The drug fentanyl, showing up in street drugs, is causing overdoses, deaths

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. The Drug Enforcement Administration recently sent warnings to federal, state and local law enforcement agencies about a nationwide spike in fentanyl-related mass overdose events. This is an issue that the Upstate New York Poison Center is very familiar with. And today I'm talking about it with its medical director, Dr. Vincent Calleo. Welcome back to "The Informed Patient," Dr. Calleo.

Vincent Calleo, MD: Amber, thank you. It's great to be here.

Host Amber Smith: This warning from the DEA said that fentanyl is killing Americans at an unprecedented rate. Can you explain what fentanyl is?

Vincent Calleo, MD: Fentanyl is an opioid medication, and very commonly it's used to treat pain in the emergency department or in the hospital setting. Now, sometimes it can be used on an outpatient basis as well. And most commonly we see this as a prescription for something like a fentanyl patch, where it's applied to the skin and it helps to deliver pain control over a longer period of time. So when used from a prescription standpoint, fentanyl is a medication that can be very helpful for a lot of individuals. But when it's taken or used from a non prescribed standpoint, that's where we can run into trouble.

Host Amber Smith: So it can be used legitimately with a prescription. A doctor can prescribe it and people might be taking it. How addictive is it, even if it's prescribed?

Vincent Calleo, MD: So like any of the opioid medications, it does have the potential to develop long-term dependence if it's used, particularly for a longer period of time.

So there definitely is that potential to develop an addiction to it if it's used for an extended period of time there.

Host Amber Smith: What effects does it have on the body?

Vincent Calleo, MD: So it depends. So in the overdose setting, it's a little bit different than when people use it therapeutically, or like we would in the hospital, or from a prescription standpoint. Most commonly it can be used to help improve pain when there's a condition that's causing that, but in the overdose setting, or when too much is taken, you can develop some pretty scary and life-threatening conditions, including decreased ability to breathe and a change in your mental status, such that you may not be awake or be able to protect your airway, for example, if you were to vomit.

Host Amber Smith: When fentanyl is misused, how is it misused? Is it smoked, or injected or swallowed? Or, what form is it in?

Vincent Calleo, MD: So there can be a lot of different forms that people can misuse fentanyl, and very commonly it's actually accidentally misused. So what we found is that over the last several years, there has been a large increase in the number of contaminated recreational substances that are out there. Some of the ones that we see commonly are things including heroin or even cocaine. But now we've actually been seeing over the last few years, there have been some increases in medications you can swallow as well that havefentanyl contaminated within those, too. So depending on the route, it can be used in several different ways. So that could include smoking, injecting, or being swallowed along with even dermally on the skin, if people are using a fentanyl patch or something like that, if it's not prescribed to them.

Host Amber Smith: So do you believe that many of the overdose victims had no idea that they were ingesting fentanyl?

Vincent Calleo, MD: Yeah. You know, sadly, that's one thing that we have been hearing in the last several years is that a lot of people that are buying some of their recreational substances of use, they don't actually know what's in those substances. And in many cases, someone who has a heroin use disorder, for example, may use the normal amount of heroin that they typically use. But if they're not aware that it's contaminated with something like fentanyl, they could actually become much sicker and potentially develop significant life-threatening complications, including respiratory depression, where their ability to breathe is decreased or mental status depression, where they can't protect their airway and they may choke if they vomit, for example. So yeah, a lot of people are unaware that they have a product that's been contaminated with fentanyl.

Host Amber Smith: So the, the dealers that are producing and selling these drugs on the street, if fentanyl is such a dangerous substance, why would the drug traffickers secretly mix it into their drug product?

Vincent Calleo, MD: Well, you know, I feel like there are probably a lot of different answers to this question and many of which I don't know the answer to, but one of the reasons it's commonly placed in products is it does, in many cases, give someone a more powerful high. That's one of the reasons, to develop an increased addiction potential to the substance. Now, sometimes they will mix it with other substances, including cocaine or a number of other things too, that are not necessarily opioids like heroin is, but they oftentimes will mix it in with other substances too. And it's hard to say the exact reason all the time, but in many cases, it's to increase the addiction potential.

Host Amber Smith: You mentioned that it could be transmitted dermally through the skin. Would a drug trafficker face danger, if they're working with fentanyl to mix it? Would it potentially get into their skin when they didn't intend for it to?

