Fentanyl Vaccine - How to Vaccinate Ethically

[AbidingArs]

The recent fentanyl vaccine article on Ars (originally from wired.com) got me interested in wondering about the ethics of such a vaccine, its use, and how it is likely to be used in the real world. Assuming it works as advertised on fentanyl and fentanyl-derivatives without targeting other opioids or having other side effects, I wonder how people think it should (and will) be used in the United States of America.

My main concern (beyond general safety) is articulated in some of the responses in this set of interviews of 74 volunteers that were "adolescents and young adults with a diagnosed opioid use disorder (from Boston Children’s [Adolescent Substance Use and Addiction Program]), their families, experts in substance use treatment, clinicians, scientists, and the general public":

“Parents who had lost kids to overdose were especially enthusiastic, saying ‘Every kid should get this’ or ‘Every kid going to college should get this,’” says Weitzman.

I understand the sentiment. And I'm usually in favor of broad vaccination requirements for diseases. But I worry that in this case, a vaccine would be forced on a broad population that is not at risk of encountering fentanyl. My second worry is that it will be forced on those at risk through coercion: as part of drug treatment programs or avoiding/reducing sentences in the justice system. Or, as put in a two-day conference discussing concerns with a fentanyl vaccine, "the ethical challenges to trialing a vaccine to prevent overdose, the need for protections from coercion, and the importance of autonomy and the right to make ‘bad’ choices."

Another big concern raised in the comments on the article were the effects of the vaccination on pain management using hospitals - with numerous posts on being stuck unable to communicate while still in pain during an emergency operation. I wish the conference had included a bit more discussion on these issues, as I didn't find this very detailed beyond a general "it's complex and we're thinking about it" (which I imagine it is but is not helpful for a lay person considering the issue):

Drs. Joe Kossowsky, PhD, MMSc (Boston Children’s Hospital, Harvard Medical School) and Sharon Reif, PhD (Brandeis University) shared perspectives on the complexities of fentanyl vaccination given widespread use of fentanyl as an analgesic and the overlap between several risk factors for substance use disorder and overdose and value of fentanyl for pain management. Subtle tradeoffs and operational complexities were discussed including those related to characteristics of fentanyl that make it a first line analgesic for surgical, emergency and military/battlefield uses. Many of the populations that might benefit from fentanyl as an analgesic for emergency and military purposes are paradoxically at high risk of overdose given potential for post-traumatic stress disorder [51], substance use/addiction [52,53], and pain [54].

That conference had other concerns as well: evidence of systemic racism in the availability of naloxone point to concerns about equitable access to a vaccine:

From 2019 to 2020, Black individuals had the highest rate of increase of fatal overdose (44 %) [23] and lowest rates of naloxone access and training compared to other racial and ethnic groups [24]. Intersectional stigmas resulting from systemic racism and biases against substance use drives racial inequities in treatment and outcomes of substance use [25,26].
Dr. Margarita Alegria, PhD (Massachusetts General Hospital) described disparities and fragmentation of the substance use treatment system. She advised following a public health approach for promoting and distributing a fentanyl vaccine to avoid perpetuating and exacerbating disparities, and to ensure equitable access. Moreover, she emphasized the importance of a comprehensive approach to preventing overdose in which a vaccine would comprise a component within a broad set of initiatives and services.

Broader issues of addiction treatment in America:

Barriers to substance use treatment persist for individuals with co-occurring mental health disorders [31], in rural areas [32], holding marginalized identities [23,33], and with inadequate insurance coverage [34], exacerbate disparities in overdose rates and substance use harms.

The participants considered whether the human papillomavirus (HPV) vaccine is analogous in treating/preventing the outcome of behaviors that may have stigma attached from various social groups:

Parallels between the HPV and fentanyl vaccines were outlined, including for example, potential for opposition stemming from concerns that vaccination could inadvertently increase risk behaviors (e.g., sexual activity among youth for the HPV vaccine, and substance use for a fentanyl vaccine). Lessons can be learned from the successes and weaknesses of HPV vaccine promotion efforts, which were strengthened by educating the public about the relationship between HPV and cervical cancer [46], but vaccination was nonetheless stigmatized and faced related hurdles [47].

They also looked at lessons from the COVID vaccination efforts and discussed the importance of crafting an appropriate message for a fentanyl vaccine (which I think has also been applied to some of the recent measles outbreaks, to varying levels of effectiveness):

They noted that decision-making around vaccination is weighted toward emotional rather than rational decision-making, underscoring the value of narrative and storytelling for promoting adoption. Relatedly, they echoed comments on the influence of local connections and ties in fostering trust in the messages of experts. Use of tailored and targeted messaging is likely to be needed for advancing acceptance of a fentanyl vaccine demographic and geographic variation in risk factors for overdose and norms related to vaccination. Established strategies to confront vaccine hesitancy involve using personal narratives within public and patient education to help persons who might benefit from a fentanyl vaccine understand the issues involved in vaccine acceptance [44], an approach demonstrated with COVID-19 vaccines [45].

