“Fentanyl is so deadly, in the geographic regions where it’s been flooding in, deaths soared like we’ve never seen before.”
~ Dr. Andrew Kolodny, Co-founder, Physicians for Responsible Opioid Prescribing
In a just-published report, the Centers for Disease Control and Prevention has concluded that fentanyl is the deadliest drug in America. According to research conducted by the CDC, fentanyl is involved in more overdose deaths than any other drug. Alarmingly, it’s getting much worse.
Let’s take a closer look at the drug that is driving the worsening drug crisis in the United States.
First Things First – What is Fentanyl?
“While fentanyl has been a significant cause of overdose death elsewhere in the U.S., our state is now seeing the rise of its deadly impact. We need people who take illicit drugs to seek treatment and take other actions to reduce their risk of an overdose.”
~ Dr. Kathy Lofy, MD, State Health Officer and Chief Science Officer for Washington State
Fentanyl is an extremely-powerful synthetic opioid that was first created in 1960 by Dr. Paul Janssen, one of the most celebrated chemists in the world. During his lifetime, Dr. Janssen won 80 medical awards was presented with 22 honorary doctorates.
As a medication, fentanyl has a number of legitimate uses. It is usually prescribed for acute pain that cannot be controlled by any other methods or medications. Most frequently, it is given for severe end-of-life pain, such as that experienced by terminal cancer patients. It is also used by paramedics as an emergency painkiller for extraordinary injuries. When used in combination with certain other drugs, fentanyl can also be used as an anesthetic during surgery.
Because of the variety of applications, fentanyl is the most widely-used synthetic opioid painkiller in medicine. The World Health Organization has placed fentanyl patches on its “List of Essential Medicines”. This means that when it is used properly, fentanyl is considered to be a particularly safe and effective drug.
Interestingly, it does not “block” pain. Rather, it changes how the person perceives their pain.
Prescription fentanyl is dispensed under several brand names, including:
Fentanyl is up to 50 times more powerful than 100% pure, laboratory-grade heroin, and up to 100 times stronger than morphine. In fact, some fentanyl analogues, such as carfentanil, are up to 10,000 times more potent.
It is important to note that while fentanyl has legitimate medical applications, none of the 12 analogues that have been identified so far have a medically-valid use in humans. For example, carfentanil is used to sedate large animals such as elephants.
Fentanyl as a Drug of Abuse
“There’s never been a drug like fentanyl before. For street drugs, this absolutely destroys anything else in terms of lethality and danger.”
~ Josh Bloom, Senior Research Director at the American Council on Science and Health
As a side effect, fentanyl—like other opioids— also affects the pleasure centers of the brain and causes a euphoric high. This means that even when it is legitimately prescribed, it has an extremely high potential for abuse.
Fentanyl can be taken orally, snorted, smoked, or injected. When the abused fentanyl comes from legitimate medical supplies that have been diverted for sale on the black market, lozenges and patches are the most popular. Addicts will squeeze the gel from the patches and either inject it or consume it.
Fentanyl users say that it gives them a “sharp, crisp high” that reminds them of cocaine. One fentanyl abuser was quoted as saying, “If you’re on F and you smoke H, it just doesn’t work.”
Fentanyl: The Statistics
“In terms of danger level, opioids are bad, heroin is worse, and fentanyl is the worst. When these pills hit the street and you as an addict think you`re taking Oxy, and you take 10 pills, it’s very likely they could contain fentanyl, and just one of those pills could kill you.”
~ DEA Agent Tom Lenox
In 2016, 29% of all overdose deaths involved fentanyl. To put that in perspective, in 2011, only 4% of drug fatalities were fentanyl-related. In fact, between 2013 and 2016, the rate of overdoses involving fentanyl skyrocketed by 113%…each year.
- In 2017, there were 29,406 deaths involving fentanyl in America.
- That is a roughly 50% increase from 2016’s total of 19,413.
Washington State is seeing an increase that is much higher than the national average. During the first half of 2018, there were 70% more fentanyl overdose deaths than there were during the same timeframe in 2017.
Where Does Fentanyl Come From?
