Research Update –

Fentanyl is the New Purdue Pharma:

Usefully Distracting Attention Away From the Unchecked Forces Driving Lethal Epidemics

by Clark Miller

June 19, 2019

New research affirms a body of direct observations and reports of the ecology, psychology and behaviors driving illicit economies of compulsive opioid misuse “on the street” – fentanyl is used knowingly, sought out, used with knowledge of its potency and associated risks according to research from the British Columbia Centre for Disease Control (BCCDC).

The fact more relevant and important than users knowing they are getting fentanyl in the drug they intentionally obtain illicitly is that they know the real risk of high likelihood that fentanyl will be present, whether sought out or not, in any substance obtained on the street. That is, users are choosing – and have been over past years while opioid overdose mortality increases – increasingly to risk overdose and lethal overdose instead of accessing or benefitting from widely and increasingly available substitute opioid medical “treatment” (medical provision of the substitute opioids methadone or buprenorphine) programs, or from hypothesized “Do-It-Yourself” use of diverted suboxone widely available on the street for “treatment” or to avoid high risk use.

High-risk use constitutes lack of benefit attributable to the never-validated medical “fix“.

And they are not retaining in those programs, or do and continue to abuse illicit opioids and other drugs, divert and abuse the prescribed opioids, and engage in high-risk opioid use including injection, as evidenced by increasing rates of injection-related infectious diseases.

But that doesn’t make sense at all in the context of mass consensus assurances from the same medical-media alliance that fabricated evidence to generate the lethal opioid epidemic – that the medical OST fix is effective treatment. Does it? Because available not just from medical providers but on the streets are opioids like buprenorphine and heroin that are much safer and as easily accessible as fentanyl if the user’s purpose and motivation is for withdrawal management while trying to quit, to moderate use, or to manage pain.

Users knowing the risks associated with fentanyl and having been exposed to assurances of an effective medical “treatment” for compulsive opioid use are weighing the alternative of that medical “treatment”, increasingly widely available in medical settings or in “DIY” form on the street, and are sticking with, compelled to continue, high-risk use. At risk of death and fueling continuously worsening mortality and public health costs of high-risk opioid use fueled partly by a street economy that includes prescribed buprenorphine and other opioids as currency and abused substances. New reporting “from the street” in San Francisco in the U.S. affirms that picture of a new fentanyl (and naloxone) evolving culture of high-risk opioid abuse.

The explanation supported by evidence is the one already established, the one we already know: the predictable failure and contribution to worsening epidemics, as in generation of the opioid crisis, of medicalization of and provision of medical fixes for entirely non-medical problems. Those medical fixes – opioid pain medications for the non-medical (psychogenic) problem of common chronic pain in the case of generation of the opioid crisis – instead, predictably, are driving and supplying expanding and increasingly lethal street economies of illicit misuse of opioids and other drugs.

As explained in a recent post and recapped below, the emergence of fentanyl on the street, instead of explaining away the medical “fix” of opioid substitute treatment (OST) predictably failing and instead worsening a lethal iatrogenic opioid crisis, instead makes a stronger case for that failure: against the known increased risk of OD and lethal OD the branded, sold, and paid for with public healthcare resources medical “treatment” continues to fuel continuously increasing high-risk opioid use and a worsening epidemic rather than providing benefit. Users are not choosing to access and therapeutically engage in it as an effective therapy. They’re choosing fentanyl instead.

That tragic and predictable result, of course, was predetermined from longstanding, established understanding of the nature of compulsive substance use – determined and explained by the psychology and psychosocial and developmental ecology of: choice, compulsion, behavior, motivational deficits and state, distorted beliefs and inner states driving the compulsive use, unresolved and unmanaged inner distress linked to early trauma and other adverse experiences, and other psychological drivers – and has nothing to do with brain chemistry, manufactured fictional diseases, or medical conditions. It’s a no-brainer.

Consistently and predictably: there has never been credible evidence to support OST as effective in reducing high-risk opioid use and preventing opioid-related deaths, instead relevant lines of evidence disconfirm that presumed effectiveness.

That’s not a problem for pharmaceutical industries desperate to protect profits, or for a medical industry desperate to distract attention away from the medically-generated opioid crisis and associated deaths and to create and protect a sheen of competence and relevance, authoritative status, and the lucrative “addiction medicine” entitlement system. Popularizing, research-illiterate writers without competence and capacity to critically evaluate the relevant research are willing, as in generation of the opioid crisis, to spin and help brand OST as effective “treatment”, a “fix” for the opioid crisis from entirely inconclusive evidence, in an unfortunate confluence of group think, ignorance, and the power of cultural capital in a post-factual world to create meaning as needed.