For better or worse, it looks like the United States of America is very interested in developing a fentanyl vaccine to combat overdoses. In 2022 (even with the concerns about vaccines), Governor Abbott of Texas was excited about such a vaccine back in 2022:

"Fentanyl remains the single deadliest drug threat our state and nation has ever encountered, and Texas continues leading the fight against this clandestine killer," said Governor Abbott. "I am proud to be at the University of Houston today to celebrate the brilliant achievement of Dr. Colin Haile and his research team on creating a fentanyl vaccine. This incredible, groundbreaking new therapy has the potential to revolutionize how we combat fentanyl deaths in our communities and end the afflictions of addiction that burden so many innocent Texans and Americans across the country. I look forward to working alongside the University of Houston and Dr. Haile in Texas' continued efforts to save innocent lives from being lost to this deadly drug."

So I am interested in the thoughts of the forum-goers here: do you think a vaccine is likely to be approved? How widely will/should it be used? Any other concerns or am I just being overly worried?

 

[fractl]

The vaccine sounds interesting. One question I had was how long the vaccine would last? Say you get the fentanyl vaccine and later get cancer that is very painful. Does that mean you’d never be able to use fentanyl for pain relief?

 

[Kyuu]

It's really disheartening to me that so many people even here at Ars are so quick to want to legislate and moralize this vaccine due to it being for a drug. I think the people who might benefit should get to weigh the pros and cons themselves, along with any relevant parties such as their doctor, and then be able to take it without any judgement from others if they choose.

The whole "but what about legitimate use of fentanyl for pain relief" concern seems way overblown to me, also.

 

[AverageDutchGuy]

Parallels between the HPV and fentanyl vaccines were outlined, including for example, potential for opposition stemming from concerns that vaccination could inadvertently increase risk behaviors (e.g., sexual activity among youth for the HPV vaccine, and substance use for a fentanyl vaccine).

This feels like a slightly stupid take. The HPV vaccine prevents the person taking it from getting a very nasty and potentially deadly illness and has (for the vast majority) no side-effects. The Fentanyl "vaccine" (I would maybe prefer calling it a Fentanyl blocker) PREVENTS fentanyl from working and stops the high. In what way would it INCREASE risk behaviour if it stops the high that normally leads to addiction? Are they worried people would start doing fentanyl because there's a vaccine available if they get addicted? Ignoring all the nasty side-effects of a fentanyl addiction both before and after that point? Imho the fentanyl "vaccine" is more of a longer lasting version of naloxone/Narcan than a anything. I can see how the HPV vaccine might make someone thing "i'm now prevented from getting HPV, lets duck like a rabbit" but... you're not stopping that person from doing it anyway without the vaccine either imho.

 

[wxfisch]

I think a lot more attention needs to be given to how this impacts/effects on-label use of fentanyl in healthcare settings. Anyone that has gotten surgery has almost certainly had fentanyl in the mix their anesthesiologist gave them. Just hand waiving it away as "yeah, that may be a problem we need to look at more but I am sure it'll be fine" is the most wishful of thinking.

 

[AverageDutchGuy]

It's really disheartening to me that so many people even here at Ars are so quick to want to legislate and moralize this vaccine due to it being for a drug. I think the people who might benefit should get to weigh the pros and cons themselves, along with any relevant parties such as their doctor, and then be able to take it without any judgement from others if they choose.

The whole "but what about legitimate use of fentanyl for pain relief" concern seems way overblown to me, also.

You seriously don't see the potential for ethical issues due to coercion (of even low risk groups) into taking a vaccine that might render legitimate medical use of an opioid ineffective?

 

[papadage]

That is an argument for treating the vaccine differently from others, by adding requirements for more robust informed consent and mandatory counseling for at-risk folks. Who would be included in a tricky question? Certainly, people with current and past addiction issues should be candidates since the risks from addiction are more severe and immediate. But I am not sure how to draw the line for people who are at increased risk due to genetics, such as having the dopamine receptors that make them 40-60% more likely to be addicts when exposed. That could be a factor that is weighed along with family history, how common addiction is in their social circle or locale, and others.

It's a tricky question that will get short shrift with the current FDA and HHS.

