The Pursuit of Stronger Opioids: Fentanyl and Inevitable Risks

Why do pharmaceutical companies continue to invent stronger and stronger opioids, such as Fentanyl, when seemingly a simpler solution exists? Exploring the reasons behind this development involves understanding both the medical and industrial contexts.

The Risks of Long-Term Drug Use

My understanding of medicine is that prolonged exposure to any drug is harmful, irrespective of its category. However, opioids represent some of the most dangerous substances. The longer one is on an opioid, the more they are at risk of organ damage. Just like any other harmful substance, including aspirin, the effects of prolonged use manifest later in life when the importance of health becomes more evident. It’s not until later that one truly regrets the foolishness of their youth and faces the harsh realities of pain and aging.

Thus, if a patient’s condition does not require the use of an opioid for their survival, the benefits of avoiding these substances far outweigh the risks. While there might be situations where opioids are necessary, it is crucial to weigh the potential harm against the benefits.

The Problem with Fentanyl and Lower Potency Opioids

Interestingly, the necessity for stronger opioids like Fentanyl arises from the complexities of dosing and the properties of the drug itself. If a stronger opioid is required for a patient, using a less potent opioid would generally lead to significant respiratory depression, which could be fatal. This underscores the critical importance of precision in opioid dosing and the challenges associated with achieving comparable effects using less potent alternatives.

The Marketing and Patent Business

The development and marketing of stronger opioids like Fentanyl go beyond medical necessity. Pharmaceutical companies often have vested interests in maintaining a steady stream of profitable products under patent. This can lead to the creation of these stronger substances as a means to maintain market share and prevent competition.

Another logistical issue is the practicality of administering drugs. For instance, when handling large and potentially dangerous animals like elephants, a less potent but highly effective opioid like carfentanil is significantly more convenient compared to a higher dose of a milder opioid. This approach not only ensures the safety of the environment but also simplifies the process of sedating the animal.

A Personal Story: Codeine and Increasing Pain Tolerance

Efforts to develop stronger opioids are also motivated by real-world experiences. Take, for example, my mother's accident a few decades ago. She was involved in a severe car accident, suffering a serious neck injury that required a neck fusion surgery. Back then, the only non-cancer-related opioid approved in Canada for this type of pain was codeine. The condition and pain my mother experienced were intense, and within a short period, she was taking 1 gram of straight codeine twice daily.

To put this into perspective, a single Tylenol 4 capsule contains only 60mg of codeine. Therefore, at 1200mg per day (or 30 capsules), the dosage was enormous. Even accounting for her natural tolerance and the tolerance she developed from taking other opioids, the pain was still unmanageable. This story highlights the need for more potent opioids to manage severe pain effectively while reducing the burden of taking multiple pills.

Furthermore, different opioids do not work the same way for everyone. In my personal experience, a 10mg dose of oxycodone was more effective for bone-deep pain than 4mg of hydromorphone, Dilaudid. This variability in response underscores the importance of developing stronger opioids to address the unique needs of different patients.

Understanding the complexities of opioid dosing, medical necessity, and the commercial interests of pharmaceutical companies provides insight into the ongoing pursuit of stronger opioids like Fentanyl. While such developments present challenges, they also offer hope for managing the most challenging cases of pain effectively.