Contemplating Fentanyl’s Double Duty

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Sabrina Ford, PhD

In August 2018, Nebraska used fentanyl as part of a lethal cocktail to execute Carey Dean Moore, a prisoner sentenced to the death penalty for committing murder. This action by the state presents an ethical paradox. Tens of thousands of lives are lost to opioid overdose each year and fentanyl now was being used as part of a powerful execution cocktail. How do we comprehend this curious juxtaposition of the use of synthetic opioid drugs, complicated by our understanding of the human condition? To further muddy this absurdity, President Donald Trump suggested that illegal dealers of synthetic opioids, like fentanyl, should be sentenced to death if convicted.

To be clear, this neither is a commentary on the death penalty nor is it intended to be read as a political stance, but instead is an exploration of the phenomenon of dousing physical pain and avenging emotional pain. That is, how do we understand powerful pain-killing prescription medications as a solution to relieve suffering… physical, emotional, societal?

To give further context to this conundrum, the news media seemed equally confused. On August 14, 2018, The Washington Post reported on the fentanyl execution in Nebraska, with minimal mention about the epidemic of deaths by synthetic opioid. In fact, the word “overdose” did not appear in the news article. On August 18, 2018 the Post ran a separate opinion piece on synthetic opioid overdose deaths in the United States, but failed to mention the execution that took place just four days earlier. On August 23, 2018, Bloomberg reported on Trump’s comment about enacting the death penalty for those convicted of illegally dealing fentanyl. Does it stand to reason that a fentanyl dealer would be executed by a fentanyl cocktail? This gives new meaning to “all who draw the sword will die by the sword”.5

Image description: a medical syringe is shown on a flat white surface, with the needle in focus with a drop of liquid hanging from the tip of the needle. The background is not in focus. Image source: Dr. Partha Sarathi Sahana/Flickr Creative Commons

Connecting the Dots

BBC News did attempt to connect the dots between overdose and execution, but only as factual statements placed side by side. The BBC News and other news outlets outlined the combination of drugs used to execute Moore including diazepam, fentanyl, cisatracurium besylate, and potassium chloride. One reason why Nebraska State Penitentiary chose fentanyl was because that drug is obtainable – available in the prison for the medical treatment of pain for inmates. Interestingly, controversy about the use of this drug combination was not because it included fentanyl, with a reputation for ending life, but instead was because it was an untested chemical combination administered by lethal injection to enforce the death penalty.

Pleasure and Pain

Human suffering typically is experienced existentially – mentally and physically. In our daily lives, we often think of suffering as psychological and emotional, and in sickness and death, suffering is associated with a physical state. The philosophical understanding of suffering is grounded in Hedonism. Hedonism is an ethical framework that posits pleasure is good and pain is bad. There is not enough space to explore ethical and epistemological digressions, but let us take a short cut for now.* Pleasure and pain present a long-standing dilemma to the human experience. As hedonistic creatures, we are wired to seek pleasure and longevity, but sometimes our search for pleasure ends in pain, suffering, and even death—the very state we seek to avoid. Akin to searching for the fountain of youth, some opioid users are searching for good in the form of pleasure, an ethereal altered state of consciousness. Too much of a good thing can lead to bad, in the form of death by opioid overdose. How to untangle the conundrum of addiction is something physicians, psychologists, and philosophers have attempted to solve for thousands of years.

Double Duty

Alas, we know that opioid addiction has as one of its greatest risks, titration of just enough of the drug to achieve the ultimate high—just close enough to death to touch heaven. Fentanyl as a prolific painkiller has become America’s death knell. On August 14, 2018, fentanyl also became an elixir to carry out justice and avenge murder. Interestingly, as mentioned above, the pharmaceutical combination was administered by a series of four drugs delivered by intravenous drip: diazepam, to induce sleep; fentanyl, a potent pain medication; cisatracurium besylate, to paralyze and stop breathing; and potassium chloride, to stop the heart; not too different from the process of dying by opioid overdose.