It’s in that lethal history and context that the synthetic opioid fentanyl has become a new Purdue Pharma, the necessary confabulation distracting away from the driving forces and failure and predictable harm generated by the medical fix for the medically-generated lethal opioid crisis.

Fentanyl, a potent opioid that’s become increasingly present on the street and mixed with heroin and other street drugs, increasingly present in the labs of overdose victims, is misrepresented to distract from the elephant in the room, to assert that the elephant isn’t really there.

That elephant is the consistent pattern – nationally and at lower population and epidemiological levels – of high-risk opioid use and mortality continuing to increase over years in response to significantly increased provision of the medical “treatment” for the opioid problem: the “anti-addiction” opioid substitutes methadone and buprenorphine (suboxone).

Multiple posts here at A Critical Discourse have provided analysis with links to primary research and other sources of why that worsening effect was predictable. And why the successful branding of opioid substitute treatment (OST) as a credible and effective “treatment” – primarily by research illiterate popularizing writers – was never supported by critical evaluation of the claims and evidence. Just as in the media and medical industry collaboration to fabricate the deceptions fueling the opioid crisis.

The attempts at obfuscation, deception, and distraction continue and include the argument that goes something like this: over decades of increasing provision of substitute opioid treatment with methadone and buprenorphine as the effective, evidence-based medical “treatment” for problem opioid use, the associated continuing increase in overdose deaths, high-risk use, and other opioid-related morbidities is explained by the emergence and presence of illicit fentanyl in street economies of drug abuse, masking the known effectiveness of methadone and buprenorphine – the medical treatment gold standard – in reducing of high-risk opioid use and deaths.

The argument is false, invalidated on multiple lines of evidence –

1. National Trends

Fentanyl increased in presence in 2014 and rapidly after that:

If the increased risks of overdose and overdose deaths due to highly-potent fentanyl masked what would otherwise be apparent as reductions in OD and OD death incidence due to increasing provision of medical model OST/MAT, then we would expect to see evidence of that benefit prior to 2014, after, for example, provision of buprenorphine had significantly expanded over the prior decade, with high-risk opioid use and overdose deaths instead increasing steadily in response.

SAMSHA bupe client trends2

The more medical cure provided to the diseased brains, the more deaths mount.

Overdose deaths US trend The Guardian

2. Arizona

In Arizona, where fentanyl would have been available and part of high-risk street opioid use beginning with its emergence and increase in presence in 2014. A recent, more short-term, immediate response over the years 2017 – 2019 to a naloxone campaign followed by abrupt increases in provision of methadone and buprenorphine factors out (holds constant) the role of known risk of fentanyl, already present and known to be present to users.

As explained in detail in this post, results are unequivocally supportive of the consistent pattern seen in numerous settings in the U.S. and Canada: naloxone (Narcan) accounting entirely and directly for moderation of opioid-related OD deaths while increased provision of the medical “treatment” is correlated with worsening high-risk opioid use.

3. Fentanyl cannot explain away Medical Fix OST worsening injection-related disease

Another direct measure

of high-risk use of opioids is incidence of opioid injection-related infectious disease, like endocarditis.

Think about it. We are looking at incidence of infectious diseases caused by injection of opioids. That use of opioids is high-risk. If OST provides benefit to at-risk users, the mechanism is by reducing risk and associated problems related to opioid use.

Trends of decreased incidence of an injection-related infectious disease could be attributed to a variety of factors including: changes in public health, prevention, or medical interventions; decrease in high-risk opioid use including use by injection; clean needle exchanges; behavioral health treatments; others. Identifying the factor(s) any decreases could be confidently attributed to would require that multiple congruent, well-designed studies and other lines of evidence point to those factors and not others.

Increases in incidence, like those we’re seeing, are different. If increases of significant magnitude occur over the same time period that an intervention, like the medical OST fix, hypothesized to be a “treatment” or protective factor has also increased, then that constitutes strong evidence against that intervention as beneficial in reducing high-risk use.

As we would predict from everything we know about problem substance use and the failure of medical approaches to provide benefit for that non-medical problem, those diseases are increasing in prevalence.

That’s been true in Ontario, Canada and in Columbus, Ohio.

In Franklin County Ohio –

In Franklin County, Ohio, cases of drug-injection-related infectious endocarditis, a measure of injection drug use, have skyrocketed over the years 2012 – 2017.

Specifically, the increase in incidence of those cases increased 436 percent, most of that increase attributable to use of heroin by injection.

