Is Fentanyl Abuse More Deadly Than Heroin?
Fentanyl, a drug previously unheard of by many, has become notorious in recent years due to the spike in overdose deaths from heroin laced with the potent prescription narcotic. It gained even more notoriety when the April 2016 death of iconic singer, Prince, was attributed to an accidental fentanyl overdose.
As an extremely strong painkiller that produces effects similar to heroin, fentanyl has made its way from the hospital to the street, and the consequences are often deadly.
Where Does Fentanyl Come From?
What Are Opiates/Opioids?
Opiates are derived from the opium poppy plant, nicknamed the “flower of joy.” There are roughly 20 different opiate alkaloids that are derived from the plant, including heroin, morphine, and codeine. Opioids are a class of drugs with similar pharmacological properties to opiates; however, the opioids are either partially or fully synthetic substances 9.
The human body produces its own supply of opioid peptides. Perhaps the most commonly known are the endorphins (the others are the enkephalins and dynorphins). Endorphins bind to opiate receptors in the body, blocking pain. If you get hurt, your body will release endorphins to provide you with pain relief.
When opiates and opioids bind to opioid receptor sites throughout the brain and spinal cord, they influence how a person perceives pain, effectively diminishing the pain signal sent from the body to the brain. In essence, opiate and opioid drugs don’t make your pain go away, they just change the experience of pain.
Fentanyl is a synthetic opioid that is 50 times more potent than heroin and 100 times more potent than morphine. The FDA approves this powerful painkiller for 1,2:
- Use before surgery as an adjunct to anesthesia, and in some cases, during postoperative recovery.
- Treating chronic or acute pain in opioid-tolerant individuals, or those individuals who have become tolerant to their narcotics and need a stronger analgesic.
- Managing advanced cancer pain.
The United States is in the middle of a fentanyl public health crisis. Today, there is more fentanyl available than at any other time since 1959 when the drug was first created. From 2013 to 2015, the Drug Enforcement Administration (DEA) seized 239 kilograms of illegal fentanyl 3. Although this may seem small compared to the amount of other illicit substances seized by authorities, fentanyl is more lethal than many of these other drugs because even an extremely small dose (2 milligrams) can be fatal 3.
Illegal, non-pharmaceutical fentanyl (NPF), also called illicitly manufactured fentanyl (IMF), is made in clandestine labs. NPF is sold illegally, and it is highly sought after because it produces heroin-like effects 1 and can be cheap for manufacturers to make. On the street, it is sold under various names, such as “China Girl” and “China White” 4.
NPF is often laced with heroin or cocaine without the buyer’s knowledge. This phenomenon of adding chemical adulterants to street drugs contributes to the rising number of fentanyl-related deaths in the United States because users are unaware of their drug’s potency 5. According to the Centers for Disease Control and Prevention (CDC), in 2015, 55% of people who died from an overdose of fentanyl additionally tested positive for heroin or cocaine, compared to 42% between 2013 and 2014—a concerning uptick that may reflect an increase in the widespread availability of an adulterated street product.
Within the illegal drug market, fentanyl provides the opportunity for manufacturers and dealers to make a substantial sum of money. A kilo of NPF is reported to sell for roughly $1.3 million dollars, whereas a kilo of heroin will sell for a relatively mere $271,000 3.
There has been a spike in the number of fentanyl drug seizures in the past 2 years. In 2012, the DEA reported 618 seizures; in 2013, they reported 945 seizures; in 2014, the DEA reported 4,585 seizures. The problem seems to be somewhat localized, with more than 80% of the seizures occurring in just 10 states, with Ohio, Massachusetts, and Pennsylvania leading in the number of seizures 6. Of those states affected, Florida and Ohio are of extreme concern due to sharp increases in the number of fentanyl deaths in these states 1.
