As the Chief of Medical Toxicology at UMass Chan Medical School, I have studied fentanyl and its analogs for years. As fentanyl has become ubiquitous across the U.S., it has transformed the illicit drug market and raised the risk of overdose.
Fentanyl and its analogs
Fentanyl is a synthetic opioid that was originally developed as an analgesic – or painkiller – for surgery. It has a specific chemical structure with multiple areas that can be modified, often illicitly, to form related compounds with marked differences in potency.
Drug dealers have used fentanyl analogs as an adulterant in illicit drug supplies since 1979, with fentanyl-related overdoses clustered in individual cities.
The modern epidemic of fentanyl adulteration is far broader in its geographic distribution, production and number of deaths. Overdose deaths roughly quadrupled, going from 8,050 in 1999 to 33,091 in 2015. From May 2020 to April 2021, more than 100,000 Americans died from a drug overdose, with over 64% of these deaths due to synthetic opioids like fentanyl and its analogs.
Illicitly manufactured fentanyl is internationally synthesized in China, Mexico and India, then exported to the United States as powder or pressed pills. Additionally, the emergence of the dark web, an encrypted and anonymous corner of the internet that’s a haven for criminal activity, has facilitated the sale of fentanyl and other opioids shipped through traditional delivery services, including the U.S. Postal Service.Fentanyl is driving an increasing number of opioid overdose deaths.
Fentanyl is both sold alone and often used as an adulterant because its high potency allows dealers to traffic smaller quantities but maintain the drug effects buyers expect. Manufacturers may also add bulking agents, like flour or baking soda, to fentanyl to increase supply without adding costs. As a result, it is much more profitable to cut a kilogram of fentanyl compared to a kilogram of heroin.
Unfortunately, fentanyl’s high potency also means that even just a small amount can prove deadly. If the end user isn’t aware that the drug they bought has been adulterated, this could easily lead to an overdose.
Preventing fentanyl deaths
As an emergency physician, I give fentanyl as an analgesic, or painkiller, to relieve severe pain in an acute care setting. My colleagues and I choose fentanyl when patients need immediate pain relief or sedation, such as anesthesia for surgery.
But even in the controlled conditions of a hospital, there is still a risk that using fentanyl can reduce breathing rates to dangerously low levels, the main cause of opioid overdose deaths. For those taking fentanyl in nonmedical settings, there is no medical team available to monitor someone’s breathing rate in real time to ensure their safety.
Despite the evidence supporting these measures, however, local politics and funding priorities often limit whether communities are able to give them a try. Bold strategies are needed to interrupt the ever-increasing number of fentanyl-related deaths.
Kavita Babu is Chief of the Division of Medical Toxicology at UMass Memorial Health and a Professor of Emergency Medicine at UMass Chan Medical School. She conducted a NIDA-funded investigation of patients with near-fatal overdoses who presented to the Emergency Department and was first author of a New England Journal of Medicine article titled, “Prevention of Opioid Overdose.”