What Is Fentanyl and Why Is It So Dangerous?
The opioid crisis has only intensified as more illicit drugs have entered the market. Drug overdose deaths reached a record high in 2021, with more than 100,000 people lost to the continuing epidemic, fueled by the potent synthetic opioid fentanyl. The drug, according to the Centers for Disease Control and Prevention, can be up to 50 times more potent than heroin and 100 times that of morphine. Illicit forms of fentanyl are mainly manufactured by drug cartels in Mexico and spreading in the U.S.
What is fentanyl?
Fentanyl is a heavily regulated legal medication, prescribed largely for pain relief in cancer patients, postsurgery and for people with chronic pain who have developed tolerance for other opioids.
When prescribed by a doctor, fentanyl can be given as a shot, a patch that is placed on a person’s skin, as lozenges that are sucked like cough drops or film that sits between the cheek and gum, according to the American Society of Health-System Pharmacists Inc. It also can be sprayed in the nose or under the tongue.
The illicit form of fentanyl, a powder that is often mixed into other drugs, has overtaken the drug market in the U.S. Fentanyl is made in clandestine labs in Mexico from easily sourced chemicals.
Which drugs are typically laced with fentanyl?
Fentanyl is often found mixed into heroin, cocaine and methamphetamine, according to the CDC. The drug is also made into fabricated pills that are often indiscernible from commonly prescribed medications such as Percocet (the narcotic oxycodone), Xanax (the sedative alprazolam) or even Adderall (an amphetamine).
Chinese chemical companies are making more ingredients for illegal fentanyl than ever, including N-Phenyl-4-piperidinamine, which Mexican cartels purchase to make into fentanyl.
Drug manufacturers in Mexico also mix illicit fentanyl with other materials, such as baking soda, starch and sugar, to create a powder that can be smoked or dissolved into liquid and injected, a process called “cooking,” or fabricated pills purchased on the illicit market.
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Fentanyl is so powerful that in pure form the amount in roughly two sugar packets can provide a year’s supply for a user. When drug suppliers mix fentanyl into drugs or press it into illicit pills, a few grains too many can be enough to trigger a fatal overdose. It is unclear why fentanyl is showing up in such a large array of drugs. Evidence that fentanyl is showing up in more places comes from laboratory tests of drug seizures, toxicology testing and death certifications that take months to complete, according to the National Institute on Drug Abuse. Law-enforcement officials believe that in some cases, the drug is mixed in accidentally by drug manufacturers working with multiple white powders in the same lab, while at other times, drug manufacturers are experimenting in the attempt to create new psychoactive substances.
How often are illicit drugs laced with fentanyl?
Fentanyl has infiltrated virtually every channel of the illicit drug supply, according to U.S. law officials. The proportion of seized counterfeit pills in the U.S. containing a potentially lethal dose of fentanyl increased to 60% in 2022 from 10% in 2017, according to samples analyzed by the Drug Enforcement Administration.
Tainted drugs are so common in cities across the country, including Columbus, Ohio, that the city offers a program for distribution of fentanyl testing strips to users so they can determine whether substances are contaminated with the drug.
In New York City, authorities have been warning of the risks of unknowingly taking fentanyl in cocaine and of its increased presence in cocaine seized by police. Of 980 cocaine deaths in 2020, 81% involved fentanyl, according to recent New York City health department data.
People who use methamphetamine are also sometimes accidentally exposed to fentanyl. But many users are intentionally using meth and opioids simultaneously or in sequence in search of balancing or offsetting effects, researchers say. The drug combination is becoming an emerging driver of U.S. overdoses.
What is fentanyl’s effect on the human body?
Fentanyl works by binding to the body’s opioid receptors—found in the areas of the brain that control pain and emotions, according to the National Institute on Drug Abuse. Some of the effects of fentanyl include euphoria, relaxation, pain relief, drowsiness and sedation, among others, according to the U.S. Drug Enforcement Administration. With repeated use, the brain adapts to the drug, making it hard to feel pleasure without it. Stopping the use of fentanyl leads to withdrawal, or “dope sickness,” which can include extreme anxiety, vomiting, muscle pain, chills, racing heartbeat and profuse sweating. Many chronic users have long since stopped feeling the euphoric effects of fentanyl and use it to avoid feeling sick.
Drug users who are accustomed to using heroin or prescription pain pills say illicit fentanyl’s effect can be more dramatic and shorter lasting than other opioids, making it more difficult to hold down a job as they seek out drugs every few hours.
What are some of the signs and symptoms of someone overdosing on fentanyl?
Fentanyl slows the body down and reduces respiration but becomes deadly when it suppresses breathing to such slow shallow breaths that a person can’t sustain life and their heart stops. If someone is unconscious, awake but unable to talk, or their breathing slows sharply, that could be an early sign of an overdose. According to the New York State Department of Health, that person’s skin may soon turn bluish purple or ashen. In some cases, a person overdosing will have a faint heartbeat. An overdose can also lead to hypoxia, the decrease in oxygen to the brain, according to neuropsychopharmacologists.
