Sunday, July 9, 2017
Fentanyl: a killer drug crisis
Fentanyl: The king of all opiates, and a killer drug crisis
It’s stronger than heroin and more potent than OxyContin. It’s also cheap, ubiquitous, and incredibly deadly. Inside the rise of fentanyl.
Jonathon Gatehouse and Nancy Macdonald
June 22, 2015
Michael Morton and his friend had a plan, and they’d done their homework. It started with the opportunity for high school co-op placements at local pharmacies, and a favourite rap song that rattled off a list of drugs to abuse. “OxyContin, Xanax bars, Percocets and Loritab,” Lil Wyte rhymed in Oxy Cotton. “Valiums, morphine, patches, ecstasy. And it’s all up for grab.” Within weeks of starting their jobs, the two teens from Barrie, Ont., had pilfered enough prescription narcotics to start their own drugstore. And via the Internet, they researched how to best misuse them, right down to the dosages and the proper order in which to take them in order to build up tolerance.
Sitting in a coffee shop, with the history of his high school years neatly spelled out on pieces of foolscap before him, Michael, now 26, still gets a little misty about what he calls “the king of all opiates.” He and his friend had amassed a stash of more than 200 fentanyl patches, but kept away from them for months out of a healthy respect for a pain reliever that is 20 times stronger than heroin and up to 100 times more potent than morphine. But, just before Christmas of his Grade 11 year, Michael had been caught breaking into lockers at school and expelled. His bosses at the pharmacy—rightly suspecting him of stealing there, too—also dismissed him. Now sitting at home, grounded and alone all day, he had the motive and opportunity to push his limits. He unwrapped a patch, squeezed out a tiny amount of gel from between its plastic layers, and put it in his mouth. “I fell back in my seat and I fell in love,” he says. “It was the best high I ever had.”
Within a year, he was going through two of the patches—each designed to provide 72 hours of steady relief for people suffering from intense, chronic pain—every day, chewing them, or scraping out the gel to smoke or inject. He came close to overdosing on many occasions, and frequently passed out, as the drug slowed his breathing and pulse. “Every time I did it, my heart dropped to, like, 30 beats a minute,” he says, “but I thought I was invincible.” It took the deaths of four of his friends and fellow abusers—two of them still in their teens—to convince him to seek help. Six years later, he’s still on methadone, struggling to taper his daily dose and construct a future. “It’s hell, but it saved my life,” he says, “because the urge always comes back.”
Over the past few months, fentanyl has been making headlines across North America, as police discover more and more of it on the streets, and overdose deaths surge. Authorities in Alberta linked the drug to 120 fatalities in 2014, and 50 more in just the first two months of this year. In British Columbia, it killed almost 80 people in 2014, and was responsible for a quarter of all drug deaths, up from just five per cent in 2012. In Ontario, where 625 people died of opioid overdoses in 2013, fentanyl was involved in 133 of those cases and, each year, it now kills twice as many people as heroin.
Michael Morton. (Photograph by Cole Garside)
But the deeper story of the drug and its abuse is even more worrying. Police and health workers now face an unprecedented situation, with a burgeoning street trade in both the legitimate prescription patches and illicitly manufactured fentanyl—often sold in pill form and made to look like OxyContin, a far less powerful narcotic. The drug, also available in liquid and powder form, is increasingly being used to cut cocaine and heroin, dramatically boosting their potency, often with fatal consequences. Indeed, fentanyl seems to turning up almost everywhere you look. And it’s killing both inexperienced newbies and hardened addicts:
In Montreal, in the summer of 2014, there were at least 25 overdose deaths—six of them in just one week in June—linked to fentanyl-laced heroin.
Police in Moncton, N.B., found two dead men inside an apartment last November, with a package of fentanyl powder they had apparently purchased online.
In Durham region, east of Toronto, there were 11 fentanyl overdoses—eight of them fatal—in November and December.
Two major busts in Barrie, Ont., involved health care workers. One trafficking ring, in which false prescriptions were written with the help of a medical secretary, included two dozen people and 1,000 patches. The other involved an emergency-room physician, who was charged with 68 counts in connection to fraudulent prescriptions for 515 doses.
Since last summer, 16 deaths and dozens of non-fatal overdoses have occurred on the Blood First Nation reserve near Lethbridge, Alta., population just 12,000.
