Thread by @DrSarahAxelrath

I was talking to a patient recently about her different experiences using heroin vs fentanyl. She’s been using opioids a long time. Too long, by her count.

She explained the difference to me like this (shared with permission):

1/x

With heroin, she had a 6-12 hour period after using when she could reliably expect to feel well. She could work, or visit with family. She could get a full night’s sleep and know she had enough left over to get well in the morning. She managed this way for years.

2/x

With the transition of our street drug supply from heroin to fentanyl, all that relative stability and predictability was lost. Because fentanyl is so short acting, she has to use every 3-4 hours to stay well. She wakes up in the middle of the night sick, forced to use.

3/x

Because illicit fentanyl is so unpredictable, she never has enough to make sure she can stay well until tomorrow. What if this batch is bunk? What if the next one is? With such variable potency she is constantly worried about running out and becoming sick.

4/x

With heroin there was some reprieve, but with fentanyl the hustle to stay well is relentless. She likened the stress of her fentanyl habit to being homeless - constantly worried about how she’s going to get this basic daily need met, and what will happen if she can’t.

5/x

She’s housed now, but “with fentanyl, it’s like I’m homeless in my mind. I can’t let my guard down to rest, not even for one second. I have to stay in the hustle every moment to stay safe, to stay well.”

6/x

Also shared with permission: she sells fentanyl to make enough money to support her own dependence. She doesn’t like doing it, but day labor has become nearly impossible with all the time and energy it takes to manage her habit.

7/x

Increasingly harsh punishments for possessing and selling fentanyl, like those under consideration in the CO legislature, won’t solve the problem when most people who distribute are doing so at low levels to support their own dependence.

8/x

You know what WOULD stop her selling fentanyl? Easier access to #MOUD like methadone, buprenorphine, sustained-release oral morphine, and prescribed injectable heroin to stabilize her dependence. No need for fentanyl ➡️ no need to hustle ➡️ less fentanyl bought and sold.

9/x

She would love to stop selling, but will never be able to as long as she herself is reliant on an unforgiving, unpredictable street drug supply. Given a safe supply, she WILL use it and be under considerably less pressure to sell herself.

10/x

Just some food for thought @jaredpolis @COAttnyGeneral @pweiser @leslieherod @pettersen4co @DenCityCouncil @KyleClark @kyle_a_harris @RubinoJC @jeremyjojola

For the people asking “but can’t she be on methadone or buprenorphine?!” - yes. We discussed both options in great detail, as that is literally my job. She’s engaged in care and getting the best possible treatment under the circumstances. I won’t be sharing anything more.

Wow, I’m blown away by the overwhelmingly positive response. For every 1 stigmatizing or uninformed comment, there have been 100+ wanting solutions rooted in evidence-based #harmreduction, NOT punishment & incarceration. We are not in the minority, and we ARE voting constituents.

I will be sure to share your messages of support, compassion, and hope with my patient. Imagine if *everyone* who struggles with chaotic substance use could feel this outpouring of unconditional love.

Finally, before I mute replies, hello to all my unexpected new followers! I tweet about #harmreduction, addiction medicine, and heavy metal. I love people who use drugs and pitbulls. That’s all you really need to know about me. 😘