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What are the most dangerous opioids and the strongest opioids?

I remember reading an article about anesthesiology residents and opioid overdose. The program administrators were worried about the new residents and overdose deaths.

The problem they were having is that doctors, especially those talented enough to get into an anesthesia residency, are smart and curious people. They become interested in the opioid experience, and some of the world’s most powerful opioids are sitting right in front of them, day in and day out.

Apparently, according to the article, opioid misuse is rampant among these doctors in training. One problem is that, when they would steal and divert a synthetic opioid from the workplace, they would choose the most potent opioid, since they could take less, and it would not be missed from the unused opioids of the day’s surgeries.

If you know anything about opioid medication, you may think that the residents were stealing fentanyl. While fentanyl is commonly used in many surgeries, one of the main opioids of concern in the article was a prescription opioid known as sufentanil.

Sufentanil is even more potent than fentanyl. Where fentanyl is up to 100 times the potency of morphine, sufentanil is up to 1000 times as strong as morphine.

The article described a training video for residents about the dangers of drug abuse and drug overdose. At one point, an image was shown of a dead resident in a bath tub with a syringe in his arm.

One problem with opioid addiction and opioid effects on the brain, is that a person’s judgement is affected, and they tend to make impulsive and dangerous decisions when obsessing over using drugs such as heroin, fentanyl, or prescribed opioids.

Pure sufentanil in a syringe is practically a death sentence. Imagine smart anesthesia doctors looking for easy ways to get high, working with the most deadly drugs, sneaking out a bit of sufentanil. The problem is that even the most steady hand cannot safely push a small syringe filled with super potent synthetic opioid.

When I spent a month doing an anesthesia rotation as a student, the anesthesiologists seemed irritable, and I felt as if there was unrest in the department. I remember the OR head nurse questioning one of the doctors about his fentanyl supply for surgeries, and he angrily asked why he had the amount that he had.

Months later, I returned to that same hospital for another rotation, and I noted that the same angry anesthesiologist now had a desk job in the administrative offices. Was he misusing opioids, risking respiratory depression and a fatal overdose?

Another doctor in the department once gave us a talk on the topic of opioids and relative potency. He seemed to get very excited, talking about opioids that were much more potent than morphine. “Fentanyl is one hundred times more potent. Sufentanil is 1000 times more potent!”

I remember my questions would get him angry and irritable. During that lecture, I asked, “wouldn’t you just use less of a more potent opioid, so it wouldn’t really matter that it is so much stronger than morphine?”

Of course, I should not make assumptions about those doctors from my sometimes stressful training. That particular hospital no longer exists, and most likely, the doctors involved in the story have probably retired long ago.

On the news these days, we hear a lot about fentanyl overdose related to opioid abuse.

My story about hospital doctors and opioids used in surgery was from over twenty years ago. How is it that fentanyl and similar drugs, such as the powerful carfentanil, are still around? If they are so dangerous, why wouldn’t the FDA ban them from use?

The issue is that the fentanyl that is causing drug overdose deaths on the streets is illicit fentanyl, which is not the same drug as what is used in US hospitals. These new street drugs, Illicit street fentanyl opioid drugs, or fentanyl analogs, are types of illegal drugs that are almost completely different substances.

While chemically related to prescription painkillers and the strongest pain killer drugs, such as fentanyl and morphine, these deadly drugs are manufactured in Chinese labs, and have very different properties from their relatively clean, short-acting pharmaceutical cousins.

Many of the opioid painkillers approved by the FDA in the US are very short-acting. While there are some exceptions, and various long-acting mechanisms, typical prescription pain relievers and opioid prescriptions last for only a few hours at most.

Chinese fentanyl, on the other hand, has a very unusual property, making it one of the most dangerous drugs on the planet. While the euphoric effects that drug users are seeking only last for a very short time, the drug stays in the drug user’s system for days. The result of long-lasting exotic fentanyl analogs is that a person using the illegal drug to avoid opioid withdrawal and to chase the high that their fentanyl addiction tells them is still there, will be at higher risk of a fatal overdose.

It’s not only that fentanyl is one of the most potent opioids, it is also how long it lingers in the person’s system.