“China is a global source of illicit fentanyl… because the country’s vast chemical and pharmaceutical industries are weakly regulated and poorly monitored… Deficient local drug inspection and enforcement capabilities, coupled with corrupt practices among local officials, also limit the effectiveness of China’s chemical regulations.”
Fentanyl’s potency, along with a cheap and easy manufacturing process, has made the drug a popular and profitable product for foreign cartels.
Although some fentanyl medication is diverted for misuse, the majority of fentanyl in America is made illicitly in clandestine laboratories, primarily in China. In fact, it is estimated that 90% of the illicit fentanyl in this country was originally manufactured in unauthorized labs in China.
From there, it is then smuggled into the United States or Mexico, usually through the mail. For example, between the 2016 and 2017 the amount of illicit fentanyl seized by US Customs and Border Control agents more than doubled. Specifically, 75% of those Customs seizures were made at international mail facilities.
One regular first-class envelope can contain enough fentanyl to get 50,000 people high.
Smuggling practices have gotten increasingly sophisticated. In fact, some Chinese narcotics distributors are so confident that they can avoid detection that they will guarantee their customers that if their shipment is seized by law enforcement, a second replacement shipment will be sent free of charge.
Some of the methods used to smuggle fentanyl into the United States through the mail system include:
- Purposefully mislabeling shipments as detergent or some other harmless product.
- Gift-wrapping the package
- Putting the fentanyl inside the silica packages that typically accompany other goods.
But the biggest way that illicit drug manufacturers circumvent international laws is simply by slightly altering their production process. These new drugs, with their modified chemical structure, are not legally considered control substances under Chinese or American law. Therefore, they cannot be seized until changes to drug Schedules are made.
In fact, the serious problem of Chinese fentanyl reaching the US has become a source of international tension. New York Senator Chuck Schumer has called for fentanyl to be made part of the US-China trade discussion.
“I am demanding negotiators impose real pressure on China to stop the export of fentanyl. As the scourge spreads and addiction grows, China’s authorities continued to turn a blind eye. Negotiators must not leave the table without addressing the export of fentanyl. This issue must be a major priority, because too many lives have been lost, and too many others are at stake…”
Mexico and Fentanyl: The Growing Threat
“It is really the next migration of the cartels, in terms of making profit. This goes to the heart of the marketing genius of the cartels. They saw this coming.”
~ Jack Riley, Acting Deputy Administrator of the Drug Enforcement Administration
But although most of the fentanyl in America originates in China, Mexican drug cartels re now getting in on the action. In addition to receiving shipments from China, the cartels are using their own labs to produce increasing amounts of fentanyl.
This business decision comes down to two factors—changes in the drug market and visionary opportunism.
It started with prescription painkillers. Misrepresentations by Big Pharma, combined with rampant overprescribing, created a generation of opioid addicts. And when measures have been finally taken to curb the epidemic, there were no longer enough black market opioid medications to meet the demand.
As a result, cartels saw an opportunity and increased their heroin cultivation, production, and manufacture. This gave opioid-dependent customers an option. In fact, 80% of heroin addicts started out by misusing prescription painkillers. Of special relevance, 94% say that they made the switch because heroin was cheaper and easier to obtain.
For example, while black market prescription painkillers can cost up to $80 per pill, a dose of low-grade heroin costs about the same as a pack of cigarettes.
But heroin it is expensive to produce, in terms of the huge commitments of land, time, and manpower needed. Cartels wanted a more cost effective-option, and they found it in illicit fentanyl.
Because fentanyl is completely synthetic, meaning it does not need to be extracted from the opium poppy, as heroin is. In other words, fentanyl can be entirely made in a lab. There is no need to plant, tend, cultivate, harvest, and process acres of plants.
Roger Crystal, the Chief Executive Officer for Opiant Pharmaceuticals, says, “It doesn’t take much more than a half-competent chemist to be able to manufacture it. And it’s cheaper to manufacture than heroin.” Opiate is testing an anti-fentanyl overdose medication that it hopes to have FDA approval on by 2020.
