ebola from malaria, until Ebola more fully presented itself. So why not err on the side of caution? Gather together everybody who might have Ebola and treat them as a group?  

The problem was that Ebola was very contagious; it spread mostly by personal contact with people who are infected; and it was difficult even for health care workers to avoid getting it in a hospital setting.  So if you took someone who had malaria and put him [or her] in with Ebola patients, the malaria sufferer could get Ebola as well. Also, two years ago there was no known cure for Ebola. The best the so-called treatment centers could do was offer “palliative” care, i.e., infusions of fluids, etc., to help sustain the patient until his or her immune system deployed against the disease. I don’t have any statistics, but my impression is that palliative treatment was more effective than expected, but wasn’t available everywhere.

This is not to criticize the brave people who fought Ebola in West Africa. They did the best they could with what they had, and the epidemic was contained. But even so why didn’t everybody cooperate with authorities in the crisis? Well, because there were major incentives to do the opposite.

This is the point of The Ebola suspect’s dilemma, the article we quote at the beginning of this piece. The argument is simple. Two years ago in West Africa:

  • If you had malaria, you had a 0.2% chance of dying from it at home, and no chance of dying from Ebola Virus Disease;
  • If you had undiagnosed malaria and you went to an Ebola Treatment Unit, you had a 16.1 % chance of catching Ebola and dying from it.[6]
  • If you had undiagnosed Ebola and stayed home you had a 70.8% chance of dying from it.
  • If you had Ebola and were treated at an Ebola Treatment Unit, you had a 64.3% chance of dying from Ebola.[7]

So think about it. What’s the rational thing to do? If a patient knows he [or she] has malaria, and not Ebola, he/she would be stupid to go to an Ebola Treatment Unit, even if the Government wanted that. There’s too high a risk that the patient will get and perish from Ebola, and malaria is not that hard to treat at home and survive.

In our example the patient doesn’t know his illness. Nobody, with or without Ebola has very good luck at the ETUs. If they don’t have Ebola they may catch it; and if they do have it, the ETUs aren’t very good at curing people. Why don’t they just rationalize; tell themselves they have malaria and stay away from the ETU?

There is a reason to do the other thing, but it’s altruistic, not practical. If Ebola is everywhere, and spreading rapidly, perhaps citizens with undiagnosed illness ought to isolate themselves from the community. Perhaps it’s better to check into an ETU, even a dangerous one, rather than risk spreading a virulent disease. I’m not sure how many folks accepted this notion in West Africa, but altruism was on display during the Ebola crisis. Think of the health care workers, for example, who worked the front lines of the epidemic and died on the job. No doubt there were lots of other people like that who we didn’t hear about.

Nevertheless, getting back to our authors and their quote, it’s not clear they accept altruism as socially useful. Is it simply a concept left over from “western philosophy,” and therefore to be discarded? Or are they saying we should avoid the need for self-sacrifice by doing more advanced planning? Or are they saying both things?

I would agree with the second point, but not the first. Health crises tend to expand from one place to others. It’s better to prepare now rather than wait for the crisis to come to us. And what about altruism? Well, sometimes we just have to do things for the greater good. Self-sacrifice is not immoral.


Since we’re talking about planning and looking to past experience to guide the future, let’s consider Ebola vaccines. There the news is pretty good. Currently there are at least 8 of them in clinical trials[8], with one granted Breakthrough Therapy Status by the FDA and PRIME status by the European Medicines Agency. Research is continuing to extend the immune response generated by all research approaches. The most recent information suggests that all of them should continue for now. “[I]t would be unwise to rely on a single vaccine candidate, and it is reassuring that the assessment of other potential vaccine strategies is ongoing.”[9]

So perhaps competent research, world-wide, really is a way to tackle potential epidemics. Did you expect me to say something else?

[1] See The Lancet, Comment, Richardson, et al., The Ebola Suspect’s Dilemma (March, 2017), available at (Cited hereafter as Dilemma at __).

[2] See The Washington Post, Sun, ‘Super spreaders’ were driving cause of 2014 Ebola epidemic, study finds (February 14, 2017) at p. A2.

[3] See Dilemma at e254.

[4] See, e.g., CDC, Morbidity and Mortality Weekly Report,  Ebola Viral Disease Outbreak — West Africa, 2014 (June 27, 2014), available at “On March 21, 2014, the Guinea Ministry of Health reported the outbreak of an illness characterized by fever, severe diarrhea, vomiting, and a high case-fatality rate (59%) among 49 persons (1). Specimens from 15 of 20 persons tested at Institute Pasteur in Lyon, France, were positive for an Ebola virus by polymerase chain reaction (2). Viral sequencing identified Ebola virus (species Zaïre ebolavirus), one of five viruses in the genus Ebolavirus, as the cause (2). Cases of Ebola viral disease (EVD) were initially reported in three southeastern districts (Gueckedou, Macenta, and Kissidougou) of Guinea and in the capital city of Conakry. By March 30, cases had been reported in Foya district in neighboring Liberia (1), and in May, the first cases identified in Sierra Leone were reported. As of June 18, the outbreak was the largest EVD outbreak ever documented, with a combined total of 528 cases (including laboratory-confirmed, probable, and suspected cases) and 337 deaths (case-fatality rate = 64%) reported in the three countries. The largest previous outbreak occurred in Uganda during 2000–2001, when 425 cases were reported with 224 deaths (case-fatality rate = 53%) (3). The current outbreak also represents the first outbreak of EVD in West Africa (a single case caused by Taï Forest virus was reported in Côte d’Ivoire in 1994 [3]) and marks the first time that Ebola virus transmission has been reported in a capital city.”

[5] See Dilemma at e254. “West Africa is the region with the world’s highest incidence of malaria.”

[6] Id. As the authors explain, that’s about a 25% chance of catching Ebola, adjusted by a 64.3% mortality rate. A disease caught at a hospital is called “nosocomial.” Write that down for future reference. No doubt you and I will need to know the word at some point.

[7] Id.

[8] See The Lancet, Comment, Snape, Persistence of immune responses induced by Ebola virus vaccines (March 2017)  (Cited hereafter as Immune Response at __).

[9] See Immune Response at p. e239.







[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 Henceforth this will be cited as DEA 2015 Alert.

[2] Since 1960, if you’re curious. See the Wikipedia entry on fentanyl at

[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

[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

[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 . “’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

[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

[17] See the Wikipedia discussion at Naloxone; available at    “[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  “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

[20] That’s from Marcus Tullius Cicero, a Roman dude I was once forced to translate. You can find it on Brainy Quote, at: