Fentanyl/Street Oxy

January 2016

Rekha Jabbal, Barbara Zahnd, Tricia Hoffart

 Disclosure

• We currently have no financial rela8onship

with commercial enterprises & cannot
iden8fy any poten8al conflict of interest for
the purposes of this presenta8on.
Presenta8on Objec8ves

Upon comple8on of this course,

par8cipants will be able to:
• Describe how fentanyl works, what its
side effects are, and how it is used
medically
• Iden8fy the features of the street
version of fentanyl, why it is so
addic8ve and the concerns with abuse
Presenta8on Objec8ves

• Assist families and clinicians in

determining what they can do, and
where they can be referred in Alberta.
The Essen8al Message
 The Essen8al Message

• “You won’t see, smell or taste Fentanyl,

but it could very easily kill you,”
~ Dr. N Etches (Medical Office of Health
AHS)
History of Fentanyl

• Fentanyl has been around for nearly a

century.
• Developed by Paul Janssen in 1959
and originally used as anaesthetic
under brand name Sublimaze
• Slow release patches for chronic pain
relief were introduced in mid-1990’s

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History of Fentanyl

• Fentanyl has historically been used as

a weapon – US Military developed an
aerosol version of the narcotic. Was
considered the active ingredient in the
gas that Russians used to knock out
Chechen terrorists in 2002.

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Fentanyl Abuse in Alberta

• Provincial data suggests fentanyl-related

deaths are increasing steadily since 2012
with over 100 deaths in 2014.
• Police say they have been seizing record
amounts of fentanyl in communities
around Alberta, including more than
88,000 tablets since April 2014.

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Fentanyl Abuse in Alberta

• Fentanyl abuse has become a huge

problem throughout Alberta
• Organized crime is a driving force behind
the making and marketing of the drug
known on the street as "greenies”.

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 What are Opioids (Narco8cs)?

• Opioids are used in medicine primarily to

treat pain (acute & chronic)
• They work in the brain to change the
percep8on and emo8onal response to pain
• Morphine is naturally occurring opioid
(narco8c) from poppies; Fentanyl is a man-
made opioid
(C. McMinis, personal communica8on, September 3, 2015)
 Opioid Side Effects

• Seda8on
• Respiratory depression
• Mood changes (euphoria or “high” feeling)
• Low blood pressure, cough suppression
• Cons8pa8on, nausea, & bladder reten8on

(C. McMinis, personal communica8on, September 3, 2015)

 Fentanyl - Pharmacology

• Fentanyl is 80-100 8mes stronger than

morphine
• Fentanyl 0.05-0.1mg is similar to a dose of
morphine of 10mg
• Fentanyl is so strong it is used as an
anesthe8c
(C. McMinis, personal communica8on, September 3, 2015)
 Fentanyl - Pharmacology

• Onset of ac8on is rapid and dura8on of

ac8on is short
• Fentanyl is not absorbed well from the
stomach or intes8nes; it is given by injec8on
or in a patch absorbed through the skin or
through mucosal 8ssue (like inside your
mouth, nose or rectum)
(C. McMinis, personal communica8on, September 3, 2015)
 Physiological Addic8on to Opioids

• All opioids are addic8ve; your body quickly

becomes used to having the chemical in your
system and withdrawal symptoms occur if it
is not there
• Characteris8c withdrawal symptoms include
swea8ng, anxiety, diarrhea, bone pain,
abdominal cramps, shivers or ‘goose flesh’
(C. McMinis, personal communica8on, September 3, 2015)
 Why Fentanyl?

• 2012 – Oxycon8n discon8nued from the

Canadian market.
• Replaced with OxyNeo
• Fentanyl (fake “Oxy”) filled the gap
• Green tablet with “Oxy 80” inscribed sold as
equivalent to Oxycon8n 80 mg
• Each tablet sells for ~$40-80
 Supply

• Majority of supply is coming from China

• Individuals can Google “fentanyl for
purchase” and purchase fentanyl online
• Can be bought via postal service
• Dealers buy fentanyl as powder then convert
it to tablets using an easy to obtain pill press
(Detec8ve C. Harris, personal communica8on, August 18, 2015)
 What Are You Buying?

• Each tablet is supposed to be equivalent to

1mg fentanyl (size of 2 grains of salt)
• Opioid naïve individual 1 mg can be fatal
• 2 mg fentanyl (size of 4 grains of salt) can
cause overdose and death – even for
experienced users
(Detec8ve C. Harris, personal communica8on, August 18, 2015)
 What Else Do You Get?

• Non pharmaceu8cal fentanyl tablets are omen

combined with
– Caffeine (90% of 8me)
– Methamphetamine
– Heroin
– Xylazine (used in veterinary medicine to
anesthe8ze large animals)
hqps://www.youtube.com/watch?v=UCAj2IBdlMA&feature=youtu.be
 Common Street Names

- Green beans
- Beans, Greenies
- Green apples
- Shady eigh8es
- Eigh8es
- Fake oxy
(Detec8ve C. Harris, personal communica8on, August 18, 2015)
 How Do You Use It?