 

[AbidingArs]

This feels like a slightly stupid take. The HPV vaccine prevents the person taking it from getting a very nasty and potentially deadly illness and has (for the vast majority) no side-effects. The Fentanyl "vaccine" (I would maybe prefer calling it a Fentanyl blocker) PREVENTS fentanyl from working and stops the high. In what way would it INCREASE risk behaviour if it stops the high that normally leads to addiction? Are they worried people would start doing fentanyl because there's a vaccine available if they get addicted? Ignoring all the nasty side-effects of a fentanyl addiction both before and after that point? Imho the fentanyl "vaccine" is more of a longer lasting version of naloxone/Narcan than a anything. I can see how the HPV vaccine might make someone thing "i'm now prevented from getting HPV, lets duck like a rabbit" but... you're not stopping that person from doing it anyway without the vaccine either imho.

I think there are two arguments. The first is the general narrative in American society against "shortcuts" for behavioral issues; I would point to some of the debates on GLP-1 drugs that condemn the drugs because of the sentiment that "people need to overcome hunger through willpower" and that people are trying to take the easy way out of the consequences of their behaviors. I don't view that as a very good argument.

The other argument is that fentanyl is cut into other illegal drugs, which is why there are efforts to provide testing kits to check for the presence of fentanyl in drugs. In this argument, the threat of rapid death from any illicit drug use would keep people away from all drugs. This is ultimately the same argument used against providing those testing kits, needle exchanges, or Narcan/naloxone.

This paper claims that their testing has shown a rise of fentanyl mixed with other drugs over time.

Samples with reported heroin have consistently had the highest proportion of co-occurring fentanyl, increasing from 0% in early 2013 to 20% by 2018 and about 50% in 2023 (Fig. 1A). Fentanyl co-occurrence with club drugs (e.g., MDMA) rose from approx. 0%–5% from 2016 to 2019 and stayed at that level since, though with some variation over time. Fentanyl co-occurrence with methamphetamine and cocaine (Fig. 1B) has been increasing but remains under 4%. By 2023, fentanyl was detected in less than 4% of cocaine samples and around 1% of methamphetamine samples, up from <0.05% to <0.01% respectively in 2013. Fentanyl co-occurrence with prescription opioids reached over 1% by 2023, though also with substantial variation over time (Fig. 1B). Fentanyl co-occurrence with cannabinoids remained below 0.3% over the study period (Fig. 1C), while co-occurrence with hallucinogens, prescription stimulants, and prescription benzodiazepines varied substantially but was largely ≤1% (Fig. 1C).

Note that there is also substantial variation in the percentages found in states and over time, so national statistics may be misleading for the risk a user might be facing:

While fentanyl co-occurrence with cocaine was ≤4% nationally, parts of the Northeast had higher rates, with recent co-occurrence rates over 10% in New Hampshire, Connecticut, and Rhode Island. Kentucky and Ohio also had similarly above-average levels of co-occurrence with cocaine (Fig. 4). Fentanyl co-occurrence with methamphetamine showed similar geographic concentration, arising mostly in Massachusetts (21.7% in 2017), New Hampshire (over 8.0% from 2019 to 2020), Connecticut (over 10.0% from 2017 to 2018), and New Jersey (7.0% in 2019). State-level trends (Supplementary Table S5) in fentanyl co-occurrence with club drugs, cannabinoids, prescription opioids, hallucinogens, prescription stimulants, and prescription benzodiazepines generally remained under 2%, albeit with occasional spikes in some states and years (Supplementary Figure S2), particularly for club drugs and, more recently, cannabinoids in some northeastern and Appalachian states (e.g., Kentucky).

 

[GohanIYIan]

My understanding is even skin contact with fentanyl can be dangerous and more pronouncedly so in kids because their bodies are smaller. So there's some public safety argument for giving it to children, but I don't know enough about medical use or the viability of alternate pain killers to weigh the counter argument side of it.

 

[rain shadow]

I was looking at the figures in https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates

OD from fentanyl is skyrocketing starting about 2014. It looks absolutely terrible, 70k deaths in 2023.

But looking a little closer, deaths from alternatives like heroin and prescription opiates/opoids have dropped by tens of thousands. Overall, it's still worse than it was but I think the fentanyl crisis is about 30% overstated when you adjust for lower deaths from the alternatives.

 

[acefsw]

This feels like a slightly stupid take. The HPV vaccine prevents the person taking it from getting a very nasty and potentially deadly illness and has (for the vast majority) no side-effects. The Fentanyl "vaccine" (I would maybe prefer calling it a Fentanyl blocker) PREVENTS fentanyl from working and stops the high. In what way would it INCREASE risk behaviour if it stops the high that normally leads to addiction? Are they worried people would start doing fentanyl because there's a vaccine available if they get addicted? Ignoring all the nasty side-effects of a fentanyl addiction both before and after that point? Imho the fentanyl "vaccine" is more of a longer lasting version of naloxone/Narcan than a anything. I can see how the HPV vaccine might make someone thing "i'm now prevented from getting HPV, lets duck like a rabbit" but... you're not stopping that person from doing it anyway without the vaccine either imho.

