When we go charging in blood vessels at breathtaking speed to relieve the blockade that otherwise may bring a sad end to life, we expect to be doing it for the mature and elderly. The stress and strains upon the heart through the journey that is life upend the natural rhythm and flow, with the turbulence churning up clots like butter from milk that flow downstream till the narrowed channels bring them to a halt. Or there is a similar ravage somewhere in the body, requiring the mind to finally pay the dues. The physician must race to disrupt this settling of scores before it is too late. Again, we anticipate fighting such battles in the bodies of those long in the tooth, not in the flush of youth. Yet, more and more, it is the younger lot presenting with the disease typical of the aged and in a manner untypical of the disease. We are witnessing another manifestation of fentanyl addiction. Imagine the sigh of relief and a smile when the blocked artery is unplugged and vital blood flow to the brain is restored, only to be left aghast by a fatal bleed deep in the core of the brain, far removed from the offensive lesion just treated. The mortal bleed is a telltale sign of skyrocketing blood pressure or a catastrophic rupture of abnormal vessels.
The account above is colored by my niche in the complex vocation, which is medicine. Other specialists witness a different face of the Grim Reaper. Since time immemorial, addiction has caused concern. The outstretched arms of Morpheus have held an allure through the ages, leading countless to take one step too far, never to awaken again. If the United Kingdom stupefied the Chinese by forcibly pushing their Indian subcontinent-produced opium upon them, they tasted their own medicine and then some in the form of the far more potent heroin. Then, along came fentanyl and its various allies. In a historical irony, the “importer-exporter” roles were also reversed.
It is no longer a matter of the depth of narcosis and the severity of withdrawal. Like a cluster bomb, the drug bears other poisons that wreak havoc on living tissue, piercing and charring it. Not nations but “ordinary people” manufacture fentanyl in their garages. Wherever and whoever is involved in the clandestine trade is unsqueamish about what else goes into their product, to cut or contaminate it. Therein lies the cause of weird stroke presentations in the addicted.
When I expressed my chagrin to a colleague about the relative youth of patients, the uptick in strokes that had occurred during a particular period, and being left flummoxed when defeat was snatched from the jaws of victory, she somewhat humorously but astutely observed that the local sheriff needed to spread the word, “Don’t buy Joe’s fentanyl, but John’s instead,” to increase the likelihood of survival.
Stroke is an unintended consequence. The crux of the matter is the addiction. How can it be cured? History may help with the answer. One could follow the example of China’s strict penal measures, e.g., execution, life imprisonment, or a sound whipping. That is a bit much! One could go the way of the Dutch, who seem not to care and do not have a major fentanyl problem. Case in point: in 2021, the USA lost 76,601 persons to fentanyl; the Netherlands, 298. We could also look inward, where we achieved substantial, even if incomplete, success. Or, we could compare the U.S. and U.K.’s past policies for alcohol. We could also glean from whatever is successful in others’ addiction control measures. The answer cannot be unfathomable.
For two countries with cultural commonalities, the U.S. and the U.K. approached controlling alcohol consumption differently in the earlier part of the twentieth century. The U.S. enforced prohibition, driving the trade and drinking underground. The U.K. taxed it, which, at least fiscally, may have been a better response. The U.K. government, rather than bootleggers, reaped profits that likely went towards the Second World War effort.
When it came to smoking, the U.S. exercised a more effective policy. Anyone flying from an airport in the U.S. to one in Europe, say Charles De Gaulle, earlier during this century, would have been struck by the difference in air quality. The nostrils perceived air that was sparklingly pristine in the former and reeking of nicotine in the latter. There was success in the meaningful reduction of smoking because it turned from a socially acceptable, even aspirational pastime into the indulgence of (almost) social pariahs. From the time when the smoker Queen Mary of Teck presented Prince Albert (the future King George VI, who died in his 50s from lung cancer) with a cigarette case for his eighteenth birthday, to the Queen Mother and Princess Margaret, to relatively recently, when smokers have had their life made difficult with limited spaces where to indulge and coughing up higher prices to do so, the turnaround has been dramatic indeed. Who can imagine Prime Minister Churchill without his cigar? But then, Queen Elizabeth II compelled Prince Philip to cease and desist! The turnaround has been thanks to effective campaigns, public education, and legislation with teeth. The laws imposed cannot be considered heavy-handed, either. Anyone choosing to smoke is free to do so as long as it does not affect others. The taxes imposed on cigarettes are fair. In fact, they don’t even begin to cover the cost of unavoidable, untoward health consequences that the health system will bear for the smoker who will inevitably present down the road.
Then, there is fentanyl. It has struck the U.S. like nowhere else. It is an epidemic. Multiple factors are responsible, one ironically being that the European market, especially the “permissive” Netherlands, was already saturated by high-quality heroin (from Afghanistan). Reportedly, while there is the production of synthetic drugs in the Netherlands, they are largely exported. The other difference between the U.S. and Europe is the health care system. The European systems, by and large, provide robust, free, or very affordable coverage to their people. By contrast, large swathes of the U.S. population do not have coverage or are inadequately covered. The USA also went through a phase of narcotic prescription, where physicians were encouraged, even exhorted, to prescribe liberally. They were not to question whether the patients’ demands were warranted or otherwise. Just as during the WWI era, many patients were prescribed morphine for pain and became indefinitely dependent upon it; the U.S. patients fared no better. In fact, they were worse off, for the narcotics had progressed in potency. Heroin is 100 times more potent than morphine, and fentanyl is 50 times more than heroin. Frequently, unbeknownst to the user, there are contaminants or additions to fentanyl of other synthetic drugs, which are many orders of magnitude more potent than fentanyl. Nor are contaminants responsive to the antidote.
