A conversation about the current fentanyl crisis in Wyoming
Fentanyl-related deaths in Wyoming have been on the rise since 2015. There were 106 overdose deaths in 2021 alone. Wyoming Public Radio’s Sage Davis spoke with Melissa Hunter, the drug information director at the University of Wyoming (UW) to understand just how dangerous fentanyl can be.
Editor’s note: This story has been lightly edited for clarity.
Melissa Hunter: A lethal amount [of fentanyl] can actually fit on the tip of a sharpened pencil. Two milligrams can be a lethal dose, and two milligrams is so small it can fit on the tip of the pencil.
Sage Davis: It's just crazy. When you don't have those analogies, like you just said, it's so hard to visualize what actually is going on. What type of health conditions or issues would fentanyl usually be prescribed for in the medical field?
MH: Typically, fentanyl is prescribed in a hospital setting. So, it's used for surgeries. It's used for severe acute pain, and it's usually injectable at that point. When somebody has chronic severe pain, sometimes we'll use it in the outpatient settings for severe pain, like cancer pain or extreme chronic pain.
SD: As a pharmacist do you see fentanyl being prescribed pretty commonly? Or is it more on a dire need basis?
MH: Fentanyl is not our first choice of pain relief. We save fentanyl for patients who have severe pain. In the hospital, it's used every single day for a variety of acute pain things that happen when people are in a hospital. Like I said, especially in surgeries, we use it all the time. When it comes to outpatient at a pharmacy, it's dispensed, at least probably multiple times per day for people that have chronic pain. But when it's dispensed from a pharmacy it’s typically in a patch that delivers the fentanyl through the skin. It also exists in a lollipop, but those are way more uncommon because those are for extreme acute pain. So, you would see those for people who were in extreme pain, typically from cancer.
SD: And when you mentioned the different ways of [dispensing fentanyl, like] the patches, the lollipops. Does that affect how your pain is being managed?
MH: So the patch takes about 12 hours to start having pain relief and it lasts for about three days, in perfect circumstances. And so, it is a very low dose that goes through the patch, and it's consistent. Once it starts working, there's a consistent level of pain relief. For the lollipops, it is much quicker because it's absorbed through the tissue in the mouth, and goes straight to the brain to give that pain relief. When we're using it for pain relief, the dosing is an order of magnitude smaller than what is used when people are typically abusing this product. When people are using it for pain, they're not going to get the high that you would from abusing heroin or cocaine or any of the other products that people are abusing. And why fentanyl is such a problem right now is because it's being used at different levels and it's lacing other products. Someone might go get some heroin off the street, not knowing that it's laced with fentanyl and can have an overdose because they didn't know that the fentanyl was even in the product that they were purchasing.
SD: Do you feel like the benefits of prescribing fentanyl when people are in that much pain outweigh the risks?
MH: Absolutely. When it's used appropriately, the benefits outweigh the risk. And that's really one of the challenges that we have in pain medicine is that we see all the dangers of fentanyl, and we hear about it on the radio and we hear about it in the news. And so sometimes people who have legitimate pain don't want to take it because they're afraid of getting addicted to it. And that's unfortunate because it does treat pain very, very well. It's when it's laced in illicit products and when it's not being used for its intended purpose, that's when it causes a problem.
SD: Do you feel like because of this ever growing crisis, we should start steering away from that or do you feel like in the medical sense [prescribing fentanyl] is not the biggest problem?
MH: If a prescriber’s writing it for somebody that has pain, that should not be stopped because it is a very good drug when it's used appropriately. And the access to fentanyl for people that need it needs to be to stay in place. The problem is, we found out that fentanyl is so much more potent, it crosses the blood brain barrier, way faster than morphine does, even faster than heroin, and it binds to the receptors in the brain so much more tightly that it causes a bigger, faster high. When a product is laced with fentanyl, and the person doesn't overdose, they're going to be chasing that high that they got from the laced product. They're going to want more and more to match that high that they got from the first time they did fentanyl. It's the illicit manufacturing and the illicit use of it that needs to stop.
SD: A lot of times when we talk about the opioid crisis, [opioids] were over prescribed [and] people had extras. Do you feel like for fentanyl, that's the case? Or do you feel it's more so people have found a way to make it on the streets, and that's why we're seeing so much increase of it being laced in products and people having more access to it outside of the medical field?
MH: Fentanyl is a synthetic compound. And so the illicit manufacturers have figured out how to manufacture it and can create pounds of fentanyl when our typical dose is in micrograms. It's a huge order magnitude difference in the doses and it's being laced in everything. There's been heroin, cocaine, fake Oxycodone tablets, fake Xanax tablets, pretty much anything that's fake. I saw something online today from the DEA [Drug Enforcement Administration] that said, at least six of ten fake prescription pills contain a potentially lethal dose of fentanyl.
SD: If people had a better understanding of just how little of an amount is safe, do you think that would decrease the number of people overdosing?
MH: Unfortunately, no, because addiction is so strong. Addiction is such a powerful state that knowing that it can kill you isn't going to stop someone from using it. It's unfortunate that in the grand scheme of the universe, fentanyl is very cheap to make. By lacing other products, the drug dealers are getting people more addicted to the fentanyl products, and we're going down a really dangerous path. If you're going to be taking drugs, make sure you know where it came from. There's 150 people dying every day from a fentanyl overdose. And that's heartbreaking. I think the bottom line is, the danger of fentanyl is that it's up to 50 times more potent than heroin and up to 100 times more potent than morphine. It is more addictive because it's just so powerful of a drug. It is a great drug when it's being used appropriately, but it's very dangerous when it's not used appropriately. If anybody knows someone who is at risk for an overdose, it's important that they have access to Narcan because Narcan can save lives, if it's used when somebody is overdosing.