Many patients believe that abusing prescription pain pills is a lot safer than abusing heroin or fentanyl. They assume that taking pharmaceutical grade opioids approved by the FDA guarantees that they will get a predictable effect. There are two main problems with this assumption. The first factor that affects predictability is drug-drug interactions.

The dosage of opioid medication necessary to cause an overdose could be substantially lower when taken together with benzodiazepines (xanax, ativan, klonopin, valium, etc.) or alcohol.  Opioids, benzodiazepines and alcohol all cause respiratory suppression and the drug user might not have taken into account the additional effects when taking her/his usual dose of opioids. Hence, about one third of all fatal opioid overdoses involve benzodiazepines and over 20% involve alcohol. Even more scary, overdoses involving opioids plus benzodiazepines or alcohol do not respond as well to Narcan (the drug first responders and emergency rooms use to revive someone overdosing from opioids). This is because Narcan does nothing for the respiratory suspension due to alcohol or benzodiazepines.

The other HUGE problem with abusing pain pills is that, increasingly, pain pills off the street are counterfeit, or FAKE pills. With mounting government scrutiny of doctors’ opioid prescriptions over the past few years, fewer pain pill prescriptions are being written. As a result, it is getting harder and harder to find these pills on the street. Patients tell me the cost of pain pills has gone up considerably in recent years. With the supply of pain pills dwindling but the street price for pain pills going up, drug dealers are resorting to making counterfeit pills using fentanyl, which is much cheaper. The profit from passing fentanyl off as expensive pain pills is much greater than from mixing it into heroin. Machines known as pill presses can make pills that are indistinguishable from genuine pills, even when you compare them side-by-side. A trained pharmacist might not be able to tell them apart.

Makers of homemade counterfeit pills do not always mix their ingredients well. “Hot spots” can develop in a batch of powder containing fentanyl used to make the fake pills. This results in some pills having much more fentanyl than other pills in the same batch. This is likely what killed Rock Legend, Prince. One week prior to his fatal overdose, Prince’s plane was diverted due to him experiencing an overdose while on the plane. Prince did have a bottle of pills that were identified at the hospital as hydrocodone, or generic vicodin. When Prince died of a fatal overdose one week later, police found a bottle of hydrocodone but analysis showed it contained counterfeit pills containing fentanyl. It is likely Prince did not believe that bottle of pills had anything dangerous because he had taken pills from that bottle before without problems. What he did not realize was that different pills in the same bottle could contain vastly different amounts of fentanyl. His autopsy found “exceedingly high” levels of fentanyl in his system.

Compounding the problem further, counterfeit pills containing fentanyl are not limited to fake vicodin or Percocet but even counterfeit xanax. This could be particularly dangerous because people abusing xanax might not have any tolerance to opioids so a little bit of fentanyl could prove fatal. There have also been cases of fentanyl-laced marijuana.

In summary, pain pill addiction isn’t necessarily any safer.

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