Buying drugs on the street is like playing Russian roulette. From Xanax to cocaine, drugs or counterfeit pills purchased from non-medical establishments can contain life-threatening amounts of fentanyl.
Physicians like myself have seen an increase in the inadvertent use of fentanyl by people who buy prescription opioids and other drugs containing or adulterated with fentanyl. Heroin users in my community in Massachusetts realized that fentanyl had entered the drug supply when the number of overdoses skyrocketed. In 2016, my colleagues and I found that patients who presented to the emergency room with complaints of heroin overdose often had only fentanyl in their drug test results.
As director of medical toxicology at the Chan School of Medicine at the University of Massachusetts, I have studied fentanyl and its analogues for many years. As fentanyl became ubiquitous in the US, it changed the illicit drug market and increased the risk of overdose.
Fentanyl and its analogues
Fentanyl is a synthetic opioid that was originally developed as an analgesic or pain reliever for surgery. It has a specific chemical structure with several regions that can be altered, often illegally, to form related compounds with a marked difference in potency.
For example, carfentanil, an analogue of fentanyl formed by replacing one chemical group with another, is 100 times more effective than its original structure. Another analogue, acetylfentanyl, is about three times less effective than fentanyl, but still resulted in clusters of overdoses in several states.
Despite the number and variety of its counterparts, fentanyl itself continues to dominate the illicit supply of opioids. Milligram for milligram, fentanyl is about 50 times stronger than heroin and 100 times stronger than morphine.
Lacing or replacing drugs with fentanyl
Drug traffickers have been using fentanyl analogues as an additive in illicit drug shipments since 1979, with fentanyl-related overdose cases concentrated in individual cities.
The modern epidemic of fentanyl adulteration is much broader in terms of geographic distribution, production, and death toll. Overdose deaths have roughly quadrupled, from 8,050 in 1999 to 33,091 in 2015. From May 2020 to April 2021, more than 100,000 Americans died from drug overdoses, with more than 64% of those deaths involving synthetic opioids such as fentanyl and its analogues.
Illicit fentanyl is synthesized internationally in China, Mexico and India and then exported to the United States as a powder or compressed tablet. In addition, the emergence of the dark web, an encrypted and anonymous corner of the Internet that is a safe haven for criminal activity, has facilitated the sale of fentanyl and other opioids via traditional delivery services, including the US Postal Service.
Fentanyl is sold on its own and is often used as an admixture because its high potency allows dealers to sell smaller quantities while still maintaining the drug’s expected effect. Manufacturers may also add excipients such as flour or baking soda to fentanyl to increase supply without increasing costs. As a result, cutting a kilo of fentanyl is much more profitable than a kilo of heroin.
Unfortunately, fentanyl’s high potency also means that even small amounts can be fatal. If the end consumer is unaware that the medicine they have purchased has been counterfeit, this can easily lead to an overdose.
Prevention of death from fentanyl
As an emergency physician, I give fentanyl as an analgesic or pain reliever to relieve severe pain in an emergency setting. My colleagues and I choose fentanyl when patients require immediate pain relief or sedation, such as anesthesia during surgery.
But even in a controlled hospital environment, there is still a risk that fentanyl use could lower the respiratory rate to dangerously low levels, the leading cause of death from opioid overdose. For those taking fentanyl in a non-medical setting, there is no medical team available to monitor their breathing rate in real time to ensure their safety.
One measure to prevent fentanyl overdose is to distribute naloxone to passers-by. Naloxone can reverse an overdose as it occurs by blocking the action of opioids.
Another measure is to increase the availability of opioid agonists such as methadone and buprenorphine, which reduce opioid withdrawal symptoms and cravings, helping people stay in treatment and reduce illicit drug use. Although these drugs are life saving, their availability is limited by restrictions on where and how they can be used, as well as an insufficient number of prescribers.
Other strategies to prevent overdose deaths include lowering the entry barrier for addiction treatment, fentanyl test strips, controlled places of consumption, and even prescription diamorphine (heroin).
However, despite the evidence supporting these measures, local politics and financial priorities often limit the ability of communities to try them. Bold strategies are needed to stop the ever-increasing number of fentanyl-related deaths.
Kavita Babu, professor of emergency medicine, UMass Chan School of Medicine
This article is republished from The Conversation under a Creative Commons license. Read the original article.