It’s important to observe that within substance use disorders and addictive disorders there are certain levels of severity, although some recovery circles promote that everyone should just identify as “an addict”, the reality of the situation is that there is very key difference in different style of addiction. The severity of addiction can also be split into different levels also. These may be based on the drug itself but also the biological, psychological, sociological and even spiritual aspects of a person’s being.
Some people drink alcohol on a regular basis, but don’t increase the amount by much, however if you were asking them to refrain from it entirely, they might find that difficult in a way. Same with smoking cigarettes, some people smoke a certain number of cigarettes each day but never feel the need to increase that amount but they would certainly feel something is amiss if you ask them to totally abstain from smoking. Some people even prefer different drugs but they have somewhat a stable relationship with that drug or substance. They may fall under the category of having an addiction of sorts if we were to base in on their interaction and inability to refrain from that substance. However, there is certainly a population of people who find that their substance use will increase with a certain substance. They may also progress on to harder more dangerous drugs, some people will not only move on to harder drugs but they may also develop more chaotic patterns of usage which lead to death and destruction.
The purpose of this series of articles is to look at the different reasons why people seem either drawn or robotized towards this level of addiction.
Death by Fentanyl
Around the time of Prince’s death (Prince Rogers Nelson the singer “Prince”) I was chatting with a friend and he asked me “how did he die?”, I looked it up via google and it stated that Prince had died due to Fentanyl (Levenson, 2016). He recoiled in horror stating that he could never imagine Prince ever taking such a drug. To him, a relatively recreational drug user Fentanyl seemed like an immediate suicide, he’d heard nothing but bad things about the drug things like ‘1000 times more powerful than heroin’.
“You’d think being that famous someone would have warned him about that”, my friend stated. I agreed in part, but I weighed it up with progression of drug use in some cases and sometimes when going deeper into opioid it’s somewhat logical progression.
Fentanyl is an odd drug for me, I first encountered fentanyl when I saw it being used in hospitals for operations. It was an opioid, it’s worth pointing out that I often hear fentanyl being called a “synthetic opioid” which is a misnomer, the word opioid immediately tells you it is synthetic, non-synthetic drugs of this class are called Opiates – which means it comes from Opium Poppy sap. Fentanyl is entirely created in laboratories, there is no element of it that comes from poppies.
Fentanyl is a powerful opioid which is usually used in the “Peri-operative” (meaning where they commence surgery) environment, it used during surgery and more commonly used in major operations to reduce pain to minimum. It is also available in patch or tablet form which can be prescribed in the treatment of severe pain, acute or chronic. When I first encountered this drug it had no street value whatsoever, I’d never heard of anyone using it on the streets (this was in 2004). I had no idea that drug would go on to become so infamous.
Fentanyl is very similar to heroin, except it’s synthetic and much stronger. Heroin is already quite a powerful drug, it has quite a high chance of over-dose potential when injected, it causes respiratory depression and slows down the heart. During an operation this is closely monitored so it isn’t much of an issue, the anesthetist gives other drugs to counter act the effect of depression and your breathing is done via an anesthetic machine. Opioids/opiates don’t really present much issues for seasoned practitioners who are monitoring their patients carefully.
Public Enemy Number One
Fentanyl has become quite a public enemy in the USA, hundreds have died from using it and many more have died from unwittingly ingesting it in counterfeit drugs (Portland Press Herald, 2018). Sometimes it is mixed into benzodiazepine tablets and also mixed with cocaine – when people use those drugs without tolerance to opioids they can sometimes succumb to the deadliest effects of the drug. Some parents, law officials and speculative members of the public believe drug dealers deliberately cut their products with fentanyl to increase the addictive nature of it. I’m rather skeptical of this viewpoint, as it seems very counter productive to potentially kill your customers each time it is mis-sold, but it wouldn’t be the first time this practice has come to light.
You’d have to be living under a rock to not have heard fentanyl is more deadly than heroin. So why do some people take the extra risk in wanting to do fentanyl?
