Every year in the United States, more than 100,000 people die from drug overdoses. Of that horrifying total almost two-thirds – 64,000 – are killed by fentanyl, a powerful synthetic opioid that is 50 times more potent than heroin and 100 times stronger than morphine. Fentanyl is now by far the leading cause of death for Americans aged 18-45, killing as many each year as Covid, car accidents and suicide combined. The overdose rate is highest in Black and Indigenous Americans, and has risen most rapidly among young people. Huge numbers of these deaths go unreported, but a handful make national headlines. Just last month, NFL linebacker Jaylon Ferguson was found dead from the combined effects of cocaine and fentanyl. He was 26.
Many of those who die from fentanyl overdoses have no idea they’ve even taken it. The substance has been found in counterfeit pills that purport to be prescription medications including Oxycodone, Percocet and Xanax. It has also found its way into street drugs such as cocaine, meth and heroin, which means even longtime users may be unprepared for their potency. After the death of The Wire actor Michael K Williams last September from a combination of cocaine, heroin and fentanyl, his nephew Dominic Dupont made it clear that Williams “would not have knowingly taken fentanyl”, stating: “I know that like I know my first name.”
The dangers are so serious that in April the Drug Enforcement Administration (DEA) sent a letter to federal, state and local law enforcement bodies warning of a nationwide spike in fentanyl-related mass-overdose events. These types of events, defined as three or more overdoses occurring around the same time in the same location, had taken place in seven American cities stretching from Colorado to Florida. “Already this year, numerous mass-overdose events have resulted in dozens of overdoses and deaths,” said DEA administrator Anne Milgram. “Drug traffickers are driving addiction, and increasing their profits, by mixing fentanyl with other illicit drugs.”
This interpretation – that dealers add fentanyl to other illicit drugs in order to cut costs and hook users – is disputed by experts. Morgan Godvin, the founder of Beats Overdose, a harm reduction charity based in Portland, Oregon, has lost people close to her from overdosing. “My friend died last March of a fentanyl overdose after doing cocaine,” she says. “This is real, but when people say that dealers are bulking out cocaine that’s very ignorant because that’s just not how the business works. It’s not logical for dealers to add fentanyl to their cocaine. They don’t want to kill their customers, that’s bad business, and people who are doing uppers don’t want downers. It’s actually about cross-contamination, when people are selling fentanyl and cocaine simultaneously and they get mixed up.”
Dr Ryan Marino, a medical toxicologist and addiction medicine specialist at University Hospitals Cleveland Medical Centre, concurs with this explanation. “It seems for the most part to be about accidental contamination rather than anything malicious,” he says. “Because fentanyl is so potent, even trace amounts can be a problem. If there had been cross-contamination of other drugs in years past it maybe wasn’t as much of a problem and that’s why we didn’t see [a similar increase in overdoses]. It does seem to be a more contemporary phenomenon. I don’t really remember anything like this before.”
The best way to reduce overdose deaths, Dr Marino argues, would be to legalise and regulate the supply of all drugs. As it is, many of those dying from fentanyl overdoses are essentially being killed by a lack of health and safety regulations in the supply chain. “I think the fact that these are black-market drugs explains why there’s no kind of purity regulation process in place,” says Dr Marino. “People don’t have clean workstations when they’re cutting these drugs, and they’re not keeping them separate. It’s not even just fentanyl. There’s always been weird things in street drugs, but the quantity and effects of the newer synthetic compounds that are out there like the long-acting benzodiazepines that are showing up are very problematic. They’re hurting people and killing people when 20 or 30 years ago that wasn’t the case and we were orders of magnitude lower in terms of deaths.”
In terms of the black market of drugs, fentanyl is here to stay
Fentanyl was first synthesised in 1960 by the Belgian physician Paul Janssen. It has been approved for medical use in the United States since 1968, and continues to be regularly used in hospitals all over the world. Dr Marino says he uses it on an almost daily basis in the emergency room, where it’s commonly used to help treat those with broken bones and is also often used in surgery as well as in labour and delivery settings. “Fentanyl is a wonderful medicine,” says Dr Marino. “It is one of the most effective, well tolerated and safest opioid pain medications that we have.”
It is only since around 2013 that fentanyl has been seriously disrupting the illegal drug market, when dealers began to capitalise on the demand for opiates such as heroin and prescription painkillers. Godvin, who herself spent five years addicted to heroin, recalls the way the synthetic drug came to supplant the existing supply. “I started hearing about it while I was still using heroin, but I was on the west coast and back then it was an east coast phenomenon,” she says. “It started upticking and you were getting a lot of news reports out of the northeast: fentanyl, fentanyl, fentanyl. The United States is sort of divided into two different heroin markets by region. Certain markets had ‘black tar’ heroin, rather than powdered heroin.”
Black tar heroin is a sticky, tar-like substance predominantly produced in Mexico that has historically dominated the drug market west of the Mississippi. Powdered heroin, which is manufactured in South America and southeast Asia before arriving in the US via various clandestine routes, tended to be sold east of the Mississippi. “Powdered heroin became almost exclusively fentanyl much quicker, but now even black tar heroin has mostly been supplanted by counterfeit pills,” explains Godvin. “Users know that they’re fentanyl pills, and call them ‘blues’ or ‘dirty 30s’. When those pills get into the hands of unknowing people, they cause huge amounts of tragic overdoses of people who thought they were taking a pharmaceutical medication.”