I think there are legitimate concerns raised, but I concur that this vaccine is not analogous to the HPV vaccine.

HPV is a communicable virus that can lead to developing various deadly cancers. Everyone has sex, (yes there are some outliers), and risks being exposed to the virus, everyone breathes and can be exposed to a multitude of viruses by that vector, and so forth but not everyone is going to abuse fentanyl. It's not a communicable disease that can spread and harm others's health, (yes, there are other social harms).

So, I think it does raise more legitimate ethical questions about administering a vaccine for fentanyl as a preventative as opposed to vaccines for communicable diseases. It's sorta in a category all it's own.

 

[ramases]

The vaccine is an experimental vaccine that can prevent a fatal outcome in medical conditions that, to the unvaccinated regularly lead to their death.

As such the standard concerns around vaccine ethics and safety, especially for experimental vaccines, apply.

Beyond that I cannot see how you would argue that this vaccine is different without also somehow arguing that those that take drugs somehow are deserving of the fatal outcomes drug use can produce; this necessarily will also lead to arguing that drug users, at least in some circumstances, deserve death.

Honestly I don't like drug use and the effects it has on people and their loved ones. Yet, I will always choose preserving their life over preserving my abilities to judge them for their life choices

 

[Garfield the Cat]

My understanding is even skin contact with fentanyl can be dangerous and more pronouncedly so in kids because their bodies are smaller. So there's some public safety argument for giving it to children, but I don't know enough about medical use or the viability of alternate pain killers to weigh the counter argument side of it.

That is 100% not true (skin contact is dangerous). If it were, we would be seeing all sorts of healthcare workers going down from accidental exposure via the skin.

Maybe if it is a Fentanyl patch, but that would be on for hours to get any sort of problematic dose.

 

[AbidingArs]

That is 100% not true (skin contact is dangerous). If it were, we would be seeing all sorts of healthcare workers going down from accidental exposure via the skin.

Maybe if it is a Fentanyl patch, but that would be on for hours to get any sort of problematic dose.

Echoing this with a source from UC Davis Health:

Can fentanyl be absorbed through the skin or by touching an item or surface where it is present?
It is a common misconception that fentanyl can be absorbed through the skin, but it is not true for casual exposure. You can't overdose on fentanyl by touching a doorknob or dollar bill. The one case in which fentanyl can be absorbed through the skin is with a special doctor-prescribed fentanyl skin patch, and even then, it takes hours of exposure.

Looking at the symptoms of an overdose, it sounds to me like a lot of the reactions in various videos to perceived exposure (where the overdose victim, usually a cop, is freaking out) is likely an anxiety attack? I sympathize - I would probably have one as well if I thought I was about to die. It doesn't match up at least:

What are the symptoms of a fentanyl overdose?
When someone overdoses on fentanyl or any opioid, their respiratory rate will slow, they will get sleepy and by the time we would say that they have overdosed, they would be unconscious. They would also have small pupils and would be minimally breathing or not breathing at all. People who have overdosed on any opioid need help immediately.

 

[acefsw]

The vaccine is an experimental vaccine that can prevent a fatal outcome in medical conditions that, to the unvaccinated regularly lead to their death.

As such the standard concerns around vaccine ethics and safety, especially for experimental vaccines, apply.

Beyond that I cannot see how you would argue that this vaccine is different without also somehow arguing that those that take drugs somehow are deserving of the fatal outcomes drug use can produce; this necessarily will also lead to arguing that drug users, at least in some circumstances, deserve death.

Honestly I don't like drug use and the effects it has on people and their loved ones. Yet, I will always choose preserving their life over preserving my abilities to judge them for their life choices

I don't think it's a question about them deserving it or not. Yes, it's experimental. If it does turn out to significantly lower the effectiveness of opiates used in medical procedures, it may not be beneficial to innoculate the whole population since the overall risk of overdose is quite low.

We really need more testing in order to assess whether this should be given to the population as a whole or just to those who have demonstrated they are at risk of overdose.

 

[ramases]

I don't think it's a question about them deserving it or not. Yes, it's experimental. If it does turn out to significantly lower the effectiveness of opiates used in medical procedures, it may not be beneficial to innoculate the whole population since the overall risk of overdose is quite low.

We really need more testing in order to assess whether this should be given to the population as a whole or just to those who have demonstrated they are at risk of overdose.

"Should we deploy this vaccine to the entire population?" is a different question than whether the vaccine should be available to the entire population, and IMHO the answer to that is, "mu"/無.

The vaccine should be available to all who ask for it. Despite the rhetorical figures used opioids are not an infectious disease, so there is no good public policy justification to go further than to delegate that decision to each person individually for their own body.

