Opioids Threat
November 12, 2017 7:58 PM   Subscribe

A Visual Explanation of the Relative Toxicity of Opioids. Fentanyl is so lethal, it requires new procedures for first responders. Carfentanil though is in a class by itself. There are concerns it can be used as a WMD.
posted by storybored (62 comments total) 34 users marked this as a favorite
 
That's a great use of the arbitrary length of a webpage for getting a point across. Not all visuals need to be able to fit on a poster.
posted by clawsoon at 8:15 PM on November 12 [17 favorites]


Oh man, don't read the comments.
posted by octothorpe at 8:17 PM on November 12


That Guardian link about Cincinnati is worth clicking. Horrifying drug, and my paranoia creeps out and wonders if this is a test run.
posted by Nancy_LockIsLit_Palmer at 8:19 PM on November 12 [3 favorites]


i dunno...the data design lacks for me. a log scaled bar chart, or even a linear one would show comparisons between all drugs; scrolling would still work to communicate the giant carfentanil bar.

more importantly...ELEPHANT TRANQUILIZER IS ON THE STREETS! DAMN.

i think dea can turn away from cartels and smalltime dealers. diversion intervention is the ticket. we might have to impact corporate profits.

but we see how effective that is with oxy in WV...
posted by j_curiouser at 8:42 PM on November 12 [1 favorite]


I read somewhere that the therapeutic index (as a ratio) for carfentanil is actually higher than usual for an opioid. Unfortunately it is so potent in absolute terms that this doesn't matter that much.

Also I'm under the impression that the risk of dry skin contact with powder is probably oversold. Seems like there could plausibly be an inhalation hazard under some circumstances, though.
posted by atoxyl at 8:45 PM on November 12 [2 favorites]


i think dea can turn away from cartels and smalltime dealers. diversion intervention is the ticket. we might have to impact corporate profits.

The ultrapotent fentanyls are probably not mostly diverted from domestic pharma. They're made in clandestine or grey area labs, particularly (at least originally) in China.
posted by atoxyl at 8:48 PM on November 12 [9 favorites]


Police officer overdoses after brushing fentanyl powder off his uniform (cnn)

fentanyl, mind you. not carfentanil.

thanks for the illumination, atoxyl. it seemed to me that it would necessarily be factory-made - inferring corporate control. my bad.
posted by j_curiouser at 8:51 PM on November 12 [4 favorites]


"Law enforcement officers have been warned that even touching a small amount of carfentanil powder with bare skin can cause severe effects."

While I appreciate that this infobit is one of a number of other pieces of information in the article concerning the drug, there is clear historical evidence of similar information being provided to law enforcement officers regarding other drugs in the past without much apparent attention to actual scientific confirmation. The intent of such inflammatory information, from my perspective, was to seek increases in both the intensity and violence of subsequent LEO behavior in enforcement situtations in which the given substance of concern might be expected to be encountered by the concerned officers. I have no basis to doubt the other facts presented in the piece, but I will very firmly state that the piece falls into the venerable tradition of new-drug apocalypse propaganda, even if every single reported fact in the material is unequivocally true and factual. As a result, it puts persons of risk in marginal opportunity populations at greater risk. I find myself angered by it. I do not see it as helpful with regard to the current opiod crisis.

Such pieces, and the style of reportage, are unequivocally part of the long-term erosion of trust in journalism and the consequent, current, incipient failure of democracy in the United States.
posted by mwhybark at 8:54 PM on November 12 [48 favorites]


i'm not going to strongly disagree that the hyperbolic press is not very useful.

i remember the bullshit angel dust stories.
Studies by the Drug Abuse Warning Network in the 1970s show that media reports of PCP-induced violence are greatly exaggerated and that incidents of violence are unusual and often limited to individuals with reputations for aggression regardless of drug use...reports of physical violence on PCP have often been shown to be unfounded.
posted by j_curiouser at 9:04 PM on November 12 [10 favorites]


It's not all hyperbole. The first link provides reason to think that the Russians have weaponized carfentanyl, and that they used it in the Moscow theatre hostage taking of 2002. The problem seems to have been that it's too easy to overdose on it; it was intended as a nonlethal weapon but killed 167 hostages.
posted by justsomebodythatyouusedtoknow at 9:58 PM on November 12 [10 favorites]


“The odds of an overdose from such a freak incident are infinitesimally small — if not strictly impossible.”