How do we as Americans make sense of this strange state of affairs? We want our suffering to stop, whether it be physical, mental, or even societal. It would seem that fentanyl has become a drug of choice.

*Suggested reading: Epicurus. Epicurus – Stanford Encyclopedia of Philosophy. Metaphysics Research Lab, Stanford University. 2018.

Many thanks to Jamie Alan, RPh, PharmD, PhD and Cara Poland, MD, Med, FACP, DFASAM for technical assistance.

ford-cropSabrina Ford, PhD, is an Assistant Professor in the Department of Obstetrics, Gynecology and Reproductive Biology and the Institute for Health Policy in the Michigan State University College of Human Medicine. Dr. Ford is also adjunct faculty with the Center for Ethics and Humanities in the Life Sciences.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, December 13, 2018. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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Bioethics for Breakfast: Treating Pain Without Feeding Addiction: Is There a Goldilocks Solution?

bioethics-for-breakfastForrest Pasanski, JD, and Steven Roskos, MD, presented at the Bioethics for Breakfast event on April 20, 2017, offering perspective and insight on the topic, “Treating Pain Without Feeding Addiction: Is There a Goldilocks Solution?”

In August 2016 the Michigan Department of Licensing and Regulatory Affairs (LARA) created a permanent Drug Monitoring Section to stem the state’s prescription drug abuse epidemic, tightening its monitoring of physicians’ opioid prescribing. Certainly as the ones who write the prescriptions, physicians should help remedy the prescription opioid epidemic. But they also have a responsibility to effectively manage the pain their patients experience. In striving to meet one of these responsibilities, will they fail to meet the other? Or is there a place in the middle that is ethically “just right?” How might they optimally collaborate with the state to ensure the best interests of its citizens?

Mr. Pasanski discussed the scope of the opioid epidemic in Michigan as well and the state’s response, highlighting efforts to identify, investigate, and take substantial licensing actions against overprescribers. Dr. Roskos offered a physician perspective, touching on trust in the doctor-patient relationship and how state regulations may create tension within that relationship.

Forrest Pasanski, JD
Forrest Pasanski, JD, is Regulation Section Manager, Drug Monitoring Section for State of Michigan, Michigan Department of Licensing and Regulatory Affairs, Bureau of Professional Licensing where he oversees the Michigan Automated Prescription System (MAPS) and staff who identify, investigate, and bring administrative actions against health professionals who overprescribe, overdispense or divert controlled substances. He studied philosophy and political science at Grand Valley State University and graduated from the Michigan State University College of Law.

Steven Roskos, MD
Steven E. Roskos, MD, is an associate professor in the Department of Family Medicine in the Michigan State University College of Human Medicine, where he also serves as associate chair for academic affairs. He received his MD from Temple University School of Medicine, Philadelphia, Pennsylvania and completed a family medicine residency at Lancaster General Hospital, Lancaster, Pennsylvania. Dr. Roskos practiced in southern Appalachia for seven years, then taught at the University of Tennessee before completing a fellowship in academic medicine at Michigan State and then joining the faculty. He has a clinical interest in treating patients with chronic pain and served on the Michigan Advisory Committee on Pain and Symptom Management for five years.

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.

White Horse, White Faces: The Decriminalization of Heroin Addiction

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series

By Karen Kelly-Blake, PhD

The U.S. is in the grips of an opioid addiction crisis. According to the CDC, the rate of opioid (prescription and heroin) overdose deaths has quadrupled since 1999.

Consider the following:

Economic Impact of the Opioid Epidemic:

  • 55 billion in health and social costs related to prescription opioid abuse each year
  • 20 billion in emergency department and inpatient care for opioid poisonings

On an average day in the U.S.:

  • More than 650,000 opioid prescriptions dispensed
  • 3,900 people initiate nonmedical use of prescription opioids
  • 580 people initiate heroin use
  • 78 people die from an opioid-related overdose

There is a strident call for prevention, treatment, research, and effective responses to quell this modern day public health scourge. The Obama administration is calling on Congress to 1) expand access to medication assisted treatment (MAT); 2) improve prescription drug monitoring programs; 3) advance prescriber education; 4) encourage safe pain management; 5) accelerate research on pain and opioid misuse and overdose; 6) expand telemedicine in rural America; 7) safe disposal of unneeded prescription opioids; and 8) improve housing support for those in recovery.