A Vancouver police raid in March netted 29,000 “fake Oxy” fentanyl pills and $215,000 in cash. Police in Alberta, meanwhile, have seized more than 20,000 pills in the last year.
Dr. Karen Woodall, a toxicologist with the Ontario Centre of Forensic Sciences in Toronto, regularly testifies as an expert in fentanyl cases. She first noticed the drug in 2005 in the autopsy files that cross her desk. She later traced deaths as far back as 2002, mostly via people overdosing after chewing cut-up bits of patches—a particularly dangerous practice, since there’s no way to predict the quantity of the drug in each piece. “The big problem with fentanyl is that a lot of people who aren’t tolerant to the drug are taking it. And if you’re not tolerant, it’s a lot more likely to cause serious toxicity and even death,” she says. “It severely depresses breathing and the heart rate.” Combined with alcohol or other drugs that slow the central nervous system, it becomes even more dangerous. “It’s a serious issue,” says Woodall. “We’re seeing more and more deaths.”
(Surrey RCMP)
Kelly Best of Saskatoon died late in the morning of Jan. 3, 2015, the city’s third fatal fentanyl overdose in five months. The 19-year-old took half a “fake Oxy” pill, then lay down in the living room with his blanket and his dog, Kush. He placed his glasses and favourite blue ballcap on the couch beside him. He never woke up.
It was the second time he’d ever taken the drug. His first was the night before. Kelly’s older brother, Kayle, who has long struggled with addiction, was already at the dealer’s apartment when Kelly showed up at around 11:30 p.m., driving their mother’s car. He made Kelly take half the pill in front of him and “hang out awhile,” to ensure he could handle the drug. “I knew how f–ked up the life was, but I felt hypocritical telling him he couldn’t—because I was using,” says Kayle. “So I told him, ‘Be careful.’ ”
Their mother, Marie Agioritis, was in Calgary visiting family when her ex-husband, Don Best, phoned, screaming, “He’s dead! He’s gone!” Marie was sure he was talking about Kayle. After all, their eldest, now 21, had been in the grip of an opiate addiction for four years. And he had survived three overdoses, including one last May, that left him clinically dead, although doctors were eventually able to revive him in hospital. Don had to keep shouting into the receiver, knowing Marie didn’t understand: “No, Marie. It’s Kelly. Kelly is dead.” It took a few moments for the reality to sink in.
Kelly had always been the voice of reason, the responsible one, who helped his parents cope with the emotional toll of Kayle’s descent into drugs. He hadn’t travelled to Calgary with Marie, because he had a shift at the Keg restaurant he couldn’t miss. It was the first time he’d been allowed to stay home alone.
Half a year later, the family is still racked with guilt and grief. Don, who owns a golf course in Prince Albert, Sask., says he’ll find himself getting short with customers. He can’t sleep. He can’t focus. He says he feels nothing but sadness. Marie, who is on leave from work, is channelling her energy to advocacy: fighting to get the Saskatchewan government to collect and release overdose statistics, and to make the take-home drug-test kits (for concerned parents), which are commonly available in U.S. drugstores, available in Canada. She also worries—endlessly—about Kayle: “He was in the room when that pill was sold to Kelly. He didn’t stop it. He’s got to live with that, too.”
Kayle hasn’t used street drugs since the day Kelly died, and is now on methadone to treat his addictions. Slowly, he’s starting to join the family now and again. But he struggles with his weight, his physical strength, his short-term memory, and depression: “There’s days where I don’t want to live. It’s hard for me to leave my house,” he says. The toughest part is that Kelly looked up to him. “I gave him a pretty s–tty example.”
Fentanyl abuse may be a relatively new problem in Canada, but the drug itself has been around for more than half a century. First developed by pharmaceutical trailblazer Paul Janssen in 1959—he patented more than 80 drugs in his lifetime—it was originally used as an anaesthetic under the brand name Sublimaze. The slow-release transdermal patches for chronic pain relief were introduced in the mid-1990s.
Its dangers have also long been recognized. There have been a number of scholarly studies about all the doctors and nurses, especially anaesthesiologists, who have become addicted to it, and notable victims such as Jay Bennett, the late guitarist for Wilco, who died of an accidental fentanyl overdose in 2009 after being prescribed the patch for an old hip injury. And the drug’s illicit analogues—there are at least a dozen variations—have been killing people on the streets since the late 1970s, most infamously under the name “China White.”
