The current spotlight on fentanyl as the culprit causing the sharp spike in opioid deaths in the United States, is motivated by a well-intentioned effort to address an alarming public health concern, but is blaming fentanyl and the drug industry an effective way to address the root cause of the epidemic, or a desperate effort to find a quick fix?  New Hampshire began a survey in 2016 of fentanyl-related deaths in the state, and the forensic  data reveal some surprising findings suggesting that the causes of the epidemic go well beyond fentanyl and big pharma.

“Fentanyl is one of the most dangerous drugs there is,” said Senator Tom Cotton (R-AR) in a March 22, 2018 press conference announcing new legislation on distribution and trafficking of the drug.  “It killed more than 20,000 Americans last year and has been a driving force behind the opioid crisis in the United States.”  Fentanyl’s high potency increases the likelihood of respiratory problems and the need for a very quick response to deal with overdoses.  Other legislators, and lawyers filing class action suits, accuse the pharmaceutical industry of fueling the nation’s opioid crisis by pushing sales of fentanyl and other opioid pain killers, such as OxyContin and Vicodin.  Senator Claire McCaskill’s (D-MO) has been especially active in pressuring pharmaceutical companies for culpability in the crisis.  Last week, six more states filed lawsuits against pharmaceutical companies that produce opioids in an effort to address the current crisis.  These remedies may fail to cure the nation’s deadly opioid problem if they only treat the symptoms and not the cause.

When legendary rock musician Tom Petty died of a drug overdose in October, 2017, the medical examiner’s autopsy found fentanyl in Petty’s system.  But there were also many other drugs in his system, including benzodiazepines, oxycodone, acetyl fentanyl and despropionyl fentanyl, temazepam and alprazolam, and citalopram, an antidepressant. Was it the fentanyl that killed him?

According to an expert I spoke with, that is what medical examiners will conclude when they spot fentanyl in a toxicology report.  But as we all know from warning labels advising us not to mix alcohol with many prescription drugs, the combined action of multiple drugs have different, potentially deadly, actions than the individual drugs do.  When people abuse multiple drugs simultaneously — often illicit synthetic drugs with unknown purity, potency, and physiological properties, death is most likely caused by the combined actions of all the drugs in the system.

Deaths related to illicit fentanyl overdose in the state of New Hampshire climbed from 145 to 362 in 2016.  Researchers reviewed all available data in medical records of people who died from fentanyl-related overdoses in the state, and found that in most cases, the overdose victims had multiple drugs in their system when they died.  Indeed, 90% of people who O.D. on fentanyl had more than one drug in their bloodstream.  20% had 10 or more drugs, and one individual had 19 substances in their system that could be identified at autopsy!  Some illicit drugs elude detection because the drug pushers who cook up synthetic versions of marijuana, opiates, and other drugs, are constantly modifying their concoctions to elude federal regulations.  On average 6.2 different drugs were identified in these people whose death was attributed to fentanyl.

The drugs found in combination with fentanyl in these overdose victims span across many different categories:  heroin/morphine (21%), non-fentanyl opioids (34.5%), cocaine (31%), benzodiazepines (28%), and alcohol (33%), marijuana (38%), cocaine (37%), antidepressants (24%), amphetamines (10%) — a toxic brew indeed.  Although moderate alcohol and marijuana consumption may not be lethal from a toxicological perspective, they can be deadly from a behavioral perspective. Just as alcohol and marijuana can prove fatal if they precipitate a car wreck, so too can they prove deadly if they facilitate the use of fentanyl and other drugs by lowering inhibitions.

Fentanyl and other opiates are miracle drugs for people suffering from excruciating pain.  According to a CBS news report, 1 out of three Americans used a prescription opioid pain medication in the year 2015, yet only 6% of patients prescribed opioid pain medications for medical purposes: to control pain after injury or surgery; for example, become addicted to opiates.

The essential question is this:  Who can and who cannot take opiates without undue risk of becoming addicted?  Therein lies the nub of the problem.  What are the genetic, physiological, psychological, and situational factors that put a person at risk of becoming dependent on opioids, and what drives certain individuals to seek solace by abusing drugs of all kinds, often in desperate combinations?

Those answers are more difficult, but they are knowable, and actions and legislation to address this — the heart of the problem — will be the most effective way to help people who are addicted to opiates, to prevent them from becoming addicted in the first place, and to prevent tragic overdoses that have taken the lives of so many talented individuals like Tom Petty, and countless others.

This article was first published in Psychology Today