May 10th is National Fentanyl Awareness Day. I feel both relieved and hopeful about the attention that has finally been given to the fentanyl epidemic as it has been lurking in the shadows of the opioid epidemic far too long. It is time for it to be front and center as the destruction left behind by illicitly manufactured fentanyl (IMF) is a public health crisis. As a Clinical Psychologist, I am acutely aware of the devastation that is being caused by IMF in the US. It is more urgent now than ever before that people are aware of the dangers as the number of fatal drug overdoses continues to reach record-high numbers. Over 75,673 people died from opioid overdoses in the year ending April 2021, up from 56,064 the year before.
What is happening with illicit fentanyl in the US?
Across the US, criminals are manufacturing fake pills and passing them off as prescription pills such as oxycodone (brand name – OxyContin®) and even benzodiazepines such as alprazolam (brand name – Xanax®). These counterfeit pills are scored and dyed to look seamlessly identical to legally manufactured pills. Testing by the US Drug Enforcement Administration (DEA) found that 4 in every 10 pills containing fentanyl have a concentration strong enough to be potentially lethal. More than 9.5 million counterfeit pills have been seized so far this year.
Fentanyl that is approved by the Food and Drug Administration (FDA) is an extremely potent opioid drug that is indicated for use as an analgesic, for treating severe pain, and as an anaesthetic. When it is prescribed in this way, for short-term use, it is a highly effective way of treating acute pain. It is roughly 50 to 100 times more potent than morphine. It is important to understand the difference between FDA approved fentanyl and illicitly manufactured fentanyl (IMF). There are multiple analogues of IMF in which the half-life, purity and potency vary, making it difficult to predict how much fentanyl can lead to a fatal overdose. It is also imperative to learn the difference between a fentanyl overdose vs. a fentanyl exposure or poisoning.
Keep in mind, there is no quality assurance process that takes place on the streets, in the illicit drug market. Every time a person buys drugs illegally (for example: from another person or through social media), it is like playing Russian Roulette because you never really know what you are getting.
Who is most at risk?
Broadly, there are two groups of people at risk of unintentional death due to illicitly-manufactured fentanyl. The first are people who already have opioid dependency and have built a tolerance to opioids. Even though these folks consume opioids daily, they do not know what type of fentanyl to which they are being exposed when purchasing illegal opioids. There are various analogues that represent an array of purity and potency, some of which are fatal. Therefore, opioid dependent individuals are not “safe” or “inoculated” from a fatal fentanyl overdose because they are opioid tolerant. For example, an individual who has an established tolerance to consume 50 mg of oxycodone, may consume what they believe to be 50 mg of oxycodone, but in reality they are counterfeit pressed IMF pills, that may lead to a fatal overdose. The same applies for individuals abusing heroin. They might have an established tolerance of consuming 6-bags of heroin but experience a fatal overdose due to IMF because the heroin has either been “laced” (adulterated) or replaced with IMF.
The second group of people are recreational drug users, and sometimes first-time drug users, who may buy what they believe to be an opioid like oxycodone or a benzodiazepine like alprazolam (brand name – Xanax), when in fact, they are getting a counterfeit pill pressed with IMF. These counterfeit pills are scored and dyed to look like the “real thing.” Deaths involving fentanyl are fastest growing in 14–23-year-olds, which is typically the ages at which young people are trying things out and going to college. People in this second group do not have a previous substance use disorder and are considered opioid naïve, meaning they have no tolerance to opioids. This speaks to one of the key takeaways for National Fentanyl Awareness Day, which is making the public aware and helping them understand that – One Pill Can Kill.
It is also important to call attention to drug-dealers who may be exposing other drugs, including marijuana and stimulants such as cocaine, with fentanyl due to cross- contamination. Cross-contamination occurs when one drug such as cocaine is contaminated with fentanyl. Cross-contamination may be intentional or unintentional. For example, a dealer may be packaging up fentanyl on a designated area and neglect to clean it before emptying and packaging another drug, such as marijuana on the same surface area. The consequence that follows is exposing an individual who intended to buy only marijuana with fentanyl, which could unfortunately result in a fatal fentanyl exposure or poisoning.
What’s your advice for people who could be at risk?
Counterfeit pills available on the street and online are easy to get hold of and look just like the real thing. The best advice I can give to anyone is not to trust anything they find on the street or online, such as through social media platforms or websites. Only take medications that are prescribed to you by a medical professional and that are dispensed by a licensed pharmacist.
If you are a parent or caregiver for an adolescent, keep talking with them. Be honest about the reality and risks of taking drugs and give the education and honesty they need to make the right decision when – they are offered drugs and you are not around to steer them in the right direction. There are excellent resources such as https://www.dea.gov/onepill designed to educate young people about IMF and counterfeit pills2.
Finally, if you or someone you know is struggling with opioid abuse, please reach out for help. I know that it is not easy, but you are worth it!