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Hayley: Hello, my name is Hayley. And thanks for joining me for this episode of Straight Talk With The Doc, the podcast that breaks down topics on addiction, mental health, and treatment. I’m here with addiction medicine specialist Dr. Bhatt and our content director Jeff. How are you guys doing?
Dr. Bhatt: Good, Hayley. Jeff, how are you doing?
Jeff: Doing good today, doing good.
Hayley: Me too. In past episodes, we’ve talked about drugs like methamphetamine and cocaine. Breaking them down and explaining why they have such a strong effect on people, and how someone can become addicted to them. In this episode, we’re going to be talking about a drug that has constantly been in news headlines for some time now. Just because of the sheer danger of it and how many overdoses it’s been involved in. And that drug is, of course, fentanyl. I know fentanyl is a synthetic opioid, but what does that mean? How is a synthetic opioid different than an opiate?
Dr. Bhatt: I think many people, Hayley, use that term interchangeably: opiates and opioids. But technically, an opiate is something that is derived from the natural poppy plant and from opium which is the active ingredient there. Versus opioids which is something that’s man-made. A synthetic product that has been produced in a laboratory which probably has the same purpose- for pain relief analgesia. But that’s the main difference. Man-made: opioids, naturally occurring: opiates.
Hayley: What’s used to create synthetic opioids?
Dr. Bhatt: Most of the synthetic opioids are chemical structures that are produced in labs and have similar qualities that an opiate would have. That can ultimately be put together to, hopefully, execute the purpose that it’s intended to. If it’s an opiate that’s intended for, obviously, pain relief, that it does that in the safest possible way and with the least amount of side effects. But most of them are chemical structures or compounds that have similar effects and mechanisms and structures as traditional opiates. And these are put together, again, in the lab.
Hayley: Why were synthetic opioids created? Was it because opiates weren’t potent enough?
Dr. Bhatt: Yeah that was something that was looked at. In terms of why do many pharmaceutical agents come on the market? And it’s often we’re looking for a better type of medication or medicine to treat something. And similarly with opioids we try to have something that was stronger or longer lasting, something that could be more controllable. But the intent was to have a better product on the market, often that can provide the best relief, the quickest, more reproducible things that can, obviously, be distributed to individuals to provide proper treatment. But one of them, like you mentioned, was to be more potent.
Hayley: What’s the story with fentanyl? Who was that initially intended for?
Dr. Bhatt: Fentanyl has been around for quite a few decades. When it was discovered and it was used, it was traditionally used for people with pretty severe pain. It was, for example, post-op for surgical issues and people who have significant trauma or chronic moderate to severe pain often from maybe cancer. But it’s beyond those few indications, it really wasn’t meant to be used or hasn’t been meant to be used in a broader sense. It’s a very, very potent substance. Fentanyl is really reserved, again, for those major pain situations. And it’s pretty significant when used in the wrong way.
Hayley: Can you give me an example of how potent it is compared to other opioids?
Dr. Bhatt: It’s probably about one hundred times more potent than morphine. So, it’s pretty significant. We use it in very, very small increments and micrograms and that’s because it’s very, very strong. And again, we’ve been seeing so much significance when this has been diverted and people have used this in abusive ways. And unfortunately, it’s led to a lot of overdose and deaths. It’s a very, very strong drug.
Hayley: I know that the opioid epidemic has come in waves. But could you talk about fentanyl’s role in the opioid epidemic?