 

[AbidingArs]

The vaccine sounds interesting. One question I had was how long the vaccine would last? Say you get the fentanyl vaccine and later get cancer that is very painful. Does that mean you’d never be able to use fentanyl for pain relief?

It sounds like it is too early in the process for experimental results in humans but it might be a year based on what they saw in rat subjects.

The effects lasted for at least 20 weeks in the rats, which Gage thinks could translate to a year of protection in people.

I've seen various figures for a year or two in the other literature but I'm not sure if that is a different vaccine candidate or a duration they hoped to hit.

 

[Coriolanus]

You seriously don't see the potential for ethical issues due to coercion (of even low risk groups) into taking a vaccine that might render legitimate medical use of an opioid ineffective?

Doctors can't even convince a lot of people to vaccinate themselves or their kid for measles, or HPV, or chicken pox. And some of those diseases can wind up killing you or making your life really terrible for a while.

Do you think doctors are really in the position to coerce people into vaccinating for fentanyl?

 

[Kyuu]

You seriously don't see the potential for ethical issues due to coercion (of even low risk groups) into taking a vaccine that might render legitimate medical use of an opioid ineffective?

Not really. It doesn't render all opioids ineffective, and rendering a single painkiller ineffective for a period of time is a much lesser problem than, y'know, dying from a fentanyl overdose. Or even just being addicted.

A lot of clutching at pearls, seems to me.

 

[acefsw]

"Should we deploy this vaccine to the entire population?" is a different question than whether the vaccine should be available to the entire population, and IMHO the answer to that is, "mu"/無.

The vaccine should be available to all who ask for it. Despite the rhetorical figures used opioids are not an infectious disease, so there is no good public policy justification to go further than to delegate that decision to each person individually for their own body.

Yeah, I phrased that poorly. Since it's not communicable, (which I stated earlier upthread), it's not something that needs to be distributed population wide. I thought the person I was replying to was for such distribution.

 

[Tijger]

Make it available? Yeah, I'd be somewhat in favor provided people would very clearly understand that in future it could have negative effects for them when given fentanyl in a medical setting.
I do find it a bit awkward when considering taking fentanyl is something people do voluntarily and to get high, I'm not fan of encouraging that behavior and that is what this would do, I think.

Would I ever take such a vaccine? No. I'm never going to take fentanyl for any other than medical reasons and I would damn well hope it works as intended if I ever needed it.

 

[Megalodon]

Not really. It doesn't render all opioids ineffective, and rendering a single painkiller ineffective for a period of time is a much lesser problem than, y'know, dying from a fentanyl overdose. Or even just being addicted.

A lot of clutching at pearls, seems to me.

Consider that in medical ethics the threshold for doing a medical intervention on someone with nothing wrong with them is incredibly high. Vaccines against communicable diseases meet that bar because the risks are negligible and the potential benefit is enormous. But for a drug that not everyone takes and has potential beneficial therapeutic uses the justification just isn't there to do it at a population level. Maybe for individuals if there's evidence-based ways to use it, but to promote it for widespread prophylactic use is just prohibition. It's that ugly American puritanical streak rearing its ugly head once again.

And I'm going to be perfectly honest, fuck anyone that wants to make the latest front in the war on drugs my own body. If you want to manage drug abuse the way to do it is to a) treat it as a public health problem and b) take public health problems seriously. And while you're at it c) how about we try to address the social conditions that lead to the population having such high drug abuse potential to begin with. Drug abuse, particularly opioid abuse, is a symptom of people whose lives are fucked up in ways they can't do anything about because it creates a temporary respite from their lives, and we're currently doing our best to make sure as many people as possible need that.

This idea you're going to find a magical body modification that cures people of sin is illusory and it is, frankly, evil. It's the same kind of thinking that had the entire US mutilating (aka circumcising) kids on the notion that it prevents masturbation (it doesn't), premised on the notion that masturbation is a problem to be solved (it's not).

And fentanyl for all its problems is still one of the most important tools in managing crippling amounts of pain. Who are you to decide it's beneficial to make that unavailable to people? It's Goodhart's law, "When a measure becomes a target, it ceases to be a good measure.". In this case, overdoses are at least in part a symptom of other things, and rather than address those other things we are prepared to torment people to game the metric. Fuck everything about that.

 

[AbidingArs]

Doctors can't even convince a lot of people to vaccinate themselves or their kid for measles, or HPV, or chicken pox. And some of those diseases can wind up killing you or making your life really terrible for a while.

Do you think doctors are really in the position to coerce people into vaccinating for fentanyl?

