The Ripple Effect, Part Two: Is Illicit Fentanyl Really That Dangerous?

In a word, yes. And we should all be concerned. Most people have heard the statistic: Fentanyl, a synthetic opioid, is up to 50 times stronger than heroin and 100 times stronger than morphine. We’ve seen the graphic showing a pencil tip with a tiny amount of fentanyl that is deadly. But, many of us assume our lives will not be touched – that problems with illicit fentanyl are something that happens to other people. The reality is that illicit fentanyl has made its way into households across the United States, devastating individuals, families, and communities – from all neighborhoods, all socioeconomic backgrounds, all ages, all races. While the impacts of fentanyl have hit some communities harder than others, no community is immune.

According to the Centers for Disease Control and Prevention (CDC), synthetic opioids are currently the main driver of drug overdose deaths. In 2022, more than two-thirds (68%) of the reported 107,081 drug overdose deaths in the United States involved synthetic opioids,  primarily fentanyl. Alarmingly by 2021, the number of overdose deaths had increased nearly 23 times the rate in 2003 with numbers surging for young people. The situation is dire, with similar trends observed globally.

What is Fentanyl?

Fentanyl is a synthetic opioid that has been around since the 1960s and is used in the medical field as a legitimate and effective pain reliever and anesthetic. Unlike opium, which is derived from the poppy plant and used to make substances like morphine, codeine, heroin, and oxycodone, fentanyl is manufactured in labs.  Pharmaceutical fentanyl can be used to treat severe pain, such as in cases of advanced cancer or surgery, in emergency departments, or for individuals experiencing chronic pain that does not respond to other treatments. Typically, patients are given a fentanyl patch, lozenges, or shots and are monitored by a physician.

Why is Illicit Fentanyl So Dangerous?

Variable Dose of Active Substance in Clandestinely Manufactured Pills | Source: United Nations Office on Drugs and Crime

Problems arise when fentanyl – a Schedule II narcotic – is manufactured and sold illegally on the black market. Increasingly, illicit fentanyl and fentanyl analogs (chemical alterations) are mixed with other substances such as heroin, cocaine, meth, and counterfeit prescription pills such as oxycodone. This deadly combination amplifies the risk of overdose or poisoning, making every encounter with illicit drugs more dangerous and making effective treatment trickier. Pharmaceutical fentanyl is given under controlled conditions and carefully measured according to a patient’s needs and tolerance. By contrast, when illicit fentanyl is mixed with other drugs by amateurs in clandestine labs, the process is imprecise, which leads to highly varied and deceptive products. As a result, often, people don’t know that the drugs contain fentanyl. Plus, fentanyl is incredibly strong without a distinct smell or taste, making detection unlikely. Just 2mg, similar to the amount of residue left in an empty restaurant sugar packet, can be life-threatening. According to the DEA, 6 in 10 fake prescription pills bought online or on the streets are laced with fentanyl. So what people believe is an Oxy or Percocet pill actually may unknowingly contain poisonous levels of illicit fentanyl.

What Does Fentanyl Do to the Body?

Fentanyl works by rapidly binding to the body’s opioid receptors and changing the way that the brain and nervous system respond to pain. In a clinical setting, this can be extremely effective – think of someone who was in a car accident and has arrived at the emergency department with a fractured femur or a patient admitted with severe burns. In these situations, medical staff would verify the patient’s dose in vials or prefilled syringes measured in micrograms, not milligrams. They would then administer the appropriate dose, and the patient’s vitals would be closely monitored. 

Besides its potency, what makes fentanyl particularly dangerous is its effects on the respiratory system. A study conducted at Massachusetts General Hospital found that in a clinical setting, fentanyl stops people’s breathing before other noticeable changes and before they lose consciousness. Researchers discovered that the drug begins to impair a person’s breathing about four minutes before any change in alertness – before they even realize what is happening. This lack of oxygen decreases the oxygen available to the brain, a condition called hypoxia, which can lead to permanent brain damage or death.

What Is the Difference Between Overdose and Poisoning?

An overdose typically involves ingesting too much of a known substance, resulting in either accidental or deliberate illness or death. Overdose can happen after ingesting one substance or a combination of substances, known as polysubstance use. The CDC notes a 10-state study concluding that almost 57% of people who died from an overdose tested positive for fentanyl and fentanyl analogs (drugs with similar chemical structures) also tested positive for cocaine, methamphetamine, or heroin.

On the other hand, poisoning usually involves ingesting toxic amounts of an unknown substance, leading to illness or death. Poisoning is almost always accidental and can occur when individuals think they are taking one kind of substance that is actually something else or laced with an unknown additional substance. Many poisonings result from substances provided by close friends or trusted sources, who also did not know the drugs were fake. The rapid spread of counterfeit prescription pills that are laced with fentanyl has dramatically increased the number of fentanyl poisonings across the United States.

Distinguishing between overdose and poisoning is important for a number of reasons. First, words matter. Though an overdose is, medically speaking, still a poisoning, the term carries with it an implied meaning: that a person chose to take a particular drug, which led to the overdose. On the contrary, most people associate “poisoning” with something accidental. Some states have even passed or introduced legislation that requires death certificates to state “toxicity” or “poisoning” as the cause of death instead of overdose when fentanyl is involved. Of course, while addressing both overdoses and poisonings is important, approaches to treatment and prevention may look different. Factors such as the underlying causes of substance use, whether an individual is struggling with addiction or is experimenting with drugs, and the role of polysubstance use all play a role in creating effective treatment and prevention programs and resources.

Communities in Crisis

From counterfeit prescription pills like Adderall and Xanax to drugs like cocaine and meth, many communities throughout the U.S. are in crisis as they face the growing threat of illicit fentanyl. Clearly, fentanyl’s reach and impact are widespread and devastating. Addressing the opioid crisis – specifically fentanyl – can seem daunting, and knowing where to begin is difficult. In an earlier blog, we examined how fentanyl makes its way from labs, primarily in China, to Mexico. But how is it crossing our borders and getting into our communities? And what is being done about it? To learn more, stay tuned for the next installment of our documentary blog series.