• Majority of users will grind the tablet and

snort the powder
• Previous slide – “Fentanyl is not absorbed
well from the stomach or intes8nes”
• Individuals have been very crea8ve about
how they use it (patches)
(Detec8ve C. Harris, personal communica8on, August 18, 2015)
 Cause for Concern?

• In 2013 in Alberta alone there were 387

deaths related to acute drug toxicity OR
acute drug and alcohol toxicity.
• 291 had opioids found on toxicology results
• Compare this to 358 deaths from MVC, or 30
deaths in hospitalized cases of influenza in
2013-2014 flu season
(Presenta8on by Dr. H Virani June 2015 AMH SCN Mee8ng)
 Cause for concern?

• Calgary police service see at least one

overdose/day
• Office of the Chief Medical Examiner has
confirmed that fentanyl was a cause, or a
contribu8ng factor in 120 drug overdose
deaths in Alberta in 2014, quadruple the
number of fentanyl-related deaths in 2012
(Detec8ve C. Harris, personal communica8on, August 18, 2015)
Overdose Deaths by Opioid Type
 Cause for concern?

• Stats from Jan – Sept 2015 in Alberta

• 213 deaths associated with fentanyl
• 1773 ER visits due to opioid poisoning
• On average ~100 calls to Health Link
(811) per month regarding opioids

(AHS Fentanyl Facts and Figures, November 2015)

 Symptoms of Overdose

• Signs of overdose
– Sleepiness
– Trouble breathing (may sound like
snor8ng)
– Slow, shallow breathing
– Cold, clammy skin
 Symptoms of Overdose

• Signs of overdose
– Unresponsive to s8muli
– Pin point pupils
– Decreased heart rate
• Resul8ng in the individual’s breathing to
stop, which leads to death
 Emergency Interven8on

• Call 911
• Perform Rescue Breathing
• Administer naloxone – takes 2-5 min to see
response. May need to give another dose
• Naloxone’s dura8on is 30-60 min, while
many opioids can act much longer
• Important to s8ll take individual to hospital
Emergency Interven8on
 Take home Naloxone Program

• Alberta government funding new project

that provides take-home Naloxone to
Albertans at high risk for opioid overdose
www.health.alberta.ca/health-info/AMH-
Naloxone-Take-home.html
• List of agencies that provide kits:
www.albertahealthservices.ca/info/
Page12491.aspx
 Take home Naloxone Program
• Kit is provided free of charge and contains:
– 2 doses of Naloxone
– 2 single-use syringes
– 1 pair of latex gloves
– 2 alcohol swabs
– 1 one-way rescue breathing
barrier mask
– 1 community based take home
naloxone brochure
 Accessing Help

Services and Supports for

Individuals Struggling with
Fentanyl Addiction and their
Families in the Calgary Zone
Where do I go to find help?

• Health Link at 811

– Information on services and where
to get a take home naloxone kit
• Alberta’s Addiction Helpline
1-866-332-2322 (toll free).
– Support, information, and referral

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Where do I go to find help?

• Access Mental Health 403-943-1500

– a centralized information and referral
service within AHS – Calgary Zone.
They provide information,
consultation and referral to addiction
and mental health resources in the
Calgary area.

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Types of Treatment Services

• Self-Help Services (ie. NA, SMART

Recovery)
• Outpatient Services (ie. Adult
Addictions, Addictions Centre, Opioid
Dependency Program)

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Types of Treatment Services

• Day Programs (Youth Addictions Day

Program; Adult Addictions Day
Program)
• Residential Care (ie. Claresholm Care
Centre; Landers; Aventa)

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What you can do to help

• Talk about it
• Know the options
• A comprehensive list of resources
can be found at
calgaryaddiction.com

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What you can do to help

• Remember that all services are

voluntary
• Encourage them to seek help
• Discuss obtaining a naloxone kit

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A special note for families

• Take care of yourself

• Seek help
– Counselling
– Peer support

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 Online Resources
Calgary addiction services and treatment facilities
• www.calgaryaddiction.com
AHS Fentanyl Information
• www.albertahealthservices.ca/drugsfool.asp
• www.albertahealthservices.ca/info/Page11357.aspx
Safeworks Harm Reduction Program:
• www.albertahealthservices.ca/services.asp?
pid=service&rid=1702

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Community Resources

Telephone-based information
• Health Link 811 (Alberta-wide)
• Access Mental Health
403-943-1500 (Calgary)
• Addiction Helpline 1-866-322-2322
(Alberta-wide)

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Community Resources

Crisis Support
• Distress Centre 403-266-HELP (4357)
• Mobile Response Team/PORT Mobile
(via Distress Centre 403-466-4357)