Here are some of the reasons commonly known:
- Heroin no longer delivers a high via tolerance
- Shortage of heroin
- Morbid curiosity
- Seeking extra boost
- Mis-sold fentanyl as heroin
- Dealers pushing fentanyl as a better alternative
(Sources (see refs): Carroll, et Al., 2017. Mars, Rosenblum, Ciccarone, 2019. MENA report, 2017. )
Tolerance
If we look at addiction, a lot of drugs of addiction work via G Protein-Coupled Receptors (GPCR) on the cells of our brains (Johnson & Lovinger, 2016). These receptor sites are only in finite amount, in order for a user to feel high from the drug they must have these protein reception sites available for the drug to bind to and activate the effects – as in the case of drugs of addiction they mostly activate the release of the reward chemical DOPAMINE (this is a simplified version, if you’d like to see the precise mechanism of this please go to: https://www.frontiersin.org/articles/10.3389/fncel.2016.00264/full ).
Think of the drug like a key and the protein site as a lock, the key goes in and unlocks this ability in the brain.
A drug goes into the body, into the blood and makes its way to the brain where the chemical is spread across the brain and particles of the drug rub up against the GPCR and some of that drug activates the GPCRs. The GPCR binds with the chemical of the drug and gets the braincell to perform an action. This is what makes a person feel high, this roughly similar for most drugs you can become addicted to, including cannabis.
Overtime and sometimes even from the first usage, some of the GPCRs become damaged and no longer work, but you’ve got trillions of them? So, no worry, right? Well, not quite. Unfortunately, we’re not all totally equal when it comes to genetics, life and other experiences. We can be quite different individually and different compounds/drugs affect us in different ways.
As the GPCRs decline in their numbers the effect from the drug will become much less profound, a moderate dose will now no longer achieve the same effects, this is the mechanism (amongst some other psychological triggers) that encourages users to begin to increase their dosage.
A good example of this is cocaine, which is a GPCR binding drug (Yu, et Al., 2017). If you had never taken cocaine before if you go over a certain dose you can incur rather negative effects, in some cases these negative effects can be mortal. Cocaine causes increased contractions of the heart, which not only feel very unpleasant to some but can also cause heart attacks and death. A seasoned user of cocaine doesn’t always experience this, they can take large amounts of cocaine and actually just feel more with it or happier. The drug just isn’t as potent for them, they may sniff or inject large amounts with only feeling a small part of the negative effects – but also not feeling the positive effects as much either.
They simply no longer have the GPCR’s available as much as a new user and that GPCRs have cause synaptic plasticity which lends itself to progressive neuroadaptations in the brain (Preston, 2021) .
It is worth noting that this is where addiction to different drugs can deviate away from each other. If you are a straight up cocaine user, you will not have tolerance for opioids, no matter how far you’ve been with cocaine, they bind to different receptors in the brain. You might not get as high because all the feel-good chemicals in your brain have probably been burnt out by cocaine. If you’re already used to one particular type of drug, you’re just used to messing with your mind as opposed to being tolerant towards it.
If you’ve been using heroin or other opiates/opioids for several years, there’s a very good chance that the drug does very little for you. It might be as strong as a cup coffee or smoking a cigarette. It will only satisfy cravings and give mild relief, it may also offer freedom from withdrawals if dependent (not all heroin users of decades are dependent).
One must remember if you are taking a drug to rid yourself of something, such as anxiety, guilt and trauma. When that drug no longer is working those conditions that drove you into drugs are likely to return, usually in a much worse way – which pretty much explains addiction in a nutshell. Problems you escape from are now much worse from a notable decline of bio-psycho-social-spiritual aspects of substance use disorder.
So back to fentanyl, it seems that it blends in quite well with substance use disorders. It’s relatively affordable, it’s very similar high to heroin, it’s available and fulfils that desire to push things further. However, there is a reality to the drug, as it’s potentially much stronger than heroin there is only so much the human body can take.
Overdose
Unfortunately for heroin users and opioid users, there sometimes isn’t any warning signs with drug. The drug can make users unconscious as soon as they push down on the syringe. Other drugs someone may receive a window of opportunity where they notice that the drug is going to have toxic effect, they may feel a sense of severe impending doom, a terrible sickness or physical pain (such as chest pains). This gives the user a chance to raise alarm. However, heroin, fentanyl and other opioids you are much more likely to just fall unconscious due to an overdose (Kuczyńska, et Al. 2018).
Unless there are people around you who able to maintain your airway, reserve the effects of opioids or restart your heart (as there is in an operating theatre) there isn’t going anyway to pull you out of your overdose. Not all overdoses are fatal, but they are incredibly risky. I have talked with a few heroin and opioid users who’ve told me they’ve woken up in a smashed up bathroom in a pile of broken porcelain. They went into a bathroom for a hit and just recall their eyes going crossed as they pushed the plunger. Next thing they know their jaw is feeling broken, their needle is snapped in their arm and they’ve been unconscious for 3hrs in a pile of broken sink.