Vincent Calleo, MD: Yeah. So that's actually a great question, Amber, and a really salient one to what we've been seeing a lot of in the news lately, which are concerns for first responders, including police officers and EMS and fire fighters being exposed to, or potentially exposed, to fentanyl. The good news is, if you were looking at the data coming from some of the various toxicology experts in the country, what they put out as a position statement kind of states that in order to get toxicity from dermal exposure -- so skin exposure, or even inhaled exposure -- you really have to have a lot of exposure for a prolonged period of time, essentially, meaning that it's really unlikely for an accidental dermal exposure to result in clinically significant symptoms. And those include the changes in the mental status or the change in the breathing abilities. So it's actually really, really rare and unusual for that to happen. Fentanyl, even as a patch, if you put it on, it requires a special vehicle in order to get into the body. And usually that takes a few hours after you put it on your skin. So it would be really unusual for an accidental small exposure to the skin to result in clinically significant symptoms.

Host Amber Smith: A while back we heard about carfentanil. Can you tell me about the difference between carfentanil and fentanyl?

Vincent Calleo, MD: Yeah, of course. So carfentanil is a medication that is also an opioidlike substance, so in some ways it's similar to fentanyl in the way that it works on the receptors in the body. But it is different in the sense that it's a much more potent version of that. And it's about 10,000 times more potent than morphine. Whereas fentanyl is only about 50 to 100 times more potent than morphine. There was a lot of concern, particularly several months ago, that there was some increased exposure to this substance. And fortunately, at least within our area, we haven't had very many recorded cases of a confirmed carfentanil exposure, though it is something we always are concerned about.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with Dr. Vincent Calleo, the medical director of the Upstate New York Poison Center.

Now the Drug Enforcement Administration mentioned several mass overdose events involving fentanyl, where more than three people overdose around the same time in the same location, in cities in Florida, Texas, Nebraska, Colorado, Missouri and Washington, DC. They said in recent months there were 58 overdoses, including 29 deaths. Do you know how many fentanyl-related deaths have been recorded in Central New York?

Vincent Calleo, MD: I don't know the exact numbers for all the Central New York, but, I did recently review some of the data from the Onondaga Health Department website, and what it looks like is that over the course of the last year or so, in 2021, it was reported that of the 139 deaths that were from opioids within the Onondaga region, it reported that about 91% of those deaths were fentanyl related. And about 38 were possibly from fentanyl- and heroin-related together. So that makes up the vast majority of that number. And so I'd say that at least in Onondaga,County, a good number, or a large number of those deaths was related to fentanyl in some way, shape or form.

Host Amber Smith: So this is a threat here that we need to be kind of mindful of?

Vincent Calleo, MD: Yeah, absolutely.

Host Amber Smith: Now, what do you think makes the difference between life and death? Cause I saw that there's a lot of overdoses, but maybe half resulted in death. What determines who lives and dies?

Vincent Calleo, MD: Well, again, there are a lot of different pieces that really go into that equation, but I think one of the biggest things that can help reduce the number of deaths is going to be early administration of naloxone, which is an antidote to help people breathe again. And in addition to that, it's good supportive care, which is essentially helping people to breathe. So if you notice anyone who is found down and there's, a naloxone kit available, administering that may be the difference. It may help that person live. And early health care treatment, including calling 911 and getting someone who can help the patient breathe on their own or assist with it, early on, may be the big difference between life and death. Because the vast majority of deaths that occur from fentanyl overdoses tend to be related to hypoxia, which is a condition where there's not enough oxygen in the blood. And in many of these cases, it's because the body is unable to breathe as it normally does, as a result of the exposure to the fentanyl.

Host Amber Smith: When a person who's overdosed arrives in the emergency department, the doctors aren't going to know what they took, necessarily. How do they find out whether it's fentanyl or do they just, at this point, assume that it is and treat for that?

