Why is it causing such a problem?

The opioid crisis has been going on for several years. However, in the past few years, there’s been a lot of talk about fentanyl and its impact on the crisis. With the Covid-19 pandemic, it seems to have only gotten worse. So, what is fentanyl? Why is it all of a sudden a problem? What can be done to minimize its impact?

On average, over 150 people die every day from overdoses related to synthetic opioids, like fentanyl. Even in small doses, fentanyl can be deadly because it’s up to 50 times stronger than heroin and 100 times stronger than morphine. It causes an intense, short-term high, relaxation, and temporary feelings of euphoria. Also, it can result in pain relief, sedation, confusion, drowsiness, dizziness, nausea and vomiting, urinary retention, pupillary constriction, and respiratory depression.

There are two types of fentanyl: pharmaceutical fentanyl and illicitly manufactured fentanyl. Pharmaceutical fentanyl is used to treat severe pain, especially after surgery and for advanced-stage cancer. It requires a prescription from a doctor.

Most cases of fentanyl-related overdose are linked to illicitly manufactured fentanyl (IMF), which is available on the drug market in different forms, including liquid and powder. Illicitly manufactured fentanyl is produced in China, Mexico, and India and then exported to the U.S. The dark web, an encrypted and anonymous corner of the internet, allows the sale of fentanyl and other opioids shipped through traditional delivery services. Street names for fentanyl include Apace, China Girl, China Town, China White, Dance Fever, Goodfellas, Friend, Jackpot, Murder 8, Great Bear, He-Man, Poison, and Tango & Cash.

Powdered fentanyl looks just like many other drugs. In liquid form, IMF can be found in nasal sprays, eye drops, and dropped onto paper or small candies. Fentanyl is not more dangerous than other opioids if the correct dose is used. It’s sold alone and added to other drugs because its high potency allows dealers to traffic smaller quantities but maintain the drug effects. This makes the drugs cheaper, more powerful, more addictive, and more dangerous.

Since IMF isn’t regulated, quality control of street-bought products is poor. The problem is that many users believe they are purchasing one type of drug and don’t know they’re buying fentanyl. This often results in overdose deaths. Despite the risk, fentanyl is so potent that it quickly becomes the drug of choice. Basically, fentanyl is cheap to buy and easy to put into other drugs. The combination is pushing the other drugs out of the market.

Fentanyl’s specific chemical structure has multiple areas that can be easily modified to form related compounds with different potency levels. One equivalent, acetylfentanyl, is about three times less potent than fentanyl. However, another, carfentanil, is approximately 10,000 times more potent than morphine and 100 times more potent than fentanyl. Carfentanil’s primary use is as a tranquilizing agent for elephants and other large mammals. Unfortunately, it’s making its way into the illicit U.S. drug markets, which is concerning since the relative strength of the drug could lead to an increase in overdoses and overdose-related deaths, even among opioid-tolerant users.

What is the Level of Impact of Fentanyl?

Per the Centers for Disease Control and Prevention (CDC), 1 in 14 Americans suffers from addiction to legal or illegal substances. Overdose deaths take more than 100,000 lives a year, or roughly 12 every hour. Overdose deaths rose from 8,050 in 1999 to 33,091 in 2015. According to the CDC, there has been an even greater increase in opioid-related deaths during the Covid-19 pandemic. The data shows a 30% rise in 2020 and a 15% increase in 2021. The agency’s numbers indicate that in 2021, overdoses amounted to one of the leading causes of death, similar to the number of people who died from diabetes and Alzheimer’s disease, and roughly a quarter of the number of people who died from Covid-19, the third leading cause of death.

The CDC’s report also shows that fentanyl overdose deaths tripled among teens over the past two years and surged five-fold among Black teens. The recent sharp increase in overdose deaths among teenagers might be explained by a new study that found the drugs being seized by drug enforcement authorities contained pills marketed as OxyContin, Xanax, or Adderall that have fentanyl in them.

