Synthetic Opioid Fentanyl: Now the #1 Drug Involved in Overdose Deaths

Syringe with powder closeup.

One thing is for sure is that the world of drug use, addiction and overdoses never stays the same for long. The drugs bought and sold change, the threats change, the patterns of overdose deaths also change. A few years ago, when the American landscape of drug supplies changed to include a growing quantity of fentanyl, this change was catastrophic, indeed.

Originally, fentanyl was a prescription drug that was rigidly controlled. It was only used in cases of severe pain that nothing else would touch. In hospitals, in hospices, this powerful opioid painkiller made life livable. When a person was at home suffering from severe pain, a fentanyl patch could ease their suffering.

And then foreign chemical and pharmaceutical manufacturers had the bright idea to create batches of fentanyl and send them into the American illicit drug market—a market ripe for a new opioid. In small numbers, Americans who had been misusing prescription drugs or using heroin began dying of fentanyl overdoses.

Now we’ve reached the point that fentanyl is the #1 drug involved in overdoses. A recent report from the Centers for Disease Control and Prevention (CDC) provides insight into this horrific change. Their report published December 2018 includes the following details:

  • The ten most frequently-mentioned drugs contributing to overdose deaths include fentanyl, heroin, hydrocodone (Vicodin, Lortab), methadone, morphine, oxycodone (OxyContin, Percocet and others), alprazolam (Xanax), diazepam (Valium), cocaine, and methamphetamine;
  • In 2011, the top drug taking lives was oxycodone;
  • Between 2012 and 2015, the top ending lives was heroin;
  • In 2016, the top drug was no longer a painkiller or heroin. It was illicitly-manufactured fentanyl;
  • Between 1999 and 2016, the U.S. rate of overdose deaths more than tripled, going from slightly more than six deaths per 100,000 population to nearly 20 deaths, with fentanyl contributing an increasing number of these deaths.

The next statistics describe the wide swath of devastation caused by fentanyl:

  • In 2013, there was less than one (0.6) fentanyl-related death per 100,000 population;
  • By 2016, this number had increased nearly tenfold to 5.9 deaths.

The Many Unique Challenges Related to Fentanyl

Fentanyl glass ampules.

Heroin is deadly, misusing opioid painkillers can be deadly, even cocaine and methamphetamine can kill. So what makes fentanyl such a killer drug?

There are several reasons.

First, there’s the incredible potency of this drug. Regular pharmaceutical fentanyl is 50 to 100 times stronger than morphine. Heroin is only 4 or 5 times stronger. This makes it very easy to overdose if you get your hands on a batch of drugs that has been doctored with fentanyl to make it more potent or it contains only this drug and nothing else.

But wait—there’s actually a large family of fentanyl-related products. These chemically-similar drugs are called fentanyl analogues. There are dozens of analogues in existence. Several have shown up in illicit drug supplies. For example, in Ohio over a five-month period from October 2017 through February 2017, acrylfentanyl took 202 lives and furanylfentanyl took 192.

Carfentanil is the most powerful analogue found on the illicit market. This drug is approximately 10,000 times more powerful than morphine. Carfentanil hit the country hard and its presence keeps increasing. The CDC reported that in 2016, carfentanil had been detected in drug samples from 54 counties nationwide, but by early 2017, this number increased to 77.

Fentanyl or any of its analogues could be present in a bag of drugs that you think contains heroin. Or an enterprising drug dealer could buy a pill press and some coloring powder and press fentanyl, carfentanil or any other analogue into a pill form. You could think you’re buying a blue OxyContin pill from a dealer but actually it is fentanyl mixed with powdered baby laxative.

Fentanyl has even been found in cocaine and methamphetamine. More than ever before, you take your life in your hands if you buy any illicit drug.

The last unique challenge related to fentanyl is that it is so powerful that it’s hard to bring a person back from an overdose. The opioid antidote naloxone is given to a person who is unconscious and not breathing after an opioid overdose. When the drug causing an overdose is heroin or oxycodone, a single dose of naloxone could be expected to revive the individual. But when it’s fentanyl or an analogue causing the overdose, it will often require multiple doses. This is a whole new world of emergency medicine.

Fentanyl Spread Fast, Taking Lives Wherever it Went

Opioids and money.

Following the increased prescription of opioid pain reliever by physicians in the late 1990s, the number of heroin users increased 254% in nine years, going from 373,000 users to 948,000. This increase in heroin users meant that there were a lot more customers for this drug.

It is way too easy and profitable to boost the potency of a batch of heavily diluted heroin with a little illicit fentanyl from overseas. Those accustomed to a certain typical potency to their heroin could find their drug supplies suddenly becoming deadly.

Fentanyl is so potent that a single kilo of it is strong enough to kill hundreds of thousands of people. A seizure of 120 pounds of fentanyl in Nebraska in 2018 was calculated to provide enough of this synthetic opioid to end the lives of 26 million people.

Once the drug began flowing into the country, it didn’t take long for supplies to make their way into every corner. In 2015 there were 14,440 samples of this drug submitted to law enforcement labs for analysis. In the first six months of 2017, there were 25,460 samples submitted. Drug manufacturers and drug traffickers have seized upon this opportunity and are ready to profit from it, no matter who gets hurt—or killed.

Those who are raking in the profits from making it and trafficking it to America or selling it on the street are going to be hard to stop. Law enforcement agencies are working hard to target fentanyl dealers and take them off the street. But it’s very hard for American law enforcement to put foreign drug manufacturers out of business.

Those people who habitually use opioids have developed a variety of techniques to avoid overdosing on these synthetic opioids. Whereas once they might have simply cooked up a batch of heroin and loaded it into a syringe for injection, now they might use any of these methods to avoid overdose:

  • Injecting just a small portion of the dose they expect to take and then waiting to see its effects before injecting the rest;
  • Snorting, smoking or tasting a small amount of their drug purchase to determine its potency;
  • Watching while someone else who is more accustomed to using opioids than they are uses a dose from their supply;
  • Always buying opioids from the same person who has been trustworthy in the past.

These are very dangerous ways to try to survive the presence of fentanyl, a drug that may be found in any corner of the country, or in any counterfeit pill or bag of powder. The sooner any addicted person can find recovery, the more certain their very survival will be.

Reviewed by Claire Pinelli ICAADC, CCS, LADC, RAS, MCAP


Karen Hadley

For more than a decade, Karen has been researching and writing about drug trafficking, drug abuse, addiction and recovery. She has also studied and written about policy issues related to drug treatment.