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Comment by refurb | Hacker News Reader

Indeed. Fentanyl is used thousands of times per day in the medical setting because it is a safe drug.

I do agree that the potency makes preparation difficult. Few dealers have the equipment to either accurately weigh it out or dilute it such that the product is homogenous. When you move up to even more potent opioids like carfentanyl or sufentanyl, the risk is even higher. Who has the ability to accurately weigh out 0.030 mg?

That said, dying of a “hot dose” of heroin is not exactly uncommon either.

Interestingly, opioids are toxic at high doses as they depress the breathing response to blood CO2 levels. If someone overdosed and you breath for them (CPR or ventilator), you can just wait for the effects to wear off and they’ll be none the worse for wear. I’ve read case reports where a users friends maintain CPR for an hour plus until they started breathing on their own.

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> Fentanyl is used thousands of times per day in the medical setting because it is a safe drug.

Fentanyl is not a safe drug. Period. It is a powerful and dangerous drug with dangerous and potentially lethal side effects and classified as such. It's also and incredibly useful drug, potentially of great benefit to people in severe pain - benefit that must be balanced against the danger and risk.

In controlled settings (e.g. in a hospital bed with physiological monitoring) many dangerous drugs can be used in a safe way, Fentanyl included. But that doesn't make Fentanyl a safe drug, just a drug that can be used safely.

In the same way TNT and rockets can both be used safely - neither are sensibly intrinsically safe.

> If someone overdosed and you breath for them (CPR or ventilator), you can just wait for the effects to wear off and they’ll be none the worse for wear.

I think this is too complacent. Aspiration is a real risk, they could choke, pneumonia can be life threatening. If somebody has overdosed, get professional medical care - management of the compromised airway is no DIY project.

I think the point was it’s not any more dangerous than heroin and morphine, and can be safe when properly administered in a medical setting.

I have no idea why we're talking about it in a medical setting when this is clearly meant to show how dangerous it is in the hands of the public. Fentanyl is dangerous on the streets and safer in the hospital sheets, of course, but that basically has no bearing on how it's used by addicts and cartels.

Have you ever seen a HN thread that stayed strictly on topic?

I can't help but feel that writing "because it is a safe drug" implies that the supposed safeness has something to do with the properties of fentanyl, rather than the manner in which it is used.

It’s implied for an drug that safety means specific uses within strict guidelines. Only specific dosages and usages are approved. If using the drug couldn’t go wrong it would be called harmless. Like every commercial says, ‘Use as directed’.

Not to mention that if someone had several hours of CPR done to them they are almost certainly going to need to go to the hospital anyways. Not to mention the average person can only sustain effective CPR for a few minutes.

>I’ve read case reports where a users friends maintain CPR for an hour plus until they started breathing on their own.

Were they doing CPR or Rescue Breathing or both?

I'm not a doctor but an hour of chest compressions to someone with a functioning heart seems bad.

Sorry! You are right, not CPR. Just rescue breathing!

> Indeed. Fentanyl is used thousands of times per day in the medical setting because it is a safe drug.

It's the painkiller I was given in the recovery room after a shoulder surgery and let me tell you, I can see why folks would grow fond of that feeling. There followed possibly the best nap of my life.

Off topic, but it's insane to me, people in the US get opioids for small surgeries. Here in Germany I had a motorcycle accident resulting in multiple (around 12) face fractures and later I had to get an incredibly painful eye surgery and both times I was given large doses of ibuprofen for the pain (which didn't do much).

At the time I wished for better painkillers, but maybe it's actually better that way...

No, that is crazy. Opioids and opiates certainly have their place in e.g. post-recovery for various types of surgeries. That's just proper and humane pain management.

But I recognize the attitude. I live in a Nordic country, and I think they're still pretty conservative with pain management on the public side especially. Although that used to be way worse. I don't think what you described could happen here normally. Availability of stronger opioids like oxycodone and fentanyl are more strictly controlled, and they try to keep them confined to hospital use and only for severe pain, cancer patients etc., at home. But stuff like codeine is prescribed much more and could be the stuff you get to take home after even a smaller surgery.

Opioids are probably ok for short term pain like surgery, where they're given by healthcare professionals in a medical setting.

A lot of the US problem is that those patients will then be given a big box of opioids to take home for the next week. They then have some opioids spare which they keep insecurely in a cupboard. A relative or neighbour gains access to these and starts their addiction.

> A lot of the US problem is that those patients will then be given a big box of opioids to take home for the next week.

Even the week isn't really a problem, in fact that's become one of the restrictions here in Ohio because the normal practice was to prescribe entire months at a time. People were ending up with 30-60+ day supplies of extended release medications like oxycontin for recovery from procedures that shouldn't have been all that painful for more than 10-12 days.

Now if a doctor wants to prescribe opiates for acute pain after a surgery or something, it can't be more than a 7 day supply, any longer and the pharmacist can't fill it. A completely new prescription is required for every additional 7 day supply.