Overdoses are claiming the lives of Black, American Indian, and Alaska Native people at rates never seen before. The hardest hit demographic is Black men. The Centers for Disease Control and Prevention notes that the overdose death rate among Black people rose 44% and 39% among American Indian and Alaska Native people in the first year of the pandemic alone, compared to 22% among white, Asian, or Pacific Islander, or Hispanic people. A study published in March 2022 found that in 2010 the overdose death rate among Black people was half that of white people, but in 2020, that flip-flopped. The numbers also show that most people who died didn’t receive treatment for substance use disorder in the past. White people who died appeared to have higher treatment rates than other groups. Researchers have released recent studies showing how overdose mortality changed from 2019 to 2020. Nationally, overdose mortality among Black people rose by 48.8% in 2020 versus 26.3% among white individuals.

The disparities are partly due to health inequities, such as unequal access to substance use treatment and treatment biases. Black populations are underserved when it comes to mental health services and addiction services, which means there’s less economic, clinical, and social resilience. The historic lack of investment in predominantly Black neighborhoods, higher incarceration rates, and homelessness are now colliding with an increasingly dangerous drug supply.

The country’s resources for fighting addiction have not been effectively targeted to reach Black Americans. In the past, Black people with opioid addiction have been directed to programs that offer methadone. While effective, it’s tightly regulated, requiring daily trips to a clinic to get a dose, which is a significant barrier. Researchers have found that even if Black people see a doctor, they’re less likely to be prescribed buprenorphine (another opioid addiction medication that can be taken at home).

Incarceration plays a considerable role. Black people are far more likely to be incarcerated on drug charges. When in prison or jail, there’s minimal addiction care. So, when an individual leaves, they’re particularly vulnerable to overdose. First, their tolerance has dropped. Second, they don’t know how the drug supply has changed.

Another issue is homelessness. Nationally, Black people are five times more likely than white people to be homeless. Studies show people who are homeless face higher overdose dangers.

The Covid-19 Pandemic & Fentanyl

Overdose deaths started spiking as Covid-19 forced shutdowns. The pandemic has caused stress, isolation, and economic upheaval while robbing people of treatment options and support systems. The way addiction changes the brain has made the pandemic particularly challenging for those with substance use disorder. Experts point out that isolation is the major contributor to the rising number of deaths. Isolation keeps people from social support networks and gives them more privacy to use substances.

Further, the pandemic has severely undercut efforts to control the opioid epidemic. Public health officials had to shift their focus to the coronavirus, meaning the suffering and death of substance abuse dropped in priority. Also, similar to other goods, supply chains for drugs have been unended during the pandemic. Many users are turning to unknown suppliers, which means they can end up with counterfeit drugs. Since many restrooms and public spaces have been closed during the pandemic, people are using drugs in more public areas. As a result, they’re rushing and not always taking the time to use test strips that can detect fentanyl.

What’s Being Done?

While the country has devoted billions to fighting addiction in recent years, the response hasn’t considered how to distribute resources in equitable ways. Programs aren’t designed for specific populations or don’t engage community groups already providing services in areas that need to be reached. People who use drugs are often treated poorly at medical centers, compound that with the long-running mistreatment of Black patients generally, it’s no wonder Black individuals are reluctant to seek care. One idea to combat this is to put clinics in Black churches because they would be able to receive care at institutions that have the community’s trust.

Lawmakers are trying to stop the flow of fentanyl, but many say that curbing the supply is only part of the problem. There’s still a demand for the drug. At the beginning of May 2022, the White House announced President Biden’s first national drug control strategy. The primary tactic is harm reduction. The goal is to lower the risk of dying or acquiring infectious diseases by offering sterile equipment (ex. needle exchanges) or tools to check drugs for the presence of fentanyl. Test strips that can detect fentanyl have become increasingly valuable resources. Some states have moved recently to decriminalize them. Overdose prevention clinics supervise people using drugs, offering medical support and safety. According to a recent study published in the International Journal of Drug Policy, these programs have successfully reduced fatal overdoses and increased access to health services. Some criticize these approaches as enabling drug users but are praised by addiction experts as a way to keep drug users alive while providing access to treatment and support.

