Fentanyl, a highly addictive opioid used to combat intense pain, has become world-famous for the worst drug crisis in US history. In Spain, the dispensing of this medicine is very controlled and the formulations that create the most addiction are practically reserved for oncology patients. But some voices are already warning that it is beginning to be prescribed excessively to patients for whom it would not be indicated.
Narcís and Inma were prescribed it, and now they are addicted to fentanyl. Narcís (fictitious name) is 68 years old and started taking fentanyl eight months ago to cope with the pain in his leg after a “bad” surgery, in which a nerve was cut 20 years ago. He has used morphine patches and “various pills” that took away “a little” a pain that has never completely gone away. And less than a year ago he was prescribed fentanyl: one pill a day. No one warned him of the addictive potential, he says. Within a month, he went from one to three tablets, and after a few weeks at home they were worried because he was taking eight every day. “I’ve ended up taking 15”, he explains sitting in his psychiatrist’s office. The worst thing is that he recognizes that they don’t take away the pain completely, but they have created an addiction for him.
This patient has been placed in the hands of Tre Borràs, psychiatrist psychotherapist and head of the addictions and mental health service at Sant Joan de Reus University Hospital. They managed to lower his dose, although there are days when he increases it. “There are times when I need it, even if I’m not in pain.”
Inma Fernández is hooked and considers herself addicted to fentanyl patches. This 44-year-old Catalan woman was prescribed it more than two years ago to control the chronic lower back pain she had as a result of the treatments to overcome cancer. He started with 25 micrograms, but he says that when he complained of pain, the doctor – from public health – raised the dose to 400 micrograms every three days. In August it started with tremors, vomiting, sweating and “unbearable” muscle pain. He had withdrawal syndrome, they explained to him at the hospital where he kept asking for “fentanyl”. Now she is waiting to be able to enter a detoxification center for which she does not have a place until the beginning of 2024. With the reduced dose and no substitute, this woman with two children spends the days of abstinence in bed. He reported the situation on TikTok and says he’s been getting more case stories since then.
Psychiatrist Tre Borràs has noted a slight increase in patients who have been medicated with opioid painkillers and who have become addicted to them. It caters to people who take quite a high dose.
And if in 2018 fentanyl was prescribed to 1.8% of patients who were treated with opiates, in 2022 the figure rose to 14%, according to the Ministry of Health’s Ages survey, which has assured this newspaper that the Aemps monitors this and works in a coordinated manner with the communities in order to “optimize the prescription”.
In Catalonia, Joan Colom, deputy director of addictions at the Department of Health of the Generalitat, points out that no more fentanyl is prescribed in the public sphere, and that it has decreased in the first half of 2023. In Galicia, Indalecio Carrera, a psychiatrist in Aclad (the addiction center of reference in the health area of A Coruña), questions the “joy” with which opioids such as tramadol, l ‘oxycodone and fentanyl itself, and claims that they have seen an increase in cases of addiction to this substance. Carrera explains that concern has been raised throughout the State and that in Galicia a commission has been created with recommendations on this issue.
When people like Narcís come to Dr. Borràs’ consultation, an initial assessment is made and treatment is proposed. In many cases, the medication is reduced to switch to other slow-release opiate alternatives. We always try to personalize the proposal and agree on therapeutic goals to reduce the medication, explains the psychiatrist. Despite this, he adds that in a moment of despair in pain the patient does not always listen and that is why he thinks it is important to carry out a continuous explanation to “prevent certain situations”. Borràs points out that social concern is being generated by the US scenario and there is concern among patients, but he emphasizes that the situation in Spain has “nothing to do”, because there fentanyl is present in the field of street, something that doesn’t happen here.
Currently, pharmacological treatments for opioid addiction use methadone and buprenorphine. These are drugs that also generate dependence in the long term, but make it possible to improve consumption, explains Genís Oña, associate professor at the Rovira i Virgili University of Tarragona and researcher at the Iceers Foundation. For three years, the Reus hospital has been working with an experimental drug called Ibogaine with people with methadone addiction. In addition to being less addictive, it represents a “paradigm change” in relation to other substitution treatments such as methadone or buprenorphine. It is taken very rarely and “manages to reduce the withdrawal syndrome”. The idea is that with one dose once a week and a maximum of six, the person gets off methadone forever.
“They make you addicted to it and now they leave you in the lurch”, laments Inma Fernández about the neglect of her addiction. This Catalan woman saw in fentanyl the solution to her problems. “It gave me a lot of energy and I could work 12 hours straight,” he says. But after a year it stopped working and the doctor gave him tramadol, trankimazine and fentanyl again. “A bomb”, he describes. Now he hopes to enter a drug addiction care and follow-up center, and his opiate dose has been reduced “without any substitute”. He asks that the box that was removed be restored to him so that he can hold on until admission. “I feel like a drug addict,” laments this woman, who has been off work due to addiction since May. He explains that he is afraid. His personal history is delicate, with an attempt at self-harm, and he doesn’t know if he can hold on. “I want to work, go out with my friends… live!”
There are also patients who live with pain and who ask that this drug not be criminalized. This is the case of Leonor Pérez de la Vega, who has neuralgia that forces her to take between 10 and 15 pills of different drugs daily. “We are afraid that they will take away our medication, that they will stigmatize us,” says this university professor who retired prematurely because of the disease. He has trigeminal neuralgia and fentanyl is the rescue resource when the pain becomes unbearable. That is why she asks that a necessary drug for people who, like her, live with unbearable pain, not be questioned. “We don’t take it for pleasure” he claims.
Addicts also fear stigma. “My family suffers because of my pain and because of my dependence”, admits Narcís. “If I find out, I don’t take it. I would have less pain and less addiction”, he summarizes.