Fentanyl has even been used as a weapon. The U.S. military spent a decade tinkering with an aerosol version of the narcotic, trying to create an incapacitating spray. And it is believed to have been the active ingredient in the gas that Russian commandos used in 2002 to knock out Chechen terrorists who were holding 750 people in a Moscow theatre, fatally poisoning 117 hostages in the process.
To date, the biggest cluster of fentanyl deaths came between 2005 and 2007, in and around Chicago, Detroit and Philadelphia, with 1,013 confirmed fatal overdoses. The U.S. Drug Enforcement Agency eventually traced their source back to a single clandestine laboratory outside Mexico City, run by a Breaking Bad-style chemist nicknamed “El Cerebro” (the Brain). The powder he made was exported to the States, then cut into heroin and distributed by a Chicago drug gang known as the Mickey Cobras. Users understood that the hybrid smack was potent and extremely dangerous, and that was a big part of the attraction. On the street, it went by names such as Suicide Mission, Code Blue, Reaper and Lethal Injection. It disappeared after the Mexican lab was shut down and the Brain and 47 Cobras were arrested.
The illicit fentanyl that’s currently flooding Canadian markets in pill form has more benign nicknames: greenies, green beans and green monsters (all references to its emerald hue). But that doesn’t make it any less deadly. Stamped as OxyContin, the fentanyl has been retailing for as little as $10 a pill—an indication of how cheap it is to manufacture, and how easy it is to obtain the raw material. The big B.C. investigation in March turned up two industrial pill presses that were used to make the 29,000 tablets. Two of the 14 people arrested in associated raids in Alberta and Saskatchewan are “full-patch” members of the Hells Angels. A third man is the president of an affiliated motorcycle gang, the Fallen Saints.
Shutting down the “fake Oxy” trade won’t be simple, however. This time, there seem to be multiple sources for the fentanyl. Police have suggested that Mexican drug cartels are involved in its importation, but that it’s being manufactured even farther afield, in places such as Turkey and China. It can even be ordered online. “Companies guarantee delivery, even if it’s seized by the Canadian Border Services Agency,” Staff Sgt. Martin Schiavetta, of the Calgary police drug unit, said in a recent interview with the CBC. In fact, so much of the raw powder is now coming into the country that Canadian dealers are said to be exporting their excess product to the northwest United States.
Then there’s the other problem: the growing abuse of the legitimate pharmaceutical version of the drug. Prescriptions for high-dose painkillers have skyrocketed over the last 15 years. A study by a group of Ontario researchers, published last fall in Canadian Family Physician, crunched six years of drug data and determined that Canadians are now the world’s biggest per capita consumers of legal opioids, with more than 30 million high-dose tablets and patches distributed every year. (Statistics Canada estimates that one in 10 Canadians suffers from chronic pain.) “Clinicians haven’t been given a lot of guidance on how to deal with long-term pain,” says Tara Gomes, scientific lead for the Ontario Drug Policy Research Network and one of the authors. “There is a place—a really specific place—in therapy for these drugs, when people have horrible, intractable pain. But not when they have a sore knee from golf.”
Such widespread availability of opioids inevitably leads to widespread abuse. A recent meta-analysis by an American scientist, published in the journal Pain, found that the average rate of misuse of prescribed painkillers is around 25 per cent, and that one in 10 medical users ends up addicted. In recent years, it was OxyContin that was driving that trend, because it could easily be crushed and snorted. But, once governments forced the manufacturer to introduce a tamper-resistant formulation, called OxyNeo, to the Canadian market in early 2012, the preferred high quickly became fentanyl.
“There’s definitely a correlation between the decline of Oxy and the rise of fentanyl,” says Const. Chris Auger of the Ontario Provincial Police drug diversion unit. “You don’t need to import it into the country; it’s readily available, and it’s basically free.” A three-month supply—10 patches—costs $52.75, plus dispensing fee, in Ontario, and is fully covered under many private plans, as well as the provincial drug-benefit scheme for fixed- or low-income earners. The going rate on the street for a single patch ranges from $100 in southwestern parts of the province, to $300 in Barrie and $600 in North Bay. “The people who sell patches are mostly the people who have prescriptions,” says Auger.
