Tox Tuesday: W-18 and the war on opiates

Alarmed by the rising death toll from prescription painkillers and frustrated by a lack of federal action, some state lawmakers are beginning to take matters into their own hands by forming legislation that could change how prescription painkillers are prescribed in their states.

At the same time, however, a new opioid designer drug, known as W-18, has surfaced in Canada, adding further to the issues of drug abuse and overdose several countries are facing today.

According to an article, W-18 is a synthetic opioid with no known clinical use. It comes in powder form, and likely derives from Chinese labs where little-known drugs and analogues of known drugs are mass-produced and sold online. W-18 is 10,000 times more powerful than morphine and 100 times more powerful than fentanyl, another prescription opioid, greatly increasing the likelihood of overdose and death.

According to the B.C. Centre for Disease Control, the drug comes from a “W-series” of opioid compounds first discovered at the University of Alberta in 1982. There are 32 compounds, W-1 to W-32, with W-18 being the most toxic. W-18 is not currently regulated under the Controlled Drug and Substances Act and can be manufactured and bought freely, the article states.

“There is no way to really reduce the supply side because it’s being produced in a foreign country,” Martin Schiavetta, staff sergeant with the Calgary police drug unit said in the article. “We really have to focus on the demand side, through awareness education and prevention.”

Warnings to citizens regarding W-18 have come in the wake of a spike in fentanyl deaths and the ongoing battle to control prescription drug abuse across the U.S. and Canada. According to the Centers for Disease Control and Prevention (CDC), in 2014 more than 47,000 drug overdose deaths occurred in the U.S., a 14% increase from the previous year.

Opioids — primarily prescription pain medicines and heroin — were the main drugs responsible for overdose deaths. In fact, in many recent heroin deaths, illicitly produced fentanyl, which is often mixed with heroin, was also found.

Opioids “are passed out like candy in America,” Gov. Peter Shumlin of Vermont said in a recent article. Federal data shows that health care providers write more than 250 million prescriptions a year for painkillers, enough for every American adult to have a bottle of pills.

Statistics show the use of opioids began to skyrocket in the 1990s in the face of claims by pharmaceutical companies and medical experts that opioids could be used to treat conditions like back pain and arthritis without fear of addicting patients. As their misuse and abuse became rampant, however, public health officials, doctors, regulators and pain-treatment advocates remained deadlocked for years over how to address the public health crisis. In the meantime, designer drugs like W-18, which can be concocted in a laboratory, also began to gain popularity.

The lack of action and “push back” from doctors and prescription drug companies, is now what has caused several elected state officials to introduce legislation that could control how these types of drugs are prescribed. In fact, Massachusetts lawmakers recently passed a bill which would sharply restrict the number of pain pills a doctor can prescribe after surgery or an injury to a seven-day supply. This is in sharp contrast to the 60–90 prescription pain pills that some doctors and dentists are prescribing patients today.

Officials in Vermont and Maine are considering similar actions, the article states. And that’s not all, according to the American Academy of Pain Management, there are currently about 375 proposals in state legislatures that could regulate pain clinics and several aspects of prescribing painkillers. In addition, governors across the country are set to meet this summer to develop a broad approach that could reduce the use of painkillers, the misuse of drugs, and the incidence of addiction.

However, another article states it is unclear what effect these types of laws could have on overdose death rates. Some experts argue that measures to reduce prescribing painkillers may be having the unintended consequence of driving people to try heroin and other illicit drugs. Others dispute that, pointing out that the shift toward heroin use happened before the recent policy focus on opioids took hold.

Regardless, there has been some success in slowing the number of prescriptions written for painkillers, including in Kentucky, where a series of measures passed in 2012 now requires doctors to check a statewide database before writing a prescription for an opioid medication. The database, which all states have, with the exception of Missouri, monitors the names of individuals who have received prescriptions for painkillers and stops people from getting prescriptions from multiple doctors.

According to a 2015 report, opioid prescribing in the state fell 8.6% in just one year. States have also started to look at other programs as a possible model to reduce opioid addiction, including one used since 2012 by insurer Blue Cross and Blue Shield of Massachusetts.

Under the program, doctors cannot initially issue more than a 15-day supply of painkillers and doctors are restricted from prescribing more than 30 days worth of the drugs over a two-month period. In addition, they must seek prior approval from the insurer before prescribing long-acting narcotics such as OxyContin, except for cancer patients or those receiving palliative care.

As stated in the article, over the last three years, Blue Cross and Blue Shield of Massachusetts has found an 18% decline in the volume of opioid doses prescribed and a 50% drop in prescriptions for OxyContin and other long-acting opioids.

“If we could adopt policies regionally or nationally, we could make some real progress,” Governor Shumlin said.

To deal with the rapid increase in opioid-related deaths and the emergence of W-18, also known as “beans” or “shady 80s,” Alberta Health Services announced recently there will be expanded access to naloxone, a medication that aids in reversing the symptoms of an opioid overdose. However, due to the strength of W-18, there is little evidence to suggest naloxone would have an effect in treating an overdose, the BC Centre for Disease Control said.

Similarly, New York government officials announced last week that pharmacies around the state can sell opioid-blocking naloxone over the counter, without a prescription. Governor Andrew Cuomo said he hopes this will be an example to other states, as access to treatment lags locally and around the nation.

Furthermore, the CDC is expected to issue guidelines urging doctors to use opioids sparingly and treat pain first with non-drug approaches. In addition, the Senate passed a bill last week that would authorize funds for states to underwrite addiction treatment services and prescription monitoring databases, though it did not provide immediate money for the measures.

While there is certainly much more work to be done, government and health officials are in agreement that these steps must be taken at both a state and national level and marks only the beginning of what needs to be done to combat the issues of opioid addiction in the U.S., Canada and abroad.

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