Dr. Bhatt: I know we spoke about this in another episode. The opioid epidemic, for many people who haven’t heard or maybe just guessing on it. The theories behind it have been when pain was being under recognized and there was a push by the world health organization and other health care sectors to address pain. Mixed with a very robust, and maybe even inappropriate, marketing campaign by different pharmaceutical companies, there was a significant amount of pain medications prescriptions that went out. And in the 80’s and 90’s, especially, we saw that and that led to many people becoming physically dependent on opioid class medications. Unfortunately, as the government started to regulate, and different processes were in place to ensure that there wasn’t this overzealous prescribing of these pain medications. People who were left unfortunately physically dependent on these things, or who were abusing them, or might have diverted them, started to see lack of supply and filtered out onto the street. And then we saw an uptick in other opiate type substances. We saw the rise of heroin came again as the street supply of these pills occurred. As we go along, then it’s a supply and demand situation. Again, with heroin and the time, the process of making it, producing it, and distributing it, fentanyl found its way out of the proper places that it was in the health care sector and it found its way also onto the street. And being that it was so potent and not very expensive, again, from a supply and demand issue at the time, fentanyl started getting intertwined with not only heroin but then again on its own. Again, its all is in evolution from when somebody who has been exposed to opioids develops a physical dependency or develops an addiction, can’t get ahold of the substance they become dependent on often will transition to something else. And it just happened that fentanyl was just the next stronger substance that at that point was less expensive and could provide a significant high. And got incorporated into the black market and on the streets, and unfortunately, now is a huge problem for the United States and many countries around the world.
Hayley: I think people would be afraid just because of hearing about so many overdoses that involve fentanyl. Are people seeking out fentanyl to get high or do they usually end up taking it by accident?
Dr. Bhatt: You use the word afraid, Hayley, and I wish people were afraid. I wish for people that fear was a deterrent to substance use. I think then we would have a little bit more leverage on helping people stop using. But unfortunately, when somebody is suffering from full blown addiction, fear is something that is masked. And being afraid, or even just thinking rationally in general, gets thrown out the window. That’s kind of the nature of addiction. We don’t think clearly; we don’t think straight. Once people are trying to pursue a high, often to feel good or often to escape the withdrawal, they will go to any extreme necessary and even if it means teetering with a drug that in micrograms can kill you. People are out there pursuing them.
Hayley: You hear a lot about drugs being cut with fentanyl. Why do drug dealers cut other drugs, like pills, with fentanyl?
Dr. Bhatt: Again, this is just to enhance the potency of your product. We talked about previously, fentanyl is a very potent product, it’s a very potent chemical. And if you mix it with heroin that’s often cut or mixed with other things that are bulking, this can give you the additional psychoactive substance that makes one high. It’s often added to make it more potent, as a whole to heroin, or in itself. It’s pressed into different pills and then sold in very, I guess, wide range of mixtures and impurities and combined with it. It’s a scary thing because one: using drugs of course is dangerous. But then using drugs when you don’t really know what you’re getting with such a lethality and potency to it, it’s very, very unpredictable. And unfortunately, we are seeing results in the deaths and the overdoses that we see all around the country.
Jeff: I was just going to add that a lot of times fentanyl is mixed with other things simply for cost. Because fentanyl is so much more potent than say heroin, a much smaller physical amount of fentanyl will provide the same kind of high. And it’s therefore much cheaper and comparatively for the people who are doing the smuggling, safer to smuggle smaller amounts of fentanyl, which decreases costs all up the supply chain. Also, while fentanyl was initially looked on with suspicion when it first entered the drug market, now a lot of drug users actively seek out fentanyl. And that’s why it’s mixed with so many things, due to demand.
Dr. Bhatt: Oh, for sure. You make a great point Jeff. These are things that the supply and demand business plays a huge role and why things are put out there. Highlighting what you said, and what we said before, it’s just so potent that you add it to the heroin and it becomes just a more addictive substance. And you can use less of it and it becomes in a way more cost effective. It’s absolutely true that we’ve seen it and people are asking for it. And we are seeing people come to treatment and seeking help for just pure fentanyl addiction. It’s become more and more common place.
Hayley: That brings me to the next question I was going to ask. How often do you actually see somebody with a specific fentanyl addiction, like that’s their drug of choice, is that very common?
Dr. Bhatt: Over the last 5 years we’ve seen it rise considerably. And again, depending on what geographical area you are within the country, and if speaking specifically of course here in the United States, yeah, people are coming in specifically using fentanyl. Again, it comes down to supply and demand and what they might have used as of late. And many people who use opiates are switching around. They are going from pills, to heroin, to fentanyl and back again. And it really depends on what’s available on the street, what they can afford. And a lot of this stuff is coming in from outside of the United States. As Jeff mentioned previously, people who are smuggling this stuff and it’s not always very consistent. And that also translates into this “I want to get high on what I can get”. But definitely, fentanyl has been more and more prevalent in the drug scene over the last many years.