I agree that coercion from doctors is not my main concern. My worries are mostly on drug treatment programs in prisons mandating its use or it becoming mandatory in such programs that would coerce prisoners or to avoid prison time altogether. If the fentanyl vaccine becomes a normal part of treatment for addiction, then why should it not be mandated as part the treatment required in prison or as part of avoiding prison via drug court? I can also see a lot of pressure from parents of youth as they are going off to college - as exemplified by the general sentiments of "every kid going to college should get this." I understand the sentiment and can see the logic, given the difficulty of determining the risk that someone's child will experiment with drugs in college (or is already using). And getting it used fairly uniformly could help with the stigma, to avoid the feeling of "my parents think I'm going to get addicted to drugs in college."

The element of coercion from doctors I could see would be more tied into prescriptions (and not be pressure from doctor's themselves necessarily). Consider the difficulties those who are judged to be drug-seeking in getting prescriptions for opioids filled. Pharmacists can and do question prescriptions and refuse to fill them; in some cases, police are called and driver's licenses kept. Could there be a requirement to show proof of fentanyl vaccination to be given any pain relief drugs? Might it go further and require family members to be vaccinated? After all, risk factors for overdose include "being a recipient of an opioid prescription" and "being a family member of someone who is on prescribed opioids". It does seem like a stretch to me, but I don't think it could be ruled out.

 

[Kevin Lantz]

I mean fentanyl is a go to medication in nearly all surgeries... I'd hate to think about this being in a patient's system without a anesthesiologist aware of it...

 

[demultiplexer]

I feel like in this entire discussion, all if not 99.9% of concerns Ars commenters have pointed out are just otherworldly.

• Nobody coerces you to take such vaccines
• You're not going to get the vaccine if you post on ars. We're all basement dwellers, where the fuck would we even get drugs? Outside? Fuck that
• This vaccine is never going to be put into general rotation among vaccines for communicable diseases. Don't forget: the reason fentanyl overdose happens so often is because the unit risk is incredibly high, not because a lot of people are taking it. 100% of people get exposed to rubella viruses, maybe 1% of people ever take opioids recreationally (60 million worldwide according to the WHO).
• Your kids are not going to get this vaccine. Again, what kids? You're currently not wearing any pants and just tabbed out of Hearthstone
• Obvious opioid addicts in surgery are not going to get fentanyl as a painkiller. What the fuck, people.
• The lack of uniform medical records is going to mean there will be vaccinated people who end up with underdosed painkillers, specifically in cases where they are noncommunicative and have no relatives to inform the staff. This is 0.0000000000000000000001% of surgeries.

What I feel gets missed but is actually in the article: this is not a cure, this is not addiction prevention, this is not a panacea. This is not 'good enough', even in principle, to even warrant consideration as a broadly rolled-out preventative treatment. This is long-lasting narcan, but then only good for one specific opioid that is currently causing trouble. That's how to treat this. It's a very narrow medicine.

 

[dzid]

I feel like in this entire discussion, all if not 99.9% of concerns Ars commenters have pointed out are just otherworldly.

• Nobody coerces you to take such vaccines
• You're not going to get the vaccine if you post on ars. We're all basement dwellers, where the fuck would we even get drugs? Outside? Fuck that

I could almost certainly purchase fentanyl more quickly than I could get a six-pack of beer (note: I will do no such thing). Many of you no doubt could as well. It's that pervasive, in large part due to the well-known fact that most fentanyl is brought to the U.S. by Americans via official border crossings. but that doesn't seem to be a focus of interdiction efforts.

• This vaccine is never going to be put into general rotation among vaccines for communicable diseases. Don't forget: the reason fentanyl overdose happens so often is because the unit risk is incredibly high, not because a lot of people are taking it. 100% of people get exposed to rubella viruses, maybe 1% of people ever take opioids recreationally (60 million worldwide according to the WHO).

You know all those stories about some kid OD'ing on fentanyl and how it "must have been the coke was laced with it?" Vanishingly few cases where samples were available and properly analyzed showed that to be the case. Why would they lie?

• Your kids are not going to get this vaccine. Again, what kids? You're currently not wearing any pants and just tabbed out of Hearthstone

Hmm. Pants, check. No kids by choice. Other people's kids? Take this example. It's not a hypothetical. Regular high school kid's been taking pills his friend buys off Spotify's dingier corners. Thinks they're Xanax. Friend runs out, and kid starts to get sick. He can't go through withdrawal because his parents would lose their minds if they knew their kid was a junkie. He's terrified, and his friend offers some street fentanyl to get through the next few days... That's why they lie in many cases. The stigma.

• Obvious opioid addicts in surgery are not going to get fentanyl as a painkiller. What the fuck, people.

The fuck?

• The lack of uniform medical records is going to mean there will be vaccinated people who end up with underdosed painkillers, specifically in cases where they are noncommunicative and have no relatives to inform the staff. This is 0.0000000000000000000001% of surgeries.