Investigators found that overall admissions for infective endocarditis at Ohio State University Wexner Medical Center increased 101% from 2012 to 2017, with most of the increase coming from the 436% jump in drug-related cases. The research, which was presented at the American College of Cardiology (ACC) 2019 Annual Scientific Sessions in New Orleans, LA, found that most of the cases of endocarditis related to drug use involved heroin.

Significant, extended increases in medical provision of buprenorphine and methadone OST should necessarily have resulted in the opposite outcome – decreases over the same time period of high-risk opioid use . . . unless . . . as is generally and predictably the case, the provision of a medical model “treatment”, unsupported and indicated against by research evidence for an entirely non-medical condition – compulsive problem opioid use – has predictably resulted in a worsening of an iatrogenic lethal opioid crisis rather than providing benefit.

New reports suggest that the same effect is occurring nationally. In response to large increases in provision of the medical OST fix for high-risk opioid use, over decades –

SAMSHA bupe client trends2

 – nationally incidence of opioid-injection-related diseases have increased as well, the opposite of predicted if OST is providing benefit.

“ . . . growing rates of certain infectious diseases, including HIV/AIDS, hepatitis, heart infections, and skin and soft tissue infections.”

4. Use with Known Risks is High Risk Use

Fentanyl does not explain away or qualify the links – between increasing opioid-related OD deaths and high-risk use and failure of opioid substitution treatment and MAT as implemented – because users on the street KNOW THE RISKS. Apologists for increasingly invalidated OST/MAT argue disingenuously that OST/MAT really does work, despite invalidation by all lines of evidence, and that continuous increases in opioid-related ODs and OD deaths are attributable to the effects of fentanyl in heroin on the street.

This argument falls apart because users know fentanyl is on the streets, expect it to be, may seek it out, that is, engage in high-risk use KNOWING THE RISKS OF FENTANYL, with steadily increasing provision of the medical “anti-addiction” drugs buprenorphine and methadone providing no protective effects to moderate that high-risk use EVEN AGAINST KNOWN INCREASED RISK ON THE STREET OF OD due to presence of fentanyl. Increasing threat of lethal overdose by fentanyl should have provided motivation by users for increase in compliant, therapeutic use of buprenorphine – whether directly in programs or diverted – and that would have resulted in reductions in high-risk use. Instead, provision of buprenorphine by medical providers is fueling economies of high-risk opioid use on the streets and in prisons.

5. In Kentucky –

where OD death rates (high-risk opioid use) has been tracked by opioid type – OD deaths continued to increase for not just synthetics (fentanyl) but heroin and prescription opioids as well.
Increased as provision of the medical cure by “anti-addiction” substitute opioids methadone and buprenorphine increased substantially.

That’s another consistent result invalidating presumed benefit from provision of the medical fix of provision of substitute opioids as “treatment” for problem opioid use and the opioid crisis.

The evidence is clear. Diversion of public healthcare funds away from evidence-based treatments to sham medical “treatments” for a non-medical condition predicts harm, predicts lethal public health epidemics.

It is the medical profession and its practitioners who are the most ardent and unified proponents of the invalidated medical “fix” for the opioid crisis created by runaway, medically-inappropriate dispensing of Schedule II opioids for the  non-medical condition of common chronic pain. No one else was legally authorized or licensed to dispense those addictive substances whose generation of the crisis was predictable from all lines of longstanding evidence.

Apart from anomalous exceptions, like Sam Quinones’ unflinchingly “True Tale” in Dreamland, you wouldn’t get that from the necessary fabricated distortions and media focus on Big Pharma as criminal accomplice in the epidemic. As if those representatives and executives themselves were distributing the addictive Schedule II opioids, against evidence – all longstanding lines of relevant evidence – predicting harm, as if the pharmaceutical reps and execs were in the exam rooms, coercing MDs and other licensed medical providers, or forging their signatures on the prescriptions.

As if those licensed medical providers, over the course of an American medical education, would not have necessarily become aware of the evidence and their clinical and ethical obligations to practice accordingly, based on the longstanding indications against the runaway provision of those Schedule II opioids: the potential for hyperalgesia; the addictive potential of opioids; the lack of evidence for effectiveness; the psychogenic nature of common chronic pain; and the effective, durable, indicated use of cognitive behavioral therapy (CBT) for common chronic pain.

All lines of evidence that were established prior to generation of the opioid crisis and would have been part of any legitimate medical training, training that would have – one presumes – been taken as more compelling than the assurances of pharmaceutical representatives. Or not.

Lines of evidence that give no credence to the weak excuses of Obama Surgeon General Vivek Murthy.

