Oregon sees spikes in fentanyl overdoses

The opiate fentanyl is 50-100 times more powerful than methadone, heroin and other narcotics. And it’s behind recent spikes in fatal and nonfatal overdoses in Oregon. Some teens are using social media like Facebook messenger and Snapchat to connect with dealers and buy the drug. John McIlveen is the State Opioid Treatment Authority at the Oregon Health Authority. He joins us to tell us more about the rise in fentanyl use and some of the strategies to prevent fatal overdoses.

This transcript was created by a computer and edited by a volunteer.

Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. We’re going to start today with the latest on the synthetic opioid, fentanyl, which is up to 50 times more powerful than heroin. Over the last few years it’s been implicated in a huge increase in fatal overdoses in Oregon and around the country, even as there’s been a lot more media attention about the dangers of this drug. John McIlveen is Oregon’s State Opioid Treatment Authority. He joins us now to talk about the rise in fentanyl use and some of the strategies to prevent overdoses. John McIlveen, welcome to Think Out Loud.

John McIlveen: Thanks Dave, nice to be here. Thanks for having me.

Miller: It’s good to have you on. Let’s start with the basics here. What is Fentanyl?

McIlveen: When we talk about Fentanyl, Dave, what we’re really talking about is a synthetic opioid analogue. Fentanyl, originally or traditionally has been used as a very, very strong pharmaceutical opioid for things like surgical procedures and the like. As we’ve moved through this period of the opioid overdose crisis or however we want to characterize it, isn’t new. We’ve had waves over time and most recently into the late 2000′s, 20-teens, the spread of prescription drug overdose misuse. And now we’ve kind of morphed into this unfortunately different time in the opioid crisis or epidemic where a lot of that has been prescription drug overdose and the like has really plummeted in Oregon. And I think a lot of that’s due to a lot of people’s hard work at that. Unfortunately it’s been replaced by the ever-present synthetic opioid analogues, like Fentanyl and all the different varieties. Because there’s a number of them.

Miller: So these are not like not unlike Percocet or Hydrocodone or some of the drugs that were eventually leading to prescription overuse, and people seeking heroin. These, as you noted, are drugs that doctors and surgeons use. So where does the Fentanyl that’s ending up, in the black market, where is it coming from?

McIlveen: That’s a good point. Dave, just for clarification, they’re not necessarily the same drugs but they’re mimics, that’s why we call them analogs. They’re essentially chemical compounds that are created in laboratories by chemists to produce the same effects. When we talk about opioids as a class of drugs, the effect, the euphoria and analgesia that come from the opioid, that remains consistent throughout the whole, let’s call it the opioid family, right? Naturally occurring opiates, like we talked about morphine and the basis for heroin and the like, when we talk about synthetic opioids that are used for a variety of different analgesia and other medical procedures, so the pharmacological reaction or the reaction of the body is somewhat similar. The vast difference in what makes this so particularly insidious, Dave, is the, and I think you mentioned before, is the potency is tremendously exponentially greater than many of those other opioids that we mentioned earlier. And that’s really one of the main drivers of the rash of opioid overdose and death that we’re seeing across the country and also here in Oregon.

Miller: Is the basic idea in terms of where they’re coming from, that large drug cartels have their own drug factories?

McIlveen: Well, I think, and again, not being in law enforcement, but working closely with several folks in law enforcement and I think every indication is that is true, Dave, and also we have to remember that, we have highly developed drug distribution networks and then, the impact of the pandemic, where drug supplies were disrupted. What I think the overall takeaway is that we’ve gotten to a point where we talk about fentanyl contaminating the drug supply or bad batches that they talk about. I think we’re really at a point now where Fentanyl has taken over the place of many of those other forms of opioids that were abused and that are the source of overdose and unfortunately death. So the entire West Coast, Fentanyl has been an issue in the Northeast and the industrial upper midwest for years. Throughout the late 20-teens it really never hit in the West Coast and that is occurring like a tidal wave, I don’t want to be overly dramatic, but I think that that’s a fair analogy.