If you look at a pain medication list of narcotics drugs, strongest to weakest, you will see high potency painkillers, such as fentanyl, at one end, and others, such as codeine and tramadol at the other end. Tramadol is so mild that it was, up until recently, not even considered to be a controlled substance. Tramadol used to be the only drug on an opioid drugs list that was not controlled.

More recently, at least in the US, tramadol is now controlled as a narcotic. In other countries, it is not. For example, on a recent vacation, I noticed tramadol being sold over the counter in a Mexican pharmacy.

You might imagine that such a pharmacy, selling prescription medication, including the opioid pain reliever, tramadol, without need for a prescription, would be a dark, dirty place, in a bad neighborhood.

Yet, it was a very clean, well-lit pharmacy, with the pharmacist readily available to answer questions. And, it was only a short walk from the cruise ship.
Tramadol is a relatively low-potency opioid, but it is also limited by a dangerous side effect. If a person takes too much, they are at risk of dangerous seizures.

Opioid users tend to be very knowledgeable about their drugs of choice, so they are usually aware of the limitations of the weaker opioids, such as tramadol or codeine. Similarly, codeine is limited by an unpleasant side effect, constipation.

Codeine is not known to be a major drug of abuse because drug users know that they may become severely constipated from only a small amount of the drug. In pain management, codeine is rarely used, except for short-term, acute pain treatment, such as after a dental procedure.

While there is a great dramatic effect of pointing out that heroin is four times as potent as morphine, in practice, it is not that important.

On the streets, the dose is the dose. Users have a sense of what works for them and what will not lead to an overdose. Unfortunately, fentanyl, having a dramatically higher potency, is harder for clandestine drug labs to work with. Overdoses are often caused by fentanyl being present when the drug user was not expecting it to be in their drug supply.

Fentanyl is not only added to heroin, it is also found in meth, cocaine, marijuana, and just about any other street drug you can think of. Additionally, fake pills are being pressed to look just like real prescription medication, but they are mainly manufactured with high potency fentanyl.

What about the other basic pain management opioids and their potencies? What about hydrocodone (Vicodin, Lorcet) and Oxycodone (oxycodone brand names: Percocet, Roxicodone)? Or, what about hydromorphone (dilaudid) and oxymorphone (Opana)?

Interestingly, hydrocodone and oxycodone are about the same potency, though people have the general impression that oxycodone is the more potent of the two. Hydromorphone (dilaudid) is significantly more potent than oxycodone.

In fact, it is about four times the potency. Do doctors and pharmacists panic over the high potency of Dilaudid? No, because the tablets are dosed accordingly.

A high potency oxycodone tablet is 30 mg, while a high potency hydromorphone tablet is 8 mg. Rather than doing complex conversion math, a doctor may simply choose to prescribe one tablet or the other, when providing a prescription drug for pain relief. These opioids may be prescribed for either chronic pain or acute pain, after an injury or surgery.

What is the best type of addiction treatment for drug addiction involving opioids?

The first and most important drug used for harm reduction and saving the lives of people addicted to opioids is naloxone, sold as the brand, Narcan. Narcan is an opioid overdose reversal drug.
While giving a person overdosing on an opiate a spray of Narcan in their nostrils will induce unpleasant withdrawal symptoms, it will also possibly save their lives. Naloxone nasal spray is an important tool in treating opioid dependence and opioid addiction.

Substance abuse with opioids is difficult to overcome because there is both psychological and physical dependence, similar to other sedating drugs, such as alcohol and benzodiazepines. Opioid dependence recovery is not easy. Fortunately, there are effective medications to help.

Buprenorphine has quickly become the gold standard of medication-assisted treatment drugs. Buprenorphine is typically combined with naloxone and provided as a sublingual preparation that dissolves under the tongue.

Why under the tongue? Because bupe works best either by injection or sublingually (under the tongue). Since having patients with addiction issues give themselves injections with a syringe and needle is not a great idea, the medication is offered in a sublingual film or tablet.
Naloxone serves only as an abuse deterrent, to keep people from trying to inject buprenorphine to get high. It is an unusual situation, where a doctor is prescribing a drug that provides no direct benefit to the individual patient.

