The Developing Brain and Opioids

"Many of the young adults that I see are actively seeking fentanyl over heroin. One 17-year-old girl had received a large dispense of oxycodone from her surgeon for pain following cosmetic surgery. She began refilling it every two weeks, saying she had ongoing pain, but confided that she was really using it for sleep and to share with her friends to get high. She was cut off by her doctor after about a month, then developed opioid withdrawal and ended up buying it on the street."
"Over time oxycodone became too expensive, so she turned to cheaper heroin and fentanyl."
Rashmi Chadha, addictions physician, Vancouver Coastal Health

"Simply put, the teen brain is not the adult brain. Through adolescence into the mid-20s, our brain gradually strengthens our ability to self-reflect, organize toward goals, plan out steps toward those goals, and perhaps more importantly, inhibit impulses that aren't the wisest and regulate emotions -- basically, things we would associate with a mature adult."
"I talk to parents all the time and say, 'You still need to be [your teens'] prefrontal cortex during this time'."
Sion Harris, co-director, Center for Adolescent Substance Abuse Research, Boston Children's Hospital

"While there are no published neuro-imaging studies on fentanyl and the teen brain, we can see from research on oxycodone that these opioids decrease the connectivity in the pre-frontal cortex and alter the thickness of the cortex."
Dr. Marisa Silveri, professor of psychiatry, neuroscientist, Harvard Medical School

"We know that fentanyl binds very tightly to the opioid receptor and it permeates the blood-brain barrier quickly. All this translates to a small dose of the drug having a huge effect. Essentially, you would need 40 to 50 times more heroin to get the same effect."
Hakique Virano, public health and addictions medicine specialist, University of Alberta

"[U.S.] studies of teens show a decline in experimenting with opioids, but an increase in the risk of overdose, which in part may be due to fentanyl making its way into the drug supply."
"In my practice it's common to have a 15- or 16-year-old with opioid addiction tell me they remember having a different experience with codeine in cough syrup when they were a child, that they could feel it affected them more than [it would] other kids."
"Those of us who are pediatric addiction specialists know that one of the most important things we can do is intervene quickly when early signs of addiction are present."
"Rather than jumping in and asking a teen directly whether they've used substances, it may be easier for parents to start the conversation by first asking what they are seeing in school among their peers -- that gives a sense of their risk environment, and is a nice opener to a discussion in which a parent can then find out whether their teen has used substances."
Scott Hadland, specialist, adolescent and addiction medicine, Boston Medical Center 

The Canadian Institute for Health Information reported last November that Canadian youth between the ages of 15 to 24 were responsible for a 62 percent increase in hospitalizations since 2007, related to opioid use, establishing that this age group represented the fastest increase in opioid use and addiction in the country. The Ontario Drug Policy Research Network reported more recently that fentanyl-related deaths in the province in all age groups has seen a whopping increase of 548 percent  from 2006 to 2015.

And a report issued in 2014, from the Centre for Addiction and Mental Health, released the data that ten percent of Ontario students in Grades 7 to 12 self-reported the use of prescription opioids for non-medical reasons on at least one occasion during the year previous, while four percent reported having used these drugs on six occasions or more, in the past year. Numbers that are suspected to represent underestimations.

"It is more difficult for teachers and parents to detect opioid use as compared to the use of alcohol or marijuana so we are relying more heavily on self-report", explained the study's co-author. The 2014 study failed to ask specifically about fentanyl, but this year's survey, underway currently, does. Statistics out of British Columbia are particularly troubling, with 12 overdose deaths from illicit drug use among 14 to 18-year-olds last year, according to the B.C. Coroners Service; half of which were confirmed to be fentanyl-related.

A bag of Fentanyl pills -- Edmonton Sun/Postmedia

The period identified as adolescent-young adult, biologically represents a key transition for the brain where "neurons" (brain cells) undergo pruning, a process where some connections are retained while others are abandoned. The volume of white matter increases, becoming increasingly organized, and grey matter - cell bodies themselves -- decreases.  The prefrontal cortex development represents the most significant change in the teen brain, involving that part of the brain tasked with executive functioning: "higher order" functions such as decision-making.

Not fully developed until past age 25, the prefrontal cortex functions to override impulsivity in risk-taking. So while adolescents are undergoing a still-developing prefrontal cortex, it is at a stage where it can facilitate drug-seeking behaviour, enabling the drug to alter the development of this area of the brain's function. Powerfully addictive opioids, particularly fentanyl, act on special opioid receptors in the brain; the strength of the opioid depending on how swiftly it reaches the brain through the blood and  how tightly it binds to the opioid receptor regulating the reward pathway of the brain.

The more powerful version of fentanyl, carfentanil, is being distributed now, binding even more tightly to the opioid receptors, reaching the brain far more rapidly than its weaker cousin fentanyl. Fair Vassoler, a neuroscientist at Tufts University who studies the effects of opioids on rats advises: "We have to remember that our bodies make opioids -- the 'feel-good endorphins' from pleasurable activities for instance. They help us deal with stress, and bind to these receptors we have in the brain. These external drugs can alter that."

When an overdose occurs, pinpoint pupils occur, the victim becomes unconscious and breathing stops (respiratory depression); the typical, feared and powerful "opioid overdose triad". 

Image by NIDA The brain's reward circuit