Prince's death from fentanyl is only the tip of the global overdose iceberg

A United States medical examiner has reported that musician Prince died from an overdose of fentanyl, a powerful pain killer and synthetic opioid 100 times stronger than morphine.

Pharmaceutical opioids, drugs resembling properties of the opium poppy, have an important place in medicine. They are used for pain relief, particularly in illnesses such as cancer and in palliative care.

However, Australia has seen a steady increase in the non-medical use of prescription opioids, more recently in fentanyl.

Fentanyl is available in the form of long-acting patches called fentanyl transdermal patches. The only form of these patches available in Australia are the drug-in-adhesive, or matrix patch, where fentanyl is contained in the glue that holds the patch on the skin.

The patch is designed to deliver the drug preparation through the skin over a period of 72 hours.

Recreational or non-medical use of fentanyl has contributed to increased overdose deaths in Australia and globally. A 2014 report found the accidental overdose death rate outside of Sydney doubled since 2008, from 2.25 to 4.72 per 100,000 people. Without singling out any particular drug, the increase overlaps with that of fentanyl overdoses in regional and rural New South Wales.

The increase in deaths is related to increased availability of prescription opioids and reduced availability of heroin.

A coronial investigation into 136 fentanyl-related overdose deaths recorded between 2000 and 2011 in Australia found that around one-third (34%) were due to fentanyl poisoning, half of the people (54%) had a history of injecting drug use and two-thirds (64%) had not been prescribed the drug that killed them.

Non-medical use of fentanyl patches involves high risk preparation and administration methods. The patch is heated with an acidic agent such as vinegar or lemon juice and the resulting solution injected.

Rural areas are over-represented in the overall number of Australian deaths.

Our study of 12 rural fentanyl users found that though they were experienced injecting drug users (between six and 20 years of use), they had limited knowledge of the amount of fentanyl in the patch, where it was located in the patch and how much was extracted during their preferred preparation method.

The people interviewed for the study said they got information about the drug and how to use it from their friends and drug dealers; or just did what they usually did with other opioid drugs. Haphazard preparation techniques and incorrect drug information were shared across drug user groups in rural areas.

Not surprisingly, all the study participants knew people who had died from fentanyl overdose or had been injured themselves.

The effects of fentanyl don’t last as long as other opioid drugs and tolerance builds up quickly so that more is required to get the same effect and to avoid physical withdrawal symptoms. The increasing tolerance and severe withdrawal quickly locks people into a cycle of dependence.

One study participant said:

Once people go to fentanyl, they make that change, they can’t go back because they just want stronger, stronger, stronger, and so fentanyl is the strongest. They can’t go back… the Oxies (oxycontin, a different prescription pain killer) are shit.

Some people will continue to use drugs regardless of the risks. Another fentanyl user in our study said:

Since the fentanyl come out I’ve been sharing needles all the time. Just because if I don’t have money and I need that hit, or if I do have money and I can’t get that fentanyl, I would use someone else’s spoon they’ve double dipped in, or I would even use their dirty needles. That’s how strong the hold is that it has on you.

Under the Australian National Drug strategy, harm from drug dependence to communities, families and individuals, is reduced through initiatives such as drink driving legislation, the provision of drug and alcohol treatment services, and community education.

Global harm-reduction strategies aim to prevent or reduce the severity of problems associated with non-medical use of addictive drugs. Approaches such as needle and syringe programs are based on human rights principles. They are inexpensive, easy to implement and have a positive impact on individual and community health.

However, as available drugs and methods of use change, knowledge among drug users and health workers needs to be updated to maintain good harm reduction practices .

The medical examiner recorded Prince’s death as accidental. Accidents are common when it comes to fentanyl.