In early September, actor Michael K. Williams was found dead in his Brooklyn penthouse apartment. Williams, known for his role as stick-up man Omar Little on "The Wire," and more recently as Montrose Freeman in the HBO drama series "Lovecraft Country," had been found by his nephew. Three weeks later, the New York City Medical Examiner's Office announced that Williams died from "acute intoxication by the combined effects of fentanyl, p-fluorofentanyl, heroin, and cocaine." The manner of death was ruled accidental.
Williams had openly spoken about his mental health and addiction struggles. Brought up in the projects of East Flatbush in Brooklyn, Williams was exposed to crime and sexual abuse, and he became addicted to drugs in his teens. On his 25th birthday, Williams was attacked in a fight, leaving him with a long diagonal scar across his face, which seemed to radically change his image. He started getting roles in music videos and later in film, typically playing gangster characters.
Acting became a double-edged sword for Williams, sometimes keeping him sober, and at other times causing him to relapse. In a June 2017 New York Times interview, Williams explained that, "The characters that mean the most to me are the ones that damn near kill me. It's a sacrifice I've chosen to make."
Realizing that through his acting work he could be an advocate and make a difference in his community, Williams worked to overcome his addiction: "Addiction doesn't go away. It's an everyday struggle for me, but I'm fighting."
In 2016, Williams hosted a Vice News program called "Black Market," and in 2018 produced the documentary "Raised in the System" for the HBO Emmy-winning weekly news magazine series "Vice."
Fentanyl
Fentanyl was first developed in 1959 and introduced in the 1960s as an intravenous anesthetic. It is legally manufactured and distributed in the U.S. as a prescription drug, but it is also made and used illegally. A powerful synthetic opioid, it is chemically similar to morphine, but is 50 to 100 times more potent. Like morphine, it is typically used to treat patients with severe pain, often after surgery. It is also sometimes used to treat patients with chronic pain who are physically tolerant to other opioids.
When prescribed by a doctor, fentanyl can be given as an injection (Sublimaze), a patch that is put on a person's skin (Duragesic), or as lozenges that are sucked like cough drops (Actiq).
Although fentanyl can be diverted via theft; fraudulent prescriptions; and illicit distribution by patients, physicians, and pharmacists, it is also manufactured in labs and sold illegally as a powder, dropped onto blotter paper, put in eye droppers and nasal sprays, or made into pills that look like other prescription opioids. The National Institute on Drug Abuse (NIDA) has warned that some drug dealers are mixing fentanyl with other drugs, such as heroin, cocaine, methamphetamines, and MDMA. It takes very little fentanyl to produce a high, making it a cheap additive to increase the euphoric effect of the drugs. This is often done without the user's knowledge, putting them at higher risk of an overdose.
How Does Fentanyl Affect the Brain?
Like heroin, morphine, and other opioid drugs, fentanyl works by binding to the body's opioid receptors, which are found in areas of the brain that control pain and emotions.
Fentanyl's effects on the brain may include:
- Extreme happiness and euphoria
- Relaxation
- Drowsiness
- Confusion
- Sedation
- Dizziness
- Unconsciousness
Fentanyl's effects on the body may include:
- Respiratory depression
- Pain relief
- Nausea
- Vomiting
- Urinary retention
- Pupillary constriction
As with other opioids, fentanyl can be highly addictive with prolonged use. In addition, tolerance to the drug causes users to seek larger doses, increasing their risk of overdose.
Symptoms of Fentanyl Overdose
Overdose may result in stupor, changes in pupillary size, cold and clammy skin, cyanosis, coma, and respiratory failure leading to death. The presence of a triad of symptoms, such as coma, pinpoint pupils, and respiratory depression, are strongly suggestive of opioid poisoning.
Fentanyl Overdoses
According to the CDC, more than 36,000 deaths involving synthetic opioids (other than methadone) occurred in the U.S. in 2019. Synthetic opioid-involved death rates increased by over 15% from 2018 to 2019, and accounted for nearly 73% of all opioid-involved deaths in 2019. The rate of overdose deaths involving synthetic opioids was more than 11 times higher in 2019 compared with 2013.
The latest provisional drug overdose death counts through May 2020 suggested an acceleration of overdose deaths during the COVID-19 pandemic, with synthetic opioids being the primary driver. The 12-month count of synthetic opioid-related deaths increased 38.4% from the 12 months ending in June 2019 to the 12 months ending in May 2020. Overdose deaths from cocaine have also increased over the course of the pandemic, and many of these involve both cocaine and synthetic opioids.
The Drug Enforcement Administration (DEA) has recently launched a new initiative called One Pill Can Kill. DEA Administrator Anne Milgram has warned that there are now an alarming amount of counterfeit pills containing lethal fentanyl: "They're marketed as prescription drugs, sold online or through social media, but are actually fake, often containing powerful, deadly fentanyl ... sometimes methamphetamine."
Counterfeit pills are more lethal than ever before. The number of DEA-seized counterfeit pills with fentanyl has jumped nearly 430% since 2019. DEA lab testing has revealed that two out of every five pills with fentanyl contained a potentially lethal dose.
Healthcare professionals should warn patients that the only safe medications are those prescribed by a trusted medical professional and dispensed by a licensed pharmacist.
Treatment of Fentanyl Overdose
As previously mentioned, many drug dealers mix the cheaper fentanyl with other drugs like heroin, cocaine, MDMA, and methamphetamines to increase their profits, often making it difficult to know which drug caused the overdose. Naloxone is a medicine that can treat a fentanyl overdose when given right away. It works by rapidly binding to opioid receptors and blocking the effects of opioid drugs. However, fentanyl is stronger than other opioid drugs like morphine and might require multiple doses of naloxone.
If you suspect that someone is overdosing, the most important step is to call 911, so they can receive immediate medical attention. Once medical personnel arrive, they will administer naloxone if they suspect an opioid drug is involved.
Naloxone is available as an injectable solution (Narcan) or nasal sprays (Kloxxado).
People who are given naloxone should be monitored for another 2 hours after the last dose to make sure breathing does not slow or stop.
Some states have passed laws that allow pharmacists to dispense naloxone without a personal prescription. Additionally, friends, family, and others in the community can use the nasal spray versions of naloxone to save someone who is overdosing.
Michele R. Berman, MD, is a pediatrician-turned-medical journalist. She trained at Johns Hopkins, Washington University in St. Louis, and St. Louis Children's Hospital. Her mission is both journalistic and educational: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.