Codeine to carfentanyl: A guide to Saskatchewan's deadliest drugs
Addiction expert digs into Coroners Service report on drug toxicity deaths
The names are at once mysterious and familiar: fentanyl, carfentanyl, hydromorphone, oxycodone.
Familiar because they turn up consistently in news stories about the opioid crisis in Saskatchewan and overdose deaths.
Mysterious because, beyond reading in a news story that a drug caused an overdose death, does a person without medical training really know the difference between carfentanyl, acetylfentanyl and codeine?
Peter Butt knows the difference. Butt is an associate professor at the college of medicine at the University of Saskatchewan and a consultant in addiction medicine.
"These names get tossed out and people don't really understand the range of potency," he said.
"If you were to put it on a scale from lower to higher, it would go from codeine to morphine to oxycodone to hydromorphone and then to fentanyl."
According to the Saskatchewan Coroners Service, fentanyl played a part in a significant portion of overdose deaths in 2020 — 144 of the 283 fatalities recorded across the province. More people died in Regina, 119, than anywhere else, followed by Saskatoon at 70.
Butt said that people may not realize fentanyl is the name of the parent drug of a number of related drugs — carfentanyl, acetylfentanyl, parafluorofentanyl, furanylfentanyl.
Pharmaceutical fentanyl was developed for pain management treatment of cancer patients, applied in a patch on the skin. It's generally viewed as being between 80 and 100 times more potent than morphine.
Fentanyl variations were then developed for different uses with varying degrees of potency, Butt said.
"Carfentanyl is categorized as being 100 times more potent than fentanyl. It was developed primarily as an anesthetic for an elephant," he said.
Given this potency, and the complete absence of quality control at the street level, it's easy to see why the fentanyl group is responsible for so many deaths. Users are playing roulette when consuming street narcotics.
"Fentanyl is brought into the country and it's cut down," Butt said.
"It's pretty crude processing that they do, you can imagine mixing bowls and somebody's kitchen. So the problem is not only the high potency, but the uncertainty of actually how much fentanyl is not only in the mixture, but when it comes to them creating a powder that they sell or tab that they press, how much of that is in part of that mix."
Morphine and Codeine
Compared to fentanyl, morphine and codeine are "low potency opioids," but they are still capable leading to overdose deaths, Butt said. Both are prescribed for pain relief and management.
"The problem with codeine is that it can be abused like any other opioid. Some people work the pharmacies and are picking it up from different pharmacists at different times," Butt said.
"Sometimes people take so much codeine, frequently mixed with aceteminophin — trade name Tylenol — that it poisons their liver and they die of liver failure."
Hydromorphone
Butt says hydromorphone as a "prescription-grade opioid" that's more powerful than morphine and is often given to patients in palliative care for acute pain.
"It's diverted to the street by people who have access to it because of the street value. It has a pretty high value on the street, in part because people know what it is — it's prescription grade," he said.
Oxycodone / Oxycontin
"Oxycodone is what was marketed as Oxycontin, and for a long period of time it was promoted as a safer form of painkiller," he said.
"That was false marketing by the pharmaceutical company and, unfortunately, a lot of people got addicted to oxycodone."
Butt said that drug dealers began making and selling deadly pills to people seeking oxycontin.
"With fentanyl, they began creating pills that looked like oxycontin. They were called 'fake oxy' on the street and they were known to be more potent than oxycodone, but no one really knew how much more potent."
Stimulant hybrids
The coroners service report showed that, in 2020, there were 119 deaths from methamphetamine toxicity and/or methamphetamine mixed with another drug.
Butt said that this could be a vexing combination for paramedics and other first responders.
Opioids such as fentanyl slow the respiratory system and then the heart, leading to death. The drug naloxone is used to counteract that effect.
"The problem, again, is that sometimes at the street level it's [methamphetamine] cut with other drugs," he said.
"You might have methamphetamine mixed with fentanyl and people may end up with an opioid overdose. They think they're just getting a stimulant."
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