The third and deadliest wave of the opioid epidemic began in 2013 with the increasing adulteration of the heroin supply with illegally produced fentanyl. Fentanyl is a synthetic opioid manufactured in laboratories. Fentanyl was approved by the US Food and Drug Administration in 1968. It is a pain killer, with a rapid onset and a short duration of action that has become a widely used alternative to morphine for quick acting pain relief. It is routinely used in surgery and is also used for palliative care in the form of a fentanyl patch specially engineered to be placed on the skin to deliver pain relief over an extended period of time.
The fentanyl killing people across our country is not medical-grade fentanyl stolen from hospital pharmacies or medical warehouses. The fentanyl sold on the street is illegally manufactured in clandestine labs and comes mainly in the form of a white powder that is hard to distinguish visually from white powdered heroin, making it easy for dealers to add it to heroin or sell it in place of heroin. The key factor is that fentanyl is fifty times stronger than heroin by weight (depending on the batch).
Dealers first added a bit of fentanyl to increase the potency of their heroin, but in time, in most parts of the country, fentanyl has come to displace heroin almost entirely. The reason for this is not consumer driven. Users did not demand it. The change came from the dealers. Fentanyl is simply much more profitable for dealers than heroin.
Heroin needs to be grown in fields. Its production is dependent on weather, pestilence, and avoiding police who might burn the fields down. Once harvested, the heroin has to be carried from the fields to the place where it is refined, packaged and then smuggled across the border.
Fentanyl is not reliant on weather conditions or the threat of insects. The dealers don’t have to worry about drones flying overhead to spot their fields. The most important feature of fentanyl is its strength. Because fentanyl is 50 times as strong as heroin, 50 times as much can be smuggled in the same size container. While a kilo of heroin and a kilo of fentanyl might cost the same to produce, a kilo of fentanyl will produce fifty times greater profit if priced at the same potency. If priced at double the potency, it is still making 25 times as much profit. It is this huge profit margin that is behind the fentanyl epidemic.
Fentanyl has other properties that make it better for the dealers and harder for the users. Heroin typically lasts 6-8 hours before someone who is addicted to it starts to feel sick. Fentanyl lasts 4-6 hours. Some users may require redosing even more frequently than these time intervals to avoid being sick. If you are addicted to fentanyl you will need to use more often than if you are addicted to heroin. Bottom line is more sales for the dealers.
An additional factor benefiting the dealers is that Fentanyl has high lipophilicity, which means it stores easily in the body’s fat system. For people who use fentanyl regularly and are trying to quit, this means that the fentanyl that has accumulated over time in the body fat, slowly ebbs out making it harder for the body to clear itself entirely of fentanyl. This causes a stronger and more prolonged withdrawal. Withdrawal is horribly painful and many users can’t endure the suffering knowing that they can cure the withdrawal simply by using again. Fentanyl is thus more addictive than heroin and harder to kick.
Fentanyl’s potency has other devastating effects. Today, anyone can order fentanyl on the dark web and have it delivered to their home by mail or federal express. The bar for becoming a dealer is very low. No more driving to the wrong side of town to meet a man who knows a man, who has two bodyguards who might kill you just because they don’t like the way you look at their boss. A single envelope of pure fentanyl contains enough fentanyl to start your own drug empire.
Both heroin and Fentanyl are cut (adulterated) with substances like sugars, baking soda and other powders that look the same. Adulterating the product means more product to sell as well as trying to ensure that the product is not too potent. Typically heroin was cut or adulterated to perhaps 50% heroin/50 cut. Fentanyl needs to be cut to 1 or 2% active ingredient, 98% or 99% adulterants. That’s easy to do if you are a multibillion dollar pharmaceutical company with top scientists and labs, but not so easy if you are a street level drug dealer doing the mixing on your kitchen table using a blender made for protein shakes. Whether you received your fentanyl pure from China or cut to 10% potency from Mexico, getting a consistent dose in every 0.1 gram $4 bag you package is another. Fentanyl also tends to clump, which can create the chocolate cookie effect. One bag might have a giant clump (chip) of fentanyl in it while another bag might not have any chips. A 0.1 gram bag of Fentanyl contains 100 mgs of powder by weight. 2 mgs of Fentanyl is considered a potentially lethal dose by the DEA. How do you safely measure that at the kitchen table?