Still, it can be difficult to tell if a person is just very high or experiencing an overdose, according to the National Harm Reduction Coalition. People who are high may display slurred speech or seem dazed, but still be able to respond to a loud noise or someone lightly shaking them, the group says.
How do you treat an overdose?
Naloxone is an antidote to opioids that can reverse the effects of an overdose within two to three minutes, according to the Mayo Clinic. Naloxone has virtually no effect in people who haven’t taken opioids, according to the World Health Organization.
The overdose-reversal drug binds to opioid receptors and reverses or blocks the effects of opioids. It comes in two forms: nasal sprays and injectables. Nasal sprays such as Narcan are often stocked by first responders and at healthcare facilities. Groups working with drug users typically have an injectable version of the drug on hand that can be injected into the muscle of an arm or leg to reverse an overdose. The Substance Abuse and Mental Health Services Administration recommends performing cardiopulmonary resuscitation, also known as CPR, if the person isn’t breathing on their own and said it can save a person’s life regardless of whether naloxone is present. The agency says it is important to stay with the person until medical personnel arrive, reassure them and explain what is happening, as they may reawaken agitated, confused or could overdose again if the naloxone wears off before the opioid.
Recently, the U.S. Food and Drug Administration encouraged pharmaceutical companies to apply for approval for over-the-counter versions of overdose-reversal medications such as Narcan to help address a swelling overdose crisis from bootleg versions of the powerful opioid fentanyl.
The pharmaceutical nonprofit Harm Reduction Therapeutics Inc. has already received priority review from the agency to make an inexpensive naloxone nasal spray for use without a prescription. The company said the FDA gave it a target approval date of April 28.
Emergent BioSolutions Inc.,
maker of the Narcan brand of naloxone nasal spray, said its application for over-the-counter status received an expected approval date of March 29.
What is “tranq” drug xylazine?
Xylazine is a veterinary tranquilizer that has increasingly been showing up in illicit drugs, including in fentanyl. The drug, which is authorized only for animals, has been complicating overdoses and producing severe wounds for users that can lead to serious infection and amputation.
Dealers may mix xylazine into fentanyl to save money, federal law-enforcement authorities have said. The drug—known as “tranq” among some users—can be purchased at low prices from Chinese suppliers and offset some of the opioid in the mix.
Drug users often don’t know that xylazine is being mixed into their fentanyl batch and unknowingly become hooked on both substances. Drug users say xylazine can prolong a high from fentanyl but that also often means being unconscious, sometimes for hours at a time.
In February, the FDA said it would restrict imports of xylazine and more carefully scrutinize shipments of the drug into the U.S. to check that they are bound for legitimate use in animals.
What is harm reduction?
Harm reduction is a public-health strategy aimed at reducing as much harm as possible to people while they are using drugs, rather than stopping them from taking substances altogether.
Groups that practice harm reduction for drug users teach about using clean needles to prevent infection and the spread of disease. Some groups provide fentanyl test strips so that users can test drugs for fentanyl and hand out naloxone to prevent deaths from overdose. An increasing number of groups supervise drug consumption. The Biden administration is the first to name harm reduction as a priority for drug policy.
Who is affected by overdose rates?
Disparities in access to treatment are driving up overdose rates among Black and Native American people, the CDC has said. Overdose deaths per 100,000 people increased 44% for Black people and 39% for Native Americans in 2020 from a year earlier, compared with a 22% increase among white people, according to a study in which the CDC analyzed 25 states and Washington, D.C.
Deaths from fentanyl have affected every age group, but particularly the 25-to 34-year-old and 35-to 44-year-old populations. These two groups combined made up more than half of all synthetic opioid overdose deaths in 2021, according to preliminary CDC data.
Young children have also been directly affected by fentanyl. There were 133 opioid-related deaths among children younger than 3 last year, according to federal mortality data.
Overdose rates were higher in areas with more opioid-treatment programs than average, a finding that the study’s authors said demonstrated other barriers to access for some people. Overdose rates were also higher in counties with higher income inequality, according to the study. The findings show how the escalating overdose crisis is exacting a mounting toll on minority groups that are in some cases marginalized by the healthcare system, CDC researchers said.
Some prisons and jails have programs that dispense antiaddiction medications to help put inmates who are addicted to opioids on a path to sobriety and curb overdose rates. The Biden administration has said it wants medication available for drug users in federal custody and at half of state prisons and jails by 2025.
This explanatory article may be periodically updated.
—Brian Spegele, Margot Patrick, Arian Campo-Flores and Jon Kamp contributed to this article.
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