The media could try turning their brains on for two seconds--if it were that easy to OD on fentanyl via touch, people in the trade would be dropping like flies. I don't know what it is about drugs that prompts people to so readily believe such fairy stories: maybe leftover childhood moral panic reinforced by authority figures?
posted by praemunire at 9:59 PM on November 12 [30 favorites]


If fentanyl is so dangerous, then why is it a first line opioid for first responders? Apparently that's what they keep in the ambulances these days.
posted by billjings at 10:02 PM on November 12 [1 favorite]


Back in the 80s, there was a cluster of cases of "locked-in syndrome" attributed to a bad batch of fentanyl analogs, too.
posted by littlejohnnyjewel at 10:06 PM on November 12 [2 favorites]


A very dear friend of mine, in crippling pain after two spinal injuries, hereditary spinal stenosis, and multiple surgeries, was doing really well on a carefully-monitored program of long-acting and short-acting oxycodone, monitored at monthly visits by a specialist MD at a well-recognized center for pain management. They had tried a few other drug combinations before getting to that regimen, including steroid injections into the spinal cord.

A few months ago, she got new insurance, went to the pharmacy with her oxycodone prescriptions, and found out it wasn't covered. The only thing they would cover was fentanyl patches with Vicodin for breakthrough pain.

So, while both of those medications fall under “better than aspirin,” neither falls under “efficacious in this case.” the Fentanyl patches don't stick, and have to be held down with Tegaderm dressings, which don't always stick, either. She just has that kind of skin. When it does stay on, by the end of the second day there are painful, raised, red welts around the edge of the patch and the Tegaderm. But there's some other problem that I don't quite understand, about the company only paying for small patches that she has to combine to reach her large dose instead of paying for a larger patch that she could use only one of.

And even though it's been a couple of months, a new patch puts her to sleep for hours, and a dose of Vicodin knocks her out for an hour. The Fontanel makes her so sick to her stomach that the unconsciousness, although frightening, can seem like a silver lining on bad days.

I guess what surprises me is the idea of Fentanyl not being a last, desperate resort for somebody using drugs recreationally.
posted by The Underpants Monster at 10:12 PM on November 12 [7 favorites]


The economics of it do seem a bit confusing... if, per the Guardian article, 1 kg of carfentanil is 50 million lethal doses, then the 42 kg from a single seizure mentioned would represent 2.1 billion lethal doses, enough to take out a significant fraction of the people on the planet, or 60 lethal doses for every person in Canada.

But also per that article, Chinese labs will export it for "US$2,750-per-kg". How much can anyone even make before there's more in existence than every person on Earth could use during the entirety of their lives? Why has any other opioid been produced since the 1970s when carfentanil was invented?

Why does anyone bother smuggling heroin when you could presumably bring in much-physically-smaller quantities of carfentanil and dilute it thousands of times? Does "synthetic opioid" mean that it actually requires opium poppies to be manufactured?
posted by XMLicious at 10:15 PM on November 12 [9 favorites]


There is a difference between chemical synthesis and fiscally reasonable chemical synthesis. There is, further, a difference between both of those and black-market-accessible synthesis.

...and then China appeared on the scene, willing to make anything for anyone, for any reason at all.
posted by aramaic at 10:23 PM on November 12 [2 favorites]


Synthetic opioids can be made without opium poppies. Some precursor chemicals were placed on international control lists earlier this year.
posted by a lungful of dragon at 11:01 PM on November 12 [1 favorite]


Police officer overdoses after brushing fentanyl powder off his uniform

Praemunire's link covers what I was getting at about this.

The theoretically-high therapeutic index of carfentanil may explain why the Russians felt it could be used as a non-lethal weapon. Obviously that didn't work out quite as well as could have been desired.
posted by atoxyl at 11:23 PM on November 12


Why does anyone bother smuggling heroin when you could presumably bring in much-physically-smaller quantities of carfentanil and dilute it thousands of times?

Well that's kind of the direction things have been going lately - but heroin users generally prefer heroin, so there remains demand for the real thing...
posted by atoxyl at 11:26 PM on November 12 [1 favorite]


Back in the 80s, there was a cluster of cases of "locked-in syndrome" attributed to a bad batch of fentanyl analogs, too.

I'll stop responding to individual comments in this thread for a minute because I could do like five, but - that was MPPP/MPTP (the latter being the toxic contaminant) which is closer to the far less potent Demerol. But you're right that was kinda the first round of DIY opioids.
posted by atoxyl at 11:34 PM on November 12 [3 favorites]


Why does anyone bother smuggling heroin when [carfentanil is easier to smuggle]?

Opiates have several effects:
1) euphoria
2) pain reduction
3) respiratory depression (btw, this is the one that kills you)
4) preventing opiate withdrawl sickness

All opiates have most/all these effects, but not necessarily in the same proportion.

