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Introduction

As dental professionals, we are each prescribers of opioids in the provision of “best practice” for our patients. While the addictive nature of long-term opioid use has been known since the drugs were first utilized centuries ago, presently, there is increasing concern about where prescribing habits intersect with what is rapidly becoming one of society’s modern epidemics – opioid overdoses related to increasing fentanyl presence.

How Opioids and Fentanyl are Connected

So you may ask, “I have never prescribed fentanyl and don’t intend to, so how does this affect me as a professional?” Putting aside the fact that it affects each and every one of us who has a concern about public health, consider the following before we review how fentanyl gained this foothold in our society: Statistically, last year, over 350,000 deaths in North America were attributed to opioid overdoses. This is a ten-fold increase over the past dozen years. A lot of those deaths have been directly attributable to the purposeful or secondary presence of fentanyl as an opioid recreational drug.

While Ontario is lagging behind in providing the latest full year concrete statistics and we do not have accurate Canadian-wide statistics at this point, it would be safe to say that literally thousands of young people will die this year from a fentanyl-related death where opioids are involved as recreational drugs. In 2015, the latest full year for which statistics are available, 48 deaths in the Ottawa area were due to unintentional drug overdose, 29 of these opioid-related. Consider this: In British Columbia where they have made the resources available to carefully look at the statistics involving fentanyl, in the first two months of 2017, there has been a remarkable 90% increase in the deaths attributed directly to fentanyl use compared to the same period in 2016.

This year alone, close to a thousand people will die in British Columbia in overdose cases where fentanyl is detected – and that is only one province. The government of B.C. recently declared a “public health epidemic” related to fentanyl overdose. Recently in B.C., six promising young human beings tragically died of a fentanyl-related overdose in one evening alone.

In Ottawa, public health records show emergency room visits for drug overdose have increased from an average of 80 to over a 100 per month in the last six months.

The government of Ontario and our colleges have been proactive in some cases, but primarily reactive as this epidemic has unfolded. Presently, as professionals, along with physicians and pharmacists, we are much more diligent in making sure that false prescriptions are not created. (For instance, we have added photo ID as a prerequisite for narcotic prescriptions in the past five years.) We should all by now be aware of the need for safe practices in minimizing the occasions when opioids are prescribed, being cautious about the quantities when opioids are prescribed, utilizing alternative drugs (appropriate doses of anti-inflammatories, newer drugs such as Tramadol) and educating family members and patients in the appropriate disposal of drugs.

On May 8, the Canadian Medical Association released new National guidelines for prescribing opioids aimed at limiting quantities and substituting alternative drug therapies. In the spring, the Royal College of Dental Surgeons of Ontario, the College’s upcoming actions to monitor opioid prescribing habits of Ontario dentists were laid out (as a result of the November 16 opioid summit in Ottawa).An approach I have used for the past two years when prescribing an opioid is a conversation with the patient (and parent where applicable) on the dangers and safe effective use, storage and disposal of drugs. Parents have begun to live in fear to the point of allowing their loved ones to suffer rather than utilize opioids in pain control. Responsible management of the prescription is, in itself, a preventive measure.

Why Fentanyl?

We should be aware that Canadian physicians and dentists have been identified as very heavy prescribers of opioids in North America. We have lessened our prescriptions and controlled OxyContin (a change to OxyNeo) has made it more difficult to tamper with for injection use. With their easier sources drying up, users have had to turn to alternatives. Fentanyl in its small quantities and potency can be easily transported. It is now manufactured legally and illegally in many locations through the world including China. In very small quantities fentanyl is immensely powerful – over 100 times the potency of morphine and 50 times as that of heroin. Fentomylin, its powder form, is undetectable by smell or taste and it is often used as an additive for other drugs or even as counterfeit oxycodone. Commensurately, the danger of overdose due to respiratory depression, is exponentially increased.

On the street, a kilogram of heroin (at $60,000) would be nothing compared to the value of a kilogram of fentanyl (over $100 million). Illegal drug producers throughout the world have recognized this simpler, less bulky drug as a profit centre. It has been utilized in heroin to boost effectiveness and, because of its potency in microgram amounts, mistakes are very easily made. With the better safe-guarding of prescription narcotics in our offices, pharmacies and homes, the shift to new illicit drugs is here and here to stay. What used to be limited supply when fentanyl patches were stolen, this drug which can be snorted, smoked, injected, or taken orally has risen dramatically in popularity.

Actions We Can Take

As a parent or counsellor for young people (which we all are at home and in our practices), what can we do? The arguments against use have to be persuasive. I personally believe that peer-provided education, talks from those who have experienced, and survived, the life-changing, life-threatening horrors of opioid addiction, is more effective than a parental lecture. We have to open our minds and start realizing that is here to stay and, with close to 20% of children between 12 and 17 experimenting, and the very strong gravitational pull of peer pressure we have to stress safety; and that will mean reconsidering the possibilities of safe sites.