These counterfeit pills are being produced in staggering quantities and flooding the market. Last month the DEA announced they had seized a million fentanyl pills in Los Angeles, the largest seizure in California history. They are believed to have been connected to the Mexican Sinaloa cartel, and were designed to look exactly like prescription opioid medications such as oxycodone (Oxycontin, Percocet), hydrocodone (Vicodin) and alprazolam (Xanax); or stimulants such as amphetamines (Adderall). Regardless of which prescription pill they resembled, each predominantly contained fentanyl. Special Agent in Charge Bill Bodner said: “The deceptive marketing coupled with the ease of accessibility makes these small and seemingly innocuous pills a significant threat to the health and safety of all our communities.”
Sadly, they’re probably not going anywhere. Part of the reason fentanyl has been so successful in taking over the illicit opioid market in the United States is that it’s relatively easy to produce. After the Chinese government cracked down on fentanyl production in 2019, Mexican cartels simply stepped in to fill the void. “With heroin, you used to need poppy fields, good weather and large production systems,” points out Dr Marino. “With fentanyl, honestly, it’s really easy for someone to make it at home with minimal supplies that they bought on the internet, and it’s so potent. Even if we stop all the fentanyl coming in from Mexico, people will just make it all in the United States. In terms of the black market of drugs, fentanyl is here to stay.”
While fentanyl may not be going anywhere, there are important steps that can be taken to reduce the number of lives lost to overdoses. Through her work at Beats Overdose, Godvin distributes fentanyl test strips and encourages people to test any medication that they may be unsure of. “I just did an experiment with them last week, because there was a debate raging about whether or not fentanyl test strips hold efficacy with these counterfeit pills,” she explains. “If someone only has one pill, are they really going to crush the entire thing up and dissolve it in water to test it? They can’t just test a portion of it, because there might not be fentanyl in that portion because of the ‘chocolate chip cookie effect’. So I went to the syringe exchange and we had two of the ‘Dirty 30s’ and broke them down into little tiny slivers. Every sliver we tested was positive for fentanyl. The alarming part was that when they were intact, they looked so [much like a prescription pill]. If I were to have found one of those on the ground I would have googled: ‘round blue pill M 30’ and Google would have told me: ‘Oxycodone 30 milligrams’. Ten years ago, I might have just popped that in my mouth. It’s incredibly alarming how realistic these pills look.”
As well as handing out fentanyl test strips Godvin works to distribute naloxone, sometimes known by its brand name Narcan, an overdose reversal medication that counteracts the effects of opioids including fentanyl and heroin. “It’s a nose spray, and if someone is overdosing you just squirt it up their nose and it nullifies the effects of any opioids in the body,” explains Godvin. “That is the only thing it does. If you or I were to do one hundred of them right now it would have absolutely no effect on us, so it’s an incredibly safe medication that has no effect on most people. The only thing it does is cancel out the effects of opioids, and it brings people back from overdoses. Opioid overdoses are completely reversible, 100 per cent.”
Fentanyl test strips and naloxone are both important tools, but Godvin adds that they’re also a way of sparking a wider discussion about drug use that is still often considered strictly taboo. “Those things function as physical embodiments of this conversation we need to have around overdose prevention,” she says. “We’re giving out fentanyl test strips and Narcan to people, and then they keep them in their cars or in their purse, and those things start conversations later when someone else says: ‘Oh, what’s that? What do you have there?’ We’re really trying to spark a cultural change, while simultaneously these tools have practical applications.”
Both Godvin and Dr Marino agree that the highest risk of a fatal overdose comes when the user is alone. “The most important thing that people can do is making sure not to use alone,” says Dr Marino. “It’s almost impossible to give yourself Narcan when you’re having an overdose. That’s not how it works, so the big concern is that when people are driven into using alone, using in secret, and hiding because it is criminalised, that also increases the number of people who are suffering and dying.”
What hasn’t help reduce the number of people dying from fentanyl overdoses is a recent wave of panic among police officers. There have been multiple widely debunked stories about police “overdosing” from simply touching fentanyl in recent months, as officers who’ve been told they could OD through their skin display symptoms more likely to be attributable to panic attacks. “They don’t even know the symptoms of overdose well enough to fake it,” says Godvin. “I believe that they really feel like it’s happening, but it’s not happening and it’s not real. Why this is important is that it severely hampers our ability to effectively address this crisis because people are wasting money on hazmat suits, instead of giving Naloxone to people, or offering more drug treatment.”
She adds that during her recent experiments with fentanyl test strips she inadvertently demonstrated that the substance can’t enter the bloodstream through touch alone. “I was doing it all with my bare hands,” she explains. “I would never even think about putting on gloves, because the reason people shoot drugs into their veins is because it’s not absorbed through the skin! I was able to use the fentanyl testers for their actual purpose, which is urine detection, and I was negative later that day and the next day for any trace amount of fentanyl exposure, much less a level that would have caused an overdose.”
The dangers of fentanyl are very real, and very serious, but they’re also understandable and there are effective ways to reduce the number of people dying from overdoses. Things don’t have to be this way. “Fentanyl is just another drug,” says Godvin. “It’s a normal drug. It’s not a weapon of mass destruction. It’s used in hospitals everywhere every day. It is a stronger drug, and it is killing an unprecedented amount of Americans, but if we imbue it with these supernatural, almost evil properties, we will never get a handle on it. It is just another drug, and we already know the solutions.”
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