Synthetic opioids like fentanyl accounted for around 3,000 deaths in 2013—by 2018, they accounted for over 30,000.1 Fentanyl is approximately 100 times more potent than morphine, 50 times more potent than heroin. Breathing can stop after use of just two milligrams of fentanyl. That’s about as much as trace amounts of table salt. “Ten years ago,” write the authors of a recent RAND report on the future of fentanyl, “few would have predicted that illicitly manufactured synthetic opioids from overseas would sweep through parts of Appalachia, New England, and the Midwest.” Drug epidemics and outbreaks can be surprising, taking unexpected forms at unpredictable moments in uncharacteristic patterns. But the fentanyl crisis is different. It isn’t just distressingly surprising or one more deadly drug epidemic in a grueling, tragic history of new contagions. Its magnitude, intensity, and sharp variations dwarf previous epidemics with which experts and officials are familiar, and its challenges for public health are novel and, so far, unmanageable. The recent RAND report is a comprehensive overview of the fentanyl crisis’s origins, present status, and, most disturbingly, future.
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Preliminary 2018 data from the Centers for Disease Control show a slight decline in drug overdose deaths.1 In the view of many experts, increased availability and use of Naloxone, education, and also increased access to Medication for Addiction Treatments (MAT) contributed to this decline.2 However, opioid use disorders and drug overdose rates remain extremely high nationally. Moreover, decreasing overdoses from prescription misuse and heroin should not distract from rising importation, misuse, and overdoses due to fentanyl, methamphetamine, and cocaine.3 With limited treatment options available for these substance use disorders, researchers are working to create novel approaches, using all technologies available, to prevent, treat, and improve the lives of patients and families. In a number of studies and trials, Tom Kosten and his colleagues at Baylor have looked at cocaine, methamphetamine, opioid and even fentanyl vaccines, showing promising results in reducing overdose, misuse, and treating substance use disorders.4
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The physiological cravings that accompany addiction, along with memory cues and environment triggers specific to each patient can cause a recurrence of use or relapse. As such, effective treatment needs to address a person’s behavioral health and help them learn how to cope with stress and environmental triggers.
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Alcohol use is very prevalent among Americans - more than half of U.S. adults drank last month - and alcohol is the third leading cause of preventable death after tobacco and poor diet/physical inactivity.1,2 When coupled with prescription opioid use, drinking becomes especially dangerous.3 Women are at high-risk of experiencing these adverse health effects, which worsen with age. A recent study illuminates the repercussions of concurrent alcohol and prescription opioid use in older women.
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At the center of America’s deadly opioid epidemic, non-pharmaceutical fentanyl appears to be finding its way into illegal stimulants that are sold on the street, such as cocaine. Adulteration with fentanyl is considered a key reason why cocaine’s death toll is escalating. Cocaine and fentanyl are proving to be a lethal combination - cocaine-related death rates have increased according to national survey data. This has important emergency response and harm reduction implications as well—naloxone might reverse such overdoses if administered in time. A recent study by Nolan et. al. assessed the role of opioids, particularly fentanyl, in the increase in cocaine-involved overdose deaths from 2015 to 2016 and found these substances to account for most of this increase.
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Today the Centers for Disease Control and Prevention (CDC) announced that new advice on their Guideline for Prescribing Opioids for Chronic Pain will be published in the New England Journal of Medicine (NEJM).