The police in Ottawa have recently made a very good decision, which will overnight change the outcomes for many otherwise terminal overdoses. No longer will all individuals at the scene be charged. A user who calls for help for an unconscious victim at his or her side will not be subject to criminal prosecution. This has been a huge deterrent to contacting authorities in the past. This law was just passed in early May 2017.

Prevention of fatal outcomes

In the way of prevention of fatal outcomes, Naloxone kits are critical. Our children have been wise in the area of drinking and driving; designated drivers are commonplace. We have drilled into our children’s heads the idea of safe conduct when drinking. They have, for the most part, been more responsible than our generation was. The punitive drinking and driving laws have contributed to that, but mostly it is personal education and common sense.

The same has to apply to opioid use. Naloxone narcotic reversal kits should be available to all. This would mean that virtually every site of recreational drug use would become a safer site. Of course, it is only possible if our youth get the idea of a designated non-user on site. There is the potential for much greater safety in the fact that most opioid deaths are inadvertent. These tragic outcomes were not desired and, as such, prevention is a possibility.

(One note of caution: With the recent appearance of carfentanyl and acrylfentanyl, even more lethal forms of fentanyl, even naloxone may not suffice as a reversal agent.) http://drugfree.org/article/overdose-response-treatment/;

Recognizing and seeking treatment for those addicted and convincing our health care system that this is a disease for which funding is necessary is critical in prevention and treatment.

Recent “summits” and conferences in Europe, the US and Canada, have highlighted much of the progress and rapidly developing advice on improving outcomes. Ottawa Public Health has a very good active website with statistical updates and identification of resources, and a good overview of the opioid problem.
References:
http://ottawa.ca/en/residents/public-health/healthy-living/alcohol-drugs-and-tobacco/drugs
http://ottawa.ca/en/residents/public-health/healthy-living/alcohol-drugs-and-tobacco/drugs#infographic-data-tableAs

To summarize, in our practices and in our homes:

  • As a prescribing professional,we have to make every effort to educate and limit access to opioid prescriptions – this includes substituting other pharmaceuticals for opioids whenever possible;
  • As a government, we have to allocate resources to find and limit the illicit sources of drugs while simultaneously educating the public and users as to their dangers. We have to invest more in addiction programs and recovery programs. The use of substitute non-craving medications, such as methodone and suboxone, has proven useful and, in many cases, has provided complete rehabilitation. More resources are needed in consideration of safe sites and has to be in the conversation;
  • The availability of Naloxone or reversal kits has to be universal. A recent positive development has been the introduction in social media of an app on the use of Naloxone and the importance of being prepared for adverse outcomes. It is also encouraging that the government has recently become proactive in this area;
  • As a parent, we have to develop the persuasive argument for our children and loved ones to help educate and limit the dangers posed by opioids and fentanyl by awareness. As stated earlier, peer experience has to be a large part of this program in order for it to be effective. Again, educational facilities, family professionals, physicians, dentists, pharmacists, and parents have to continually educate themselves and have frank discussions with their children. This includes the mantra – “Don’t mix your drugs”. (There are many resources available on how to have this talk with your child.)
    References:
    https://www.drugabuse.gov/publications/marijuana-facts-parents-need-to-know/talking-to-your-kids-communicating-risks
    http://drugfree.org/article/how-to-talk-with-your-teen/
    http://drugfree.org/article/secure-dispose-of-medicine-properly/
    http://drugfree.org/article/secure-dispose-of-medicine-properly/
  • Whether the patient, prescriber or dispenser, these drugs and prescriptions must be carefully monitored, locked up and dispensed (limiting the number of pills, substituting effective alternatives) and disposed of with care.
  • Encourage loved ones in the grips of addiction to consider medication-assisted treatment (anti-craving / methadone / suboxone). Encourage community-based rehab clinics. A great example is the Sandy Hill clinic in the Ottawa area. It is a beacon of hope for many in the throes of opioid addiction. (Ottawa Public Health identifies many other resources.)
As the war on drugs has taught us, we are not going to win this one, we can only put all possible programs in place to prevent adverse outcomes and treat the disease.

A quick look at the demographics of deaths related to opioid (fentanyl) overdose is chilling. In the past two years, more people have died from opioids in the United States than died in the entire six-year Viet Nam war. These are often young people at the prime of their life with great hopes for the future. Gone. Vanished. The proportion of female deaths has also been increasing, starting to rise above the 4:1 (male to female) ratio of the past ten years. This epidemic has broad-reaching implications for emotional health for all of those impacted.

We will never “cure” the perceived need for recreational drugs, we have to focus on prevention and treatment. We are now at a crossroads in Canada, where we have made a decision to legalize a commonly used drug in marijuana. Some are encouraged by recent reports that in jurisdictions where marijuana has been legalized, opioid use has decreased. It remains to be seen whether this is temporary or a true change in preferences.

One thing for sure, our responsibilities to provide education, safety, and promote moderation and treatment will only increase from this point forward. Are we ready?