Fentanyl, a highly addictive opioid fifty times more powerful than morphine that is used as an analgesic to combat high-intensity pain, has become known worldwide due to the worst drug crisis in the history of the United States. In Spain, the dispensing of this medication is highly controlled and the most addictive formulations are practically reserved for terminally ill cancer patients. But some voices are already warning that it is beginning to be overprescribed in patients for whom it would not be indicated. The greatest danger is addiction. Narcís and Inma were prescribed it for different pathologies, but they are united by one problem: they have become addicted to fentanyl. Both assure that no one warned them of the danger of a dependency from which they are trying to escape.
Narcís (not his real name) is 68 years old and started taking this opioid eight months ago to deal with the pain caused in his leg after a “bad” surgery that cut a nerve 20 years ago. He has used morphine patches and “various pills” that took away “a little” of pain that has never completely gone away. Less than a year ago they started prescribing him fentanyl: one pill a day. No one warned him of the addictive potential, he says. In one month, he went from one to three tablets a day; and after a few weeks at home they were already “worried” because he was taking eight every day. “I have taken 15 a day,” he explains, sitting in his psychiatrist's office. The worst thing is that they don't completely take away the pain but they have created an addiction. “They told me to take one a day, but at the pharmacy they give me a whole box,” he laments.
This patient has been placed in the hands of Tre Borràs, psychiatrist-psychotherapist and head of the Addictions and Mental Health service at the Sant Joan University Hospital in Reus. They have managed to lower the dose, although there are days when they raise it. “If I don't take the pill, nothing happens, but there are other times when I need it even if I don't have pain,” she confesses. He himself has been able to verify that the pills are more addictive than the patches, which he has also tried and with which, by producing a more progressive release, he does not need to increase the dose.
Inma Fernández is also hooked and considers herself “addicted” to fentanyl patches. This 44-year-old Catalan woman was prescribed them more than two years ago to control the “unbearable” chronic lower back pain that she suffered from treatments to overcome cancer. She started with 25 micrograms, but when she complained of pain, the social security doctor increased the dose until she reached 400 micrograms every three days. Last August she ran out of the dose and she started having tremors, vomiting, sweating and “unbearable” muscle pain. She had withdrawal syndrome, they explained to her at the hospital where she went begging for “fentanyl.” She is now waiting to enter a detoxification center for which she does not have a place until early next year. With the dose of fentanyl reduced without any substitute, this woman with two children spends her days as a monkey in bed, she explains. She reported her situation on TikTok and says that since then many patients have told her that they are in the same circumstances.
The psychiatrist Tre Borràs has confirmed in her service, which works in coordination with the pain units and primary care, a "slight" increase in patients who have been medicated with opiate analgesics and which have "generated addiction." She details that they are beginning to receive people who arrive taking a “fairly high” dose of opiates. And if in 2018 fentanyl was prescribed to 1.8% of patients treated with opiates, in 2022 the figure rose to 14% according to the EDADES survey of the Ministry of Health, which has assured this medium that The AEMPS monitors its use and works in a coordinated manner with the communities to “optimize its prescription.”
In Catalonia, Joan Colom, deputy director of addictions of the Health Department of the Generalitat, points out that now fentanyl is no longer prescribed and that, on the contrary, in the first half of 2023 it has decreased. Thus, according to data provided by Salut on dispensations in public prescriptions, in 2017 the doses per thousand inhabitants per day of the most addictive formulations represented 0.28, the figure grew until reaching 0.32 in 2021, in 2022 fell to 0.29 and in the period from January to September of this 2023 it is at 0.27. In the total count of fentanyl prescribed by Catalan public health professionals, there is a clear increasing trend from 2.59 in 2017 to 2.79 in 2022.
