Given the global surge in fentanyl use, the highly potent synthetic opioid – 100 times more powerful than morphine and 50 times more toxic than heroin – that has overwhelmed the US with more than 1,500 deaths each week this year, Medical Forum spoke with leading WA addiction expert Dr John Edwards, to get his perspective on Australia’s vulnerability to the drug.
According to the Australian National Centre for Clinical Research on Emerging Drugs, Fentanyl, has been linked to an almost nine-fold increase in related overdose fatalities since 2000.
Dr Edwards explained that Australia experienced a massive rise in prescription drug use from the year 2000, due in part to an international heroin drought and the uptake of methamphetamine, with fentanyl transdermal patches first listed on the PBS in 1999 for use in the management of chronic cancer pain.
“From 2000, the most common problems were with prescribed opiates rather than with illicit ones, and that expanded to the point that it has become more of a problem than heroin itself,” he said.
“It never got quite as bad as it did in the United States, but things that happen in the US tend to happen here, maybe five or 10 years later down the track, and to some extent, we were able to see this coming and have been able to alter how things were done before it got as bad.
“Fentanyl is still rare in WA and Australia, though there’s always a certain amount of fentanyl around because it’s a prescribed agent, not to mention the fentanyl that comes in through the internet in little packets that individuals may get their hands on.”
For example, the largest fentanyl seizure by the AFP was in August last year when 11kg was sent from Canada and detected at the Port of Melbourne, but otherwise, Australian authorities have only ever detected illicit fentanyl importations in minor amounts – all less than 30g, with the first case in 2013.
“We haven’t had the industrial scale fentanyl that’s occurred in the US, where something like 80% of the heroin is cut or contaminated with fentanyl to make it stronger,” Dr Edwards said.
“And with fentanyl more than 100 times stronger by weight, you only need to get that amount a little wrong and you’re overdosing people, which is what is happening in the US and Canada.
“It came suddenly into Canada, and when it did, rates of overdose deaths almost tripled in places. In Vancouver, deaths went from 600 a year to 1400 when the lethal combination hit the streets. Even though health authorities were prepared for the influx, spreading naloxone agents throughout the community, and yet it was still devastating.”
“But in that period, the number of people in WA on opiate replacement therapy has not gone down, it’s gone up yet the resources that we have to manage it have stayed the same or actually reduced – it’s an old chestnut that’s not going to go away.”
According to the most recent information available from the Australian Institute of Criminology, in 2020, an analysis of police detainees found that 3% tested positive to fentanyl, even though no one who tested positive in the study reported knowingly ever using any form of fentanyl.
“The discrepancy between urinalysis results and reported use may reflect unwitting use of fentanyl and possible fentanyl contamination of other illicit drugs,” the AIC said.
“However, 11% of detainees reported having intentionally used fentanyl in their lifetime, ranging from 10% in Perth, to 14% in Sydney, with 4% of respondents reporting use in the past year.”
Most (68%) had used nonprescribed fentanyl, mainly from a transdermal patch, typically by injecting the solution extracted from the patch, though a small number of fentanyl users had either inhaled a nasal spray (7%) or swallowed or injected a lozenge (7%).
“Detainees who reported using non-prescribed fentanyl were significantly more likely to have used methamphetamine, heroin, cocaine, and benzodiazepines during the past 12 months, with higher self-reported levels of dependence,” the Institute said.
“Most detainees who tested positive to fentanyl also tested positive for methamphetamine, and the overlap between fentanyl and methamphetamine use may suggest detainees are using fentanyl to ease the symptoms of meth withdrawal, or ‘speed balling’ these drugs—combining them to produce an intense high.”
“Some respondents who used methamphetamine may also have unintentionally consumed fentanyl, in the form of fentanyl-contaminated methamphetamine and given the prevalence of meth use among some groups, evidence of laced stimulants may suggest that fentanyl use could accelerate if it became more widely available.”
Dr Edwards pointed out that in WA, somewhere between a quarter and a third of all the people on opiate replacement were in prison.
“They could be people who are on our program and then end up in prison, or they’ll come out of prison and go on a program, and for many, the reason they’re there is related to drugs,” he said.
Dr Edwards noted that the most common reason that people initially became dependent on opiates was because of trauma and highlighted the importance of addressing drug-related stigma, especially within the healthcare sector.
“People would think it was odd if their GP said, ‘I don’t do diabetes,’ or ‘I won’t see anyone with high blood pressure,’” he said.
“But if it’s drugs or drug related issues, people seem to feel that they can be as disparaging as they want to be, and that’s okay – but it really isn’t.
“It’s terrible that there’s this level of stigma allowed to continue in a world that’s supposedly so politically correct, but there is so much shame around this type of thing that people can’t even be honest with their GP – and that’s crazy!
“Yet by giving an opiate replacement, a GP can help to hold them in a safer situation, where they can get their life in order and not have to live in the illicit world, not have to spend all their money, and not have to take the risk of exposure to fentanyl-laced drugs.”
Dr Edwards explained that one of the biggest breakthroughs in saving lives from opioid overdoses was the reversing agent, naloxone.
“Anyone can have it and as it’s not a restricted item, you can keep it at home and even if a family member just takes too many painkillers – you can reverse their overdose just by using this nasal spray,” he said.
“It was rolled out some years ago in WA but has probably not been taken up as much as it should have, and people need to be reminded that it’s there, it’s safe, it’s easy to use and could potentially save someone.
“However, it’s much more difficult to reverse a fentanyl overdose than, say, a heroin, morphine, or other opiate-based overdose.”
To read the full interview with Dr John Edwards, check out the upcoming edition of the Medical Forum Magazine, where we discuss the impact of the recent addition of opioid dependency treatment medication to the PBS.