Good Drug, Bad Drug

by Mary Fernando

I would like to introduce my colleague: an Emergency Room doctor with a passion for crime novels. He is a father and an all around good guy who saves lives regularly. He is also a passionate fan of crime novels and has some interesting ideas about murder. I will call him Emergency doctor Extraordinaire or EE for short.

My interview with EE was wide-ranging, but one of the issues he discussed at length was fentanyl - a drug that we hear about daily as a killer of addicts. In EE’s hands, fentanyl is transformed into a character, a noble one that has fallen into disrepute, and finally becomes a murderer of one person at a time, or many in one fell swoop.

Let me tell you EE’s story of fentanyl: the good guy gone horribly wrong.

Although fentanyl has been in the news as a deadly street drug, it has far nobler origins. Since the 1960s, fentanyl has been used as a pain reliever when other opioids aren't strong enough. About 50 - 100 times more potent than morphine, fentanyl is used for cancer pain and thank goodness we have it. In the hands of a doctor who prescribes the right dosage, it is a safe and decent drug. I stress the word decent, because if you haven't seen a person screaming in pain, then you have no idea how relieving this pain is the height of decency and good medicine.

However, if the dose of fentanyl is too high it can cause death. Fentanyl binds with opioid receptors in the brain that give a sense of well being. The problem is that these same opioid receptors are found in the area of the brainstem that controls breathing. So, breathing - essential to living - can be shut down by this same sense of well being - everything is fine it says - no oxygen needed. A high dose of fentanyl gives people such a sense of well being that they forget to breathe.

That last sentence should give us all pause: smothering while surrounded by air. For those of us who write about murder, the focus is always justice - righting a wrong. The murderer is that vile, unsavoury creature to be chased down and brought to justice. However, not all methods of murder are equal and, I would argue, the method of murder is a character in itself. And you will find few viler methods of murder than fentanyl and smothering a victim in air.

So, back to my EE and his thoughts: ‘In a fentanyl naive patient, it can kill at much smaller doses, so a patch that is therapeutic for cancer patients, can kill someone who has never received fentanyl.’
As with all drugs, a tolerance develops. So, patches, clear and small, can be put on the skin of a victim who is fentalyn naive. EE thinks a nicotine patch or other patch could easily hide it and be removed after. Another intriguing method of delivery is a nasal spray - so perhaps a method of substituting that for Aunt Gertrude’s sinus irrigation? Would this come up on an autopsy? EE responds by saying, “At first glance it would look like someone had a heart attack and died.”

This also brings up the issue of getting fentanyl. Healthcare workers can pretend to give it and store it up. Even a couple of patches could kill an opioid naive victim. Or there is always the street market.
EE pointed out a very frightening and immensely writeable option: weaponizing of carfentanyl. This drug is 100X more potent than fentanyl, and as much as 10,000 times stronger than morphine. There is the frightening scenario of mass murder. Carfentanyl’s deadly potential comes as no surprise to the various countries that have experimented for decades with weaponizing this synthetic opioid.
Although never officially confirmed, it was reported that the Russian military pumped aerosolized carfentanyl into a theatre to incapacitate the armed Chechens who took more than 850 people hostage in 2002. In this event, more than 120 hostages died.

This has thriller written all over it. An aerosolized form can kill many - how about a chase to find the carfentanyl and those who plan to use it?

If a character can be a focus- so can the weapon of choice. There is something poignant about a noble drug, developed to ease the extreme suffering of patients, being turned into a killer. Worse, this killer can then massacre thousands. It is a noble character gone wrong. And the making of a crime novel. Or a thriller.