The Little Devil
According to an article in the New York Times, Mexican cartels are producing fentanyl and smuggling the drug into the United States to meet the high consumer demand for this drug that produces a stronger high than heroin. Part of the allure of producing non-pharmaceutical fentanyl is that it is easy to make—it can be made in a lab and does not require growing a poppy plant. In 2015, Mexican authorities seized 27 kilograms of fentanyl – in terms of drug potency, the dosage equivalent of one ton of heroin – as well as 19,000 tablets of fentanyl that were marked as oxycodone during a raid in Sinaloa. It was during this raid that the drug kingpin, “El Chapo,” was seized 7.
Fentanyl is cut and mixed into many forms by the cartels, and in Mexico, the combination of heroin and fentanyl is known as “el diablito,” or “the little devil.” While there is minimal information on the amount of fentanyl being trafficked into the United States, there are a number of reports of drug seizures at the border. In February 2016, a 19-year-old man was stopped at the California-Mexico border carrying nearly 2,000 pills in his underwear that were marked as oxycodone 7. According to DEA lab results, the pills contained fentanyl and not oxycodone 8.
The following documentary clip sheds more light on El Chapo’s fentanyl stronghold:
The Hidden Killer
While some people knowingly seek out fentanyl for its extremely potent high, fentanyl use often occurs unwittingly, as it is often disguised as heroin or other opioid narcotics 1. Those believing they are buying their normal drug of choice (e.g., heroin) may be getting a substance that is much stronger than their bodies can handle.
Fentanyl can heighten the potency of heroin and lead quickly to fatal respiratory depression. It may also compound the toxic influence of cocaine.
Some buyers may hear of certain brands of heroin as being potent or a strong high and use it without realizing fentanyl has been added to it. This can result in immediate overdose, especially if someone uses their normal amount and expects the same effects.
Opioids like fentanyl work directly on the respiratory center of the brainstem. This can result in a depression of a person’s ability to breathe properly. In the case of fentanyl, it can kill a person rapidly by paralyzing muscles in their chest that help them breathe <10. This effect is called sudden onset chest wall rigidity, or “wooden chest”.
Heroin Laced with Fentanyl
A recent study published by the Guardian reported that the only supervised injection site in Canada found 90% of the heroin used there tested positive for fentanyl.
The clinic performed 173 drug checks for fentanyl, and 90% came back positive for the drug. The clinic was checking for fentanyl as part of a pilot program, which was inspired by similar drug checks offered at music festivals 11.
Is Fentanyl Deadlier than Heroin?
What Does Potency Mean?
Opioid medications work by attaching to opioid receptors in the brain, producing the therapeutic pain-relieving effect. Potency at a receptor level is measured as the amount of the opioid necessary to elicit the intended response.
The amount of fentanyl required to provide an equal painkilling effect to that of 10mg of morphine is a mere 0.1 mg (or 100 millionths of a gram)—making fentanyl 100 times more potent than morphine 12 and extremely dangerous for non opioid-tolerant individuals.
Although heroin is known as one of the most dangerous and addictive drugs on the market, fentanyl is even more potent and can cause rapid death.
Fentanyl’s popularity among illicit drug manufacturers and some opioid users has skyrocketed in recent years due to its ability to provide a profoundly intense euphoric high. However, this high can easily turn deadly.
The risks inherent to any form of opioid abuse, such as respiratory depression and coma, are not only present with fentanyl, but are even higher as a result of the drug’s potency.
First-time (or drug-naïve) users are especially susceptible to overdose risks. Fentanyl can be deadly any time it is used, but may be especially so in those who’ve never used it, or have opioid tolerances adjusted for lesser potency drugs (including even heroin). In fact, in March and October 2015, the DEA and CDC issued alerts that illegally manufactured fentanyl (IMF) is a threat to public health and safety. This was due to the spike in the number of fentanyl-related deaths in 2014 1.
Fentanyl is extremely dangerous not only to users, but to first responders, as well. This stems from the fact that fentanyl can easily absorb through the skin when it comes in direct contact with it, and it can also be inhaled as a powder. During a field test, police officers reported feeling dizzy and short of breath after coming into contact with a substance containing fentanyl 6.