Codeine is excellent for respiratory depression, which is why it's such an amazing cough medicine. Respiratory depression blocks the cough reflex.

Methadone is notably weak in euphoria, which is why it's used as a maintenance drug for people addicted to opiates. There's also a difference in tolerance: methadone euphoria, such as it is, rapidly diminishes with tolerance. But the pain-blocking and not-getting-sick effects build tolerance much more slowly. So as a chronic maintenance drug, you end up with just those effects and zero euphoria.

Fentanyl is also relatively weak for euphoria. All the articles talking about how fentanyl is 50-100x as strong as morphine are referring to pain killer and respiratory depression strength, since those are the things doctors actually care about. Pharmaceutical corps don't go out of their way to optimize for euphoria.

I have no idea how euphoric carfentanil is. It's possible nobody knows since it wasn't developed or tested for humans. It's probably not hugely euphoric though, or else we'd have heard about drug dealers selling pure dilutions.

TL;DR: fentanyl is 50-100x stronger than morphine for pain relief and overdosing, but not nearly that strong for getting high.
posted by ryanrs at 11:37 PM on November 12 [41 favorites]


But you're right that was kinda the first round of DIY opioids.

And I think there was a minor wave of fentanyls back then too. It's probably the advent of the Chinese custom synth shop that brought them back.
posted by atoxyl at 11:48 PM on November 12


One year ago I had surgery to replace a deformed hip. When I awoke afterward the nausea and dizziness from the opioids I’d been given was so severe I pleaded to not be given any more and begged for an alternative. Prior to surgery I’d had good results using a Maine friend’s medical cannabis and, knowing that our state had somewhat liberalized its use, asked if I could have that. I was told that no, my situation did not qualify me for its use.

For three days I existed in a state of agony that I cannot begin to describe, with no hope of sleep or relief of any kind; I was offered only IV Tylenol which did little. A parade of doctors, nurses and anaethestiologists came in to speak to me about pain management; virtually every single one expressed (1) awe that I was foregoing opioids; (2) frustration over not being able to offer me any medical cannabis; and (3) apologies that they had nothing effective to offer me.

I passed the time quietly weeping, exercising and walking the halls (and watching Grey Gardens over and over) while my fellow surgical patients snored blissfully away. Yes, I was spared respiratory and constipation issues, but the pain was indescribable. It would be nearly six weeks before I would actually be able to sleep.

It blows my mind that in 2017 medical cannabis, which has yet to claim a life, continues to be regulated away from those who’d benefit from its use while opioids continue to be dispensed like M&Ms. I ultimately was told by one nurse, ominously, that I had better never again have surgery as modern medicine has no effective way of treating my pain. Wow.

Seems like opioids are seen as so effective, no other forms of safer pain relief are being explored, which is horrifying.
posted by kinnakeet at 12:13 AM on November 13 [54 favorites]


Also looool at smuggling narcotics inside fake printer ink cartridges, that is fucking hilarious. I'm not sure of the specifics in Canada, but US Customs regularly seizes shipments counterfeit inkjet cartridges for ip/trademark/patent violations. They might as well have disguised the drugs as a shipment of ivory.
posted by ryanrs at 12:23 AM on November 13 [9 favorites]


As I understand it, Britain forced Indian opium on a very reluctant China in order to create demand for something they could trade for tea.

China hasn't forgotten this, nor should it.

It may take awhile for them to stop laughing as we plead with them to stop making the stuff and letting us buy it.
posted by jamjam at 12:29 AM on November 13 [27 favorites]


>Also looool at smuggling narcotics inside fake printer ink cartridges, that is fucking hilarious.

yucks given...so stupid, it burns, right? amirite?

A derail, but to kinnakeet, had I known at 18 how pigheaded and inhuman my representative elders would remain, I'd have ended up in jail or worse.
posted by lazycomputerkids at 12:34 AM on November 13 [1 favorite]


no other forms of safer pain relief are being explored

That's not really true. I think of naproxen as being new-ish, but maybe that's just because I'm old.

More recent are the COX-2 inhibitors, which were great until people started dying of heart attacks and strokes (see: Vioxx). Celebrex is still available though and just went out of patent a few years ago.