Hayley: On the flip side, for those who are using drugs but trying to avoid fentanyl, is there any way for someone to know that the heroin they purchased is actually fentanyl?
Dr. Bhatt: It’s very hard, unless that somebody is reporting to you, your dealer, or somebody saying that this is what’s in it. Often there’s certain colors and characteristics of the heroin. It comes in a very wide variety of texture and in terms of coloration. But unless you know that or have the ability to break it down from a chemical component, it’s often hard to decipher. And that’s why we do see people who do switch or do change or who do come out of treatment or who have been abstinent for so long, because it’s so unclear as to what you’re getting and how much of what’s in it. That unpredictive side of this whole thing is leading to so many of these negative consequences; that’s an overdose.
Hayley: I assume different types of opioid drugs that are being used are cut with fentanyl. Are other drugs also cut with fentanyl, like cocaine or ecstasy for example?
Dr. Bhatt: Yeah, it can be. We do see people who have had unfortunately, might not have wanted to be using any sort of opiate. But as we mentioned, that due to the potency of fentanyl, to the fact that it creates such a significant high in such small amounts, that depending on the intent of the drug dealer or what they’re trying to put there on the market and the fact that they want to keep addicted individuals addicted. Or people who want to get high, high. You are seeing it cross over into other classes of drugs. And again, this just adds to not only the people having unpredictable outcomes, but the cross dependencies, the experimentations, and unfortunately, again, as I said before, the deaths that are occurring at an extreme rate here in the country.
Hayley: What does a physical dependency on fentanyl look like?
Dr. Bhatt: It’s very similar to other opioids, in the sense that people feel that euphoria. They feel that analgesia. They feel that warmth. They feel those sensations where they feel great. They feel high. But with it, comes a very sedating type of aspect. It compromises your breathing, and it compromises your heart rate. And that leads to, of course, overdose, coma, or death. Because it is a similar class, it is in opioid. It has a very similar characteristic profile of other opioid drugs.
Hayley: For this question, I’m sure it depends on the individual and their tolerance, but in general, how much fentanyl can be taken before somebody overdoses?
Dr. Bhatt: You said it. With opioids, in general, the type, duration, the characteristic of the individual, it all depends on how much a person can tolerate. And especially because opioids are incrementally tolerable by individuals, those who have been using longer and in increasing amounts can steadily go further and further. Some studies show that 200 micrograms, in naïve individuals, is enough to kill somebody when it comes to fentanyl. But I really don’t just want to look at that number versus the fact that different amounts kill people in different ways. And it really depends a lot on their physical body make up, and also the tolerance that they have developed. But, in general, we’re talking about such small amounts that many people are dying on amounts that you could barely see. It’s pretty significant.
Hayley: I’d like to bring up quickly another synthetic opioid that I see people talking about, and that is carfentanyl. What’s the difference between carfentanyl and fentanyl?
Dr. Bhatt: Well, carfentanyl is a separate chemical. It’s a separate drug. It’s a synthetic compound. Also, it’s been around for quite a few decades and its made its way onto the streets, unfortunately. And this is traditionally used. It’s so potent; I’m talking a thousand times more potent than morphine. It’s used more in veterinary medicine. It’s used as a tranquilizer for very, very large animal and it really has no indication otherwise. And the fact that it’s made its way out onto the streets, it’s extremely dangerous.
Hayley: Would you say that it’s more dangerous than fentanyl?