In contrast to what was going on before, that means there are now on average 7-8 opportunities for a doctor to re-evaluate whether opiates are still appropriate over a 60 day period, rather than just 1 (the prescription for the 2nd 30 day supply).

I agree. I think lowering the cost of inpatient care will lead to more liberal drug policies in hospital and managing recovery until ibuprofen is sufficient for after hospital care.

Getting the balance here is difficult. Pain inhibits recovery, and badly managed acute pain can precipitate chronic pain. However, strong pain killers are addictive.

That said, even the simple analgesics (paracetamol, ibuprofen) have their dangers and we have maximum dosing that should not be exceeded. Paracetamol overdose causes horrible liver damage (up to and including lethal damage), and NSAIDs can cause clotting issues post-surgery, gastrointestinal issues, etc.

> Pain inhibits recovery

Not as much as you tearing your wounds open again because your body wasn't able to warn you.

I assume your suggesting that analgesia prevents the detection of wound infection? Pain is hardly the only sign: redness, swelling, heat, discharge, tachycardia, fever, etc.

> I assume your suggesting that analgesia prevents the detection of wound infection?

You misread what I said. Pain is part of the feedback loop that keeps you from straining your skin, muscle and bones past their tearing/breaking point.

People who don't feel pain are many times more likely to injure themselves, especially when they already have wounds that might re-open through the wrong movement.

Pain is likely to stop wrong movements long before you can make your condition worse.

Mostly pain is a "desirable" sensory input. But it's understandable that people don't like it.

There's obviously cases where you want to prescribe strong painkillers - but if you're taking those you shouldn't be out and about anyways and have people watching over you.

For most post-op pain you shouldn't be on strong painkillers for long though, lest you undo the work your doctors put into you.

NSAIDs were counterindicated for my surgery, as they'd increase the risk of internal bleeding. I had to avoid them for 10 days before I went in and come off paracetamol/acetaminophen 3 days prior. An uncomfortable few nights.

I think the US is much more liberal in terms of regulation, so it's very much up to the doctor. Mine is an expensive orthopaedic surgeon in NYC, he wouldn't have seen me as an addict with drug-seeking behaviour. Afterwards he gave me a prescription for the lowest-dose hydrocodone; I think I wound up taking it for about 3 days and then I didn't need it any more.

I was in pain, so I appreciated having the painkillers there to help. But I also appreciated that I don't want to form a habit, so I came off as quickly as I felt I could.

Dispensation of opiates varies wildly, like all health care in the US. I went to an ER barely walking with a large visible abscess and received no drugs for pain the entire time, since they clearly had decided I was out for drugs despite no history of any sort of that activity.

In the US, an orthodontist removed my impacted tooth (whole visit took less than 5 minutes) prescribed hydrocodone or oxycodone and some other pain killer. I didn't choose to pick up the prescription, but it was way overkill for the extremely mild discomfort I felt for the next 16 hours or so. I didn't take a single medicine other than the antibiotics prescribed, but I would have had access to tons of pain killers for no reason.

Likewise for a small procedure I had done.

Lots of people have the ability to accurately weigh out 0.030 mg, but a mistake only requires one idiot with cross-contamination of bad math. If you can pass a proper high school lab class, you can do this. What makes it easy is that these substances are soluable.

Water probably isn't the best choice, but it is cheap. You can dissolve at least 4.21 mg/L of carfentanyl in water. Call it 3 to be conservative.

Put 30 mg in 10 L of water. Each cL of water will contain the desired 0.030 mg.

Another way is to put half a pound in a 20,000 gallon swimming pool. That would get you 7.5 million of the above.

I think this stuff would be more soluble in ethanol. With that, you can solve the problem with multiple dilutions. It's like making homeopathic medicine but stopping before you run out of molecules.

One problem is people don’t know how much active ingredient 30 mg of the powder contains.

That's the problem of black markets after all. So safe to assume it's 100% active, and if the effects are not there, take a 1.25 times larger dose from the same dilution batch, and so on. The important thing is always start with assuming that the powder is pure, because the powder can be inhomogeneous.

CPR with chest compressions? Because that’s what CPR is. If you mean breathing by itself, that isn’t CPR. Doing CPR for someone with a pulse is incredibly dangerous and if you are doing it correctly, there will most likely be cracked ribs assuming you don’t induce cardiac arrest first. CPR for an hour with someone who’s heart is beating is a ultra-dangerous idea. You could cause severe heart damage. Perhaps you mean rescue breathing?

Why the hell would “friends” do CPR for an hour and presumably not call an ambulance? Some friends. Good Samaritan laws wouldn’t protect you because a reasonable person might do rescue breathing but a reasonable person would also call an ambulance. Unless you are in a very rural area, a first-responder response to CPR in progress would never be an hour.

This would never happen in America, but I wonder if deaths would go down if dealers were offered free measurement equipment, like how we offer needle exchanges and supervised injection sites.

> Who has the ability to accurately weigh out 0.030 mg?

You weigh out 3g and dilute them afterwards

That’s the issue. Unless you’re selling it as a solution, you need to dispense it in some inert powder which is hard! There are PhD scientists who work on how best to do that.

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