(CNN) At a time when the United States is grappling with an epidemic of opioid-related overdose deaths, one state is turning to a very high-potency opioid for criminal executions.
Opioids are a class of drugs that include some prescription painkillers as well as illicit drugs such as heroin and street fentanyl. The majority of drug overdose deaths nationwide involve an opioid, and about 91 Americans die every day from an opioid overdose, according to the US Centers for Disease Control and Prevention.
Now, the Nevada Department of Corrections is preparing to use fentanyl in a three-part drug combination for an upcoming execution, it said in a statement August 17.
The combination includes the sedative diazepam, which is often sold under the brand name Valium; the muscle relaxant cisatracurium; and fentanyl, according to the statement.
Opioids: Addictive painkillers
Prescription and illegal opioids are commonly abused because they are so addictive.
Opioid medications bind to the areas of the brain that control pain and emotions, driving up levels of the feel-good hormone dopamine in the brain's reward areas and producing an intense feeling of euphoria.
As the brain becomes used to the feelings, it often takes more and more of the drug to produce the same levels of pain relief and well-being, leading to dependence and, later, addiction.
Oxymorphone hydrochloride, under the name Opana ER, was at the center of an HIV outbreak in Indiana in 2015. Some addicts began injecting and shared needles increased the spread of HIV.
In June, the Food and Drug Administration requested that Opana ER manufacturer Endo Pharmaceuticals pull the drug from the market. It was the first time the agency has asked that a opioid pain medication be pulled "due to the public health consequences of abuse." Endo announced in July that it would pull the drug.
Codeine is one of the weakest opioids, often given when painkillers such as acetaminophen or ibuprofen fail to work. Because it decreases activity in the part of the brain that controls coughing, it's frequently mixed with other liquids to develop cough syrups for colds and flu. It has frequently been used for pain relief after removal of tonsils and adenoids in children.
After an investigation, the FDA restricted the use of codeine and tramadol in children under 12 and recommend against their use in children between 12 and 18 years of age. Additionally, the FDA has warned breastfeeding mothers not to take these medications due to the risk of serious adverse reactions in breastfed infants.
You can't get heroin by prescription, but many heroin users start off abusing prescription opioids, then turn to this illegal opioid.
CNN's Chief Medical Correspondent Dr. Sanjay Gupta
has reported on recent research that shows today's typical heroin addict starts using at 23, is more likely to live in affluent suburbs and was likely unwittingly led to heroin through painkillers prescribed by his or her doctor.
According to the CDC, deaths from overdoses of prescription drugs and heroin continue to be the leading cause of unintentional death for Americans, rising 14% from 2013 to 2014.
Fentanyl citrate, pictured here, is a Class II controlled substance and one of the most powerful opioids on the market. It's often administered via injection or transdermal patch, or in lozenge form for pain after surgery, for difficult-to-manage chronic pain and for people who have developed a tolerance to other opioids.
The type of fentanyl usually associated with overdoses is bought on the street in powder or pill form and is often mixed with heroin in a clandestine lab to increase the high it produces. Street names include Apache, China girl, goodfella, jackpot, murder 8, TNT and Tango and Cash.
These pills are a more powerful form of codeine, called hydrocodone, and are often mixed with acetaminophen. Hydrocodone is the most frequently prescribed opioid painkiller,
according to the U.S. Food and Drug Administration, and the most abused. An overdose of hydrocodone can cause "cold and clammy skin, severely constricted pupils, and slow breathing that can lead to a loss of consciousness and death."
Oxycodone is a powerful narcotic pain reliever prescribed for moderate to high pain relief. It's often given in an extended-release formula for patients who will need to be on pain medications for long periods of time.
Patients are warned not to break, chew, crush or dissolve extended-release tablets because the rush of oxycodone into the system could cause serious health problems, including overdose and death.
Though highly addictive, oxycodone is not thought to be as frequently abused as hydrocodone. OxyContin, Percocet, Percodan and Tylox are some trade-name oxycodone products.
Morphine is another powerful opioid often administered via syringe for severe pain. It can come in pill form, usually as extended-release tablets and capsules, and is prescribed only to relieve difficult, chronic pain that cannot be controlled by the use of other pain medications.
As with most opioids, mixing medications, drinking alcohol or taking other meds that contain alcohol, or using street drugs while taking morphine, increases the risk of breathing problems or other serious, life-threatening side effects.
Meperidine is another narcotic analgesic, similar to morphine. It's often used to help put people to sleep before an operation and to provide pain relief after childbirth.
The most common brand name is Demerol, which comes in both tablet and liquid forms. It is usually taken with or without food every three or four hours as needed for pain.
As with all opioids, meperidine can cause drowsiness, so never drive a car or operate machinery after taking it until you know how you will react.
Hydromorphone is another highly potent prescription painkiller. It's most commonly known by the brand names Dilaudid, pictured here, and Exalgo.
Liquid hydromorphone holds the dubious honor of being
frequently mistaken for morphine in hospital "wrong drug" medication errors because of the similarity of the names and appearances.