Dr. Bhatt: It’s more potent than fentanyl. When you think about it in context, yes. The short answer is yeah to those individuals. Because such small amounts, grains of salt size amounts, if they’re inhaled and stuff like that, they can kill somebody. And because it is that potent, it is that much more dangerous. I think the bottom line with all of this stuff is because of the unpredictable nature of these drugs that are getting out there on the street, the advantages that people are trying to take in terms of selling, trying to cut costs, and get people more high, and try and get their product over and distributed to a larger surface area. In this whole business of drug dealing, you never know what you’re going to get. The fact that it’s physically so habit forming, dependency creating, that the chemical nature of opioid is being so addictive. When you have these products that are so potent going out there, it’s not a surprise we’re seeing so many people dying on the street. And you said in another question before: fear. I wish fear was something that was enough of a deterrent for people to not use. But unfortunately even when people are watching others overdose in front of them, it’s not stopping them. And them overdosing multiple times themselves, being on life support, it’s not stopping people from using. And that’s the type of danger that’s out there.
Hayley: What are the withdrawal symptoms like for someone with a fentanyl addiction?
Dr. Bhatt: People who suffer from fentanyl withdrawal typically appear to look like those who suffer from opioid withdrawal in general. Most people are in extreme discomfort. They have body aches. They’re sweating. They often have nausea, vomiting, diarrhea. They are extremely dysphoric. And they are extremely uncomfortable. For the most part, we understand that opioid withdrawal is not considered a life-threatening withdrawal. But we’ve seen people who seize now and have, in those rare cases, died even from their withdrawal. Even though, like I said, prototypically it’s not a life-threatening withdrawal. But fentanyl withdrawal is a very significant, very severe, very painful, and very uncomfortable withdrawal.
Hayley: Is fentanyl withdrawal worse or different compared opioids or opiates like heroin?
Dr. Bhatt: We’ve seen it in a variety of ways. Withdrawal, it’s pretty much typical in terms of the constellation of symptoms. But as of the degree, that really depends on the individual and often times, the extent and duration of how long they’ve used. And I wish I could say just the potency of fentanyl being more portent causes a more significant withdrawal. We do tend to see, though, synthetic products, often due to their duration of action and other qualities of man-made opioids, they tend to have a more prolonged withdrawal. And we do see that often and that makes it a little more difficult in terms of tolerability. Because the withdrawal, although somewhat similar, tends to last longer, and nobody wants to have to deal with that. But unfortunately, that if often what we do see.
Hayley: Dr. Bhatt, is there anything I didn’t ask you about this drug that you think people should know?
Dr. Bhatt: I think we have said obviously fentanyl, carfentanyl, the danger that exists there. The fact that it is coming, mainly, I don’t know if we talked about this previously or in another episode, but these are coming from different parts of the world. Most of the supply of this stuff is coming from the far east, Mexico. And then there’s the ingredients that make up the chemicals that produce the fentanyl and stuff that come from different, other parts of the world. Again, the fact that it’s so potent, it’s unpredictable, it’s cut up and cut into many different things, especially, of course, in heroin. This is just getting worse. I wish again, I think I’ve said it a few times, that I wish fear was a deterrent. But this is something that as health care practitioners, we are afraid of. We’re afraid to see this, because through clear mind and clear eye we know how deadly this is. It’s just a very sad situation that people who are watching people die who experienced near death themselves, continue to use a product that’s like a bullet and a gun pointing right at them and pulling it. It’s just that crazy, and that just speaks to the nature of addiction. When we talk about addiction being a disease, I know some people can argue, is it the intoxication? Is it just the effects of this mind-altering substance? However way somebody wants to highlight certain aspects of the whole thing, this problem is huge. It’s real and it’s costing people their lives. I think we need a tremendous collaborative effort amongst everybody, as citizens of just humanity, to help in this because it’s a big deal. I’m hoping more people seek help and seek treatment and get the help that they deserve.
Hayley: Yeah, absolutely, and I’m glad you said that. Thank you, Dr. Bhatt, for breaking this down, and thank you Jeff, for also being here today. And a big thank you to our listeners who tuned into this episode. You can hear more break downs on drugs and addiction on our other episodes which are available at addictioncenter.com, as well as Spotify and Apple Podcasts. And for those we may know someone who is misusing opioid drugs, don’t wait to intervene. Help them find resources because that could potentially save someone’s life in the long run. You can find resources at addictioncenter.com if you want to learn more. And we hope to have you again for another episode of Straight Talk With The Doc.