Heroin Overdose Epidemic - what is your perspective?

[Nephrology]

I wonder to what extent Rx narcotics are being directly prescribed to the wrong people (either because of a shady MD or a convincing junkie patient) and how much of it is either overprescribing +/- or Rx theft/abuse. For example, I wonder how many cancer patients are having their fentanyl patches stolen by their shitty grandkids, how many homes are getting targeted for burglary because they might have opiate Rxs, how many old oxy prescriptions for a root canal or whatever end up getting lifted kids, their friends, etc.... and honestly, specifically for fentanyl, I wonder how much of that is coming straight over the border from the same people that are bringing over the dope.

Obviously my experience is limited and biased - I have been very fortunate to be trained by excellent physicians at institutions that are in the top 5 in the US for their respective specialties - but I really just don't see narcotics getting written for very often. When I do there is always a super clear indication (you just got hit by a car and broke 5 bones, you were diagnosed with stage IV breast cancer and have bone mets, etc). I've never seen anyone come in and be like "uh, yeah, my back hurts, kinda, 10/10, can I get some oxycodone please?" and get anything but the door. Half the time they don't even make it in thanks to our awesome triage nurses. Makes me wonder where the stuff is coming from.

[DpdG]

For the drug market I described, the fentanyl is primarily not diverted medication but manufactured in illicit labs and trafficked like any other drug.

[Nephrology]

For the drug market I described, the fentanyl is primarily not diverted medication but manufactured in illicit labs and trafficked like any other drug.

Huh - do you have any sense as to whether or not those labs are domestic or south of the border? I only got as far as organic chemistry but presumably it is a much more complicated manufacturing process than heroin. I could be totally wrong, however.

Also - to see the flip side of the DEA's efforts to crack down on Rx narcotics - this article is pretty informative. It's just one source and I don't think know what I think about it per se, but I do think it shows that we aren't exactly sitting idle and doing nothing about Rx narcotic abuse. It just happens to be that whatever we are doing probably isn't working nearly well enough.

[DpdG]

My impression is its trafficked into the US via DR/PR, then to our area distribution hubs. Again, my area is dominated by wholesalers from the DR. I have no idea if the DR folks are getting it from Asian sources versus Mexican/South American labs. I'm lead to be live these are pretty sophisticated labs, not jungle operations.

Purely speculation on my part, but I'd guess they import fentanyl, then cut with easily available agents to bulk it up to heroin dosage units. It's like buying OJ concentrate instead of fresh squeezed, except it'll certainly kill you quicker than scurvy.

The product is marketed as powdered heroin, but nobody knows if it's straight heroin, straight fentanyl, some of each, or either that's been cut.

[PNWTO]

Exactly! We have to carry it in our cruisers and it's not uncommon to have repeat customers, some as high as 5x in two weeks.

Fuck that. At that point they've made their destiny. How much does bringing back that goblin cost the taxpayer? Not to mention officer safety?

[Nephrology]

Fuck that. At that point they've made their destiny. How much does bringing back that goblin cost the taxpayer? Not to mention officer safety?

Narcan can be pretty dramatic to be sure, but usually if you have a dose of heroin onboard strong enough to suppress respiratory drive you aren't going to be doing very much very quickly.

That said I once had a patient who was IVing heroin and meth in their parents basement - combative with EMS on scene so they gifted her some IM versed. She came in with blood pressures around 80/50 but was still combative and purposeful against her 4 point restraints.... yeah. Meth is a hell of a drug.

[Coyotesfan97]

Heroin is currently on he drug of choice here closely followed by Meth so sometimes we see the cocktail. My dog alerted on a wallet last night and it had a bag of powdered cocaine which has haven't seen in a long time. We just started getting the Fentanyl bulletins here and it's supposedly being cut into Heroin and Spice. A 250 mg dose (about 3 grains of salt) will cause cardiac arrest in minutes.

We're seeing a lot of folks "chasing the dragon" by smoking it. They burn it on foil and inhale through a plastic straw. There burnt foil everywhere in a car. It's an easy alert for the dog. There's still a lot of IV users here though.

[Eric_L]

nephrology asked the difference between dependence and addiction. I copied this as it is more concise than I would have been.....



The American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine, recognizes these definitions below as the current accepted definitions.



I. Addiction:
Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.



II. Physical Dependence:
Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.



III. Tolerance:
Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.

[Nephrology]

nephrology asked the difference between dependence and addiction. I copied this as it is more concise than I would have been.....



The American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine, recognizes these definitions below as the current accepted definitions.



I. Addiction:
Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.



II. Physical Dependence:
Physical dependence is a state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.



III. Tolerance:
Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.

I think I hit most of the criteria for addiction except "continued use despite harm." Never really did anything stupid because of them, never attempted to acquire illicitly. Definitely had impaired control & compulsive use towards the end, hence why I flushed the last ~10 or so down the toilet. Too freaky. I also had cravings immediately after I flushed em...

thank you for the definitions, by the way, that is helpful.

[Lyonsgrid]

Yesterday I was part of a major multi-agency operation. Our group was briefing at 2:00pm in a parking lot of a grocery store. Something like 25 agents and narc cops everywhere. One guy looks into a vehicle sitting next to him and spots a 20 yr old guy shooting heroin, guy was so out of it. Stuff is freaking everywhere and we chase it daily.