Though methadone is used to relieve severe chronic pain, it's most commonly known for preventing withdrawal symptoms in patients who were addicted to opioid drugs, as a part of their recovery process.
Methadone has many of the same side effects as other opioids, including weakness, headache, nausea and vomiting, stomach pain, sweating, difficulty urinating, mood changes and vision problems, and difficulty falling asleep or staying asleep.
Buprenorphine is a opioid used as an alternative to methadone to help addicts recovering from heroin use. Buprenorphine is different from other opioids because it's a "partial opioid agonist," which means that when taken in proper prescribed doses, it should produce less euphoria and physical dependence, and therefore a lower potential for misuse. It's also supposed to have a relatively mild withdrawal profile.
However, if abused by crushing and snorting or injecting, it can suppress breathing and cause dizziness, confusion, unconsciousness and death.
Subutex, the brand name for buprenorphine, is taken as a tablet placed under the tongue and allowed to dissolve.
The brand Suboxone is a combination of buprenorphine and naloxone, an opioid antagonist. Antagonists block the opiate receptors in the brain, keeping the narcotic from creating the high abusers crave.
Nevada turned to fentanyl for an execution because the state had no other drugs to carry out a lethal injection after "pharmaceutical industry opposition to the use of their products in executions," The Marshall Project reported Wednesday.
The Marshall Project, a nonpartisan nonprofit news organization covering the criminal justice system, originally published news of this execution approach.
"I have one word that summarizes all of it, and it's 'irony,' " said Josh Bloom, senior director of chemical and pharmaceutical sciences for the American Council on Science and Health, adding that Nevada's decision left him "flabbergasted."
"You got something that's killing hundreds of people a day across the United States, and you got prisons who can't get death penalty drugs, so they're turning to the drug that's killing hundreds of people across the United States. This sounds like an article from the Onion," a news satire site, Bloom said.
On the other hand, Nevada's decision didn't seem to shock Dr. Edward W. Boyer, a medical toxicologist who also teaches at Harvard Medical School.
"Fentanyl itself is lethal. If you haven't heard about fentanyl-laced heroin and its impact on death rates in opioid users over the past several months, you might have been living under a rock," Boyer said.
"Fentanyl is a drug that you can inject intramuscularly, dermally and a wide number of routes," he said. "The main problem with them from a clinical perspective is that they wipe out your ability to breathe. You simply stop breathing. It causes profound respiratory depression."
'This specific chemical cocktail ... has never been used in this way before'
This fentanyl drug combination is to be used in the execution of 46-year-old Scott Raymond Dozier on November 14 at Ely State Prison in Ely, Nevada, according to the Department of Corrections' statement.
"Dozier was sentenced to death after a first-degree murder conviction for the 2002 killing and dismemberment of Jeremiah Miller, 22," the statement said. "Miller's dismembered torso was found in a suitcase that had been dumped in a trash bin.
"During the course of their investigation, police uncovered another victim of Dozier who was dismembered and buried in the Arizona desert. Dozier was found guilty of second-degree murder in that case," the statement said.
The Marshall Project reported that "Nearly a year ago, Nevada death row inmate Scott Dozier asked to be executed, telling a state court judge he would forego his appeals."
In an emailed statement to CNN, Nevada's chief medical officer Dr. John DiMuro said, "I can confirm that I am consulting with the NDOC as required by Nevada statute. This consultation process is ongoing and not complete at this time. Our expectation is that any final decision is likely to be reviewed by the Court."
The American Civil Liberties Union of Nevada opposes the plans to use the new drug combination, said Tod Story, executive director of the ACLU of Nevada.
"The concern is that this specific chemical cocktail that they have proposed has never been used in this way before. It's not like they can point to some success or result. This will be the first time," Story said.
"Using Mr. Dozier as a guinea pig is not an option, despite his stated desire to want to give up all of his rights to appeal," he said. "The use of the drugs that they have proposed are paralytics and an overdose of an opioid. So you're essentially trying to kill this person by paralyzing them to death, which sounds horrific, and it's certainly not in our perspective compliant with the Eighth Amendment of the Constitution, which is no cruel or unusual punishment."
Last week, the ACLU of Nevada announced that it filed a public records request with the Department of Corrections in order to obtain additional details about Dozier's upcoming execution.
The Marshall Project cited experts who said they saw no obvious reason why Nevada selected this drug combination.
The fentanyl and diazepam "may be trying to block the experience of suffocation," Joel B. Zivot, an Emory University anesthesiologist who has served as an expert witness in legal challenges to execution protocols, told The Marshall Project.
"The fentanyl takes away pain, and the Valium takes away anxiety. Both drugs are limited in their ability to do that, and of course neither is designed to block the pain or anxiety of death. So that's just a show," Zivot said.
However, as a former organic chemist who takes no position on the death penalty, Bloom said that he thinks Nevada's new execution cocktail is humane.
The diazepam will put people to sleep, "so they won't feel the fentanyl hitting them, and then the muscle relaxant stops them from breathing," he said. "This would legitimately be a humane lethal injection. Absolutely, no question, it would work, assuming they give enough fentanyl -- and it doesn't take much."