The danger of fentanyl and the number one reason people are dying today is that users cannot judge their dose. Even if you are the most experienced user, there is no way for you to tell the white powder your poured into your cooker, mixed with saline and then drew up with your syringe and are now are pushing into your vein is 1% fentanyl or 12% fentanyl, a dose that may kill you if you are using alone and no one finds you before your heart stops beating five minutes after the fentanyl stopped your breath cold. The overdose epidemic is now a misnomer. It has become a poisoning epidemic.
Imagine if you drank a glass of wine in a bar, and that wine, instead of 12% alcohol was 100% alcohol, but you couldn’t taste the difference. A couple of glasses could kill either through alcohol poisoning or getting in a car wreck. If it was determined the bottle of wine you drank from was incorrectly labeled, the government would institute an immediate recall of the brand of wine to protect others from being poisoned. That government doesn’t recall illicit fentanyl even though it is causing sudden poisoning in deaths in tens of thousands of Americans.
There are fentanyl test strips that you can use to see if there is fentanyl present in your powder. You could do this by putting a little bit of water in the wax fold or in the cooker and waiting a minute to see if a red line appears in the appropriate spot indicating fentanyl, but the strips won’t tell you how much fentanyl is present.
In Connecticut in 2012, 14 people died of fentanyl overdoses (5% of all opioid overdoses). By 2021, it was 1312 people or 93 percent of all opioid overdoses. In 2017, 90 percent of all heroin bags tested in Hartford had fentanyl present. Now, with harm reductionists using gas spectrometers to test street samples, it is a rare day they find any indication of heroin at all.
Nationally in 2021, according to the CDC, 89% of all opioid overdose deaths involved fentanyl, and only 13% involved heroin. Fentanyl started its reign of terror on the east coast where powdered heroin was prominent. Most heroin users west of the Mississippi generally used black tar heroin, which is a sticky tar like substance that has not been fully purified. It is typically smoked, but can also be injected. The economics of fentanyl, however, have spread fentanyl and the deaths westward. Much of the fentanyl is the west is coming in the form of counterfeit pills.
Years ago, if someone was worried that fentanyl might be in their heroin, they could seek safety in reverting to pharmaceutical pills like percocet. The pills came from a pharmaceutical company so they have to all be the same strength. Not anymore. Dealers are buying pill presses and dyes for percocet 30s and other common street pills, then pressing powder and fentanyl into counterfeit pills that look just like the originals. And like the fentanyl in the heroin bags, there is no way for a user to tell how much fentanyl is in the pill he just bought. 1% or 12%? An expected high or death. A 30 mg Oxycodone pill weighs 135 mg. The pharmaceutically produced pill has 30 milligrams (22%) of the pill as an active ingredient. But a fake oxycodone pill with just 2% Fentanyl as the active ingredient (2.7 mg) would be considered lethal. Do you trust the dealer pressing the pills to have the exact same amount of Fentanyl in each pill at a dose that is not lethal? The DEA in 2022 found that six out of ten fake pills tested in their lab contained a potentially lethal dose, up from four out of ten the previous year.
Cocaine users are not safe from fentanyl either. It is not uncommon to read newspaper headlines or hear on TV of multiple people who thought they were using cocaine to all drop dead moments after snorting their white powder. There has been wide speculation of whether or not dealers are intentionally lacing the cocaine to addict people, but I don’t subscribe to that. Cocaine is addictive enough, plus I don’t believe dealers want the reputation for selling tainted supplies. What happens is that the dealers who also sell fentanyl don’t properly separate their two operations and don’t use industrial techniques to sterilize their equipment. The same blender that was used to mix fentanyl is often used to mix cocaine. The same grainy wooden table is used to package the product. It just takes a small amount of fentanyl to get into cocaine to wreak havoc and death.
Again, these people are not dying of overdoses, they are being poisoned.
