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The fentanyl crisis

Its roots, the impact and what’s being proposed in response

Jan 03, 2017, By: Kate Jaimet
ambulance on route to an emergency

In the first nine months of 2016, more than 330 British Columbians died after overdosing on illicit drugs that contained the potent synthetic opioid fentanyl. In Alberta, nearly 200 people died of fentanyl-related overdoses during the same period. And in Ontario in 2015 — the most recent year for which data are available — fentanyl (either on its own or combined with alcohol) claimed the lives of a record 198 people, up from 91 just five years earlier. Created more than a half century ago as an intravenous surgical analgesic, fentanyl has spread throughout the illicit drug market and become a deadly part of Canada’s larger opioid crisis.

“I’ve been in policing for 27 years. I’ve seen new drugs hit our markets — methamphetamine, crack cocaine — but none that have hit and affected our communities like fentanyl and its analogues,” said Deputy Chief Constable Mike Serr of the Abbotsford Police Department, speaking at the recent opioid conference. He chairs the Canadian Association of Chiefs of Police’s Drug Abuse Committee.

Fentanyl is 50-100 times more powerful than morphine. Its use was restricted to hospital operating rooms until the 1990s, when physicians began prescribing a new transdermal patch to treat chronic pain for opioid-tolerant patients with cancer. Soon, the patch was being prescribed for patients with chronic non-cancer pain. Lozenges and tablets followed.

“We have, by virtue of our prescribing,…opened a bit of a Pandora’s box,” said Dr. David Juurlink during his keynote speech at the conference. He is head of the clinical pharmacology and toxicology division at Sunnybrook Health Sciences Centre. “We have flooded the market with drugs that don’t work as well as we were taught and aren’t as safe as we were taught.” The best available data indicates that about 10 per cent of people prescribed opioids become addicted, he said.

The increasing availability of prescription fentanyl has provided a supply stream in which criminals can steal the drug from hospitals, pharmacies and patients’ medicine cabinets and sell it on the streets. As well, Chinese labs are making and selling cheap fentanyl, which North American drug dealers import and cut into other substances to increase their profits. According to Serr, one kilogram of Chinese fentanyl that costs $12,000 can be made into a million pills worth as much as $80 million.

Harm reduction researcher Bernie Pauly is an associate professor at the University of Victoria school of nursing and a scientist at the Centre for Addictions Research of BC. “The use of opioids and risk of overdose affects all sectors of society,” she says. “That includes people who are teenagers, parents, someone’s brothers and sisters.”

Because illicit drugs, by their nature, are unregulated, it is usually impossible for people to know if the drugs they purchase from a dealer contain fentanyl. However, the Insite supervised injection site in Vancouver’s Downtown Eastside began a pilot testing program last summer.

After a client heats the drugs in a cooker, prior to injection, the residue is mixed with water and a urine testing strip is dipped into the solution. The strip indicates whether the mixture contains fentanyl. However, it does not indicate the amount of fentanyl or the presence of analogues (chemically similar drugs). The analogue carfentanil, which has begun appearing in street drugs, is 10,000 times more powerful than morphine. It was developed for large animals but never intended for humans.

Marjory Ditmars, a nurse and clinical coordinator at Insite, says that between July and September 2016, 86 per cent of tested drugs were positive for fentanyl. Although most clients still choose to inject the fentanyl-laced drugs, they take precautions such as cutting the dose in half or remaining at Insite to inject in the presence of a nurse, who could revive them if they overdosed. “It’s not unusual for us to see upwards of eight or 10 overdoses in a single shift,” she says.

A fentanyl overdose has the same clinical symptoms as any other opioid overdose, except that the onset is often faster, says Kristel Guthrie, an RN and health promotion specialist at The Works, a harm reduction program at Toronto Public Health. “Generally, they’re unresponsive. They’ve got slow breathing or their breathing has stopped completely. Erratic, weak or no pulse. The lips, fingertips and under fingernails are going to be blue or purple in colour. Ashen coloured, clammy skin. All the things that happen when you’re deprived of oxygen,” she says. “Because that’s what it is — it’s a respiratory emergency. It’s blocking these receptors [in the brain] and shutting down the basic life functions.”

