How did fentanyl become such a problem?

Our current fentanyl abuse problem is a result of the opioid epidemic, which began in the early 2000s. Opioid use in the U.S. has grown over the last two decades for several reasons. A 2001 Joint Commission on Accreditation of Healthcare Organizations decision to include pain as a vital sign when examining patients made pain treatment a larger focus for the medical community. While this decision provided some benefit for those with chronic pain, there were many unintended consequences. 

Overprescribing, aggressive drug company marketing, loose restrictions and a lack of addiction education all led to a boom in prescription opioid abuse and addiction. Opioids, originally intended as a last resort painkiller, became far more widely prescribed. Drug producers began aggressive marketing campaigns towards doctors and patients to encourage the use of opioids, in addition to sharing false information about the drugs’ efficacy and potential for abuse. Like many others, Purdue is one of the companies being held responsible for its role in the opioid epidemic. The major opioid manufacturer was convicted of fraud against the U.S. government and creating a kickback scheme that supported the diversion of opioids for abuse.

 Phases of the opioid epidemic

According to the CDC, the U.S. opioid epidemic occurred in three phases. In 1999, the first wave of overdose deaths associated with prescription opioids like oxycodone began. Pill mills, medical centers that sell prescriptions outside of the standards of practice for profit, were instrumental in growing the country’s opioid problem. Research looking at pain clinics in South Florida found that pill mills, fake symptoms/documentation, on-site pharmacies, liberal prescribing habits, “sponsoring” drug diversion and pain doctor/pharmacy shopping all drove opioid diversion and abuse.

Heroin and fentanyl’s role 

As addiction and overdose rates exploded in the U.S., national and state governments tightened restrictions and enforcement around opioids like oxycodone. This caused the opioid problem to evolve. In response to new regulations and increased enforcement, a second wave of heroin-related overdose deaths began in 2010. Because heroin was more easily available, many with opioid addictions turned to the poppy-based drug as a cheaper alternative. 

However, heroin was later replaced by an even more potent alternative. In 2013, the third and current wave of overdose deaths began, driven by synthetic opioids like fentanyl. Because of its profitability, illegal drug trades have moved into diverting, producing and trafficking fentanyl. The super strength opioid is highly addictive and easier to transport, as a small amount is extremely potent. While synthetic opioid use has grown sharply, so have overdose deaths, which have increased to an all time high. 

The pandemic and the opioid epidemic

Though overdose death rates appeared to be declining from all time highs toward the end of the decade, opioid abuse during the Covid-19 pandemic reversed any progress made. Many believe that the combined effects of the coronavirus pandemic and the opioid epidemic furthered the nation’s problem with overdose death. Isolation, feelings of depression and anxiety have all increased during the pandemic, while access to addiction treatment and support resources have become more limited. This has led to self-medicating, struggles with dependency, overdose and death. Between may 2019 and 2020, an all time high of 81,000 drug overdose deaths were registered in the United States. Fentynal has been a huge contributor to the high overdose death totals, with synthetic opioid-related overdose deaths increasing by 38.4%. 

Opioid sales, crime & fentanyl busts 

Profits from fentanyl sales have played an important role in the rise of fentanyl abuse and consequent overdose deaths. Because fentanyl is so powerful and cheap to produce, drug dealers at international, domestic and local levels have moved toward the trafficking and sale of the opioid. 

Factories in China and other countries with less strict rules around fentanyl and its precursor chemicals produce and ship it through Mexico or directly to the United States. Fentanyl may be sold on its own or used to “cut” other drugs to make them appear more powerful.

International fentanyl trafficking busts

Large-scale fentanyl busts demonstrate the opioid’s growing importance in international drug trafficking rings. According to Customs and Border Patrol (CBP), between 2018 and 2020, the amount of illicit fentanyl seized by the agency tripled and continues to climb in 2021. News outlets report that CBP seized 6,494 pounds of the synthetic opioid in the first 7 months of the 2021 fiscal year, already surpassing the 4,776 pounds seized in fiscal year 2020. 

Mexico has become a distribution hub for illegally sold fentanyl precursors produced in China, India, and Mexico. According to InsightCrime.org, fentanyl is produced in Mexico for as little as $180 per kilogram and can be sold in states like Ohio or Massachusetts for $60,000 per kilogram (2,700x the price). Two major criminal organizations control distribution, although some smaller groups also traffic precursor chemicals directly from China. Additionally, fentanyl is bought and sold illegally on the dark web, furthering the difficult task of stemming the U.S: supply.