I don't know of anything recently developed specifically for post-surgical pain, but then I'm not a doctor so I don't pay much attention (but cue cynicism re. profitability of chronic arthritis pain vs. one-time surgical pain).
posted by ryanrs at 12:47 AM on November 13


I hadn't heard about fentanyl until it was the pain relief clicky thing they gave me after surgery. It was good stuff. I felt no pain at all that whole recovery, I've suffered more from stubbed toes. But even in the fog I remember how seriously they took the changeover of the cartridge dispenser things. Always two nurses, keys to unlock it and they would grab my wrist and make me recite my full name and date of birth before they started. Plus they insisted I wear an oxygen cannula the whole time I was in my room (I was allowed to leave it to walk the ward, I guess the dvt protocol overrides the risk).

I googled it the second day and read how dangerous it could be, even for the staff when disposing them. Didn't experience any euphoria (give me propofol for that) but two clicks in the minimum timeframe knocked me out cold. I can see how it's so deadly.
posted by kitten magic at 12:52 AM on November 13 [1 favorite]


OTOH, my pharmacy let me pick up fentanyl patches for my elderly neighbor just on basis of knowing her name, with no prior arrangement by either the patient or her doctor. I'm pretty sure I didn't even have to give my own name or show ID. I was surprised because I was expecting way more hassle. (This was at a major chain pharmacy in California in 2016.)
posted by ryanrs at 1:05 AM on November 13


Fascinating the differences. The patches would be so easy for you to misuse! I had no way of accessing my fentanyl except via the clicker. Hospitals are all about the rules though, you have to hand over all your regular meds and they lock them up and dole them out on schedule. I guess they really don't want you overdosing on their watch.

Naproxen is a great painkiller imo but NSAIDS in general are pretty harsh on the stomach.
posted by kitten magic at 1:16 AM on November 13 [1 favorite]


Perhaps the Chinese remember the Opium Wars? Or, what jamjam said.
posted by infini at 3:29 AM on November 13


The problem with alternatives to opioids for pain is that opioids are so goddamn effective. I’ve dealt with chronic pain in and off for a few years, and have done (way too much) reading on the subject. We use them because they work, and they work well. It’s unfortunately also why they are so easy to abuse. They hijack the brain’s natural pain killing and euphoria system; endorphin receptors.

It would be akin to someone asking “why haven’t we found an alternative to water when solving the damn thirst problem.” Perhaps not the best metaphor, but it’s the best I have at 5am after a sleepless night.

There is interest in developing alternative pain relief medications. Gabapentin and pregabalin are two used to nerve pain but can take time to start working and aren’t effective in everyone. For me they made pain worse and pregabalin caused hypomania. That was a fun few days. Some SNRIs are intended to help with pain. I know there are others I’m blanking on. But the real problem is just that opiods work. Migraine medication is an example of a medication meant to address a certain kind of pain that had and sometimes is still treated with opiods. Certain muscle relaxers are prescribed for certain types of pain related to muscle spasms.

And medical marijuana is often touted as the answer to all pain, but I’m someone that doesn’t get pain relief from pot either. I also have problems metabolizing opiods correctly, so pain management for me is a fun adventure. Thank god for the recent advances in genetic testing where doctors can see I’m not just a complaining ninny and instead am lacking/have lower amounts of a few liver enzymes needed for most medications. It’s been a blessing that I’ve only needed baclofen (muscle relaxer) with occassional ibuprofen and Tylenol for the past year or so. Cuz prescription pain meds of all types really kind of suck.

I’m not saying drug manufacturers don’t have reason to keep pushing opioids. They’re hugely profitable. But as doctors become resistant to prescribing them, they’d love nothing more than to have something “safe” to offer.
posted by [insert clever name here] at 3:33 AM on November 13 [15 favorites]




As I understand it, Britain forced Indian opium on a very reluctant China in order to create demand for something they could trade for tea.

China hasn't forgotten this, nor should it.

It may take awhile for them to stop laughing as we plead with them to stop making the stuff and letting us buy it.


So irony for those who have red history. Wow. Much erudition. Very welstchmertz!

Meanwhile current sufferers and victims who are dying by the thousands in misery. But HEY! At least, as they gurgle their life away in agony and degradation...... they can be reassured that someone finds this a cosmic balancing of the scales of a 150 year-old imperial war that none of them - or their previous two generations - had any participation in.
posted by lalochezia at 5:14 AM on November 13 [6 favorites]


I really thought WaPo was a bit better at data visualizations than this. Up until Fentanyl, the visualizations make sense...not the way I'd do them, but whatever. The Fentanyl viz is way off though. The text says 50x-100x as strong as morphine, so we should see 50 dark boxes, and 100 dark and light boxes, as has been the case with every viz up until this point. However, there are 66 dark boxes, and a total of 116 dark and light boxes.
posted by noneuclidean at 5:31 AM on November 13


The fentanyl vials that EMTs routinely stock hold 100mcg/vial, which is not enough to be lethal.

