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Fentanyl 101: What everyone should know

October 28, 2022

Over the last decade, the conversation of the opioid epidemic has changed to include fentanyl. According to the CDC, the rate of fentanyl overdoses in 2020 was 18 times higher than in 2013. Fentanyl currently accounts for the vast majority of all opioid overdoses and almost 70% of all drug overdose deaths. Its impact on overdose deaths and prevalence in street drugs other than opioids (i.e., stimulants) has led many in the field to refer to fentanyl as the Fourth Wave of the Opioid Epidemic. In this post we’ll unpack some basics on fentanyl, how it has changed the landscape for drug users, and how we can think about effective solutions to this new problem.

What is Fentanyl?

Opioids are a class of compounds that include drugs made from the poppy plant and those that are synthetically manufactured in laboratories. Opioids found in prescribed opioid medications vary slightly in their chemical makeup compared to heroin; they also differ from each other, making them more or less potent. Fentanyl is a highly potent synthetic opioid that is used to treat severe pain and is primarily administered in hospitals following surgery; it is 50 times more potent than heroin. (Potency refers to the amount of a substance needed to have an effect. In this instance, less fentanyl is needed to have the same effect on pain or to induce euphoria. This is why we often hear that only a few grains of fentanyl can be lethal.)

In recent years the drug supply has become overrun with illicitly manufactured synthetic fentanyl, which can be manufactured very cheaply. The fentanyl we see in the US drug supply mostly comes from Mexico and China.

Fentanyl analogs, which are similar in nature to fentanyl and include substances like acetylfentanyl, furanylfentanyl, and carfentanil, have also been found in the US drug supply.

Recently, drug seizures have found brightly colored pills laced with fentanyl, also known as rainbow fentanyl. Despite media attention on the reason behind these pills, experts do not agree that the pills are being marketed to children.

Why is fentanyl in the drug supply?

Because fentanyl can be created in a lab, it is much easier to produce and is, therefore, a cheaper alternative to less-potent opioids. Fentanyl can be pressed into pill form so it appears as a standard prescription opioid or sold as a powder.

Fentanyl is often mixed with other drugs like heroin, crack, or cocaine. Sometimes people look for combinations of uppers (like crack or cocaine) and downers (like heroin) (this was once called a speedball). Although some people may seek out this combination, dealers may also mix fentanyl into other drugs to stretch their supply and increase their profits. But when fentanyl is mixed into non-opioid drugs (like methamphetamines), or when the dose of fentanyl is higher than an individual is used to, it can be lethal. Because fentanyl is typically diluted, users may not know how much fentanyl they might be ingesting. To novice users or long-term users alike, this could be fatal.

The DEA and other federal agencies have made a formal commitment to reducing the flow of fentanyl into the US.

What strategies can save lives from fentanyl overdose?

General strategies that have been used to address other waves of the opioid epidemic can be adapted to address the presence of fentanyl in the drug supply. These include:

Prevention: DEA’s new awareness campaign, “One Pill Can Kill” is aimed at educating new or novice users of the dangers of the unpredictable drug supply. Additionally, programs for younger children that promote resiliency and building strong adult relationships can help to prevent future drug use. (See Principle 3 for more information on primary prevention strategies)

Harm Reduction: A critical and continued evidence-based strategy, harm reduction provides not only education on the dangers of fentanyl, but vital resources for people in active drug use. Like other opioids, fentanyl overdoses can also be reversed by naloxone. Due to its potency, more doses may be needed, which only amplifies the need to increase access to community-based naloxone in communities.

Another strategy that harm reduction programs offer is drug testing. Fentanyl test strips are an inexpensive and effective way for individuals who use drugs to test their drug for fentanyl before they use. The strips can detect the presence of fentanyl in pills, powders, or injectables. Unfortunately, fentanyl test strips are considered paraphernalia in many states and are illegal to possess and use. {ONDCP has recently released model legislation that can be used to increase access to fentanyl test strips if your state is looking to expand access to this live saving strategy.}

Additional harm reduction strategies may also be valuable options considering the growing volatility of the drug market. Strategies of going slowly and using with another person can help to prevent overdose deaths. Overdose prevention sites allow individuals to use previously acquired drugs in a safe and supervised space to prevent overdose fatalities (for more on OPS).

What are other ways litigation dollars can be used to combat the fourth wave?

In addition to the above fentanyl-specific strategies, approaches that have worked to address opioid overdoses more generally are also applicable here. These include those outlined in the Core Strategies of the settlement agreement:

    1. Expanding treatment for people with opioid use disorder to assist people who use drugs. This can include increasing access to medication assisted treatment. These treatment options have been shown to be effective for people who use fentanyl.
    2. Funding warm hand-off programs and recovery services help to facilitate people into treatment, but can also help to support individuals along the continuum of care.
    3. People involved in the criminal justice system are particularly vulnerable to overdose. These individuals are more likely to have a substance use disorder compared to the general population. Starting treatment with methadone or buprenorphine while people with an opioid use disorder are still incarcerated has been shown to reduce overdose deaths and illicit opioid use. Improving treatment in jails and prisons is an important intervention opportunity to reduce the risk of fentanyl overdose.
    4. Supporting data collection and research can help communities understand what drugs are causing deaths in their community, where overdoses are happening, and how to target services to the greatest need.

For more information on the core strategies and evidence based interventions, read The Primer on Spending Funds.