Is buprenorphine a strong opioid?

While bupe works great to save lives and get people off of dangerous street opioids, there is some controversy surrounding it. This is because the drug, buprenorphine, is itself an opioid.

How strong is buprenorphine? According to some opioid conversion charts, buprenorphine is five times the potency of morphine.
While this fact may be great for an anti-bupe lecturer to roll their eyes while pointing to a slide showing how buprenorphine is stronger than heroin, this potency conversion does not tell the whole story.

Buprenorphine, the main ingredient in Suboxone, is not a typical opioid at all. In fact, it is more of an opioid receptor blocker, and only a partial activator of the opioid receptor. The result of bupe’s unusual properties is that patients tend not to experience the usual side effects that they get from opioids.

Buprenorphine usually does not cause patients to become tolerant to the drug, where they need more and more to get an adequate effect. They usually do not experience euphoria, brain fog, cravings, obsessions, or many of the other negative effects of opioids.

Additionally, bupe has a ceiling effect, meaning that a person cannot take large amounts to try to get high. And, it is less likely to cause respiratory depression or overdose if a person takes too much.

The reason for the ceiling effect is the blocking action of bupe at the opioid receptors. Above a certain level, somewhere around 32 mg, the receptors are mostly saturated, so there is no way for the drug to provide additional opioid effects.

Buprenorphine is sort of like a car that is set to go no faster than the speed limit. It is a car that still has some risks associated with it, but it will be far safer for people with a tendency to try racing their car on the road.

Is Suboxone one of the most dangerous drugs in the world?

You would think, by the way some people talk about Suboxone, a brand name sublingual form of buprenorphine and naloxone, that it is a danger to society. How can anyone think that it is fine to give opioid addicts more opioids?

Is Suboxone treatment simply trading one drug for another? Are rogue doctors getting people hooked on Suboxone, fueling the next wave of pill mills across the country?

I once spoke to an administrator at a rehab who looked me square in the eyes, with the most serious face, and said, “Suboxone is only for short-term use.” His facility did not offer Suboxone therapy at all.

According to his world view of medication-assisted treatment, detox programs offer a fast taper of buprenorphine over a period of maybe 1-2 weeks. Then, the patient is discharged in a detoxed state, no longer taking bupe, and no longer in opioid withdrawal.

Unfortunately, this protocol of providing buprenorphine for a very short time is a recipe for failure. While preventing opioid withdrawal symptoms is one use for buprenorphine, craving control is the most important function.

The fact is that patients who take buprenorphine for a full year or more, in the form of Suboxone, Subutex, or ZubSolv, or even the monthly injections, Sublocade or Brixadi, do better than patients who do not get medication, and they do far better than patients who are quickly detoxed.

Because of buprenorphine’s unique nature, being different from other opioids and being more of an opioid receptor blocker, with only mild agonist properties, the risk of a buprenorphine epidemic is very unlikely. We will probably never see a Suboxone crisis, other than the crisis of patients not having adequate access to this life-saving medication.

It is important that we change our thinking about this and accept the fact that patients who take buprenorphine long-term do very well. They are able to function without clouded thinking, obsessions, or cravings, and they are able to live normal lives.

Suboxone is not the most dangerous opioid in the world. Not even close. Buprenorphine medications are among the best tools that we have to combat the opioid crisis and help more people get back to living normal lives. Doctors, patients, and family members need to get over the Suboxone guilt and accept that this Suboxone treatment works, and it works well.

The most dangerous opioids by far are the ones out on the streets, with unusual, exotic properties, because they are not like the standardized opioids which have been approved by the FDA. They are dirty, dangerous chemicals, made in illegal labs, and shipped across the world to be sold on our streets.

While going after doctors, clinics, pharmacies, and pharmaceutical companies is easy, because they are considered to be the “low-hanging fruit”, we would do much better going after the sources of dangerous, imported opioid analogs. These designer drugs, crossing our borders, are the problem.

Eliminating the source of these dangerous chemicals is important. And, we must also make opioid addiction treatment programs readily available to everyone who needs help.