Vincent Calleo, MD: So in addition to working as a poison center doctor here, or a toxicologist, I also work in the emergency department too. And I've encountered this situation, not uncommonly. Now, when we think about opioids as a whole -- which fentanyl falls into that opioid category -- what we really think about is a collection of signs and symptoms that we typically see when someone comes in. To be honest with you, when I'm an emergency doctor and I'm seeing someone who's coming in after an opioid overdose, it doesn't really matter to me acutely what they took that caused their symptoms, but more importantly, what I'm going to do to treat them. So if I look at them and I have a history for an opioid exposure, or I see a collection of signs and symptoms, including that change in mental status and that decreased ability to breathe, one of the highest things on my list for what could be causing this is an opioid. And the most important thing like I alluded to earlier is helping the patient to breathe early on and getting their oxygen levels back up. And if we're able to, what we typically will consider giving will be some doses of naloxone, though again, the dose and how much we give to these patients will kind of depend on a case-by-case basis. But in general, the bigger thing when we're seeing patients come into the emergency department is focusing on treating them and helping them to breathe, making sure that they're protecting their airway. And supporting them in all the other ways they need is going to be the first thing of importance on my list.

Host Amber Smith: I understand from October 2020 to October 2021 more Americans died of drug overdose than from gun- and auto-related deaths, combined. Aside from raising awareness, as we're doing right now, are you aware of efforts to reverse that trend?

Vincent Calleo, MD: There's a lot of stuff that's been going on in the public health sphere, including a push to make people aware of naloxone and how to administer it. Because like I alluded to earlier, having early and quick access to naloxone administration could be the difference between life and death for a number of different people. And it's really, really important to help people to recognize what some of the signs and symptoms are, because early recognition and early treatment can really help to save a life. And so I think it's really important to make people aware of what to watch out for, what a overdose from fentanyl or really any opioid may look like, and what steps can be taken to help try to mitigate that or reduce the harm from the exposure.

Host Amber Smith: For people who purchase illicit drugs and, they don't know what's in them necessarily. Is there any way that they can protect themselves, or is there any way that they can verify that what they're about to take doesn't have fentanyl.

Vincent Calleo, MD: Yeah, you know there are a number of different things out there. And there actually are some fentanyl test strips that people can use. There are different ways that these can be utilized, but in many cases, what will happen is if people take a small amount of the substance and test it with one of the strips through the steps that are provided in an individual kit, it does in many cases show if there is some fentanyl in there, though, I always do urge people to take this with a grain of salt because tests are not always perfect. And if you take an entire batch of a substance there, there may be a small portion that you're testing that may not contain the fentanyl, but it might be in other parts of the batch, or it might just be that the test is not perfect at detecting it. So there are things that we call false positives and false negatives. So it could be that the test that you're doing, even if it comes back negative, may not necessarily be safe. It's something to certainly consider. And I would consider recommending to people if they want it to test for that, there are things out there, but just remember, no test is perfect. And the safest thing is to not use those substances.

Host Amber Smith: Right. One other thing, though, in New York state, the naloxone you can purchase without a prescription, right? To have ...

Vincent Calleo, MD: Yep, that's correct.

Host Amber Smith: ... at the ready.

Now for people who overdose on fentanyl, but don't die, I'm wondering what the recovery is like.

Vincent Calleo, MD: It really depends on the person, and a large part of that depends on how quickly they receive treatment and how low in particular their oxygen levels may have dropped. For most people after an overdose, if they receive very rapid health care administration, as well as administration of naloxone in a lot of cases, the majority of people actually recover very well, As long as they don't have any significant, prolonged period of decreased oxygen to the body and the brain. Most people will do well if there hasn't been significant what we call "down time," where they have beenunresponsive or not breathing for a while. Though, sadly, in some cases where people have had prolonged down time or they had a significant amount of time without oxygen getting to the brain or the rest of their body, those can have very significant and poor long-term outcomes, though fortunately early treatment and administration of health care can help to really improve a patient's likelihood of having a full recovery.

Host Amber Smith: Will their bodies crave more of a drug that almost killed them?

Vincent Calleo, MD: The way the receptors in the body work are very, very complicated. And, there are lots of things that we in the health care field don't fully understand, but are trying to study more and more fully. But one thing that we do know is that the opioid receptors in the body, still are firing. And from the physiologic standpoint, or the standpoint that affects the body, there is that very high likelihood of that dependence still being there and the body is still craving it, even if it's a substance that could have potentially resulted in significant harm.

Host Amber Smith: Interesting. Well, I appreciate you making time for this interview, Dr. Calleo.

Vincent Calleo, MD: Absolutely. And thanks so much for having me, Amber.

Host Amber Smith: My guest has been the medical director of the Upstate New York Poison Center, Dr. Vincent Calleo. "The Informed Patient" is the podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/Informed. This is your host, Amber Smith, thanking you for listening.