Another measure to prevent fentanyl overdose is increasing the availability of opioid agonists like methadone and buprenorphine. These medicines reduce opioid withdrawal symptoms and cravings, helping people stay in treatment and decrease illicit drug use. Despite their positive track records, their availability is limited by restrictions on where and how they can be used and inadequate numbers of prescribers. Policy changes made during the pandemic may provide a way to prevent more deaths. Early research had found that relaxing the rules so methadone treatment can be taken at home has been beneficial.

A further positive outcome of the pandemic is the increased treatment via telemedicine because it reduces the need for transportation. Those in the field say the new technologies could help them provide treatment to the estimated 90% of people with substance use disorder who go untreated. Others point out that while it might work for established patients, it’s much harder to develop rapport and earn trust with new patients over a screen. There’s so much to be gained sitting in a room with other people, sharing, and seeing their body language. Those who struggle with addiction in rural areas, who often drive great distances to reach clinics and would really benefit from telehealth, often lack access to broadband. So, this barrier needs to be addressed.

One key area the CDC is addressing is the length of time it takes to analyze information reported from different jurisdictions on overdoses and which drugs were involved. Experts say we need more up-to-date, real-time data to get a handle on the crisis. The CDC has started releasing provisional overdose numbers after about four or five months but notes that it takes time for medical examiners and toxicologists to complete their investigations. The agency is providing states and coroners with more resources to improve data reporting. Researchers are using other data sources, including emergency department visits for non-fatal overdoses, to better track the health impacts of drug use.

Preventing and Dealing with Fentanyl Overdose

One way to tell if drugs have been laced with fentanyl is to use fentanyl test strips, which are inexpensive and give results within 5 minutes. It’s vital to note that if the test is negative, still be careful because the test strips might not detect more potent fentanyl-like drugs, like carfentanil.

It can be hard to tell whether a person is high or experiencing an overdose. If you aren’t sure, treat it like an overdose. Signs of overdose include small, constricted “pinpoint pupils,” falling asleep or losing consciousness, slow, weak, or no breathing, choking or gurgling sounds, limp body, cold or clammy skin, and discolored skin (especially in lips and nails). If you notice any of these signs:

  1. Call 911 Immediately.*
  2. Administer naloxone, if available.**
  3. Try to keep the person awake and breathing.
  4. Lay the person on their side to prevent choking.
  5. Stay with the person until emergency assistance arrives.
  6. Continue administering a dose of naloxone every 2-3 minutes until the individual is breathing on their own for at least 15 minutes or until EMS arrives.

*Most states have laws that may protect a person who is overdosing or the person who called for help from legal trouble.

** Naloxone, or Narcan, is a life-saving medication that can reverse the effects of opioid overdose and save lives. It’s available in all 50 states and can be purchased from a local pharmacy without a prescription in most states. Rarely naloxone doesn’t counteract the effects of fentanyl on the body. However, sometimes individuals don’t awaken quickly due to other drugs or medical complications. Besides death, the most concerning medical complication is brain injury due to lack of oxygen because the person isn’t breathing.

Disparities among demographics were emerging in the pre-pandemic years and will keep growing without concentrated efforts to stem them. There’s no easy answer to stopping the opioid crisis. The pandemic has left many people too frightened to seek care. So, people are coming in really needing help because they’re waiting as long as they can. On top of that, the past year has been challenging for organizations providing treatment and other support for people in recovery. The financial toll of the pandemic means healthcare systems are cutting addiction treatment programs just when they are needed most. There’s some hope that the recent settlements with prescription opioid manufacturers and distributors will soon bring new resources. Regardless, we need to be doing everything possible to stop the number of overdose deaths.