Increasingly in the northeast and already expanding across the country, is a drug called xylazine that s being added to fentanyl mixtures. Xylazine is an animal tranquilizer that was originally designed as an analgesic for people, but was abandoned due to tests that showed it caused severe hypotension and depressed mental status. It is not an opioid and is not currently regulated. Drug dealers buy it and add it to their heroin/fentanyl mixture. Because fentanyl is ebbing away at 3-4 hours, adding xylazine adds “legs” to the drug, meaning the patient’s high lasts longer. Some users like this. Unfortunately, many don’t. They feel drugged, zombieish. The concoction was first noticed in Puerto Rico, and later found a strong foothold in Philadelphia where it is sold as “Tranq-dope.” Here in Connecticut, it seems to just be used as an additive to fentanyl and is not typically requested or advertised, at least not by the users I have talked to. It is just an unfortunate additive that comes when you buy your dope. The other unfortunate issue is it can cause severe necrosis when injected. This is attributed to how it reduces oxygen uptake in the skin, and because it is an analgesic, users often inject right back into the painful ulceration to provide temporary relief, which only makes the ulceration worse.
Another drug that has made headlines is carfentanil, an elephant tranquilizer, 100 times stronger than fentanyl. While it has been linked to deaths in a few states, it has not materialized in a manner to overtake fentanyl. Because it is so strong, it is almost impossible for dealers to use it safely.
Fentanyl Myths
There are a number of myths/misinformation about Fentanyl that are not true and need to be addressed because hysteria and false information further stigmatize users and may prevent people from assisting people who are overdosing.
Myth One: Touching Fentanyl Can Kill You
Headlines appear about law enforcement officers rushed to the hospital after being exposed to fentanyl. There were on scene when they encountered piles of powder, some powder got on their skin or some was puffed into the air. They felt faint, some even passed out. What happened? There is no danger of being exposed to fentanyl. For fentanyl to harm you, you have to inject it, snort it or ingest it in significant quantities. It is not absorbed through the skin by casual contact. There are fentanyl dermal pads that are specially manufactured to transport through the skim. They take hours to work.
What happens is the nocebo effect. The placebo effect is when someone feels better because they believe a pill is going to be good for them. The nocebo effect is where a person feels badly because they believe a pill is going to be bad for them. None of these police officers who are rushed to the hospital for fentanyl exposure ever test positive for fentanyl. These signs are not consistent with opioid overdose. Their typical complaints involve fainting, rapid heartbeats and nausea, all more indicative of an anxiety attack than an opioid overdose. The root cause is the DEA in 2016 told police officers that just touching fentanyl can kill you. So when they touch or exposed to it, unless that false information has been corrected to them, they think they are going to die. An anxiety reaction is not uncommon in such a situation. Eventually the DEA corrected the information, instructing those exposed to simply wash their hands with soap, but the rumor persists. The stories serve only to create hysteria and may prevent someone from helping an overdosed person out of fear of being contaminated.
Myth Two: Enough Fentanyl to Kill Everyone in the Country
Stories also appear about seizure of enough fentanyl to kill everyone in America. Again this is hysteria. I could say there is enough water in the town lake to drown everyone in America, or enough bullets in the local gun store to kill everyone in the state. For the amount of fentanyl seized to kill everyone in America, everyone in America would have to roll up their sleeves, apply a tourniquet and then consent to take a syringe into the arm. If you dropped the amount of fentanyl seized in this story from an airplane and bombed Main Street with it. The only ones who will overdose are those who find a big enough pile on the ground, stick their fingers in it, and then stick their powdered crusted fingers up their noses and forcibly inhale.
Myth Three: Rainbow Fentanyl is Targeted to Children
Recently law enforcement seized large amounts of multicolored percocets that were wrapped in candy packaging (Skittles) to conceal them from police. The percocets were counterfeit pills containing fentanyl. News stories appeared across the country expressing concern that drug dealers were targeting children at Halloween time in an attempt to addict them and grow their customer base. You can be sure that on trick or treat night; dealers did not hand out $20,000 bags of “rainbow fentanyl” disguised as Skittles to ten year olds. Sometimes dealers hide drugs in fish, but on discovery of the drugs in the fish, there are no news stories about drug dealers targeting cod lovers. Drugs and kids make for headlines, even when there is nothing to back it up. The real danger to kids is when those two and under are crawling around in houses where drugs are packaged. If they get into loose white powder and stick their fingers in their noses and inhale, then there may be a problem.
Fentanyl Conclusion
This much about fentanyl needs to be understood before we can solve this problem
- Fentanyl poisons people because they cannot safely judge the dose.
- Stigma and law drive users into the shadows where they die preventable deaths.
- 90% of those who die of fentanyl overdoses die because they use alone without anyone to save them when they overdose.
Address these facts, and the deaths will decline.