The average U.S. addict has little choice but to rely on unsafe street drugs. The ensuing complications include infections in any system where the blood circulates (i.e., practically every system!), chemical damage to tissues from contaminants, and ongoing debilitating conditions to essential organs such as the heart (endocarditis, heart attacks) and, of course, the brain (stroke, ruptured aneurysms). These are but just a few of the many evils wrought. The overwhelming majority of the addicted cannot afford sterile syringes, let alone rehabilitation, to break their habit. Nor is such rehabilitation readily available, even if the patient is able to afford it.
Compared to tobacco, fentanyl addiction is already socially unacceptable. No effort is needed to that end. What else can be done? Perhaps reducing the associated criminality where the end-user is concerned. Destigmatization may enable the users to venture into the daylight and seek appropriate help. That has worked in the Netherlands, where the system is permissive towards users and highly punitive for producers.
Consider the relatively cheap and easy measures, the low-hanging fruit. For example, free clean needles, syringes, and information about safe administration and risks. “Why, that is feeding the habit and throwing good money after bad!” some would say. Actually, it is pragmatic and worth pennies on the dollar. Hardly anyone is dissuaded from taking drugs for want of clean supplies, and society is left holding the bag. Such intervention at the beginning prevents the complex mess that ends in emergency rooms, requiring treatments with exorbitant price tags. A sterile syringe and needle may be had for 50 cents or less; the cost of a packet of an alcohol swab is around 2 cents. On the other hand, a thrombectomy to remove a clot from a brain vessel may cost $24,000 or more; each day of hospitalization costs approximately $2,500; rehab for physical disability costs between $20,000 to $70,000. Then, in the case of physical disability causing dependence, the annual health care costs are approximately $45,000. All this for one person! These costs don’t even factor in the expense of concomitant complications, e.g., sepsis, that frequently afflicts drug users. So, choose your poison: at the front or back end?
A commendable step that warrants pointing out is the effort to make naloxone available to those who need it. However, every narcotic prescription seems to come with an automatic pop-up message suggesting prescribing the antidote. The methodology is reminiscent of that “fad” which encouraged the liberal prescription of narcotic analgesics. How the pendulum has swung! If one could readily be suspected of lacking empathy for not prescribing enough pain pills, now one can be suspected of lacking empathy for not prescribing the antidote to all. Never mind the squeaky clean elderly lady or gentleman prescribed a short course of analgesics, maybe for the very first time in their lives, perhaps after surgery, who are left aghast wondering if it is suspected they would overindulge or the prescription is dangerously potent. While the risk-averse physician blows with the wind. Curiously, pharmaceutical companies profit, no matter where the pendulum!
Another stumbling block is the inadequacy and unaffordability of health coverage. Just like a significant swath of the population, the addict does not seek help early in the course of the disease and is likely to present in a fulminant state to the emergency room, necessitating all sorts of resources to sustain life. The United States spends the highest amount on health care compared to any other country in the world. Uncle Sam spent $4 trillion on health care in 2021, amounting to 17.8 percent of its GDP. It far outstripped the distant second: Germany (12.8 percent of GDP). It does not show. Compared to other developed countries, the USA is not just foremost in expenditure; it also has the highest rate of avoidable deaths, maternal and infant mortality, obesity, suicides, deaths from assaults (six times higher than the next country in line), and multiple chronic diseases. Where it goes low is in life expectancy (lowest), physician visits, and the supply of physicians. It has the dubious distinction of being the only developed country that does not guarantee universal health coverage for its citizens. Yet, the politicians tie themselves into knots decrying “social medicine” and wax lyrical about the U.S. having the “best health care in the world”! They are like the adoring crowd, praising the attire of the emperor without clothes. We are paying first-world prices for third-world care, with a bulk of our population going without any. Who cares what the rose is called as long as it is? So, we must not hesitate to pick what works from other systems or countries without falsely making it a point of honor.
An obvious culprit in wasteful expenditure is the entity intended to make health care affordable for all: the health insurance industry. When the CEO of United Health care made news because his private airplane came with dinnerware and faucets of gold, things had already gone wildly astray. The excess is to be anticipated because health insurance companies are traded on the stock market. They must make a profit for the investors and eye-watering pay packages for their executives. So, if costs are reined in, it is likely at that end, which is their raison d’être: affordable health care. The insured are also perpetually squeezed for all they are worth to keep the good times rolling. Why not learn from France and make health insurance companies non-profit? If hospitals can do it, so can health insurance companies.
So much for the low and intermediate-hanging fruit. The elephant in the room must be acknowledged. The fault is also in the system. It cannot be that Europeans are made of sterner stuff, and Americans are addiction-prone. The USA has a health care system that is unfit for purpose. Attempts at fixing it have failed, even as “fixing it” has become ever more politically fraught. The insurance companies, pharmaceutical and biomedical industry, hospitals, physicians, politicians, and patients all have a dog in the fight. The insurance, pharma, and biomedical industries have powerful lobbies to guard their turf. Hospitals have middlingly powerful lobbies and physicians, lamely so. The patients have their congress members and senators to mind their interests, who are beholden to the aforementioned lobbying groups. Unsurprisingly then, the result of any attempt at improving health care is stillborn or a Frankenstein’s monster. To get anywhere close to achieving a satisfactory outcome, the health insurance and biomedical industries must be brought in line, with their pricing comparable to that in the rest of the developed world.
Digression? Not really. All the above factors are in play when it comes to rampant fentanyl addiction. Remedying them makes life better not just for the drug-dependent, it will elevate health care for all. The unintended consequence of helping out the addicted may be the nurturing of a socially conscious, gentler, happier, kinder society with a higher quality of life. Now that is not just for the Scandinavians!
Shah-Naz H. Khan is a neurosurgeon.
