Fentanyl has fueled a spiraling overdose crisis in Colorado and across the United States. The drug’s increasingly ubiquitous presence, both in the illicit market overall and in other substances, has permanently changed the drug supply, officials say.
Between March 2020 and March 2021, more than 100,000 Americans fatally overdosed, the first time the country had surpassed that grim milestone in a 12-month period. Most of those deaths involved synthetic opioids, such as fentanyl. An even higher number died between November 2020 and November 2021, with synthetics present in roughly two-thirds of those overdose cases.
So what is fentanyl, why has it become so dominant and what makes it unique?
Fentanyl was first synthesized in 1960, and over the ensuing six decades it became one of the most common surgical analgesics, according to a 2014 article in the Journal of Pain. The substance is significantly stronger than morphine and heroin — its opioid cousins — and patches containing fentanyl have been used to treat some people with chronic pain, particularly related to cancer.
Among other reasons, the drug is frequently used in medicine because of the relatively quick onset and short duration of its effects, along with its relative safety in clinical settings and its cheap, easy-to-synthesize nature.
A bipartisan congressional report published in February traced the origins of the current fentanyl crisis back to the 1990s, when, spurred on by drug manufacturers, providers began writing more and more prescriptions for opioid pills, such as OxyContin, to treat chronic pain. In the years to come, that steady supply of legitimate pills seeped into America, building a demand for and supply of diverted or misused pain medications.
An epidemic’s onset
That, according to the Centers for Disease Control and Prevention, was the first phase of the opioid epidemic.
The next phase began in 2010. As states and the federal government began to crack down on the prescribing of opioids and fewer became available on the illicit market, heroin became more prevalent. It was cheaper and more available than legitimate prescription pills, according to the congressional report, and regulatory changes to prescribing habits didn’t affect the black market.
The third phase began in 2013, as overdose rates related to synthetic opioids — of which fentanyl is the primary actor — began to rise. Before then, according to the report, illicit use of fentanyl “was a modest problem.” That changed in the ensuing years, gradually in Colorado at first. But in recent years, in the wake of the pandemic and a more significant shift in the drug supply, fentanyl’s presence and impact here has grown substantially.
Illicit fentanyl’s path into the United States has also changed over the past decade. It was first shipped directly from China, often via the U.S. Postal Service. But the Chinese government cracked down on the drug and its analogues, chemically similar variations of fentanyl, which prompted a shift. The chemicals needed to make it started shipping in greater quantities to Mexico and the cartels that dominate the drug trade there.
Unlike heroin, illicit fentanyl doesn’t need to be grown or cultivated. It’s not dependent on the weather or seasons. Like methamphetamine, it can be made year-round and distributed using preexisting drug trafficking routes. Cheaper to produce, it brings in more money in smaller packages: A kilo of fentanyl — about the size of a textbook, said David Olesky, who was the acting special agent in charge of the Drug Enforcement Administration in Colorado — can yield $2 million to $3 million in revenue.
DEA seizures of fentanyl pills have grown significantly in recent years. Olesky said a seizure of 100 counterfeit pills two years ago would’ve been cause for celebration. Between October and late February, he said, the agency seized roughly 800,000 pills in Colorado alone.
Increasingly, according to the DEA and the congressional report, fentanyl is laced into heroin. According to Lisa Raville, who works with drug users at the Harm Reduction Action Center in Denver, heroin is more difficult to find on the street. For drug traffickers, it’s a simple economic decision, Olesky told The Gazette in February. The congressional report found that heroin seizures have fallen off, while those involving fentanyl or fentanyl mixed with heroin have risen.
The consequence of drug traffickers’ simple economic decision, Raville and others have said, is that people with opioid-use disorders, who previously may have used heroin or legitimate opioid pills, increasingly must turn to fentanyl, as it may be the only substance available on the market. Because the effects of fentanyl are more fleeting than heroin, users must buy the drug more frequently.
Illicit fentanyl, when in pill or powder form, can be taken orally, smoked, snorted or injected. Researchers in San Francisco found smoking fentanyl has become more common than injecting, and Raville has said that some users believe smoking is safer than injecting.
The ubiquity of fentanyl
As lawmakers debate how to crack down on fentanyl’s presence in Colorado, they encounter a frustrating dynamic that’s unique to the drug: Its presence in other substances.
As a powder, fentanyl can be laced into other substances but is most often made into pills. Officials have said that illicit fentanyl pressed into pills — often with stamps that make them appear as legitimate oxycodone tablets — is the primary way that the drug is taken in Colorado.
Don Stader, an addiction physician and the head of the Colorado Naloxone Project, said late last month that fentanyl pills, often called blues or smurfs because of their color, have been the primary drug for users here in recent years.
Those tablets are typically not pure fentanyl, law enforcement officials told Colorado lawmakers last week. According to DEA report from January 2020, fentanyl smuggled across the border is typically “low concentration, high-volume loads, (and) kilogram seizures often contain less than a 10% concentration of fentanyl.”
Illicit pills often include relatively small but still potent amounts of fentanyl, Beth McCann, Denver’s district attorney, testified this week. The bulk of the pills are made of a “filler” substance. When the DEA arrested a prominent fentanyl dealer in Grand Junction in 2018, analysis of those pills showed them to be fentanyl and acetaminophen, which is essentially Tylenol. Some may have baby aspirin, lactose or other odorless, cheap substances. One gram of fentanyl pills, then, does not necessarily equate to 1 gram of pure fentanyl.
Still, there is high variability in the strength of fentanyl pills because traffickers aren’t exactly concerned scientists. That same dealer in Grand Junction has been linked to several deaths. According to the DEA, pills they’ve seized have had fentanyl strengths ranging from 0.2 milligrams to more than 5 milligrams. Forty-two percent of fentanyl pills recently seized by the DEA have contained a potentially lethal dose, the agency said in September.
Fentanyl is increasingly being found in other drugs, including meth, heroin, cocaine and pills that look like legitimate Xanax or Adderall. That increases the overdose risk for users of those substances who often don’t realize what they’re taking. That’s not only because of fentanyl’s potency, but also because those users may not have any tolerance for opioids.
Josh Barocas, a physician who testified in front of the House Judiciary Committee, said he hadn’t seen a urinary drug screen that didn’t include fentanyl in the past six years.
The result of all of these factors is that overdoses are rising, and not just for users who knowingly use the drug. According to data from the state Department of Public Health and Environment, 650 fatal overdoses involved meth in 2021. Of those, 42% also involved fentanyl. In 2018, that figure was fewer than 4%.
The same is true for cocaine: Sixty-four percent of Colorado’s 235 cocaine-related fatal overdoses in 2021 involved fentanyl. In 2018, it was 14%.
Just how deadly?
According to the DEA, 2 milligrams of fentanyl is considered a potentially lethal dose. The strength of the drug, its ubiquity across the black market, and the absolute absence of quality control on the part of drug traffickers has fueled the overdose crisis: Nearly 900 Coloradans fatally overdosed after ingesting fentanyl in 2021, up from 41 in 2015.
However, the drug’s potential danger can sometimes be overstated. Experts and research has shown it is not dangerous to the touch or when inhaled, except in extreme and prolonged cases.
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