Face to Face with Fentanyl (After a Weekend Giving Narcan.)




We gave a lot of Narcan last weekend. Some from overuse of prescription drugs. It’s still an issue as men and women take pills, pills and more pills. As they forget that they took pills and take extra pills. As they slump in their chairs…or in the driver’s seat of their vehicles, thousands of pounds of potential murder hurtling down the highway, driven by someone insisting that they can handle their medications just fine.

Most of what we gave was probably for fentanyl overdoses.

Fentanyl. The potent synthetic opioid that brings death in its wake. It is ubiquitous, it seems; taken on its own or mixed with other drugs by illegal manufacturers.

That word fentanyl is in the press so often. According to the CDC, 150 people in the US die every single day from fentanyl overdose. https://www.cdc.gov/stopoverdose/fentanyl/index.html

Fentanyl, likely the leading cause of unintentional death among Americans18-45 years old. https://www.politifact.com/article/2022/oct/03/fact-check-fentanyl-leading-cause-death-among-amer/

It’s easy to shake our heads and scroll to the next page in the news. I don’t get that luxury; neither do my co-workers.

For those of us working in emergency departments it goes like this: the triage nurse shouts for a stretcher. ‘I need help! Overdose! He’s not breathing!’

Or someone pounding on the ambulance bay door. ‘She was shootin’ up.’ She’s slumped halfway out of the car, unaware of anything. Sometimes the driver doesn’t do the courtesy of staying.

They’re limp and they’re dusky. Their pupils are tiny. Often their arms, hands, legs and feet are scarred from injections. If they breathe at all it is shallow. The breath of a sleeping kitten in an adult human. Or it is like the guppy; the gasp and pause.

Sometimes it is impeded by their last meal; often the midnight burger and fries, the taco, that seemed to pair well with their drug use. All of it coming up, gurgling around the epiglottis, slipping into the lungs, or spewing onto the staff who scramble for suction and airway equipment as someone else grabs the precious naloxone (Narcan is one trade name.)

If an IV isn’t possible, and sometimes there’s just no time, the Narcan goes into their nostrils. Other times into an IO or Intraosseus line. A battery powered drill bores through tibia or humerus. Thick blood and marrow are aspirated back through the syringe to confirm placement. Then the Narcan is pushed into the lavish plexus of blood vessels in bone, on its way to wake them.

Narcan, the alarm clock that says ‘wakey wakey, time to stop dying!’

A few do not respond well. There may be other drugs on board. Or they may be too far gone. Some are intubated, a tube placed through the mouth and into the trachea and they are placed on a mechanical ventilator.

Most wake up, confused, surrounded by bright lights and strangers. ‘Where am I? What happend?’ They flail and try to climb out of the bed. Their euphoria interrupted to save their lives.

Some are grateful and contrite. Some furious; so furious, so frantic that they walk out of the ER, pulling off monitor leads and ripping out IVs as a trail of blood drips behind to the door and out into the parking lot and beyond.

This crisis is terrible. My heart breaks for the addicted. Nobody sets out to become an addict. I try to be kind and to offer options. I try to consider what I would think if it were my child, my wife.

And yet, my heart breaks for others besides the patient. It breaks for the children orphaned, in fact or in essence, by addicted parents. My heart breaks for grandparents who have to raise them with limited health and resources and with their own grief at losing a child into the labyrinth of addiction.

I also find myself concerned about other consequences.

We see terrible infections of the skin, the limbs, the heart valves, the spinal cord. We see hepatitis. All of this from injecting unclean substances with unclean, often shared, needles. We are going to have so many people permanently disabled, or in need of complicated heart valve surgeries, liver transplants for hepatits. People who can no longer walk or work because infection killed their spinal cords. The cost is going to be staggering; in lost lives, in lost productivity, in lost families…

These are consequences akin to a war, considering the numbers. If we’re seeing over 100,000 opioid deaths per year and about 80-90% of them are from fentanyl, then it’s hard to imagine how many are sick and permanently maimed from use of the drug. There are the dead. And there are the wounded.

I worry because, for all that I feel sadness for the addicted, their care, their recurrent overdoses, take time and resources from places already overwhelmed. In case you haven’t read my posts in the past, American healthcare isn’t very healthy itself. The pandemic pushed us closer to the edge of total disaster than I ever saw. Fentanyl could do something similar.

Those who overdose take ambulances and paramedics when both are in short supply. That is to say, the price we pay for fentanyl abuse is more than the cost of an ER visit or a dose of Narcan. Far more. And the sort of ‘laissez-faire’ tolerance we love to offer everyone is not working. Because the dealers, the users, the addicted are literally hurting others on an unimaginable scale. Drug abuse isn’t cute. It isn’t Cheech and Chong. It’s devastating a nation and generations.

I don’t claim to know the answer. I am trying to learn about the origins of this. I said earlier that the dead and wounded are on the scale of war. It may be that the entire thing has the feel of a war. A war waged by China and by drug cartels. (Here’s an article and a podcast on the topic.)


(I quite like this podcast, by the way. It’s worth listening.)

It’s obviously easy enough to blame the suppliers when our citizens keep using. And it’s easy enough to condemn low level cartel workers who probably refuse at the risk of cruel deaths for themselves and their families.

But maybe, if there weren’t so much of the stuff and it weren’t so cheap, then addiction wouldn’t be so easy. Here’s an idea of the scale, by the way. Remember that when we administer fentanyl in the hospital we give it in microgram doses. That is, in the millionths of a gram…in the article below a literal ton of the stuff was confiscated.


We aren’t funding addiction programs nearly enough. We aren’t facing the fact that a vast amount of homelessness is either mental illness or drug addiction. Couching it in the easy, tired condemnation of financial inequality isn’t solving the problem. It’s only making encampments greater sources of abuse, infection and death.

Maybe we need to go ahead and name cartels as terrorist groups and rather than engaging in foreign adventures, turn our formidable military prowess against those who are actually murdering our citizens.

If not, and given the scale of drug production, I suggest we make peace with the cartels and ask them to mass produce insulin and other drugs that are too expensive and are controlled with an iron grip by the corporate cartels of pharmaceutical companies, insurance companies and pharmacy benefit managers.

Maybe if we gave them a legitimate gig they’d turn from their reprobate ways. Not holding my breath.

But we have to do something. Because our overdose patients are holding their breaths. And without our help, they’re doing it until they die. Dusky and pale, staring silently across eternity as their family members weep at their sides.


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