Image description: An individual is shown injecting their arm with a syringe. They are seated and shown from the chest down. Image source: Flickr user Urban Seed Education.

Along with these initiatives, expanded use of naloxone is deemed critical as a lifesaving measure for first responders and others to reverse drug overdose. Injection clinics, where users can inject heroin (illegal drugs) in a safe environment is regarded as a reasonable and appropriate response to the problem.

Undoubtedly, there is a striking difference in tone about this “new” heroin epidemic compared to the old epidemic of crack cocaine, which affected predominately black, poor, and urban communities. The difference is that young white people are addicted and dying, reflecting a shift over the last 50 years in the demographic composition of heroin users. A New York Times analysis found that young white adults are dying at rates not seen since the AIDS epidemic. This new epidemic is predicated on addiction to prescription painkillers and people turning to heroin and fentanyl as cheaper alternatives with no administrative barriers (contracts, doctor visits, prescriptions).

The current narrative goes something like this: “…[B]ut these are people and they have a purpose in life and we can’t as law enforcement look at them any other way. They are committing crimes to feed their addiction, plain and simple. They need help.” So, when young white people become heroin addicts they are “people with a chronic health problem” and thus are deserving of patience, tolerance, and help. Coming from middle-class and suburban environs, they are portrayed as high achievers from exceptional families, and so the addiction is not their fault—it is not a personality flaw or character deficit.

In contrast, at the height of the crack cocaine epidemic in the mid-80s, black people were branded as pathological, unsympathetic “superpredators” and therefore deserved disdain and incarceration. Black crack addicts had several personality flaws—lazy, stupid, it was their fault that they became addicted—their addiction was the result of a moral failure.

Image description: An individual is shown injecting heroin into another individual’s hand with a syringe. Their faces are not shown. Image source: Wikimedia Commons.

Racism is in full effect in this new public health scourge. Of course, addiction requires medical intervention and all the social resources needed to help those afflicted. BUT, let’s not have a conversation about the new heroin epidemic in a vacuum with scant if any attention to the racist underbelly of the discourse. Minority and poor people were junkies and criminals deserving nothing more than a jail cell. Today’s addicts are not even called addicts. The goal is to avoid stigmatizing language and so language conveying a chronic illness is preferred such as substance abuse disorder. Addiction is a serious public health issue and it is encouraging to see the change in strategy to treat those afflicted. We know that mass incarceration is not an effective public health response.

It is problematic that we are having a white washed conversation about opioid addiction. This new conversation is occurring in an ahistorical vacuum. The goal is not to incarcerate young white heroin users, but to help them. However, this new enlightenment is a sting for black and Latino families who suffered the same problems, but they were not deemed “people with futures” or “people who deserved help.” They were junkies and criminals. Ironically, black people are suffering less from this new epidemic because of pervasive racial stereotypes whereby doctors are reluctant to prescribe painkillers to minority patients believing they will sell them or become addicted.

It is disingenuous to frame the conversation ahistorically. The current responses and narratives surrounding the heroin epidemic shows that it indeed matters who is in the grip of addiction: “White heroin addicts get overdose treatment, rehabilitation and reincorporation, a system that will be there for them again and again and again. Black drug users got jail cells and “Just Say No.”

The new white face of heroin addiction has changed the discourse of addiction from criminalization to public health, and the change is welcomed. However, it does give me pause that the white face was necessary to enact humane responses for a health problem that affects us all.

kelly-blake-crop-facKaren Kelly-Blake, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, August 4, 2016. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

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