What I feel gets missed but is actually in the article: this is not a cure, this is not addiction prevention, this is not a panacea. This is not 'good enough', even in principle, to even warrant consideration as a broadly rolled-out preventative treatment. This is long-lasting narcan, but then only good for one specific opioid that is currently causing trouble. That's how to treat this. It's a very narrow medicine.

Here I agree. It's a very narrow use case. The bigger problems are a) lack of will to truly deal with the issue, and b) Societal stigma. We know what people think of us, even those of us who left it behind.


ETA: I apologize for my tone. You didn't deserve that.

 

[Lt_Storm]

Here I agree. It's a very narrow use case. The bigger problems are a) lack of will to truly deal with the issue, and b) Societal stigma. We know what people think of us, even those of us who left it behind.

Add in that this seems like a simple solution for this issue, and I would not be shocked at all if various people think that coercing teenagers, prisoners, and other undersiables / relatively powerless people to take it is a good idea. The whole was on drugs things is built on this kind of coercion, as such the idea that "nobody coerces people to take such a vaccine" only really makes sense when such a vaccine doesn't exist.

If it does exist, it will surely be seen as a powerful weapon to be used in the war on drugs, and that means a great many people will be forced to take it or suffer worse consequences. Though, of course, many of those people are already forced to suffer those worse consequences, so... That coersion might be preferable to the status quo? Maybe?

Though, that might expand the efforts spent on the war on drugs, and, given the punitive nature of the war on drugs, such vaccines might not be punishment enough for someone to avoid those worse consequences entirely.

 

[dzid]

Add in that this seems like a simple solution for this issue, and I would not be shocked at all if various people think that coercing teenagers, prisoners, and other undersiables / relatively powerless people to take it is a good idea. The whole was on drugs things is built on this kind of coercion, as such the idea that "nobody coerces people to take such a vaccine" only really makes sense when such a vaccine doesn't exist.

If it does exist, it will surely be seen as a powerful weapon to be used in the war on drugs, and that means a great many people will be forced to take it or suffer worse consequences. Though, of course, many of those people are already forced to suffer those worse consequences, so... That coersion might be preferable to the status quo? Maybe?

Though, that might expand the efforts spent on the war on drugs, and, given the punitive nature of the war on drugs, such vaccines might not be punishment enough for someone to avoid those worse consequences entirely.

Such a vaccine, in the context of a functional public health system (implies public health no longer conflated with criminal justice) could be one option available to fully informed patients.

In our system today, the most likely scenario I could imagine would be "you can kick cold turkey in lockup or you can voluntarily sign this form that says you've been fully informed and take this vaccine. tick tock..."

 

[Lt_Storm]

In our system today, the most likely scenario I could imagine would be "you can kick cold turkey in lockup or you can voluntarily sign this form that says you've been fully informed and take this vaccine. tick tock..."

I'm guessing that would only be offered after you have spent just long enough in jail to ensure that your employer has already declared you a no-show...

 

[dzid]

I'm guessing that would only be offered after you have spent just long enough in jail to ensure that your employer has already declared you a no-show...

Usually, although to be fair on occasion one would be treated with decency. Normally cruelty is SOP.

 

[Shavano]

Such a vaccine, in the context of a functional public health system (implies public health no longer conflated with criminal justice) could be one option available to fully informed patients.

In our system today, the most likely scenario I could imagine would be "you can kick cold turkey in lockup or you can voluntarily sign this form that says you've been fully informed and take this vaccine. tick tock..."

I think you're right there's a potential for the vaccine to be forced on people for bad reasons. There's also a moral hazard where we stop other efforts to help people with addiction because the problem is supposed to be taken care of by the vaccine.

We need to remember that opioid overdose already was a significant cause of death before fentanyl started showing up in the street drug channels and would remain a problem if all the users were immune to fentanyl.

Addiction is the bigger problem. It can fuck up people's lives horribly and we need to help people
(a) avoid it and
(b) recover from it

That requires sustained effort. Something our society (and to be frank most societies) are bad at.

I don't think it's a question about them deserving it or not. Yes, it's experimental. If it does turn out to significantly lower the effectiveness of opiates used in medical procedures, it may not be beneficial to innoculate the whole population since the overall risk of overdose is quite low.

We really need more testing in order to assess whether this should be given to the population as a whole or just to those who have demonstrated they are at risk of overdose.

Yes, and fentanyl is one of the opioids that has real significant medical uses. It seems like the vaccine should not be applied to people who don't have opioid addiction.

 

[AbidingArs]

I think you're right there's a potential for the vaccine to be forced on people for bad reasons. There's also a moral hazard where we stop other efforts to help people with addiction because the problem is supposed to be taken care of by the vaccine.

We need to remember that opioid overdose already was a significant cause of death before fentanyl started showing up in the street drug channels and would remain a problem if all the users were immune to fentanyl.

