The Fentanyl and Opioid Epidemic

Overdose deaths hit a record high in 2022. An astonishing 109,680 fatal overdoses occurred during that 12-month period, according to data from the Centers for Disease Control and Prevention. Eight states saw overdose fatalities surge by 9% or more, but the greatest increases of 21% came from Washington state and Wyoming. An overwhelming majority of those overdose deaths involved fentanyl, a potent synthetic opioid that’s often mixed or “laced” into other drugs.

This is a trend that is definitely moving in the wrong direction. In 2021, the nation saw 107,622 Americans die due to drug overdose, according to a press release from the Department of Justice.

What’s more, a major study from the medical journal the Lancet predicts opioid-fentanyl overdose deaths will remain high, ultimately claiming another 1.2 million American lives by the end of the decade.

The History of Fentanyl

Fentanyl was developed as a painkiller in the early 60s. At the time of its creation, fentanyl was the most powerful opioid in the world.

By the late 70s and early 80s, fentanyl was in wide use by the American medical establishment for heart and vascular surgery. In 1981 it went off-patent, and sales jumped tenfold. By 2013, fentanyl hit the streets of the US and began its rapid takeover throughout the country. The raw ingredients originate in China, and they are shipped to Mexico for production and dissemination by cartel members. U.S. Customs and Border Protection (CBP) agents seized more than 19,800 pounds of fentanyl from October 2022 through May 2023. According to the DEA, just two milligrams of fentanyl is considered a lethal dose for most people. That’s the equivalent of a few grains of salt.

In a legal medical setting, fentanyl is administered by injection, dermal patch, or oral lozenge. When it’s produced illegally in a lab, fentanyl usually comes in powder form, making it easier to mix into other drugs (cocaine, heroin, methamphetamine, even marijuana) or press into counterfeit pills that look almost exactly like OxyContin, Percocet, Vicodin, Xanax, Valium, Adderall, or other prescription medications.

Fentanyl is cheap to make and much easier to transport because small amounts are so powerful. Smuggling a baggie of fentanyl powder across the border is simple when you compare it to the preparation cartels must undertake when smuggling kilogram bricks of other drugs for the same profit margin. In addition, fentanyl is highly addictive, so it makes individuals want/need more and more.

In the words of former CDC director Thomas Frieden, “As overdose deaths involving heroin more than quadrupled since 2010, what was a slow stream of illicit fentanyl, a synthetic opioid 50 to 100 times stronger than morphine, is now a flood.”

The “Third Wave” of the Opioid Crisis

From 2013 to 2016, deaths by fentanyl jumped by 540%, causing some to label this period the “third wave” of the opioid epidemic.

In April of 2016, pop star Prince died of a fentanyl overdose, likely from a pill he thought was Vicodin. The same year, carfentanil, an analogue of fentanyl, was making its way into American street drugs.

Carfentanil is a staggering 100x stronger than fentanyl, making it 10,000x stronger than morphine. It’s used to tranquilize large mammals such as elephants, and has even been labeled a possible agent of chemical warfare. This makes sense, given the fact that even a few grains can be catastrophic for the human nervous system.

Why Synthetic Opioids? And Why Now?

In a word, money. In order to produce heroin, you need large plots of land to grow poppies, plus a bunch of workers to farm and refine them. You also need to protect that land from law enforcement and thieves. So you’re dealing with pests, police payoffs, water supply issues, issues of protection and more.

Now consider producing drugs in a lab, which is far more predictable and expedient. It takes 1/20th the amount of fentanyl to achieve the same effect as heroin, so you can put far less in pills or powder. Thus it’s both easier to produce and can be used to make more end product.

According to the DEA, a single kilo of pure fentanyl costs about $3,300-5,000 to produce in China, but can be turned into a powder sold on the streets of southern California for $300,000. The further from the border you get, the more money you can sell the drugs for. A kilo of fentanyl can be cut into 1 million pills, often masquerading as prescription opioids like OxyContin, Vicodin, and Percocet. Each pill can be sold for ~$10-20, for a gross profit of $10-20 million.

Many drug traffickers purchase their pure fentanyl from suppliers in China or Mexico, while others produce it in labs in the US. An easy way to do this is to get the chemical precursor called 4ANPP, which costs ~$1,000/kg from China, then mix it with other chemicals to generate pure fentanyl. According to Dean Kirby, a senior forensic chemist at San Diego’s DEA lab, “If you get the right ingredients, it’s like making a cake.”

