Face to Face With Fentanyl

— A Narcan kind of weekend

A close up photo of a man holding a vial of fentanyl.
Edwin Leap, MD, is an emergency physician.

We gave a lot of naloxone (Narcan) last weekend. Some for overuse of prescription drugs. Most of it 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, more than 150 people in the U.S. die every single day from overdoses related to synthetic opioids like fentanyl. Fentanyl, one of the leading causes of unintentional death among Americans 18-45 years old.

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.

If an IV isn't possible, and sometimes there's just no time, the naloxone goes into their nostrils. Other times into an IO or intraosseous 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 naloxone is pushed into the lavish plexus of blood vessels in bone, on its way to wake them.

Naloxone, 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 happened?" They flail and try to climb out of the bed. Their euphoria interrupted to save their lives.

Many 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 occasional users who got unlucky with a tainted supply, and breaks even more 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, or liver transplants for hepatitis. 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 when we consider the numbers. If we're seeing over 100,000 opioid deaths per year and more than 80% of them are from a synthetic opioid, such as 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 users, their care and their recurrent overdoses take time and resources from places already overwhelmed. In case you haven't read my past posts, American healthcare isn't very healthy itself. The pandemic pushed us closer to the edge of total disaster than I ever saw. Could fentanyl 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 infiltrating the drug supply is more than the cost of an ER visit or a dose of naloxone. Far more. 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.

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.

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.

Edwin Leap, MD, is an emergency physician who blogs at edwinleap.com, and is the author of The Practice Test and Life in Emergistan. You can read more of his writing on his Substack column, Life and Limb, where a version of this post originally appeared.