The syringes that go into PCA machines hold 1250mcg, which if given all at once might be lethal. The machines have lock-out periods between doses and a 4-hour maximum dose limit, the parameters of which are specified by the physician. Although there’s a lot of fentanyl in each syringe, it’s fairly dilute (1250mcg/25mL I believe), so it’s not like a few drops of the stuff are going to kill you. It would take deliberate misuse for it to end up in someone’s body. Disposal does not really pose a significant risk to staff.

Fentanyl patches contain enough to potentially kill you if given all at once, but the patches are designed to release it slowly over 72 hours. Some people try to get around this by eating them.
posted by dephlogisticated at 5:51 AM on November 13 [4 favorites]


When I awoke afterward the nausea and dizziness from the opioids I’d been given was so severe I pleaded to not be given any more and begged for an alternative.

That all sounds miserable.

That may have not been an opiate at all, but the results of general sedation via propofol, or a combination of an opiate w/ propofol.

I'm not sure what the current practice is but as I understand it they tend to avoid giving you a bunch of opiates during a surgery if they put you under general anesthesia and sedation, because the combined respiratory effects can be dangerous, and coming out of a propofol sedation can be wildly unpleasant and disorienting.

I'm personally somewhat in the same boat that I find opiates to be nausea inducing. I'm also terrified of getting addicted to them because I've seen what opiod addictions do to people, so I avoid them as much as possible. I also refuse acetaminophen/tylenol entirely because of how liver toxic it is, but also because it does next to nothing for me and it isn't even worth the metabolic load.

But pain management isn't just about comfort. It's about managing and supporting recovery and healing by reducing stress. I've been lightly scolded by doctors for trying to tough out injuries and refusing pain management because it increased recovery and healing time because the stress of acute and chronic pain is really just that detrimental to the human body.

It's probably worth trying to find some middle ground between nausea and pain.
posted by loquacious at 6:23 AM on November 13 [5 favorites]


Police officer overdoses after brushing fentanyl powder off his uniform (cnn)

Maybe? I mean, we're talking about American law enforcement, which in many areas is little better than just another gang, and we're talking about someone in a profession that is known for profound and habitual dishonesty. Maybe it happened exactly like they said. All we can be confident about, though, is that the officer overdosed on fentanyl after making a fentanyl-related arrest earlier in the day. It's not like he was going to say "Oh, yeah, I stole a hit for myself and it was stronger than I expected."
posted by GCU Sweet and Full of Grace at 6:32 AM on November 13 [20 favorites]


Carfentanyl isn't the only super-agonist for opiate receptors; it's a lot more complex structurally (so presumably harder to synthesize — my organic chemistry chops are 30 years out of date) but etorphine is in the same league as carfentanyl. It has fallen out of favour with vets due to a higher level of cardiopulmonary side-effects than newer opiates.

Some years back I read a summary of a monograph on a case of etorphine poisoning. A vet was loading a 2ml syringe with a dose for an elephant — about 10mg — when they incurred a needlestick injury and went into acute overdose. Luckily they had a spotter who filled them with naloxone, and they survived. On examination, the syringe still contained 2ml of etorphine solution: the quantity in the needle barrel alone was sufficient to kill a human.

The LD50 in humans is apparently around 30 micrograms. For comparison, the LD50 of VX (the ne plus ultra of nerve gas agents) is 7 micrograms; for Sarin (run-of-the-mill nerve gas) it's 550 micrograms. Smaller is more effective ... the only deadlier poison I know of is dimethylmercury (LD50 as low as 3 micrograms/kg in humans).
posted by cstross at 6:49 AM on November 13 [5 favorites]


I can 100% buy that someone inhaled some fentanyl powder and got woozy from it. If they were 100% opioid naive, I might even think a dose of naloxone is necessary. Skin contact, though? Not unless they are bathed in sweat, and intentionally dump it on themselves. Basically, wear a mask and some eye protection, practice basic hygiene afterwards, and your risk is essentially zero.

The reason people are dying from it is that they are intentionally ingesting it, but expecting either heroin or a smaller amount of fentanyl than the dose actually contains. The other issue is people who intentionally or unintentionally defeat the patches, releasing 3 days' dose all at once. Thankfully, the latter is rare. Just read the instructions..
posted by wierdo at 7:01 AM on November 13 [2 favorites]


So, I work at an ER hospital that accepts police related injuries. When things happen, it's a pretty big deal, and you cannot miss it due to the sheer influx of police staff. It's like the entire department shows up.