Miller: Maybe this is part of the explanation for a question I had because this morning I looked at CDC numbers in the CD website for overdose death rates for a state by state comparison, and the latest data I could see was for 2019. So it’s relatively recent, but the years have elapsed since then and it was really eye opening because as serious as the issue is here, as of 2019, Oregon had a much lower death rate than most other states, a third or a quarter of that of a number of states in Appalachia in the upper midwest and in the Northeast, places like New Hampshire and Massachusetts and Maine and Vermont. So are we just behind or have we been doing something differently that actually has been to our advantage?

McIlveen: That’s a great point, historically, and I’ve been involved in this work with folks, stakeholders around the state as well as our colleagues, in the public health division throughout the 20-teens to address prescription drug overdose and misuse. We really did see a huge impact from that work. We have a very robust patient-centered and provider-focused prescription drug monitoring program, which has also really helped in terms of monitoring prescriptions and really monitoring and regulating kind of the overall macro, I guess I would call it, supply of narcotics on the streets of Oregon and in our communities. And that’s been very beneficial. And we did see an opioid death rate drop during that time, which again is great. What’s unfortunate, and I know that you mentioned seeing the CDC numbers from 2019, that trend unfortunately is over in Oregon. We’ve seen large increases for example, from 2019 to 2020 as a comparison, about a 60% increase in opioid related death, overdose deaths. And even in the first three months of 2021, just as a comparison, you mentioned 2019, we’re estimating and again, I want to be clear with all the listeners and yourself that it takes a while to get this data in. It’s collected from different counties and different sources, But we’re already at a point now in the first three months of 2021, which is some of the latest data that I have and that is publicly available, shows about in that first three months, about half of the entire death total for 2019. So 2019 total, we’re about halfway there just through the first three months of 2021. So unfortunately, the tide has turned in terms of the increase in deaths due to overdose.

Miller: I should note, it does seem that that increase too has been nationwide. So the fact that some of those in the Northeast or in the Midwest, if they started from a much higher rate that they could still be much higher than we are, even if it’s getting worse everywhere. Well, so maybe it’s obvious. But as somebody who studies this, I think it’s still worth hearing this. What are the specific ways in which the pandemic itself has increased the number of fatal or nonfatal overdoses?

McIlveen: It is unquestionably there’s been an impact. When we think about, from a research perspective, when we talk about things like correlation and associations with one factor with another, I think it’s complicated and again, more to come as we move forward and we really begin to fully see the full impact of the pandemic on all of our lives. But there’s a couple of key points, Dave, that I think are important. Unquestionably, the impact of the pandemic, being apart, separation, that has definitely impacted, I think a lot of folks, especially in the recovery community, it’s been challenging. Talking about folks who have struggled with addiction and addictive disorders before that lack of connection, really I think has impacted folk’s recovery. I think you have a lot of different factors, including just specifically in terms of overdose. When we talk about things like harm reduction to reduce or mitigate the impact of opioid overdose and other drug overdose, we talk about things like not using alone, and even in that addiction recovery sense of connection, which was really damaged during the pandemic. I think that has the stressors involved, I think that’s had a huge impact. Then there’s the other factors that we talked about a little bit earlier that are just, I don’t want to call them simple, but they’re very straightforward. We are seeing this massive wave of incredibly potent drugs that are, in fact, from a trafficking kind of perspective, they’re easier to transport. I know our law enforcement partners have reported record numbers of seizures up and down the I-5 corridor and in other parts of the state. So it’s troubling. I think it’s a combination of, the stressors from the pandemic, the development of this new highly potent drug supply that’s easily available. You’ve also got the issue, Dave, where polysubstance use is really bad, something that is becoming an increasing challenge to folks in the treatment community and in the community at large. We’re seeing a level of severity, and I think our treatment providers could speak to this, we’re seeing a level of severity of addictive disorders that is really troubling.

Miller: I should remind folks if you’re just tuning in. I’m talking right now with John McIlveen, who is the State Opioid Treatment Authority at the Oregon Health Authority’s Health Systems Division. We’re talking right now about Fentanyl in Oregon. I imagine there’s a complicated, broad answer to this because we’re talking about a lot of different populations, but can you give us a sense for the demographics of this epidemic right now?