Addiction is the bigger problem. It can fuck up people's lives horribly and we need to help people
(a) avoid it and
(b) recover from it

That requires sustained effort. Something our society (and to be frank most societies) are bad at.

Yes, and fentanyl is one of the opioids that has real significant medical uses. It seems like the vaccine should not be applied to people who don't have opioid addiction.

I had not considered that this might reduce other anti-addiction efforts. And good point on the danger of opioids outside of fentanyl and drug addiction in general.

I think there is a big drawback on your final point: the narrative of who all is at risk from fentanyl overdose is counter to the vaccine being used for just those diagnosed with opioid use disorder. I'm not sure of the validity of this, but this article discussing a fentanyl vaccine in Nature acknowledges that those with opioid use disorder are most at risk but continues with other groups that I think would be considered for inclusion (either by formal recommendations or social/parental pressure; again, see the statements from parents on whether their children should get this before going to college):

Of note, some at risk individuals, including ~65% of adolescents (under 18 years) who die of opioid overdose do not carry a diagnosis of OUD and are not known to have previously used opioids. Thus, the population that could benefit from an opioid vaccine is substantially larger than the OUD population. Indeed, several other risk factors are associated with increased risk of opioid overdose, including but not limited to, being a recipient of an opioid prescription, being a family member of someone who is on prescribed opioids, having a family history of overdose or having a personal history of other substance use disorders (Fig. 2), and overall, 80% of lethal opioid overdoses involve fentanyl.

I'm not sure how much the statistic provided can be trusted since I agree with dzid that people might well lie or minimize known drug use to avoid the stigma of seeking opioids or fentanyl.

 

[Lt_Storm]

There's also a moral hazard where we stop other efforts to help people with addiction because the problem is supposed to be taken care of by the vaccine.

Except that, here in America, we have mostly decided not to help people with addiction but, instead, punish them for it. so, the bigger moral hazard is that this becomes yet another punishment, one that can be administered before someone even has the problem.

 

[AnonymousCward]

I'm a very big fan of protecting people by encouraging risk reductions that don't involve abstinence, even if the act itself is kinda stupid. To do otherwise would be like telling people to not go horse riding, skydiving or bungee jumping instead of aiming for better safety procedures and accompanying PPE. Fear, uncertainty and doubt is what leads to unnecessary risks being taken, especially when the initial experiences of drug users don't quite appear match the doom and gloom being peddled by those who (for good reasons) don't want people to ever try them in the first place.

To that end, it would be awesome if this medical intervention was in addition to legalising and regulating what are currently only sold illegally as unsafe street narcotics. A safe, legal and well-regulated source of recreational drugs would make everyone far safer and do wonders for reducing overdose risks, even if it meant potentially more people trying said drugs in controlled environments, rather than much fewer people in a manner that's much more likely to involve complications/morbidities.

 

[m0nckywrench]

Humans will always do stupid, self-destructive acts and given the 330 million+ US population even a tiny proportion means many casualties.

Others will have legitimate needs insufficiently addressed by common practice. A fent vaccine taken voluntarily (for example in an addicted recreational users moment of lucidity) could save lives but should never be mandated because some levels of pain require it.

I was offered fent legitimately but declined because other opiods (Belbuca is worth my co-pay thanks to its linear release and lack of digestive upset) still work, no small thanks to cannabis gummies. That doesn't make fent unnecessary for everyone especially since much chronic pain is permanent, for example that caused by irreversible physical deterioration.

Demonizing opiod prescriptions is part of why my childhood best friend died of a fentanyl OD. He lacked good insurance so he self-medicated. Had I not persisted in tracking down a competent pain doc who understood legitimate opiod use and had no other option of course I'd resort to street drugs. Some pain levels effectively
end "choice" other than self-deletion (which is often legitimate since shaving X years off the inevitable end is not the same as immortality).

Some pain levels are truly excruciating and WORTH the mere risk of earlier death than otherwise. Death ends feeling and not existing deprives the dead of nothing at all because it terminates experience. Natural selection ensured humans fear death. I don't confuse that with rational fear because humans are not wired for rationality.

We can count dead people easily. It's harder to count those who benefit from legitimate pain medication use vs abuse of legal prescriptions.

 

[Bardon]

I am one of those people with a chronic condition who could not function without controlled use of opioids and unless there is a dramatic breakthrough in treatment I'll be in that position for the rest of my life.

That being said I only have one specialist, I go to the same pharmacy every time, all of my prescriptions automatically go into the national Dept of Health registry so that any health professional with a legitimate reason to look at my records can validate that I'm not doc-shopping or otherwise abusing the system.

I also get random spot-checks where a nurse will pop over and check on my meds consumption between specialist appointments.

It can be done responsibly, it just takes a modern healthcare system that focusses on patient treatment rather than profits.