I haven't seen anything related to drug overdoses nor heard anything. The EMTs around have mentioned things once or twice to me about skin related risks, but no EMT related exposures have been seen either that I know of.

It's a metro hospital with a large volume of patients and we get regular drug overdoses almost every day.

I think it's possible, but it practice it isn't happening often. There has been one or two documented cases that I know of, the CNN cite being one of them. After all, drug dealers generally do want their clientell to live, and handling becomes more complicated the stronger things are.
posted by AlexiaSky at 7:12 AM on November 13 [4 favorites]


Snopes weighs in -- tl;dr: every agency that has claimed an exposure via skin contact has walked it back.

I wouldn't chew my nails if I'd been handling the stuff, though.
posted by RobotVoodooPower at 7:29 AM on November 13 [19 favorites]


I also refuse acetaminophen/tylenol entirely because of how liver toxic it is

Gotta soapbox a minute. Forgive the diversion. Acetaminophen is unusual in that its toxicity does not follow a linear dose/response relationship. Usually, the incidence or severity of an adverse effect increases proportionally with dose--e.g., if you graph dose on the x-axis and incidence on the y-axis, it forms an upward-slanting line. With acetaminophen, this graph looks more like a stair. You get no significant toxicity up to a dose of around 4000mg/day, then beyond that the risk of toxicity increases rapidly. Again, this is very unusual, having to do with the specific mechanism of toxicity (in brief: your liver has reserves of the antioxidant glutathione, which safely neutralizes the toxic metabolite of acetaminophen, but if you take too much these reserves are eventually depleted).

If acetaminophen isn't effective for someone, or if they have some pre-existing condition like hepatitis or cirrhosis, by all means they should forego it. Otherwise, acetaminophen is perfectly safe to use at recommended doses. In fact, moreso than NSAIDs and opioids. In the hospital setting, we routinely use IV acetaminophen at max dose for post-surgical pain, despite the fact that it's stupidly expensive, because the surgeons are pretty adamant about how well it works.

Smaller is more effective ... the only deadlier poison I know of is dimethylmercury (LD50 as low as 3 micrograms/kg in humans).

Might be cheating, but the LD50 for polonium is in the 10-50 nanogram range.
posted by dephlogisticated at 7:32 AM on November 13 [16 favorites]


the only deadlier poison I know is dimethylmercury (LD50 as low as 3 micrograms/kg in humans).

I was surprised to learn recently how deadly botulism toxin is:
But back to botulium, now that we have the range of things. The LD50 for it in humans is estimated at about 2 nanograms/kilo i.v., 10 nanograms/kilo by inhalation
posted by jamjam at 7:50 AM on November 13 [3 favorites]


So irony for those who have red history. Wow. Much erudition. Very welstchmertz!

Meanwhile current sufferers and victims who are dying by the thousands in misery. But HEY! At least, as they gurgle their life away in agony and degradation...... they can be reassured that someone finds this a cosmic balancing of the scales of a 150 year-old imperial war that none of them - or their previous two generations - had any participation in.
posted by lalochezia at 5:14 AM on November 13 [1 favorite +] [!]


I think you underestimate the historical literacy (in the educated classes, at least; and probably laborer-class as well, I wouldn't be surprised) of the Chinese population — remember, the foundation of communism as a theory is historical awareness — and the VERY REAL AND INTENSE sense of personal rage and injustice average Chinese and Chinese-diaspora people still feel about colonialism to this day. A rage that is cultivated by the government, because it is useful. I mean, did you watch the 2008 Olympic opening? It was all about callbacks to their pre-colonial history, crafting the myth of China's Globally-Recognized Historical Greatness (Destroyed By The West, Of Course) Now Rebuilt And In Ascendance. Referencing China's "5,000 years of history" is so common that it's a catchphrase.

It's all very well for us Western white people to say "oh, that was 150 years ago, just forget about it!" But our sense of history only goes back 200 years. Or at a stretch 2,000. In the way you can't expect West Africa to forgive and forget slavery while America is still a world superpower and they still struggle under our thumb, you also can't expect China to forgive and forget the opium wars while their economy is bound to, and rises or falls at the the whims of, a western white superpower.

I'm sure that the Party officials meeting in secret to design the fentanyl project have this very much in mind. Because nothing at this kind of scale happens in China without the Party knowing about it, and usually directly controlling it. Which sounds a bit paranoid but it's what I've been told by people who have direct experience of working there.
posted by it's FuriOsa, not FurioSA at 8:00 AM on November 13 [8 favorites]


Gotta soapbox a minute.