John McIlveen: Well, that’s a great question, Dave. It’s also something that’s troubling. I think we have to look at, as a state as well as our stakeholders and partners, whether it’s treatment or law enforcement or the like, other communities. What I think that we’re seeing demographically is a shift. The last several years nationwide, we’ve seen an increasing impact of opiate overdose and death on different populations than maybe we did before, communities of color. It seems to be that the ages seem to be trending slightly younger. I think traditionally and I want to be really careful and I’m kind of painting this with a broad brush, but I think the key points are salient. The profile of what I think is looking like the average overdose victim unfortunately is changing. It seems to be younger. It’s impacting more diverse sectors of the population, our communities of color. It’s a changing demographic and I think that goes to a lot of the factors we spoke to before, where we’ve spoken about before about availability. The impact of the pandemic, Fentanyl just seems to have a much greater and a wider hold on various groups in our community in terms of their risk of overdose and death from it.

Miller: It reminds me of an article that we saw recently, it was one of the reasons to have this conversation. In the Portland Tribune, it was about teenagers. This was specifically in Clackamas County, but you get the sense that it’s not only there, buying counterfeit prescription drugs laced with fentanyl, often without their knowledge through social media sites like Snapchat. So let’s turn to prevention strategies or ideas. What do you see as the most effective ways to prevent opioid overdoses in the age of Fentanyl?

McIlveen: That’s a great question, and I want to really quickly just mention the thing about younger folks and teenagers being impacted. Opioids are a fascinating drug, one feature of them is, their impact is very salient and consistent, that production of the euphoria and analgesia that is at the heart of the opioid impact on the individual. But tolerance and dependence develops very very quickly with opioids, and that’s a longer conversation about pharmacology and about physiology and the like. But I think the tolerance and dependence develops pretty quickly. One of the things to the prevention and the impact on younger folks, what is troubling about Fentanyl is due to its potency that we spoke about before, when you have people that are using it that are not used to that and have not developed that level of tolerance and dependence, your risk of overdose skyrockets. So I think, circling back, just by proxy, people that are younger that are what we call more ‘opioid naive’, are at really high risk because, just putting it very bluntly, a situation where somebody at that age may have used an opioid or may use opioids occasionally, talking about our kind of traditional, legal, legally prescribed opioid analgesics, what we call short acting, your Hydrocodone and the like, whereas of course you’re always at risk for overdose when you’re misusing opioids, if that’s replaced by something that’s mainly Fentanyl, a synthetic analogue opioid. Again, your risk of overdose skyrockets. So I think in terms of prevention, education and we talk about that a lot in our work and sometimes it can sound a bit trite but I think it really has an impact of direct targeted messaging about the dangers and really replacing fact replacing fear with facts though.

Miller: It does sound like what you’re saying, based on science and fact, it boils down to just say no, right? I mean, what you’re saying is even one pill can kill, you don’t know what you’re taking and I guess I’m wondering how that kind of stark language, if that kind of language works, even if that’s the most scientifically accurate language you can use.

McIlveen: I understand what you’re saying, Dave, that’s such a fantastic point. I’ve been in the field for over 20 years and I think it’s, we talk about that and we talk about abstinence and we talk about what are the different options and different pathways to recovery and what should messaging be about drug use and alcohol use too. I think you bring up a great point and I think it’s important for us to recognize that those types of messages that are strictly fear based, ‘just say no’ message, their effectiveness, I think is dubious or it’s limited. I think I’d like to use this phrase, Dave, ‘walk and chew gum at the same time’. I think we can be direct and forward with folks without it being a fear driven message. On a broader sense, this is providing us an opportunity to message on a wider range of things. This is, yes, there is the immediacy of addressing the potency of this drug. But, in terms of education, it’s a larger issue, it’s about treatment, access to medications appropriate use disorder that we know work and that are proven to work, messaging about harm reduction, the value of it.  The value of really looking at some of the most vulnerable members of our community and having that discussion. I think there’s a lot that can go into the education around this, that goes beyond just say no, but it is a fair point that the messaging, I don’t know if it’s been particularly effective, so it has to have a different nuance to it and it’s got to be fact based.

Dave Miller: Well, John McIlveen, thanks very much for joining us. I look forward to talking again.  Thank you.

John McIlveen: Absolutely. Dave, my pleasure. Thanks for having me.

Dave Miller: That’s John McIlveen, State Opioid Treatment Authority at the Oregon Health Authorities Health Systems Division.

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