That said, fentanyl addicts aren’t particularly choosy. Used patches, which can retain up to 90 per cent of their potency, even after three days of use, are often resold. Dr. Woodall, the forensic toxicologist, says patches are sometimes peeled off dead bodies at funeral homes, and relates a tale she heard from an undercover drug officer about a very hairy man who was marketing his cast-offs. “When he took the patch off, it was like waxing, but he still managed to sell it to someone to chew,” she says.
When fentanyl takes hold in a community, the effects can be devastating. North Bay, Ont., with a population of just 55,000, has had 16 overdose deaths since 2007. To put it in perspective, the city only had one murder over the same period. “There’s a lot of negative impacts,” says Det.-Const. Brad Reaume of the North Bay police street-crime unit. “A $500-a-day habit destroys a household.” Once, he had to arrest a woman who was smoking a patch in her car with her 18-month-old strapped in a child seat in the back.
Even the users were becoming alarmed. In the summer of 2013, Reaume and his partner, Tom Robertson, were out on patrol when an addict flagged them down and begged them to get the drug off the streets. “ ‘It’s killing all my friends,’ is what he told us,” says Reaume.
The officers turned to the Internet and found an Ottawa pharmacist who was refusing to refill prescriptions unless clients brought back every single one of their used patches. After consulting with local doctors and druggists, North Bay launched its own “Patch 4 Patch” initiative that winter. One pharmacy saw the number of fentanyl prescriptions it was filling drop by 20 per cent overnight. The street price spiked and, within months, almost none was available. Some addicts have been trying to defeat the system by turning in artful counterfeit patches, but a simple test will soon be available to separate out the fakes. And a private member’s bill from local MPP Victor Fedeli, which would make the program the law across the province, recently passed second reading in the Ontario legislature.
The courts have been wielding a big stick, as well. In the false-prescription scheme in Barrie, the 31-year-old medical secretary was handed nine years in jail after pleading guilty, and her boyfriend received the same at trial. (The case against another man, the alleged ringleader, is still pending.) “Judges are taking a stiff stance,” says Det.-Const. Justin Ford, who led the investigation for the city’s drug squad. “Fentanyl cases are getting the kind of sentences you would normally get for trafficking in heroin—if not more.”
But, ultimately, it makes little difference for users whether the fentanyl is pharmaceutical or illicit; it’s a hell of a hard habit to kick. Dr. Peter Selby, chief of the addictions program at the Centre for Addictions and Mental Health in Toronto, says simple detox is both inefficient and dangerous. “People lose their tolerance, and relapses are common,” he says. “They take the same amount and overdose and die.” Methadone programs, which substitute one opioid for another more controllable one, are a better bet, although it can take years to stabilize patients. Quick fixes—such as a proposal to make fentanyl “tamper-resistant,” too, which is currently under consideration by Health Minister Rona Ambrose—don’t really do much. “If you press at one end, people just switch to whatever else is available,” says Selby.
There’s no question there’s a heavy demand for opioids on Canada’s streets. Barrie, a city of 143,000, has three methadone clinics, and there are now six in North Bay. “It’s either that, or a Tim Hortons on every corner,” says Reaume. But he, for one, would be happy to see fentanyl supplanted by the next new high. “It doesn’t matter what takes its place, because it’s not going to account for 16 deaths,” he says. “Nothing is as deadly as fentanyl.”
Six years on, Michael Morton is still trying to leave it behind. He’s had to cut ties with all his old friends, including the buddy who worked at the drugstore. He broke up with his last girlfriend two years ago when he found out she was using Oxy. Now, he’s living in an apartment with his dad, struggling to get by on welfare. “I’m lonely,” he admits. “I have nobody to talk to.”
The weekly visits to the doctor to get tested and pick up his methadone are the worst. The waiting room is packed with addicts, and all they ever talk about is drugs. The 26-year-old is still two credits short of his high school diploma, but he dreams of one day becoming a writer. Or maybe he’ll just settle for drug counsellor. “I don’t want other people to start taking fentanyl,” he says. “I’ve been through hell.”
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Source: http://www.macleans.ca/society/health/fentanyl-the-king-of-all-opiates-and-a-killer-drug-crisis/
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