Yeah, sorry, I'm not arguing that acetaminophen isn't safe or effective for others, but it's essentially been worthless to me personally for any kind of pain management. Oddly enough I think it sometimes gives me headaches and just makes me feel generally icky and unpleasant.

And since Tylenol 3 and similar variations are so frequently prescribed it's really annoying to get treated like a potential addict to try to get something without acetaminophen in it.

Thankfully the few times I've needed it, I've had docs that have known about the hydroxyzine/antihistamine plus opiate synergistic effect, which also helps manage nausea and promotes sleep.
posted by loquacious at 8:01 AM on November 13 [1 favorite]


Some people try to get around this by eating them.

Chewing them works well. You don't have to swallow.
posted by praemunire at 8:37 AM on November 13 [1 favorite]


[insert clever name here]: Thank god for the recent advances in genetic testing where doctors can see I’m not just a complaining ninny and instead am lacking/have lower amounts of a few liver enzymes needed for most medications.

Can you talk a little more about this? I've always suspected that I have a resistance to most pain medication, but I would be very interested in investigating it more scientifically. Feel free to take it to MeMail if it is too much of a derail for the thread.
posted by Rock Steady at 8:40 AM on November 13


I was surprised to learn recently how deadly botulism toxin is

Fun fact: instead of weight, Botox is dosed by units, where 1 unit is equal to the median LD50 in mice. So essentially vial sizes are based on how many mice you could kill with it. The vials appear empty prior to reconstitution because the amount of drug in them is so small.
posted by dephlogisticated at 8:44 AM on November 13 [4 favorites]


Here's what I don't get. Probably because I'm just some random layman. But I hear these stories of cops ending up in the hospital after touching a doorknob. My wife came home with some story - possibly apocryphal, who knows, it came about fifth hand to me - about a ten-year-old boy who died of a Fentanyl overdose, and they have no idea how he came into contact with it. Best guess is supposedly a towel at a swimming pool.

So if this stuff is so overwhelmingly deadly in such ridiculously small amounts, how does it make it that far down the distribution chain in the first place without someone screwing up and killing themselves? Why are the streets not clogged with the bodies of dead addicts and dealers?

We're not exactly talking about experts here. I mean the Umbrella Corporation would do a better job of safely handling dangerous substances.
posted by Naberius at 8:53 AM on November 13


Rock Steady: There are significant genetic variations in the amount of Cytochrome P450 (CYP) enzymes that people produce. Testing levels of those enzymes is part of a new field known as "pharmacogenetics," whose goal is to identify when someone is likely to get side effects or poor efficacy from certain medications. The testing is still prohibitively expensive, but some leading clinical centers are starting to test people before giving them certain antidepressants.

The classic model is that people who are extensive metabolizers of certain CYP substrates will need higher doses of those medications, while people who are limited metabolizers are more likely to get the worst side effects from them.

But, with the weakest and most common high-utility painkillers (codeine and tramadol), the model is actually reversed. Codeine and tramadol have very little activity until after a specific enzyme (CYP2D6) converts them into a more water-soluble molecule.

Thus, people who produce limited amounts of CYP2D6 get stronger effects and more side effects from many medications (SSRIs, beta blockers, etc), but won't experience much (if any) relief from taking the kinds of pain killers most of us receive after something like a dental procedure or minor surgery.
posted by prosopagnosia at 8:58 AM on November 13 [7 favorites]


I'm another that acetaminophen does nothing for, which is annoying because it gets stuck in everything in combination. Fortunately Advil and Aleve work well for me for muscle and joint pain, and aspirin for headaches.
posted by tavella at 9:00 AM on November 13


but heroin users generally prefer heroin

Citation needed.
posted by elsietheeel at 9:13 AM on November 13


Citation needed.

Um, personal experience? Or see what ryanrs said - I never actually (knowingly) tried fentanyl I just know firsthand there is at least a modest subjective difference between opioids. Plus in a lot of places heroin comes in a form that is harder to imitate from scratch than "odorless white powder."

