Comment by JonDav | Hacker News Reader

Comment by JonDav | Hacker News Reader

A man walked into a meeting with a fent sucker in his mouth treating it like a toothpick and I had to hold back my alarm so that everyone else did not ask why I knew exactly what it was. At that time no one outside of post-op, end of life cancer, or major pain management were really aware of this stuff. But to see a guy just stroll in on fentanyl like it was nothing at all was a watershed moment.

Now an addict does not need to steal from a ped surgery floor. You can buy fentanyl straight from China in a properly wrapped packet. Dosage is the problem, mixing dry is not easy, hence the street deaths.

I carried narcan back in the day because some of my friends were heroin users. But I never came across a fent addict, now I can only imagine how much of this stuff is floating out there.

Average people have no idea what this stuff feels like, what the pull is like. In reality you never get away from it; it is always there in the back of your mind but you have to tell yourself that it will destroy you.

sorry for the disjoint mess but I am being hit with the thoughts of those I knew who were lost to black.

Apparently fent is the new black.

I had interventional radiology brain surgery three times. I got a decent medical dose of fentanyl. I was strapped onto a surgery table awake because I had to hold my breath every time they put tools into my brain. I could see the x-ray image of the tools going into my brain in the corner of my eye on the screen above the table. With fentanyl the world was right as rain, however, I didn't feel any desire to have it again after. The feeling wasn't happy, sad, high, speedy, or low. It was just everything was ok.

This is the most unsettling HN comment ever. Thank you for sharing it.

The most unsettling moment of the whole situation is when I first had the operation and the doctor handing me the consent form says that the procedure itself kills 1 in 400 people. I said those odds are shitty thinking about the one time I had 4 aces in Texas Hold'em and lost to a royal flush and all the other times I had a bad beat. The doctor said for someone off the street those are bad odds but my odds of surviving without the procedure are probably much worse. I didn't have any family there with me. My friends had no idea that I was in that situation. I was a chef for a long time and said what I would say to the cooks before a busy night. We are all human, we all make mistakes, I just ask you do your personal best. I survived. The feeling I had on fentanyl under those conditions was the same the night I was in the hot baths at Esalon looking at the expansive milky way while the waves crashed on the rocks below. Awe and wonder and it's all ok.

Reminds me of the way too few times I felt during or after meditating.

Great comments but

> 4 aces in Texas Hold'em and lost to a royal flush

is not possible. Maybe four nines? Or a (non-royal) straight flush.

Maybe it is one of those things where I should take Bill Murray's advice and I can't tell anyone because nobody is going to believe me. It is possible at 1 in 165 million odds. http://imgur.com/a/Kb9Oa

Ah yeah oops my bad.

How is this unsettling? They didn't develop Fentanyl to make people's lives worse, they developed it to relieve severe pain and prevent dangerous instinctive reactions to surgeries like these; most of the time that Fentanyl is used, it is used for the right reasons.

The oral version is purportedly amazing, it is basically an off switch for pain, exactly the sort of thing you'll want if some day you get shot or stabbed, or fall over onto a hard surface and break something.

Sometimes the brain is not well equipped to handle exceptional scenarios which none of our ancestors would have survived anyway. For those scenarios, there's Fentanyl.

> I was strapped onto a surgery table awake because I had to hold my breath every time they put tools into my brain.

> How is this unsettling?

Ahh, fair enough. I completely missed that angle, I've never been squeamish about descriptions of surgical procedures, except when they involve cutting the eye. I'm probably the weird one here.

Hand and facial surgery is disturbing because we identify with those regions so much.

The scenarios you describe are excellent use cases for Ketamine which is an incredibly strong hypnotic. French EMT-equivalents use it for severe out-of-hospital cases while opioid derivates are used for diagnosed, chronic needs.

What are the economics or pharmacology that make fent apparently widely used in US medicine?

> What are the economics or pharmacology that make fent apparently widely used in US medicine?

Let me say that I am not qualified to answer that directly, but I can point to some things that I am led to believe.

> French EMT-equivalents use it for severe out-of-hospital cases while opioid derivates are used for diagnosed, chronic needs.

First of all, I don't think EMTs are regularly administering fentanyl at the scene. I could be wrong about that.

Ketamine can keep producing (a very wide range of) primary and side effects for a good 24 hours after it's administered, whereas with Fentanyl you get a lot more control since it comes on and wears off rather quickly. I know people who have used Ketamine recreationally, and the types of intense hallucinations they report seem like they would be pretty incompatible with restraints or some forms of surgery.

Other than that, I think the U.S. seems to have deployed it more quickly because the patients and their insurers are not as cost sensitive as in single payer systems. Common forms of Ketamine are not new to anyone, whereas the most common fentanyl products are from the '90s or later. People say Americans pay a lot for health care, and this is true, but they also get most of the cool new toys, drugs, and procedures first; and so take the first-mover advantages with the first-mover disadvantages.

That said, I don't think the (local) medical uses of fentanyl are particularly important to the abuse problem. I live in Canada, and I don't think we use fentanyl medically as much, but there's a lot of it on the street. It seems to be mostly coming from independent producers rather than theft or fraud against the pharmaceutical companies that package it for use in the U.S. and Canada.

> I don't think EMTs are regularly administering fentanyl at the scene. I could be wrong about that.

You are, it's more and more being advised for EMS use over morphine.

> First of all, I don't think EMTs are regularly administering fentanyl at the scene. I could be wrong about that.

I'm a paramedic in New York. We carry both fentanyl and ketamine.

