At times, it feels as though our nation’s addiction epidemic can’t get any worse.
Heroin use has nearly tripled since 2007, an estimated 4.3 million people are using prescription painkillers non-medically, and around 129 people now die each day from overdose ― more than are killed in car crashes.
But the brutal truth is that those numbers are likely to rise to even more devastating levels as the result of a synthetic opioid now flooding the illicit drug market — fentanyl.
Fentanyl made headlines after being linked to the April 2016 death of music icon Prince. And it is powerful, used for extreme pain relief and as an anesthetic, and up to 50 times more potent than heroin and 100 times more potent than morphine. These days it’s prescribed medically as a pill, skin patch, spray and lozenge.
The problem is, fentanyl is also cheap and easy to make illicitly, and in the last few years it has become a favorite of drug dealers looking to make extraordinary profits. It can be mixed with heroin to extend a batch multiple times over and boost its euphoric properties and addictive potential. And now, the DEA confirms, it is increasingly being mixed with powders and pressed into pills that look just like the prescription painkillers you get at the drug store. And you may not even know you’re getting it.
“The problem is, fentanyl is also cheap and easy to make illicitly, and in the last few years it has become a favorite of drug dealers looking to make extraordinary profits.”
That, the Minneapolis StarTribune now reports, may be exactly what happened to Prince. Pills in his possession marked hydrocodone actually contained fentanyl, and Prince had so much of the drug in his system that it would have killed anyone, much less a 112-pound man. He did not have a prescription for the drug.
Making Poison Pills
The entertainer is far from the only casualty. Deaths due to synthetic opioids such as fentanyl rose 79 percent from 2013 to 2014, according to the DEA’s 2016 National Heroin Threat Assessment. And in the first quarter of 2016 alone, counterfeit prescription pills made with fentanyl are believed to have killed 19 people in Florida and California.
Anyone willing to make a small investment for the equipment and materials necessary can quickly churn out the pills, and fentanyl pill presses have been identified in the U.S., Mexico and Canada. Considering that a single OxyContin pill can fetch up to $80 on the street, the profit margins for the lookalikes can be huge.
But it’s all too easy to kill the customer. In the 19 recent deaths in California and Florida, an analysis showed a wide range of fentanyl per pill — from 0.6 to 6.9 milligrams. About 2 milligrams is all that’s needed to kill someone new to opioids, a little more for someone who has built up tolerance. “Such wide disparity in dosing reveals that the producers were likely amateurs and new to pill production, as the fentanyl was not thoroughly mixed with the other powders before binding and pressing into pills,” the DEA threat assessment concluded.
“About 2 milligrams is all that’s needed to kill someone new to opioids, a little more for someone who has built up tolerance.”
In other words, it’s easy for a newbie to mess up and create a poison pill.
Adding Up the Risks
In a Senate committee presentation, DEA Acting Administrator Chuck Rosenberg spelled out the new reality:
“We are increasingly encountering counterfeit prescription drugs laced with fentanyl and fentanyl derivatives, as well as heroin laced with fentanyl. According to our National Forensic Laboratory Information System, there were 13,002 fentanyl exhibits tested by forensic laboratories across the country in 2015 – a 1,392% increase from the 934 fentanyl exhibits in 2013. The trafficking of this drug, which is significantly more potent than street level heroin, presents a significant risk of overdose to users and to the law enforcement personnel who may come into contact with the substance during the course of their work.”
Oxycodone painkillers such as OxyContin are the most commonly counterfeited pills, the DEA’s threat assessment noted, but far from the only one. In the recent California deaths, counterfeit hydrocodone, labeled as Norco, was the culprit. The killer in the Florida deaths was fake benzodiazepines, labeled Xanax.
In an exhaustive and chilling Esquire analysis of our drug crisis and the ability of Mexican cartels to build new profit streams in the U.S. via opioids such as fentanyl, author Don Winslow summed up the threat: “We talk about the heroin epidemic. Fentanyl will be the plague.”
Buying an Accidental Overdose
Although those who end up with the counterfeit pills or the cut heroin often have no idea that what they bought was mixed with fentanyl, others seek out fentanyl-laced products after being hooked by their potency, which can make heroin pale by contrast.
“To those of us on the front lines of the battle against addiction, the growing availability of fentanyl in the illicit market represents a terrifying prospect.”
Whether the person is ignorant of the fentanyl they are consuming or not, overdose is all too easy. And when overdose does happen, the risk of dying soars because it’s tougher to reverse the effects with the go-to antidote for opioids, a medication called naloxone. The person may need twice or triple the dose they’d need with unadulterated heroin or pain pills, and they just have to hope their emergency responder, if they are lucky enough to have one and they are reached in time, knows that. Prince, reports indicate, may have been dead for six hours before help came.
To those of us on the front lines of the battle against addiction, the growing availability of fentanyl in the illicit market represents a terrifying prospect — an easier way for people to get addicted and an easier way to die, often without even knowing they are subjecting themselves to the risk.
It’s a threat we can help to minimize by educating users about the growing danger they face from fentanyl and making sure they understand that if they buy a drug anywhere other than at a pharmacy counter, they may end up paying far too high a price.
David Sack, MD, is board certified in psychiatry, addiction psychiatry and addiction medicine. As chief medical officer of Elements Behavioral Health, he oversees a network of addiction treatment centers that includes Promises drug rehab in California and The Ranch treatment center in Tennessee.
Need help with substance abuse or mental health issues? In the U.S., call 800-662-HELP (4357) for the SAMHSA National Helpline.
