Buying drugs on the street is a game of Russian roulette. From Xanax to cocaine, drugs or counterfeit pills bought in a non-medical setting can contain life-threatening amounts of fentanyl.
Doctors like me have seen an increase in the inadvertent use of fentanyl by people purchasing prescription opioids and other drugs that have been mixed or counterfeited with fentanyl. Heroin users in my Massachusetts community came to realize that fentanyl had entered the drug supply as overdose rates exploded. In 2016, my colleagues and I found that patients who came to the emergency department and reported a heroin overdose often had only fentanyl in their drug test results.
As the chief of medical toxicology at UMass Chan Medical School, I spent years studying fentanyl and its analogs. As fentanyl has become ubiquitous in the US, it has transformed 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 analgesic – for surgery. It has a specific chemical structure with multiple regions that can be altered, often illicitly, to form related compounds with marked differences in potency.
For example, carfentanil, a fentanyl analog formed by replacing one chemical group with another, is 100 times more potent than its parent structure. Another analog, acetylfentanyl, is about three times less potent than fentanyl, but has still led to cluster overdoses in several states.
Despite the number and diversity of its analogs, fentanyl itself continues to dominate the illicit opioid stock. Milligrams per milligram, fentanyl is about 50 times more potent than heroin and 100 times more potent than morphine.
Stringing or replacing drugs with fentanyl
Drug dealers have been using fentanyl analogs as an adulterant in illicit drug stocks since 1979, clustering fentanyl-related overdoses in individual cities.
The modern epidemic of fentanyl counterfeiting is much broader in geographic distribution, production and death toll. Overdose deaths 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 being attributable to synthetic opioids such as fentanyl and its drugs. analogs.
Illegally manufactured fentanyl is synthesized internationally in China, Mexico and India and then exported to the United States as powder or pressed pills. In addition, the rise of the dark web, an encrypted and anonymous corner of the internet that is a haven for criminal activity, has facilitated the sale of fentanyl and other opioids shipped through traditional delivery services, including the US Postal Service.
Fentanyl is both sold alone and often used as an adulterant, as its high potency allows dealers to trade in smaller amounts, but maintain the drug’s effects that buyers expect. Manufacturers can also add fillers, such as flour or baking soda, to fentanyl to increase its supply without adding costs. As a result, it is much more beneficial to cut a kilogram of fentanyl compared to a kilogram of heroin.
Unfortunately, fentanyl’s high potency also means that even a small amount can be deadly. If the end user is not aware that the drug he has purchased is counterfeit, it can easily lead to an overdose.
Preventing deaths from fentanyl
As an emergency room, I give fentanyl as an analgesic or analgesic to relieve severe pain in an acute care setting. My colleagues and I choose fentanyl when patients need immediate pain relief or sedation, such as anesthesia before surgery.
But even in the controlled conditions of a hospital, there is still a risk that fentanyl use could lower respiratory rates to dangerously low levels, the leading cause of opioid overdose deaths. For those taking fentanyl in a non-medical setting, there is no medical team available to monitor a person’s respiratory rate in real time to ensure their safety.
One measure to avoid fentanyl overdose is to provide naloxone to bystanders. Naloxone can reverse an overdose as it occurs by blocking the effects of opioids.
Another measure is to increase the availability of opioid agonists such as methadone and buprenorphine, which reduce opioid withdrawal symptoms and cravings, help people stay in treatment and reduce the use of illicit drugs. Despite the life-saving track record of these drugs, their availability is limited by restrictions on where and how they can be used and an insufficient number of prescribers.
Other strategies to prevent overdose deaths include lowering the barrier to entry into addiction treatment, fentanyl test strips, controlled consumption sites, and even prescription diamorphine (heroin).
However, despite the evidence supporting these measures, local politics and funding priorities often limit communities’ ability to attempt them. Bold strategies are needed to interrupt the ever-increasing number of fentanyl-related deaths.
Kavita Babu, professor of emergency medicine, UMass Chan Medical School
This article is republished from The Conversation under a Creative Commons license. Read the original article.