Fentanyl is my preferred choice for analgesia (over morphine). It acts faster, is more effective for acute pain, and has fewer side effects.

Ketamine is used for sedation, not analgesia. It's also rarely my first choice (Versed is generally my go-to for sedation, as benzos are much safer in a prehospital setting).

Also, your claim about how the high cost of the US healthcare system is worth it because the "cool new toys, drugs, and procedures" is a common myth... Fentanyl, for instance, was developed by a Belgian company.

>Also, your claim about how the high cost of the US healthcare system is worth it because the "cool new toys, drugs, and procedures" is a common myth... Fentanyl, for instance, was developed by a Belgian company.

This is incredibly misleading. Most pharmaceutical and medical research companies make the bulk of their revenue from the US market, either directly or indirectly, regardless of where they are based.

The US market is the primary funding source for medical research, even for drugs which are developed by foreign companies.

Where the drugs are developed, where the funding comes from, and where they are first made available are three completely separate questions.

If it makes you feel any better I had fentanyl administered as a part of an endoscopy, but because it was paired with an amnesia drug (used to keep me from moving, as I was awake but unaware during the procedure), I have no memory of its effects, and obviously no desire to use it or any other opioid, so fentanyl is not exactly an absolute evil that latches into your brain and never legs go regardless of the circumstances.

Still, lot of heroin addicts around where I live. Most you wouldn't even recognize as addicts, but they're there.

My wife was given fentanyl during childbirth. They sent it directly into her spine via the epidural. Apparently it's a common use.

That's familiar to me from vicodin

So strange to me. I've had Vicodin prescribed a few times, and never felt it did much of anything.

I've had the same experience. Both codeine and vicodin.

I got Vicodin and prescription Ibuprofen after oral surgery. I preferred the Ibuprofen because it felt more effective for keeping the pain away, and the Vicodin made me intensely sleepy. So... I never experienced anything that would make me want to keep taking it. I kind of avoided it because I didn't want to be sleeping all day.

> The feeling wasn't happy, sad, high, speedy, or low. It was just everything was ok.

Sounds similar to codeine (medical use, moderate to high dose). It has no particular strong feeling in and of itself, but if I'm doing something I already enjoy it makes things feel a notch better (vs. if I'm bored/annoyed etc. it's hardly noticeable other than being in less pain).

I don't think people can feel brain surgery.

For most people driven to addiction, having something that guarantees you will feel that "everything was ok" is exactly the draw, I think. It gets worse as you become more and more addicted and have more and more to hide from as you let other parts of your life you cared about continue to slide.

> I never came across a fent addict

At least here in upstate New York, there aren't really 'fent addicts'. There are opioid addicts in general, but even the hardcore users are generally seeking heroin, not fentanyl.

People are _really_ scared of fentanyl...

And they should be. Two employees at my local hospital died sitting on the can in the bathroom, with a fentanyl Patch lying on the ground.

One was a nurse, and the other a janitor. (They took the used patches out of the garbage.).

(That said, we should legalize at least bupenorpine, the generic version. Addicts would have an alternative to street drugs, and doctors who just charge too much. Plus--drug education should be taught early in school. And tell the truth. Like for nine months, the drugs will work. Then you will spend years just trying to feel the way you did before you took opiates:; if you're lucky.)

> bupenorpine, the generic version

When talking about drugs, 'generic' refers to a nonpatented version of the same substance; buprenorphine isn't the same substance as fentanyl.

I'm not sure what you mean by "the generic version". Fentanyl _is_ the generic name (the brand name is Fentora (plus a bunch of brand names for patches).

Buprenorphine and fentanyl are _very_ different drugs.

Buprenorphine is not the 'generic' version of fentanyl. Fentanyl is the generic name for various brand-name medications such as Sublimaze. Buprenorphine is the generic name for Suboxone, Butrans, etc., and is an entirely different medication used for different purposes from fentanyl.

> we should legalize at least bupenorpine,

Like many other medications, there is a reason this requires a prescription.

It has a half-life of a few days, people die from overdoses like any other opioid and sometimes they make the mistake of having a drink (or a few) while it is in their system, which could kill them as well.

Overdoses of buprenorphine require exorbitant amounts of Naloxone to keep a patient breathing because of its half-life.

Nalaxone has a half-life of an hour or two in a healthy adult. Right now, a single metered and prepared dose of Nalaxone is roughly $4,500. [1]

> doctors who just charge too much

I agree. Suboxone is a racket, doctors need special licensing to prescribe it and they know they can charge desperate, dying people enormous amounts of money to treat them.

[1] https://www.scientificamerican.com/article/massive-price-hik...

Because it's a partial agonist, it is almost impossible to overdose from buprenorphine alone. Narcan can be purchased OTC at many pharmacies for around $100.

> A man walked into a meeting with a fent sucker in his mouth...You can buy fentanyl straight from China in a properly wrapped packet.

Talking about OTFC lollipops? You can get those in the mail from China? I'm guessing these are disjoint cases.

> Dosage is the problem, mixing dry is not easy, hence the street deaths.

I feel like the bad rap it gets is mostly about dosage, ultimately it is the market at work despite the law, producing ever more potent and compact (concealable) fixes as customers demand. If caffeine were a controlled substance, people would buy it more often in the (hazardously potent) powdered form. When booze was prohibited, it was regularly distributed in 180/190 proof.

The demand is the part you can improve, the supply is the part you think you can solve.

I'm scared I may have to advise close friends to start carrying Narcan. It doesn't really make sense how horrifying opiates are until they start ripping away people you've known for years...

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