A fentanyl overdose is treated by administering the receptor-blocking drug naloxone and performing CPR. If the patient does not revive, further doses of naloxone can be administered at three- to five-minute intervals. Naloxone is available either as an intra-muscular injection or as a nasal spray, under the brand name NARCAN.

A person who overdoses on fentanyl is often more difficult to revive than one who overdoses on a less potent opioid. “It used to be quite unusual for us to use more than one or two doses of NARCAN, whereas now the average is three doses, if not more,” Ditmars says. “We would see people coming out of full apnea, not breathing, after about 5-10 minutes. Now, we could be bagging people for about 20 minutes, before EMS gets there to take over and transfer people to hospital.”

Pauly says that evidence-based harm reduction strategies, including establishing more supervised injection sites, heroin prescription and substitution therapy, as well as expanding drug testing are “some of the biggest things we need to move forward right now to address this emergency.” She wants more front-line practitioners, including nurses, and members of the general public to be equipped with naloxone kits and trained in opioid overdose response, which includes basic rescue breathing.

“Nurses should be contributing to and supporting front-line responses,” she says. “However, they are often prevented from doing so by organizational policies that do not support their involvement in harm reduction strategies and education.

“They have the knowledge to respond to overdoses and provide education to others about overdose responses, safer drug use, substitution therapies and non-pharmacological management of pain. Just as important is their role in advocating for changes to policies that prevent implementation of harm reduction strategies.”

Conference and summit tackle opioid crisis

Federal Health Minister Jane Philpott and Ontario Health Minister Eric Hoskins convened an emergency two-day opioid conference and summit in Ottawa in November. To discuss possible solutions to the crisis, they brought together health professionals, first responders, policy-makers, community services workers, law enforcement representatives and those who have used or abused opioids.

The summit’s joint statement of action, signed by Philpott, Hoskins and 42 organizations and government agencies — including CNA, the Canadian Association of Schools of Nursing (CASN) and the Canadian Council of Registered Nurse Regulators (CCRNR) — promises to improve prevention, treatment and harm reduction strategies to combat problematic opioid use.

CNA and CASN committed to developing evidence-based educational resources for RNs, NPs, LPNs and students about opioid use and harm reduction and distributing them to provincial and territorial associations and colleges by November 2017. CASN further committed to educating nursing faculty about the growing opioid crisis through blogs, webinars and newsletter articles.

CCRNR committed to developing guidelines by June to support implementation of a standardized approach to

  • opioid prescribing for NPs
  • NP education about harm reduction, including prescribing suboxone and methadone
  • use of electronic pharmacy management e-systems that create a complete and accurate list of a patient’s medication
  • monitoring of prescribing and quality assurance
  • entry-level and remedial education on prescribing competencies for NPs
  • entry-level competencies for RNs, including ways to support effective pain management and limit potential for abuse among patients/clients.

RNs and NPs were also identified in other initiatives. The Newfoundland and Labrador Ministry of Health and Community Services committed to start covering suboxone under special authorization by March, until an Atlantic Common Drug Review can be completed. Consultations on the plan were to include the Association of Registered Nurses of Newfoundland and Labrador and conclude in January. The College of Physicians and Surgeons of Newfoundland and Labrador committed to developing and implementing a new safe-prescribing program for physicians and to later extend it to NPs, pharmacists and dentists.

In response to a question from Canadian Nurse at the summit media conference, Philpott said the federal government would publish new prescribing guidelines for opioids sometime in January. As well, Hoskins confirmed that the federal and provincial governments would discuss funding of non-pharmacological treatment of pain during health accord negotiations.

The federal government and several provinces committed to increasing the availability of take-home naloxone and buprenorphine. Philpott also promised to amend the previous government’s Bill C-2, known as the Respect for Communities Act, which imposed barriers to establishing supervised injection sites.

“I’m very encouraged by the fact that [the opioid crisis] is seen as a public health problem that is not going to be mitigated by one province, one group, one profession, one intervention,” said CNA president Barb Shellian, who attended the summit. She added that she is pleased that Philpott will be looking at Bill C-2.

Kate Jaimet is a freelance journalist in Ottawa.