Feared by drug users but hard to avoid, fentanyl takes a mounting toll

June 7, 2017 by David Orenstein  , Brown University
Maps show the close overlap between drug overdose deaths with and without fentanyl, suggesting that fentanyl is pervasive in the illegal drug supply. Redder zones indicate the highest rates of overdose deaths. Credit: Marshall et. al./Brown University

Fentanyl, a highly potent prescription opioid, has Rhode Island drug users on high alert. But despite widespread aversion, fentanyl now causes the majority of the state's drug overdose deaths.

These bleak findings by teams of Brown University researchers appear in two studies published in the International Journal of Drug Policy. They underscore the urgency of combatting the misuse of fentanyl and undermine a common perception that many users court the for its potency.

"Most people are not asking for it," said Jennifer Carroll, lead author of one of the studies and an adjunct assistant professor of medicine at the Warren Alpert Medical School of Brown University. "They can't avoid it, and their desire to avoid it is not reducing their risk."

The number of in Rhode Island attributable to fentanyl rose to 138 in the first nine months of 2016, compared to 84 in all of 2014, according to the other study led by Brandon Marshall, an assistant professor of epidemiology at the Brown University School of Public Health. In 2014, 35 percent of the state's fatal overdoses occurred because of fentanyl, but it was involved in 56 percent of drug deaths by 2016.

Moreover, mapping all 778 overdose deaths in the state during the study period showed that fentanyl-related deaths occur virtually everywhere that heroin overdoses are occurring. Fentanyl, is is often used to lace heroin but many users can't tell if it is present.

"We were surprised that we saw such similar geographic patterns," Marshall said. "What we're drawing from that is that there is widespread contamination of the drug supply with fentanyl. It's not clustered in one city or town."

The data do show ominous differences with fatal fentanyl overdoses. One is is that they are particularly likely among users who inject drugs. Another is that users are now dying younger. Marshall said his hypothesis is that with fentanyl in the mix, the lifetime risk of a deadly drug overdose accumulates much faster than it used to.

Fear of fentanyl

While Marshall's study documents the broad extent of the deaths, Carroll's study gives voice to those who are trying to survive the onslaught. In surveys of 149 users and face-to-face interviews with 47 of them, Carroll's team found a palpable fear and dislike for fentanyl among drug users. Four in five respondents said they were well aware of fentanyl and its dangers, but many described difficulty in avoiding it.

Traci Green, an associate professor at Brown and Boston University's schools of medicine and and a senior author on both papers, noted that fentanyl's appearance in the illegal drug trade occurred early on in Rhode Island. The first appearance of acetyl fentanyl was linked to a clandestine Rhode Island lab in spring 2013, she said, possibly foreshadowing the shift to including fentanyl. Unlike heroin, fentanyl can be created synthetically.

Of the 121 users who told Carroll they were aware and wary of fentanyl, 61 said they had been exposed to it. In the prior year before filling out the survey, 51 percent of those with exposure had experienced a non-fatal overdose, while only 17 percent of those who did not report fentanyl exposure said they had overdosed.

Throughout the study, Carroll and her co-authors included direct quotes from user interviews that illustrated the broader trends in the data. Matt, a man in his 20s from western Rhode Island spoke of his fear of fentanyl.

"I've seen people OD in front of me from shooting the stuff," he is quoted as saying. "People are dropping like flies. I've had three friends I grew up with since I was 10. They're all dead from [heroin cut with fentanyl]."

Another user, Jason, said that if he is struggling enough with the onset of withdrawal symptoms, he'll still use heroin even if he suspects the presence of fentanyl. So he'll try a little first to see if he feels fentanyl's very strong effects.

"[It depends on] the availability of other batches and how sick I am," he said. "If I'm sick, I gotta do it, you know? I won't do half a gram. You know, I'll do a little pinch and I'll figure it out from there, but I won't start big. It's scary. I've watched overdoses. And I've had one in front of my girl."

Carroll found that heroin users employ a wide variety of strategies to attempt to avoid fentanyl. Matt's strategy is to snort rather than inject. Jason's strategy is to try a little bit of the drug first. Sheryl said she tries to inspect the drug visually, while Carl said he can tell by the smell. But users such as Sheryl and Jeff readily acknowledged that their attempts at analysis were not very effective. Marshall's study notes that a quantity of fentanyl equivalent to just two grains of salt can kill, meaning that very little has to be cut into heroin to pose a threat.

While some users said their long-term experience with their dealers allows them to trust that they won't be sold heroin with fentanyl, others such as Maggie, a woman in her 40s, has no such trust. She told Carroll that dealers don't care whether users die because they only care about money.

Given the lack of demand they observed, the researchers suspect that supply side reasons account for the presence of fentanyl in the market.

Possible solutions

In both studies, the researchers identified several measures that can help prevent deadly overdoses.

Marshall's study notes that because fentanyl acts faster than heroin in suppressing breathing, users need readier access to the overdose-reversing drug naloxone. They also need it in higher doses.

"Programs to increase distribution of naloxone to people who use drugs, their acquaintances and their loved ones are urgently required," Marshall and co-authors wrote.

Many of the users in Carroll's study reported frustration in obtaining medication-assisted treatment with methadone or Suboxone to end heroin use because of difficulties with insurance or in finding a doctor. In Marshall's study, researchers said more doctors should receive training and a subsequent waiver that would allow them to prescribe medication-assisted treatment. The proportion of the state's physicians authorized to write the prescriptions has been growing but remains low, he said.

"People are trying to help themselves and find their way, but the system isn't exactly ready to go," Green said.