The Current Situation

Fentanyl is still much too easy to access, whether through legal channels or on the street. Since it’s so incredibly potent, small amounts of fentanyl or its analogs can be shipped through postal services, or smuggled over borders in smaller, easy-to-miss quantities. Fentanyl pours into the US from every available border now, as well as being shipped in both large and small amounts over the Dark Web.

“We’re now seeing fentanyl laced into many drugs that usually don’t usually contain opiates, like cocaine and marijuana,” says John Engebreth, head of Minnesota Outpatient Services at Hazelden-Betty Ford. “Lately, we’ve even seen fentanyl being mixed in with benzodiazepines like Xanax.”

China, with it’s well established pharmaceutical industry, is one of the main sources of fentanyl. It’s easy for nefarious chemists to hide amongst China’s above-board pharmacists, producing fentanyl on the side and shipping it to the US.

According to investigative journalist and author Ben Westhoff, “In recent years, some of the biggest new drug kingpins can’t be successfully prosecuted. The producers are coming out of China, and they don’t have to worry about being imprisoned by their government … Whenever a deadly new drug is made illegal in China, manufacturers simply tweak its chemical structure and start producing a new drug that is still legal. Many fentanyl analogues and cannabinoids have been made this way.”

Fentanyl During the COVID-19 Pandemic Era

Drug use in the US skyrocketed while Americans were in quarantine. The social isolation, uncertainty, economic distress, and emotional challenges associated with lockdown exacerbated issues of substance abuse for many. From May of 2020 to April of 2021, over 100,000 people perished from drug overdose. The majority — 64,000 — of those deaths involved synthetic opioids like fentanyl. That’s almost 30% more than the same period from the year prior.

In the words of Dr. Nora Volkow, director of the National Institute on Drug Abuse, “In a crisis of this magnitude, those already taking drugs may take higher amounts and those in recovery may relapse. It’s a phenomenon we’ve seen and perhaps could have predicted.”

Can You Tell if Drugs Are Laced With Fentanyl?

Part of the issue with fentanyl and its far more deadly cousin, carfentanil, is how difficult they are to identify.

Regrettably any illicit drugs can contain fatal levels of fentanyl, but you can’t see, taste, or smell it. In fact, it’s almost impossible to tell whether drugs are laced with fentanyl unless you use fentanyl test strips to test them. Fortunately test strips are cheap and fast — you usually get results in 5 minutes. Unfortunately even if the test is negative for fentanyl, some strips don’t detect more powerful fentanyl analogues, like carfentanil.

Given the prevalence of the issue, everyone should know the basics of what an overdose looks like and what to do in the event of one. Symptoms of overdose include:

• Inability to talk or respond to light, sound, etc.
• Shallow breathing
• Gurgling sounds
• Dark lips and/or fingernails
• Blue/gray skin color
• Pinpoint pupils

If you suspect someone may have overdosed and you can’t get them to respond to you, don’t assume they’re asleep. Not all overdoses happen fast — it can take hours for someone to die. If you take action, you could save their life. Do the following:

1. Call 911 immediately
2. Try to get the person to respond. Keep trying. If they respond, keep them awake and breathing
3. Rub your knuckles on their breast bone
4. If you’re qualified, administer CPR (if their skin is blue, do mouth-to-mouth rescue breathing)
5. Stay with them. If you’ve got to leave for some reason, put them in the recovery position (lying on their left side)
6. Look around to see if they’re carrying NARCAN (Naloxone); some users do. If not, see if there’s any in the vicinity — some institutions like schools now have some on site. Administer it. Know that it can take more than one dose of naloxone to revive someone. You will not cause harm by administering multiple doses.

Do not do any of the following:

• Induce vomiting
• Put the person in a cold bath
• Inject the person with salt water or stimulants (like meth)
• Have them “walk it off” or “sleep it off”

Where Do We Go From Here?

Most people who become addicted to heroin started out using prescription opioids that were prescribed by a physician. The pharmaceutical industry is currently under attack for the role they played in facilitating millions of people becoming addicted to opioids.

If you or a loved one is one of those millions, the important thing to do is to know that help is available. The truth is, the easiest way to stay safe from substances like fentanyl is to not use any illegal drugs. For many, this means getting assistance.

It’s not easy to overcome substance abuse, but it’s very possible, and it’s increasingly a matter of life and death. If you or a loved one needs assistance, know that it’s available, and that many places have sliding scale fees or financial aid available. Don’t let the cost be what stops you from saving your own life or the life of someone else.