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Community Resources

General Counselling
• Calgary Counselling Centre 403-691-5991
• Carya 403-205-5244
• Catholic Family Services 403-233-2360
• Jewish Family Services 403-287-3510

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Community Resources

Addiction Services:
• Youth Addiction Services 403-297-4664
• Adult Addiction Services
Calgary: 403-297-3071
• Renfrew Recovery Centre 403-297-3337

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Community Resources

Addiction Services:
• Aventa Addiction Treatment for
Women 403-245-9050
• Calgary Alpha House 403-234-7388
• Calgary Dream Centre 403-243-5598

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Community Resources

Addiction Services:
• Opioid Dependency Program
403-297-5118
• Addictions Centre for concurrent
disorders (referral via Access Mental
Health) 403-943-1500

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 Community Resources

Addiction Services:
• Landers Treatment Centre 403-625-1395
• Sunrise Native Addictions Services
403-261-7921
• Claresholm Care Centre 403-682-3500

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 Resources

• hqps://www.youtube.com/watch?
v=UCAj2IBdlMA&feature=youtu.be
• hqp://www.albertahealthservices.ca/
drugsfool.asp
• hqp://www.albertahealthservices.ca/
assets/healthinfo/padis/hi-padis-fentanyl-
faq.pdf
 Resources

• hqp://www.health.alberta.ca/health-info/
AMH-Naloxone-Take-home.html
• hqp://www.albertahealthservices.ca/assets/
info/hp/ps/if-hp-ps-no8ces-respond-
nonpharm-fentanyl-2015-05-14.pdf
• hqp://www.cbc.ca/news/canada/calgary/
fentanyl-epidemic-a-doctor-s-advice-on-talking-
to-kids-about-drugs-1.3193953
 References
• www.albertahealthservices.ca/drugsfool.asp
• hqp://www.albertahealthservices.ca/services.asp?pid=service&rid=1702
• hqp://www.albertahealthservices.ca/assets/healthinfo/padis/hi-padis-
fentanyl-faq.pdf
• hqp://www.albertahealthservices.ca/assets/info/hp/ps/if-hp-ps-no8ces-
respond-nonpharm-fentanyl-2015-05-14.pdf
• www.calgaryaddic8on.com
• CPS [Internet]. Oqawa (ON): Canadian Pharmacists Associa8on; c2015 [cited
2015 Sept]. Available from: hqp://www.e-therapeu8cs.ca. Also available in
paper copy from the publisher
• Dempster, A. (2015, June 16). Blood Tribe fentanyl deaths down, but addic8ve
painkiller s8ll a problem (Television broadcast). Calgary, Ab: Canadian
Broadcas8ng Corpora8on
 References
• Firestone, M., Goldman, B., Fischer, B., (2009). Fentanyl use among street users
in Toronto, Canada: Behavioural dynamics and public health implica8ons.
Interna'onal Journal of Drug Policy, 20, 90-92
• Kuhlman, J.J., McCaulley, R., Valouch, T.J., Behonick, G.S. (2003). Fentanyl Use,
Misuse, and Abuse: A Summary of 23 Postmortem Cases. Journal of Analy'cal
Toxicology, 27, 499-504
• Kronstrand, R., Druid, H., Holmgren, P., Rajs, J., (1997). A cluster of fentanyl-
related deaths among drug addicts in Sweeden. Forensic Science Interna'onal,
88, 185-195
• Lexicomp Online, Lexi-Drugs Online, Hudson, Ohio: Lexi-Comp, Inc.; 2015;
September, 2013.
• hqp://www.macleans.ca/society/health/fentanyl-the-king-of-opiates-and-a-
killer-drug-crisis/
 References
• Marinez, L.J., Ehlers, B.J., (2014). A Series of Forensic Toxicology and Drug
Seizure Cases Involving Illicit Fentanyl Alone and in Combina8on with Heroin,
Cocaine, or Heroin and Cocaine. Journal of Analy'cal Toxicology, 38, 592-598
• hqp://news.na8onalpost.com/news/canada/two-die-on-blood-tribe-reserve-
from-probable-overdose-of-extremely-potent-fentanyl-16-dead-since-August
• hqps://prezi.com/twks7ksqr3et/w{-what-the-fentanyl/
• Southwick, R. (2015, November 19). Alberta police chiefs worry China’s fentanyl
regula8ons will spur drug produc8on in Canada. Retrieved from
hqp://calgaryherald.com/news/crime/alberta-police-chiefs-worry-chinas-
fentanyl-regula8ons-will-spur-drug-produc8on-in-canada
 References
• Southwick, R (2015, November 12). Blood Tribe forbids five suspected drug
dealers from returning to reserve. Retrieved from
hqp://calgaryherald.com/news/crime/blood-tribe-forbids-five-suspected-drug-
dealers-from-returning-to-reserve
• hqps://www.youtube.com/watch?v=UCAj2IBdlMA&feature=youtu.be