According to the Centers for Disease Control and Prevention, illegally manufactured synthetic opioids took 5,554 American lives during 2014. This number has continued to increase as 64,070 deaths were reported in 2016 ("US Overdose Deaths From Fentanyl," 2017). It is now thought that accidental opioid overdose deaths are the leading cause of accidental death in the United States.
On March 1, 2017, China banned the illegal production and export of carfentanil and its analogs. Carfentanil is an analog of the synthetic analgesic fentanyl that acts primarily on the mu opioid receptors and exerts its principal pharmacologic effects on the central nervous system (Wolozin, Nishimura, & Pasternak, 1982). The potential toxicity of carfentanil is immense. Because of its greater affinity for the mu receptor, it is ~10,000 times more potent than morphine and ~100 times more potent than fentanyl, which itself is ~50-100 times more potent than heroin (U.S. Drug Enforcement Administration [USDEA], 2016). Carfentanil (which looks like table salt, making it difficult to identify) also risks the lives of first responders, doctors, and border control agents. The lethal dose range for carfentanil in humans is very low and varies from person to person (USDEA, 2016). Carfentanil is sold on the streets of the United States by mixing it with heroin or other opioids or by being diluted (which makes proper distribution imperative). The U.S. Drug Enforcement Agency believes that the drug is being illegally imported from China where it is used to tranquilize large animals, like elephants and polar bears (USDEA, 2016). The drug is not a controlled substance in China, making it easy to obtain and share with the world. A kilogram of carfentanil costs a mere $2,750 (whereas a kilogram of heroin costs more than $11,000) and is much easier to hide when shipped or smuggled ("Several Chinese Companies," 2016). Perhaps most unsettling of all, carfentanil is easily procured online anonymously in large amounts.
Providing a solution to this opioid epidemic will require the combined efforts of law enforcement, legislation, research, and the healthcare system. With patients with active opioid addiction receiving carfentanil-laced products, one solution that has shown great promise in other countries is to provide injection centers where heroin can be injected under clinical supervision and patients have an opportunity to receive medical counseling. In the 1990s, the Netherlands initiated a program that provided prescription-quality heroin at no cost to addicted people ("Only in the Netherlands," 2014). In 2009, Britain concluded a 4-year trial where addicted patients were given prescription heroin via injection (Strang, Groshkova, Metrebian, & EMCDDA Insights, 2012). Spain, Germany, Canada, and Switzerland have investigated the use of similar approaches (Strang et al., 2012). Other countries may soon follow. In February 2016, the mayor of New York proposed to develop the country's first heroin injection center ("Upstate N.Y. Mayor," 2016). Thus far, the use of injection centers has shown effectiveness in reducing overdose deaths and treating heroin addiction and revealed a significant reduction in subjects using "street" heroin (Strang et al., 2012).
In addition to injection centers, naloxone is another tool that may be very useful in the fight against opioid overdoses caused by carfentanil. Naloxone is a lifesaving antidote in cases of emergency because of opioid overdose. Unfortunately, because carfentanil is so highly potent, repeated naloxone dosing is oftentimes required to reverse the overdose (Centers for Disease Control and Prevention, 2015). To maximize its utility, most states have made naloxone available to the public without a prescription. Similarly, lay people are now being trained and certified in naloxone administration in record numbers. Despite these measures, the deleterious effects of this potent synthetic opioid are likely to increase before things will get better. Law enforcement, legislation, research, and the healthcare system must work together to combat this rapidly developing opioid epidemic, which includes carfentanil as the most potent opiate available currently, before it takes even more lives.
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