Overdose is a major concern for those abusing fentanyl. While there is an “antidote” treatment helpful in the event of a fentanyl overdose, action must be taken extremely quickly. In many cases, fatal respiratory depression occurs too quickly before help can intervene.
Fentanyl was responsible for more than 700 deaths in the span of one year, and the DEA noted that the actual number may potentially have been higher since many coroners’ offices do not specifically test for fentanyl 6.
In 2014, Ohio reported 514 fentanyl-related overdoses, compared to just 92 in 2013 6.
Reversing Fentanyl Overdose with Naloxone
Due to rising numbers of overdoses from fentanyl and other opioids, the CDC recommends that law enforcement officers and first responders increase the amount of naloxone they have on hand.
Naloxone (brand name: Narcan) is an opioid antagonist. Naloxone temporarily blocks opioid receptor sites in the central nervous system. Naloxone can reverse the potentially fatal effects of fentanyl. While naloxone doesn’t always immediately reverse an opioid overdose, it can help victims to regain consciousness so they can breathe on their own.
If a person is given naloxone and they slip back into unconsciousness, medical personnel may continue administering the drug so that the person can breathe again. If a person overdoses from a high dose (or multiple doses) of fentanyl, it may require multiple doses of naloxone to reverse the effects.
Naloxone is administered through 9:
- Intramuscular (IM) route: When naloxone is administered through IM, the effects can take place within 2-3 minutes.
- Intravenous (IV) route: This is the quickest route of administration. The effects can take place within 1-2 minutes.
Naloxone may also be administered subcutaneously (SQ), should lack of IV access be an issue, or via an endotracheal tube (ET), if airway management has already begun.
There are some reported side effects of naloxone use. Possible side effects can include 9:
- Acute opioid withdrawal syndrome (if the individual is addicted to narcotics).
- Non-cardiogenic pulmonary edema (a catecholamine neurotransmitter-mediated shift of fluid from the vascular space to the lungs).
Repeated use of naloxone can be fatal in individuals who develop pulmonary edema.
The CDC and DEA have called for increased access to naloxone, especially among community members. In Ohio, emergency medical services responded to 82% of fentanyl deaths—and there was at least one bystander at the scene in 72% of those cases. Reportedly, only 41% of people who died from a fentanyl overdose received treatment in the field with naloxone 1. Providing better access to naloxone can prevent tragic numbers of fentanyl overdoses.
Laypersons in a Position to Reverse Overdose
People who use drugs, family members, and other “laypersons” are more likely to witness an opioid overdose, and thus may be in a better position to combat high overdose rates. According to a national survey conducted by the CDC, in 82.8% of overdose cases, naloxone is administered by other drug users 13.
Although the number of organizations that provide naloxone kits to laypersons has increased dramatically since 2010 (an 183% increase), 30% of organizations reported trouble keeping an adequate supply, and 54% of organizations reported inadequate resources to expand their naloxone programs and give out naloxone kits 13. In May 2016, the Senate passed several bills that include measures to combat the opioid epidemic—one of which is to expand the availability of naloxone.
Fentanyl and the Opioid Epidemic
In recent years, there has been an increase in the number of prescriptions for opioid painkillers written, as well as the number of overdoses from opioids. According to the CDC, overdose deaths involving opioids have quadrupled since 1999. In 2014, over 14,000 people died from overdosing on prescription opioids like fentanyl 14.
Ambulance services noted that since the mid-90’s, overdoses from prescription painkillers and heroin have been increasing. In the 1980s, ambulance operators in the U.S. may have seen only a few cases each year but are now seeing dozens to hundreds per year 9.
Both prescription and recreational use of oxycodone, hydrocodone, and fentanyl are increasingly common, and the use of heroin is on the rise (partly due to the transition to heroin by many prescription drug abusers)—all contributing to the “opioid epidemic.” According to the 2015 Substance Abuse and Mental Health Services Administration (SAMHSA) nationwide survey, 3.8 million Americans aged 12 or older reported currently misusing prescription painkillers. The survey also found that about 329,000 people were regular users of heroin in 2015 15.