And because fewer resources are needed, profits go up.
A kilogram of heroin can be purchased from Columbia for approximately $6000. It can then be cut and portioned out and sold for around $80,000.
But a kilogram of pure Chinese fentanyl can be purchased for less than $5000. Because it is so potent, adding cutting agents like talcum powder can stretch the amount to as much as 24 kilograms. Each of those kilograms can then be sold for $80,000, generating a profit of $1.6 million.
Professor Jorge Romero Vadillo of CIDE, a university in Mexico City, says, “Cartels and drug traffickers are not stupid. They are rational economic actors, whose actions and decisions are directly related to demand.”
And how much fentanyl is coming in from Mexico?
In 2016, law enforcement agencies seized a record amount of fentanyl—287 kilograms. That is an alarming 72% increase over 2015’s 167 kilograms.
In April 2018, a Nebraska State Trooper stopped a truck containing 118 pounds of fentanyl. That’s enough to kill 25 million people.
The Role of the Dark Web
“(The Dark Web) has become such an important source of distribution for this sort of deadly drug. It has enabled distribution channels that previously didn’t exist.”
~ Kathryn Haun, Digital Currency Coordinator for the Justice Department
There is a now another source that threatens to surpass even the threat of international drug cartels.
To be more specific, fentanyl smugglers are no using that part of the Internet known as the “Dark Web”, where anonymous transactions are the norm. Purchasers can use special browsers to purchase almost any illegal substance imaginable. Digital currencies such as Bitcoin are used because they are harder to trace than ordinary credit cards.
An available illicit product + anonymous and untraceable purchasing + PO Box or home delivery = a growing drug menace in the United States.
A quick query on one of the top Dark Web drug marketplaces returns more than 21,000 results for opioids in general and over 4100 listings specifically for fentanyl and its close analogues.
More than ever before, the Dark Web now brings the drug threat closer to home. It is no longer enough just to know where your loved ones are or who they are with. Fentanyl now has a high-speed connection straight to your home.
Counterfeit Drugs: A Deadly Game of Russian Roulette
“It is a phenomenon that is an absolute game changer in the world of drug abuse. Because people unknowingly come across these counterfeit pills or they buy something on the street that resembles heroin they’ve been using forever, and if it contains fentanyl it can be lethal.”
~ Carol Falkowski, CEO, Drug Abuse Dialogues
Once extreme new danger or ALL drug users is the emergence of “counterfeit drugs” that are represented as one substance but have in reality been laced with or even entirely replaced with fentanyl.
Originally, illicit fentanyl was often mixed in with cheap, lower-grade heroin to boost its potency and effects, but in recent years, fentanyl is increasingly being pressed into pill form and passed off as other medications – OxyContin, Vicodin, or Xanax, for example.
Here’s the thing – without a specific laboratory analysis, it is impossible for the drug user to know if their expected “Vicodin” or “heroin” is actually far-more-lethal fentanyl. When they take their “regular” amount, they end up fatally overdosing.
Strangely, this does not scare away other potential customers. Instead, it serves as positive advertising that this particular dealer is evidently selling the “good stuff”. Losing customers to fatal overdoses does not concern the cartels, either, because there are ALWAYS new addicts to take their place.
How Does Fentanyl Kill?
All opioids are Central Nervous System depressants. They lower the user’s heart rate, blood pressure, and especially, their breathing. At high enough dosages, the cause of death is respiratory depression. In essence, the person “forgets” to breath.
This deadly effect is greatly magnified if the user has also consumed alcohol, benzodiazepine tranquilizers, or other opioids.
How much is too much?
Fentanyl is so powerful that an amount the size of just six grains of salt can kill a full-grown man. With the analogue carfentanil, a fatal dose is the size of one single grain.