Marshall's study also suggests increasing peer education efforts among users and investigating whether to establish supervised injection facilities, where users could take their with medical providers standing by. Carroll acknowledged that the idea is controversial, but she said purely from a public health standpoint, research shows that such facilities save lives.

Finally, Marshall praised a relatively new development currently being studied in Rhode Island and Massachusetts: the distribution of testing strips that can allow users to detect the drug.

Explore further: US drug overdose deaths soar in 2016: report

More information: International Journal of Drug Policy (2017). DOI: 10.1016/j.drugpo.2017.05.029

Related Stories

US drug overdose deaths soar in 2016: report

June 6, 2017
US drug overdose deaths surged 19 percent to at least 59,000 last year as deadly manufactured drugs like fentanyl intensified a national opioid addiction crisis, New York Times data showed Tuesday.

The latest opioid street mix causing concern: 'Gray death'

May 4, 2017
It's being called "gray death"—a new and dangerous opioid combo that underscores the ever-changing nature of the U.S. addiction crisis.

Canada says it will restrict fentanyl chemicals

September 1, 2016
Canada plans to restrict six chemicals used to make the drug fentanyl in a bid to stem what it called a national opioid crisis, the Canadian health minister said Wednesday.

'Unprecedented' overdose epidemic from fentanyl in US

August 25, 2016
Painkillers containing illegally made fentanyl, a synthetic drug up to 100 times more potent than morphine, are responsible for a surge in overdose deaths in the United States, health authorities said Thursday.

Quasi-legal drug 15 times stronger than heroin hides in plain sight

August 18, 2014
Emergency physicians should expect "an upswing in what on the surface appear to be heroin overdoses," but are actually overdoses tied to acetyl fentanyl, an opiate that is mixed into street drugs marketed as heroin. The looming ...

New twist in addiction crisis: Deadly painkiller impostors

February 29, 2016
Authorities are sounding the alarm about a new and deadly twist in the country's drug-addiction crisis in the form of a potent painkiller disguised as other medications.

Recommended for you

Shortcut strategy for screening compounds with clinical potentials for drug development

December 4, 2018
Developing a new drug often takes years and costs hundreds of millions of dollars. A shortcut has now been reported in a study led by City University of Hong Kong (CityU), which can potentially reduce the time and costs of ...

Drug wholesalers drove fentanyl's deadly rise, report concludes

December 4, 2018
Fentanyl, a powerful synthetic opioid implicated in nearly 29,000 overdose deaths in the United States last year, most likely spread because of heroin and prescription pill shortages, and also because it was cheaper for drug ...

Global review reports on administration of children's antibiotics

December 4, 2018
Researchers analyzing the sales of oral antibiotics for children in 70 high- and middle-income countries found that consumption varies widely from country to country with little correlation between countries' wealth and the ...

Opioid prescriptions from dentists linked to youth addiction risk

December 3, 2018
Teens and young adults who receive their initial opioid prescriptions from their dentists or oral surgeons are at increased risk for opioid addiction in the following year, a study from the Stanford University School of Medicine ...

Rise in meth and opioid use during pregnancy

November 29, 2018
Amphetamine and opioid use in pregnancy increased substantially over the last decade in the United States, a new Michigan Medicine-led study finds. And a disproportionate rise occurred in rural counties.

Mouse model aids study of immunomodulation

November 19, 2018
Because mice do not respond to immunomodulatory drugs (IMiDs), preclinical therapeutic and safety studies of the effects of IMiDs have not been possible in existing types of mice. This has led to an inability to accurately ...


Adjust slider to filter visible comments by rank

Display comments: newest first

5 / 5 (1) Jun 07, 2017
The solution of course is to legalize opiates, allowing users to buy them from sources that control the quality of the product.
1 / 5 (1) Jun 07, 2017
Sorry BackBurner, I just don't see it that way. Alcohol is legal and controlled and close to 90,000 people a year die from alcohol related causes. Marijuana is legal in many places and marijuana related car crashes have tripled. It doesn't work.
not rated yet Jun 07, 2017
Illegal fentanyl is an effective dimwitocide.
not rated yet Jun 08, 2017
Heroin overdose deaths, fentanyl deaths, so easy to die easily and painlessly with illegal drugs. Yet every state struggles to find legal drugs to kill death penalty recipients while the illegal drugs that work perfectly languish in virtually every police station in the country. Just one of literally thousands of examples of the pandemic of stupidity that our society protects and nurtures, the pandemic that will never allow us to survive what we are doing to this planet now. Kiss your dumb assgoodbye, it's the price of freedom. Want to know if you are one of the dumb ones? Do you think you have a right to an opinion on anything? Yes? Then you are one of the dumb ones.
not rated yet Jun 08, 2017
Sorry BackBurner, I just don't see it that way. Alcohol is legal and controlled and close to 90,000 people a year die from alcohol related causes. Marijuana is legal in many places and marijuana related car crashes have tripled. It doesn't work.

What doesn't work is stupid people voicing opinions about things they know nothing about. One of the main reasons our species is on the decline, people like you. Why don't you call up Pratt and Whitney and tell them how you think they should design turbine blades since you think your opinion should matter on subjects you know nothing about.

And legalizing opiates did work in Holland
not rated yet Jun 08, 2017
while the illegal drugs that work perfectly languish in virtually every police station in the country... What doesn't work is stupid people voicing opinions about things they know nothing about
You mean like people who think you can grab a bunch of drugs from holding and force some convict to ingest them until he dies? Or find some doctor willing to cook them up and inject a convict with them?

Illegal drugs are undependable which is why dimwits sometimes die from them. I guess stupid people don't know this.

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.