Users of opioids are often on the lookout for an even more potent high, which makes drugs like fentanyl an attractive option, despite its dangers. There have even been reports of people chewing or eating fentanyl patches to receive a stronger high 9.
Are Prescription Drug Companies to Blame?
Some pharmaceutical companies have come under fire for contributing to the opioid epidemic with potentially unethical practices. INSYS (the supplier of Subsys—a sublingual spray formulation of fentanyl) is under investigation for putting profits ahead of patients. Since June 2015, Subsys has brought in $147.2 million in sales.
Subsys is sold as an oral spray, and one package can cost between $900 and $3,000. The oral spray is intended to treat patients with cancer pain; however, former employees of the company have come out publicly about INSYS’s unlawful sales tactics. According to this article in CNBC, the drug company has been marketing Subsys for off-label use and they have even paid doctors to write more prescriptions for the drug 16.
Help for Opioid Addiction
When people use drugs like fentanyl when they are not experiencing pain, they can experience an intense rush of euphoria. When someone continually seeks this euphoric state, it can result in addiction.
Those who struggle with opioid dependence often fear the onset of acute opioid withdrawal, which will inevitably occur when attempting to quit. Withdrawing from fentanyl is seldom life-threatening; however, it can be extremely uncomfortable. The withdrawal symptoms can vary from person to person, but may be quite severe.
Treatment centers offer inpatient and outpatient resources to help individuals who are addicted to fentanyl wean themselves off of the drug safely. Medical supervision during detoxification can help manage withdrawal symptoms and lessen the odds of relapse after leaving treatment.
Inpatient treatment programs often last between 30 and 90 days. If your addiction is severe and your environment is unsafe or full of triggers to use fentanyl, inpatient treatment may be the more appropriate option for you. Inpatient treatment offers access to 24/7 care.
Outpatient treatment is an appropriate option if your addiction is less severe and you think that it is possible for you to live at home while you get treatment. Outpatient programs require that you go to the clinic periodically throughout the week for treatment and therapy. Group therapy is at the crux of outpatient treatment and it can help you create a support network that is drug-free.
- Centers for Disease Control and Prevention. (2016). Increase in Fentanyl-Related Overdose Deaths – Florida and Ohio, 2013-2015.
- UptoDate. (2016). Fentanyl: Drug Information.
- Drug Enforcement Administration. (2016). Counterfeit Prescription Pills Containing Fentanyls: A Global Threat.
- National Institute on Drug Abuse. (2016). Fentanyl.
- Centers for Disease Control and Prevention. (2016). Fentanyl.
- Centers for Disease Control and Prevention. (2015). Increases in Fentanyl Drug Confiscations and Fentanyl-related Overdose Fatalities.
- New York Times. (2016). Drug That Killed Prince Is Making Mexican Cartels Richer, U.S. Says.
- United States Department of Justice. (2016). Hundreds of Counterfeit Oxycodone Tablets Seized at Port of Entry Contained Ultra-Deadly Fentanyl
- Barker, K., & Hunjadi, D. (2008). Meet Narcan. The amazing drug that helps save overdose patients. JEMS: a journal of emergency medical services,33(8), 72.
- Burns, G., DeRienz, R. T., Baker, D. D., Casavant, M., & Spiller, H. A. (2016). Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse?. Clinical Toxicology, 54(5), 420-423.
- The Guardian. (2016). Safe injection clinic says 90% of clients’ heroin had dangerous drug additive.
- Pharmacist’s Letter. (2012). Equianalgesic Dosing of Opioids for Pain Management.
- Centers for Disease Control and Prevention. (2015). Opioid Overdose Prevention Programs Providing Naloxone to Laypersons – United States, 2014.
- Centers for Disease Control and Prevention. (2016). Prescription Opioid Overdose Data.
- Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health.
- CNBC. (2015). The pain killer: A drug company putting profits above patients.