Here are the warning signs of a fentanyl overdose:
- Blueish lips and/or fingertips (20% of cases)
- Snoring, gasping, or gurgling sounds – also known as the “death rattle” (16%)
- Extreme muscle rigidity, to the point of seizures (13%)
- Foaming coming from the mouth (6%)
- Confusion or odd behavior (6%)
- Discolored skin: Blueish-purple for light-skinned people, or Gray/Ashy for dark-skinned people
- Slowed, shallow breathing
- Weak, barely-detectable pulse
- Very low blood pressure
- Pinpointed pupils
- Cold, clammy skin
- Tongue discoloration
- Loss of consciousness
- Unresponsiveness to outside stimuli
There are a couple of critical things to keep in mind about a suspected fentanyl overdose:
FIRST, a person who is merely very high will still be able to respond to outside stimulus – hearing their name called, being shaken, pain, etc. However, a person who is overdosing will typically be totally unresponsive.
SECOND – Fentanyl overdoses do not usually kill the victim right away. In fact, it takes between 1 and 3 hours for the person to die. There is still time to act and it get help.
Fentanyl: More Powerful Than Narcan
“The problem is those drugs that become much more potent will require ever higher doses of the Narcan to reverse the overdose and at some point you won’t be able to give enough of the naloxone, that Narcan, to effect an overdose by one of these really potent drugs, so that is a real problem the emergency medical community and the medical community is facing.”
~ Dr. Jerry Goldbaum, Snohomish County Health District
The standard emergency first aid for any suspected opioid overdose is to immediately administer Narcan, the opioid overdose reversal drug that restores breathing. Narcan is extremely easy to use, so even bystanders can be lifesavers.
But fentanyl can affect breathing so profoundly that it may take multiple applications of Narcan to successfully revive the overdose victim. While there is a major nationwide push to make Narcan more widely available to everyone, it still is not very likely that someone will have multiple doses on hand.
And while first responders WILL have multiple doses, they may not always know to administer it. Narcan has no effect on drugs other than opioids. So if a person is overdosing on fentanyl that has been labeled as Xanax—a benzodiazepine—paramedics will not immediately give Narcan. And that delay can mean the difference between life and death.
Why is Fentanyl More Dangerous than Other Opioids?
“It is a weapon of mass destruction.”
~ Michael Morrell, former Acting Director of the Central Intelligence Agency
There are several reasons why synthetic opioids in the fentanyl class are particularly dangerous. To summarize:
FIRST, they are so much stronger than the difference between a high and an overdose can be measured in micrograms.
SECOND, drug dealers and cartels often seek to improve the potency of their other inferior products by mixing in – or even substituting – fentanyl.
THIRD, this is done without the user’s knowledge. When they take a counterfeit drug at their accustomed-to dose, they are at extreme risk of overdose.
FOURTH, although all opioid drugs trigger respiratory depression, fentanyl does so to a far greater degree and for a much longer period of time. But just as significantly, however, fentanyl interferes with normal breathing without producing the same level of sedation as other opioids.
This difference makes ALL the difference.
Because extreme sedation is one of the major warning signs of an impending opioid overdose, a person who has just taken fentanyl may think that they are still within their personal “safe tolerance threshold”. In fact, they may take the lack of sedation as a sign that they are not quite high enough and take even more of the drug. This can be a fatal mistake.
FIFTH, fentanyl overdoses may require multiple applications of Narcan.
SIXTH, counterfeit drugs can cause a delay in proper emergency treatment.
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The Bottom Line about Reducing Fentanyl Overdose Deaths
Fentanyl has overtaken heroin as the single-deadliest drug in the United States. And as tragic as the tens of thousands of fatal overdoses are, the tragedy is magnified further by the fact that so many of these deaths now involve counterfeit drugs containing fentanyl.
Cocaine, methamphetamine, Xanax, other opioids -there are reports about fentanyl lacing involving each of these. Most famously, musical legend Prince died after unknowingly taking fentanyl that was purposefully mislabeled as generic Vicodin.
And that highlights an inescapable fact – there is no such thing as safe drug abuse. Quite literally, every time someone uses an illicit drug, they are risking their lives.
The Washington State Alcohol and Drug Abuse Institute advise people who are addicted to opioids to “learn about treatment medications and consider starting them as quickly as possible, they support recovery and reduce your chances of dying from an opioid overdose by 50%.”
In other words, TREATMENT SAVES LIVES.