In Galicia, the psychiatrist at ACLAD (the reference addiction center in the health area of Coruña), Indalecio Carrera, questions the “joy” with which opiates such as tramadol, tapentadol, oxycodone and fentanyl itself are currently prescribed. and assures that they have observed an increase in cases of addiction to fentanyl. Carrera explains that concern has been raised throughout the State and that a commission has been created in Galicia that has made recommendations in this regard.
When people like Narcís arrive at Dr. Borràs's office, an initial assessment is made by the medical and psychiatric team and treatment is proposed. In many cases, a reduction in medication is made to switch to other slow-release opioid alternatives. An attempt is always made to personalize the responses and agree on therapeutic objectives to reduce medication, says the psychiatrist. Despite this, she explains that in a moment of desperate pain the patient does not always listen and that is why she believes it is important to carry out a continuous explanation to "prevent certain situations." Borràs points out that social concern is being generated about the situation in the United States and there is concern among patients, but he emphasizes that the situation in Spain has “nothing to do with it” because there fentanyl “enters from above and below” and is in the street, something that does not happen here.
Right now, pharmacological treatments for rehabilitation from opioid addiction use methadone and buprenorphine. They also generate long-term dependency, but allow for improved consumption, explains Genís Oña, associate professor at the Rovira i Virgili University of Tarragona and researcher at the ICEERS Foundation. He has been working at the Reus hospital for three years with an experimental drug called Ibogaine in people with methadone dependence. In addition to not being as addictive, it represents a “paradigm change” compared to other replacement treatments such as methadone or buprenorphine, he says. It is taken on rare occasions and “manages to reduce the withdrawal syndrome.” The idea is that with a dose once a week for a maximum of six you can get off methadone forever.
"They make you addicted and now they leave you in the gutter," denounces Inma Fernández. Before fentanyl, doctors tried weaker variants such as naxoprene or enantium. She then switched to tramadol, but it didn't have much effect either. She regrets the little information they gave her and that they limited themselves to telling her that if it didn't work for her they could increase the dose. This Catalan woman saw fentanyl as the solution to her problems. “It gave me a lot of energy and I could work 12 hours straight,” she says. But after a year it stopped working and the doctor gave her Tramadol, Trankimazin and Fentanyl again: “a bomb,” she describes.
Now he is waiting to enter a Cas (Center for Care and Monitoring of Drug Addictions) and they have reduced the dose of the opiate "without any substitute." This patient asks that the box that was removed be restored so that she can hold on until admission. “I feel like a drug addict,” laments this woman on sick leave for addiction since May. Inma is afraid, her personal history is delicate and she even had an attempt at self-lysis and she doesn't know if she can hold out. “I want to work, go out with my friends… Live!” she laments.
There is another group of patients who live with pain and who are crying out for a medication that helps them to have respite and be able to cope with their pathologies not to be criminalized. This is the case of Leonor Pérez de la Vega from Valladolid, who has neuralgia that forces her to take between 10 and 15 medication pills daily. “We are afraid that they will take away our medication. Let them stigmatize us,” explains this university professor, who retired prematurely due to her illness, on the other end of the phone. She has trigeminal neuralgia and fentanyl is her go-to rescue when the pain becomes unbearable.
His condition causes him a constant sensation of “having a knife burning in his jaw.” She weighs 45 kilos despite measuring 1.69 because eating is “an ordeal.” One of the last bouts of pain that knocked her down was when she tried to eat a piece of raw apple. For this reason, she asks that a necessary drug not be criminalized for people like her who live with unbearable pain. “We don't take it for pleasure,” she claims.
She defends that she is an “expert” patient and that the doctors who treat her know that she will only use the box of fentanyl pills that are left in her medicine cabinet and that she keeps like gold “when she can't take it anymore.” She assures that to reach this medication, patients like her have gone through many years of pain. “I have a friend who struggles with patches”
Addicts also fear stigma. “My family suffers because of my pain, but also because of my dependence,” Narcís acknowledges. “If I find out, I won't take it. I would have less pain and less addiction,” he summarizes.
