What the…? Safer From Harm on Why Fentanyl is in Stuff
A friend recently asked me, “Why are drug traffickers putting fentanyl in fake prescription pills? Why would they sell a deadly ingredient to their customers?”
Here’s what she knew:
Fentanyl is a synthetic opioid used legally for pain in medical settings, under carefully controlled conditions.
Fentanyl is extremely potent and can be deadly when misused.
Some people who use illegal drugs seek out fentanyl intentionally.
Traffickers are also using fentanyl, without the knowledge of customers, to lace or replace ingredients in other drugs, such as heroin and fake pills made to look like legitimate opioid prescription drugs (like Percocet).
What my friend did not understand was why traffickers would risk killing their own customers by putting deadly fentanyl into their products.
It’s a fair question, and as someone who thinks about harm reduction all day, I was grateful for the reminder that the forces driving public health crises—from opioids to smoking to sexual health—are pretty complex. Before we can even begin to talk about the role harm reduction can play in these crises, in practice and in public policy, we have to build shared understanding about what’s happening and the risks people face. That means going back to basics on the human, economic, social and political dynamics underneath it all. In the case of fentanyl, we can start by unpacking three interrelated phenomena:
1. When substances are criminalized, they get more potent
Understanding why fentanyl is surging into the illegal drug supply starts with the Iron Law of Prohibition: “[A]s law enforcement becomes more intense, the potency of prohibited substances increases.” We can see this with American alcohol prohibition: Smugglers moved from beer to spirits (including moonshine) because the latter offered intoxicating effects in smaller, more easily hidden quantities.
Heroin and fentanyl are both opioids, but fentanyl is 50 times more potent. That means a kilogram of illegally made fentanyl can be smuggled in a purse, the spare tire of a car or the mail. Fentanyl’s intense potency means that traffickers can turn that single kilogram into tens or hundreds of thousands of doses and sell them for enormous profit. In 2017, a $6,000 kilogram of heroin might have sold in the United States for $80,000, while a $5,000 kilogram of fentanyl could be stretched to create as many as 24 kilograms of drug products and sold for $1.6 million.
2. Producing fentanyl is cheaper, faster and more efficient than other opioids
Fentanyl offers traffickers low overheads, low costs and short production timescales, and some estimates put fentanyl at 99 percent cheaper per dose than heroin.
Fentanyl can be made in spaces as small as a single-car garage. Growing the poppies needed to produce a single kilogram of heroin requires almost two football fields of land.
A lab can produce a kilogram of fentanyl in a few days, compared to the 120-day growth cycle for poppies.
When law enforcement shuts down a fentanyl lab, it can be restarted quickly, with limited financial losses.
3. There’s no quality control, because illegal drugs are…illegal
As with all prohibited products, no one is in charge of quality control for illicit drugs, so unbeknownst to the buyer (and often to the seller), different sellers’ products may have different amounts of fentanyl in them. Because fentanyl is so potent, a tiny miscalculation could result in a deadly dose.
People who habitually use opioids might develop a higher tolerance for fentanyl over time, but this lack of quality control means that the risk of overdose is still present. Some people who use drugs try to counteract the quality control problem by working only with trusted sellers. However, law enforcement interventions can disrupt these relationships: One study found that police drug seizures in Indianapolis were associated with nearby increases in overdose deaths, suggesting that disrupting people’s normal supply can cause them to seek out alternative vendors, who might be selling drugs with unknown potency and ingredients.
People with lower tolerance are at risk of overdose when even a miniscule amount of fentanyl is present in the drugs they consume. This group includes people newer to opioids and people purchasing a drug that they do not know contains fentanyl. It also includes people who are coming out of abstinence, such as a person who was in recovery but is beginning to use drugs again, or someone who was incarcerated. The risk of death from overdose in the first two weeks after release from prison can be 10 or even 40 times higher than the general public, due in part to reduction in opioid tolerance while incarcerated.
What’s Next: Harm Reduction Conversations and Tools
We might hope or assume that the people around us will never use drugs. Prevention is very important, but an abstinence-only mindset can leave anyone who does use drugs, whether habitually or just once, unequipped to mitigate the magnified risks created by the fentanyl phenomenon. That’s where harm reduction comes in, via pragmatic information and tools we can give ourselves and our loved ones. Here’s what we all can do:
Obtain naloxone and learn how to use it. Naloxone is an opioid overdose reversal drug that comes in syringe and nasal spray form (the latter is often referred to as “Narcan,” the brand name for a spray granted over-the-counter status this year). The spray is available at drug stores, and its makers have a how-to guide on their website.
Give fentanyl test strips to loved ones. These strips offer a cheap and easy way to test drugs for the presence of fentanyl. This gift can be an icebreaker for talking about fentanyl risks with loved ones, including those who might not think of “taking one prescription pill I got from a friend” as “using drugs.” Take note that vendors cannot ship to addresses in the handful of states where these test strips are still illegal.
Never use alone. Using drugs with a trusted person nearby can be lifesaving. It ensures there is someone to call for help and/or to administer naloxone should something go wrong. People who don’t have someone to keep them company can take advantage of an overdose prevention hotline or app.
Talk to your people, including kids. These conversations cannot be limited to telling people never to use drugs. That’s not realistic, and it robs people of valuable information that could save their lives. We need to equip our loved ones with information about the risks, and with the tools to stay safer if they do use drugs.
What the…? is Safer From Harm’s series that breaks down harm reduction concepts and busts myths for people who don’t spend all day thinking about harm reduction.