The whole opioid/opiate buzz is a flirt with being semi-conscious, a dreamy delirious state. But there’s a line somewhere in that state where by the users can either be alive or fading away.
As in the case of Prince, I don’t like to speculate, but he was probably one of the most famous deaths from Fentanyl usage. He was found in 2016 in an elevator in his private mansion in Minnesota, from “911” calls made at the time it seems that he was found dead on arrival (EFE News Service, 2016). When a person goes into a unconscious state from fentanyl it can be very unlikely they will be able to support their own airway which causes asphyxiation or death from cardiac arrest. You can only be in a state like that for a matter of minutes before you’re unable to be resuscitated.
Despite all the above I’ve only covered one aspect of how aspect of how or why addiction can increase despite wide awareness of the risks associated with more deadly drugs. This merely covers the bio-medical factors of tolerance towards drugs of addiction. There are indeed many more factors as to why a person will increase their drug use or progress on to drug which are known to have a more deadly effect.
Come back soon for the 2nd part of this article
References:
Carroll, J. J., Marshall, B. D. L., Rich, J. D., & Green, T. C. (2017). Exposure to fentanyl-contaminated heroin and overdose risk among illicit opioid users in rhode island: A mixed methods study. International Journal of Drug Policy, 46, 136-145. doi:http://dx.doi.org/10.1016/j.drugpo.2017.05.023
Fentanyl now public enemy no. 1 in america’s war on drugs: Fentanyl caused 58 percent of maine drug fatalities in 2017, while heroin caused 21 percent. (2018, Apr 10). Portland Press Herald Retrieved from https://www.proquest.com/newspapers/fentanyl-now-public-enemy-no-1-americas-war-on/docview/2023321820/se-2?accountid=12118
Johnson, K. A., & Lovinger, D. M. (2016). Presynaptic G protein-coupled receptors: Gatekeepers of addiction? Frontiers in Cellular Neuroscience, doi:http://dx.doi.org/10.3389/fncel.2016.00264
Kuczyńska, K., Grzonkowski, P., Kacprzak, Ł., & Zawilska, J. B. (2018). Abuse of fentanyl: An emerging problem to face. Forensic Science International (Online), 289, 207-214. doi:http://dx.doi.org/10.1016/j.forsciint.2018.05.042
Levenson, M. (2016, Jun 04). Markey says prince’s death highlights fentanyl issue. Boston Globe Retrieved from https://www.proquest.com/newspapers/markey-says-princes-death-highlights-fentanyl/docview/1793707357/se-2?accountid=12118
Mars, S. G., Rosenblum, D., & Ciccarone, D. (2019). Illicit fentanyls in the opioid street market: Desired or imposed?: (alcoholism and drug addiction). Addiction, 114(5), 774-780. doi:http://dx.doi.org/10.1111/add.14474
Prince had improperly labeled pills containing fentanyl at home: PRINCE. (2016, Aug 22). EFE News Service Retrieved from https://www.proquest.com/wire-feeds/prince-had-improperly-labeled-pills-containing/docview/1812951517/se-2?accountid=12118
Preston, C. J. (2021). Progressive neuroadaptations in ventral hippocampus synaptic transmission during cocaine withdrawal (Order No. AAI28154202). Available from APA PsycInfo®. (2522420105; 2021-27913-204). Retrieved from https://www.proquest.com/dissertations-theses/progressive-neuroadaptations-ventral-hippocampus/docview/2522420105/se-2?accountid=12118
United states : With opioid crisis still raging in broome county, now exacerbated by fentanyl, senator pushes new bipartisan legislation to provide feds with more border agents, new portable labs and other high-tech tools to intercept illicit fentanyl fro. (2017). MENA Report, Retrieved from https://www.proquest.com/trade-journals/united-states-with-opioid-crisis-still-raging/docview/1892135123/se-2?accountid=12118
Yu, C., Zhou, X., Fu, Q., Peng, Q., Ki-Wan, O., & Hu, Z. (2017). A new insight into the role of CART in cocaine reward: Involvement of CaMKII and inhibitory G-protein coupled receptor signaling. Frontiers in Cellular Neuroscience, doi:http://dx.doi.org/10.3389/fncel.2017.00244
Dylan Kerr Addiction Therapy 