SG Murtha speaking

In a series of TV news interviews on the opioid crisis, Murthy repeatedly blames the runaway over-prescribing on: 1) doctors’ beliefs that the opioids – which have been listed since 1970 as Schedule II Controlled Substances due to risk of abuse and addiction – “are not addictive when prescribed for pain” and 2) “marketing” by drug companies – questioning the medical profession’s ability to independently use clinical and ethical judgment to protect patients.

The remarkable series of interviews includes the nation’s former chief medical officer and public health authority explaining the runaway over-prescription of opioids that created the opioid crisis by asserting that “practitioners were urged to treat pain aggressively” (at 1:00 in the CBS This Morning clip) and that “many of us were even taught – incorrectly – that opioids are not addictive” (starting at 4:10 in the CBSN clip).

In another interview, also from 2016, the Surgeon General repeats (starting at about 2:38 in the MSNBC clip) that “clinicians were urged to treat pain aggressively”, that he personally was trained, 20 years ago, that opioids “were not addictive so long as they were given to someone with legitimate pain”. He adds, “Even today I encounter doctors who still believe that [that opioids are not addictive] because they haven’t been taught any different”


Because they haven’t been taught any different.

Quinones, Chris McGreal in American Overdose, and some others have outlined the sordid confluence of forces – deception, fabrication, submission to pressure from patients and medical organizations, and failed responsibility to vulnerable, trusting Americans – driving generation of the lethal opioid epidemic: a remarkable abdication of competence, integrity and ethical behavior by players including big pharma, America’s top medical, oversight, and research institutions, and the medical profession, with mass media along for the ride.

As McGreal describes in American Overdose, the clinical environment in medical practice settings became coercive and toxic – a collusion of patients trained by decades of programming to seek a pill for every distress including opioids, supported by the medical/hospital/insurance industrial complex to report doctors who would resist providing opioids inappropriately and threaten them with complaints and action by professional and licensing boards.

McGreal talked to Dr. Charles Lucas, a surgeon in Detroit who resisted growing pressure to overprescribe opioids, ended up being subject to a complaint and summoned before a hospital ethics committee for failure to provide adequate pain treatment.

(from American Overdose pp 88 – 89)

The case was dropped, but it was not an isolated incident. Luca has worked closely with another surgeon, Anna Ledgerwood, since 1972. She too was hauled before the ethics committee on more than one occasion on the same charge. One of the investigations, for alleged inadequate pain management after a hernia operation, went all the way up to the state medical board. It cleared Ledgerwood, but Lucas said more junior surgeons buckled to the pressure to administer opioids just to stay out of trouble. “If they will give me a hard time, then they will surely give a young resident a harder time,” he said. “I tend to be a fighter. That’s my nature. But somebody who just wants to take care of patients, they want to be a professional physician, they don’t want to put up with all this crap; they’re intimidated. They’re also frustrated by it. The medical community knows that too many pain medicines are being written. Doctors talk about it among themselves. They’re not in a position to challenge the system. But they know.”

Lucas regarded the new pain orthodoxy as a growing tyranny, and he thought it was killing patients.

Of course they knew, but the forces driving runaway, medically inappropriate dispensing of opioids were not knowledge, competence, integrity or professional courage. There were other forces at play.

It is much less discomforting – especially for America’s journalism institutions instrumental in helping to fabricate out of nothing a bogus scientific rationale for runaway use of opioids against all evidence – to focus on Big Pharma (another example of the unfortunate excesses of corporate greed) as the reason for the lethal crisis, than to accurately indict America’s most trusted institutions including the impotent and enabling watchdog press that helped to create the needed fabrications. The more attention diverted to Big Pharma, the less on the necessary roles of media, the medical profession, research and oversight institutions. Corporate greed is a given; incompetence and betrayal by the core democratic and public health institutions trusted to protect American well-being and lives must be disguised, distracted away from.

Nothing has changed. In a recent egregious example, writers at Vox, the New York Times, other outlets in ignorance of the most basic of research interpretation errors promoted entirely unsupported conclusions promoting false confidence in effectiveness of use of electronic cigarettes or nicotine replacement therapy (NRT) products as treatments for the highly lethal condition of compulsive use of tobacco by smoking. As in the media/pharma/medical industry collaboration that created the lethal opioid crisis, significant harm is predicted by the distortions and false messaging, by promotion of false confidence in unsupported treatments for smoking. The harms include tobacco-related mortality and morbidity that eclipse that related to other drugs, and harms due to smoking linked to incidence of chronic pain syndromes and exacerbated pain perception, both factors driving opioid misuse and the opioid crisis.