RESEARCH – New warnings for injection related infectious disease as MAT fails to moderate high risk opioid use: fentanyl increases risk

By Clark Miller

Published May 13, 2019

Updated April 13, 2021; May 13, 2022


The more deaths mount,

the more pressure mounts to divert public healthcare resources to the unvalidated medical model provision of addictive, diverted and abused substitute opioids.

Perversely, tragically, and criminally, it seems, because it has been established that provision of American Medicine’s fix for American Medicine’s opioid crisis predicts, rather than harm reduction or saved lives, worsening of increasingly lethal epidemics


Continuing, persistent increases in severe bacterial infection (SBI) “mirroring the increase in prevalence of injection drug use” with fentanyl “implicated in altering injection drug use practices and subsequent risk of development of SBI”

That’s established partly because – 

Trends in opioid-related overdose deaths are not a meaningful measure of effectiveness of OST. 

For reasons discussed in this post and additional posts – each post with detailed explanation linking to primary research and other sources.

There is no body of evidence with results that control fo the most likely of confounding explanations for any slowing of mortality – increased availability and use of the OD death-reversing drug naloxone. 

On analysis of the evidence, naloxone use – its reduction of deaths acting and measured directly, unlike presumed benefit from OST – directly accounts for all apparent changes (= decreases) in opioid-related overdose deaths. This result holds when results are available on a local level (e.g. here, here, here, and here) and when national data are examined.

Attributing benefit to OST requires evidence of reduced high-risk use of opioids. 

As described in detail in this, this, and other posts, that is the mechanism by which OST could possibly provide benefit.

When outcomes are critically analyzed, the evidence points consistently to provision of the medical model fix or “treatment” for problem opioid use  worsening, not protective for, high-risk use and associated harms including opioid-related mortality. Because high-risk use, measured as non-lethal overdose incidence (eliminating the confounding, established effects of expanding naloxone use and campaigns) has increased nationally and consistently in multiple locales where data are available as dose of the medical cure increases.

As explained and established by multiple lines of evidence in this new post, emergence over past years of the potent opioid fentanyl in street economies of illicit opioid use does not qualify those invalidating results – fentanyl cannot explain away the failure of increased provision of the medical “treatment” to reduce high-risk opioid use.

New evidence below

In a variety of settings and nationally, high-risk opioid use as measured by non-lethal overdose incidence has worsened with increasing provision of the medical model fix, against prediction if OST provides benefit. Another, independent measure of high-risk use – incidence of opioid- and injection-related infective diseases including endocarditis – also shows an OST-invalidating pattern of increase in response to large increases over decades of national dose of opioid substitution medicine.

Another direct measure of high-risk use of opioids

is incidence of opioid injection-related infective disease, like endocarditis.

Think about it – incidence of infective 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, 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 evidence points to the same effect occurring nationally.

In response to large increases in provision of the medical OST fix for high-risk opioid use, over decades –


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


As with increasing rates of another measure of high-risk opioid use – non-lethal overdose – as provision of the medical cure increases, predictable outcomes and patterns are emerging.

UPDATE, 2022

Continuing, persistent increases in severe bacterial infection (SBI) “mirroring the increase in prevalence of injection drug use” with fentanyl “implicated in altering injection drug use practices and subsequent risk of development of SBI”

These severe bacterial infections (SBI) including bacteremia, endocarditis, osteomyelitis and central nervous system abscesses have been increasing in the last decade, mirroring the increase in prevalence of injection drug use [4–10]. Admission for severe bacterial infections in PWID, specifically endocarditis, is associated with sub-optimal treatment outcomes, high health care costs, and frequent readmission for re-infection [11–14].

Fentanyl has been a less well-studied potential risk factor for severe bacterial infection. Fentanyl-adulterated and/or fentanyl-substituted heroin integrated into the U.S. drug supply in the early 2010s and the vast majority of “heroin” tested positive for fentanyl by the end of the decade [33]. The introduction of synthetic opioids into the US has resulted in a significant increase in U.S. opioid overdose death rates [34]. Fentanyl, with its associated increased injection frequency and high concentration of cutting agents, has been implicated in altering injection drug use practices and subsequent risk of development of SBI [35, 36].

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

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