It may take awhile for them to stop laughing as we plead with them to stop making the stuff and letting us buy it.

from my following of the "research chemical"/"designer drug" scene over the last decade - which I'm not that up to date with any more but that's where my knowledge this stuff originates - they tend to crack down on individual drugs after a while, or at least force manufacturing more underground. I think China officially banned several fentanyls earlier this year. But at this point Eastern Europe and India probably also have custom chemical cos. and I think fentanyl in North America might be headed toward clandestine/cartel labs.
posted by atoxyl at 9:34 AM on November 13


I had no idea fentanyl was synthesized by random non-expert people, I though tall the opiods were coming from formal pharmaceutical laboratories (whether American or Chinese). Here's a story about George Marquardt who synthesized fentanyl in Kansas until he got arrested back in the 90s.
posted by Nelson at 10:22 AM on November 13


had no idea fentanyl was synthesized by random non-expert people, I though tall the opiods were coming from formal pharmaceutical laboratories

I mean we are talking professional chemists I suspect, and some might have ties to legit pharma manufacture overseas. Some seem like they may have been small chemical suppliers who switched to something more profitable. As that becomes less possible to do openly though we may see the business taken over by the folks who are already making illegal drugs at industrial scale.
posted by atoxyl at 12:16 PM on November 13


I was in Beijing over the weekend. The Saturday paper had a two pager on the opium wars, how much China suffered, and how much better things are now. The obvious sub text was that the opioid epidemic in the west is very, very unfortunate but hey, probably deserved. I imagine that the various officials are losing zero sleep.

I feel that the current crisis is yet another moral panic. We'll ban things, lock people up, make people suffer in pain, and then pat our backs and tell ourselves that we are moral exemplars. People like to get high. Some more than others. Maybe we should accept that instead of chasing our tails down prohibition (again).
posted by pdoege at 12:29 PM on November 13 [9 favorites]


To add to what prosopagnosia said, the testing may or may not be covered by your insurance. Good news though- you can get it relatively cheaply on your own using 23 and me, and then running through promethease.

At the pain clinic I go to, they described using it not just for antidepressants, but to see who the rapid metabolizers are- now when a patient describes inadequate pain management from opioids, instead of assuming they’re all drug seekers, they can see that some people burn through the medication much quicker, shortening the effective window. Or, like me, patients aren’t just “complainers” about drug side effects, we have difficulty metabolizing and therefore have higher side effects as the drugs build up or are just ineffective.
posted by [insert clever name here] at 1:20 PM on November 13 [3 favorites]


The answer to a lot of the questions above is that one batch isn't like another. First, there are lots of chemists illegally making different fentanyl derivatives with different potencies. Second, the dilution varies heavily.

If I'm used to heroin being 33% pure (below average most cities) and then receive some 100% pure stuff, that can be quite dangerous - and it's only a triple dose if I don't notice how much better it looks. Medical grade fentanyl vials are 0.005% pure (dissolved in water) You can imagine that if I'm used to my dealer giving me 0.005% pure fentanyl powder (cut with whatever other white powders) and then gets a new shipment or cuts it differently or just doesn't mix it perfectly and I now have 1% fentanyl, I've got something 200x as strong that doesn't look any different. And of course derivatives like carfentanil are more potent.

This explains why police are so cautious. Pure carfentanil can kill you if touched. Dealers haven't been dying in droves because they haven't happened to get shipments of pure carfentanil in the mail. If you were a cop, would you trust that the supply chain isn't going to mess up in that way?

As for ridiculous numbers being thrown around, they usually come from the false assumption that a shipment is pure. The police haven't been reporting actual purity percentages. It might save lives if they did, but it would be highly irregular so I wouldn't expect it.
posted by Easy problem of consciousness at 3:42 PM on November 13


Hi from Vancouver, BC.
Based on the first five months of 2017 data, the City of Vancouver is on track for 430 [fentanyl-related] deaths this year. -Georgia Straight, July 4 2017. There's more data at the link.

Fentanyl has given 3 BC [British Columbia] officers overdose symptoms from touching the powder during a bust. While it's very possible that they could be dealing with huge amounts at high purity during the bust (the article doesn't say), it was still absorbed by touch.

I go for beer with a friend in Chinatown on Fridays and there are always a few junkies around, some we know by name as they usually spare for change on the corner. One said she's lost at least 4 friends and a few people she knows to the drug. There are warnings all over "if you see any substance that you can't identify or that you suspect to be fentanyl DO NOT pick it up. Call the police."
There'll probably be a lot more until the police find a way to put a stop to it, or until the dealers realize that killing off their clients doesn't make them money.
posted by Zack_Replica at 5:02 PM on November 13


That's the thing, nobody is intentionally killing their clients. A large portion of them probably don't even know their product has fentanyl in it.
posted by wierdo at 5:45 PM on November 13


and they would grab my wrist and make me recite my full name and date of birth before they started.

They do that with antibiotics or any other medication that goes into you.
posted by The Underpants Monster at 7:09 PM on November 14


For those who have acetaminophen issues, there is a product out that is called Vicoprofen, which is a Vicodin equivalent that substitutes ibuprofen for the acetaminophen.
posted by Purposeful Grimace at 9:15 PM on November 14


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