Heroin and fentanyl trafficking

While the amount of fentanyl seized by CBP in busts has increased substantially, heroin seizures have not seen the same jump. Although heroin is still highly trafficked, organized criminal groups may favor fentanyl because it is manufactured for a fraction of the price, and is close to 100-times stronger. This means the drug is both more profitable and compact than drugs like heroin. Given its high potency and the likelihood of overdose death from just a small amount, experts like Peter Reuter worry what would happen if even 50% of the global heroin market was replaced by fentynal. 

Local fentanyl busts

At the local level, drug users may encounter fentanyl knowingly, or unknowingly. Some seek out the opioid, while others unintentionally use substances laced with fentanyl to increase their potency.  State and local authorities continue to report large-scale fentanyl busts, seizures and overdose deaths.

Massachuesettes, Ohio and Arizona are among the many states reporting such fentanyl busts. The amount of fentanyl seized has the potential to cause thousands of overdose deaths. For instance, in one Baltimore fentanyl bust alone, 400 grams of the drug was seized, enough to kill 20,000 people. Although the U.S, state and local governments are taking steps to combat the opioid epidemic, and fentanyl in particular, the challenge remains great. 

Prescription fentanyl vs. street fentanyl: Is either one safe?

Fentanyl should only be used when prescribed by a doctor and following medical instructions for use. However, patients should still be extremely cautious when taking the drug as prescribed, as opioids like fentanyl have a high potential for addiction in general. Even more worrying is the overprescribing of opioids. States like Virginia have filed suit against drug companies who aggressively sold the drug to primary care doctors, lying about its uses, efficacy and dangers. Primary care doctors have also been encouraged to overprescribe the painkiller to treat non-cancer related pain for cases where it wasn’t necessary. Misprescribing and overprescribing have caused countless opioid use disorders and overdose deaths.

Fentanyl lollipops and other ways fentanyl is prescribed

Fentyanl can be prescribed in several forms which are delivered by injection, ingestion and absorption through the skin. It may be prescribed as a fentanyl lollipop lozenge (Actiq®), effervescent tablet (Fentora®), sublingual tablet (Abstral®), under-the-tongue spray (Subsys®), nasal spray (Lazanda®), skin patch (Duragesic®), or as an injection.  

Fentanyl lollipops are especially talked about because they closely resemble the innocuous candy and are often sold illegally. They are generally prescribed to control extreme pain in cancer patients who have become tolerant to other opioids. Sugar and berry flavors are added to fentanyl lollipops to make them more appealing to patients. Unfortunately, unlike the candy, fentanyl lollipops are extremely potent and dangerous. 

Fentynal lollipop misuse

Fentanyl lollipops are widely misused. One study found that 90% of prescriptions were off-label, meaning the condition for which it was prescribed does not meet prescribing guidelines.  Like other forms of the drug, use can cause respiratory depression and other harmful effects that may result in overdose death. If one is prescribed a fentanyl lollipop, extra care should be taken to store it in a safe and secure place. Children and those who are unaware of fentanyl’s deadly effects may believe fentanyl lollipops are safe, mistaking them for candy. 

Street fentanyl in weed, heroin and other drugs

Because it requires very little fentanyl to produce a high, dealers and traffickers often use it as an additive. Drug dealers may mix fentanyl with heroin, cocaine, methamphetamine, MDMA and other drugs. Fentynal in weed has even become a problem. While users believe they are taking a potent version of an intended drug, they are actually feeling the effects of fentanyl.

Even small amounts of fentanyl on its own can cause overdose. Substance users may unknowingly ingest large amounts of fentanyl when taking cocaine, marijuana, or other drugs, causing overdose. Moreover, mixing the opioid with other drugs can create toxic interactions. For instance, combining heroin and fentanyl is extremely deadly. As a result, overdose deaths involving both fentanyl and heroin in Ohio and other states have increased sharply.

Fentanyl test strips 

Fentanyl test strips can be used to detect the presence of fentanyl in unregulated substances. These strips are often made available by harm reduction organizations. Because even a small amount of the opioid can cause death, fentanyl test strips can be helpful in overdose prevention. Although treatment and recovery from addiction is the best option, as many other drugs also cause overdose, those who continue to use substances should always test their supply for fentanyl prior to use.