The narcotics that are considered to have the greatest addiction potential
include codeine, methadone, hydromorphone, demerol
(meperidine), fentanyl, and morphine. In the US opioid dependence is increasing,
affects 5 million people and leads to approximately 17,000 deaths annually. Narcotic drugs have always been associated with addiction; however, narcotic
drugs remain the best agents to relieve pain. Pain management is the reason
people are most likely to seek medical attention. Opioids bind to opioid
receptors on neurons distributed throughout the nervous and immune systems. Four
major types of opioid receptors have been identified: mu, kappa and delta. These
receptors are the binding sites for several families of endogenous peptides,
including enkephalins, dynorphins, and endorphins.
Physicians try to balance their desire to elevate suffering against concerns
that the patient in pain just wants a drug prescription. Physicians remain
constrained by problems of drug dependence and addiction and are reluctant to
prescribe narcotics or prescribe weak, inferior narcotics such as codeine and
demerol. Weintstein et al polled 386 physicians in Texas and found that a
significant number of physicians had prejudice against the use of opioid
analgesics displayed lack of knowledge about pain and its treatment, and had
negative views about patients with chronic pain. They suggested that new
educational strategies are needed to improve pain treatment in medical practice.
In Canada and the US opioid dependence
is increasing, affects 5 million people and leads to approximately 17,000 deaths
The World Health Organization (WHO) suggested a progressive treatment of
pain. For mild pain: aspirin, acetaminophen, nonsteroidal anti-inflammatory
drugs and adjuvants. For moderate pain: mild opioids. For severe pain:
traditional opioids. Physician concerns are justified. Narcotic-dependent people
routinely solicit prescriptions from a number of physicians and become good at
feigning painful conditions. Every primary care physician will have patients who
tend to demand prescriptions for pain relievers and other psychotropic drugs and
will become chronic users, unless the physician steadfastly resists their
demands and limits prescriptions to short term use.
Prescribed narcotics are always available for sale on the street. Most
originate with doctors who are lenient prescribers. Drug traffickers have lists
of lenient Doctors who write narcotic prescriptions on demand or for a fee.
about two million Americans have admitted taking OxyContin (oxycodone)
illegitimately. The US Drug Enforcement Administration reported that it is one
of the most abused prescription drugs. Another narcotic, hydrocodone also has a high potential for abuse. Hydrocodone, as a narcotic
cough medicine, is one of the favorite drugs sought by recreational users when
they visit emergency departments. Both drugs act on the opioid mu receptor which
blocks the transmission of pain in the spinal cord. In the USA OxyContin is a
$1.5 billion per year prescription drug. A report in the New York times from rural
Kentucky ( July 2004) provides a perspective on narcotic drug use: “Ever since
prescription painkillers like OxyContin became the drugs of choice among dealers
and addicts in Appalachia, the days of small-town pharmacists' dispensing
medicines from behind an ordinary counter have become a quaint memory. Now many
pharmacies have turned into virtual fortresses. Some have bars over the windows.
The most sought-after drugs are stored in vaults. The pharmacists often work
behind safety glass, and some have even armed themselves. Surveillance cameras
and alarm systems monitor every spot. Dan Smoot, chief detective for Operation
Unite, an anti-drug task force said that prescription drugs remained the top
problem for police agencies in the mountains. Mr. Smoot recently led the largest
drug raid in Kentucky history, arresting over 200 people on charges of buying or
selling prescription drugs on the black market.” [iii]
Fentanyl has become the most potent narcotic with the greatest danger,
causing sudden death. Gatehouse and Nancy reported on the tragic rise in
Fentanyl deaths in Canada. They described:" 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 percent 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. First developed by pharmaceutical
trailblazer Paul Janssen in 1959, it was originally used as an anesthetic 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 anesthesiologists, 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 analogs—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.” 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. 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. 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,
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. 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 drug became fentanyl. 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, we’re seeing more and more deaths.”
Naloxone, the antidote for opioid overdose, is a competitive mu
opioid–receptor antagonist that reverses all signs of opioid intoxication. It is
active when the parenteral, intranasal, or pulmonary route of administration is
used but has negligible bioavailability after oral administration. The initial
dose of naloxone for adults is 0.04 mg; if there is no response, the dose
increased every 2 minutes to a maximum of 15 mg. Reversal of opioid analgesic
toxicity after the administration of single doses of naloxone is transient;
recurrent respiratory depression is an indication for a continuous infusion.[vi]
[i] Winsetin et al.
South Med J 93(5):479-487,
2000. © 2000 South Med Ass’n
[ii] David W Dixon, Glen L Xiong. Opioid Abuse.
May 03, 2017
[iii] Associated Press. Pill Thefts Alter the Look of
Rural Drugstores. N.Y. Times July 6, 2004
[iv] Roscoe, M.S, The Drug-Seeking Patient.
Undertreated Pain or Underhanded Motives? Clinician Reviews 14(2):51-58, 2004. ©
2004 Clinicians Group. Posted 03/29/2004
[v] Jonathon Gatehouse and Nancy Macdonald. 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.
Macleans. June 22, 2015
[vi] Boyer EW. Management of Opioid Analgesic
Overdose. The New England journal of medicine. 2012;367(2):146-155. doi:10.1056/NEJMra1202561.
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