Written by Laura Davies
In 2015, doughnut shop worker DJ Shanks started feeling the tell-tale nausea of heroin withdrawal and messaged his best friend Justin to let him know he was sick. Justin replied, “I got you, bud.” and pretty soon, he arrived at the shop with a dollar bill containing white powder. DJ snorted it and got back to work. Devastatingly, just 20 minutes later, he collapsed face-first into a tray of glaze and died. The powder wasn’t heroin. It was fentanyl, 50 times more potent, and the amount he’d taken was a lethal dose.
This is what’s particularly shocking about the fentanyl epidemic. Tens of thousands, like DJ, are dying, having never intended to ingest the drug. This is because it’s cheap and easy to produce, so heroin, cocaine, counterfeit prescription pills, and, rarely, cannabis are all being cut with it. Basically, no drug or medication bought on the street is safe, and it’s causing the deaths of both persistent and one-time users.
For example, in 2022, 31-year-old Sarah Claudio Grizzel’s back was hurting as a result of a previous accident. She asked a neighbour for a pain pill to tide her over until she could get to the pain clinic. Tragically, the pill was fentanyl, disguised as ordinary pain medication and she died of an overdose shortly after. Her mother-in-law spoke out, “Sarah just wanted to stop the pain, she didn’t want to die.” Fentanyl is killing so many people, it’s ridiculous. “
Just 2mg is enough to OD. That’s about the size of a grain of rice, and it’s impossible to notice in a few lines of coke or a pressed pill. It’s killing over 60,000 a year, and Americans are now more likely to die from an accidental opioid overdose than in a car crash.
Like most of humanity’s biggest man-made killers, the story of fentanyl began with good intentions. It was developed by Dr Paul Janssen and his team at Janssen Pharmaceutica, who wanted to create a new analgesic with a more rapid onset and fewer side effects than those available at the time.
In 1953, they began working with meperidine, a then popular analgesic, and experimented with altering various parts of the molecule while preserving its ability to bind to the same pain receptors in the brain. The aim was to increase fat solubility, which would allow better and faster penetration of the blood-brain barrier. The work was successful and resulted in numerous new compounds that were tens of times more potent than morphine.
In 1960, they hit the jackpot and created the fastest-acting and most potent opioid in the world at that time. Animal testing showed it was between 100 and 200 times stronger than morphine and had a therapeutic index, which is the range of dose that’s effective but not toxic, of 277, putting morphine’s 71 to shame. It was, of course, fentanyl.
However, not everyone in the medical community was excited by the new drug, and the FDA was slow to approve it. One of the most vocal opponents was Dr Dripps, Professor of Anesthesiology at the University of Pennsylvania. He had two main concerns. Firstly, it caused rigidity that required patients to be intubated for much longer periods than was standard, and secondly, it was simply too potent and was therefore extremely vulnerable to abuse. Called it.
However, Janssen wouldn’t give up. He believed in fentanyl and the good it could do, so he managed to reach an agreement with Dripp. The drug could be approved but only if it was combined with droperidol, a substance known to produce a particularly bad high. Which, you have to admit, is a pretty clever way of stopping anyone from trying to use it recreationally. Unfortunately, though, it didn’t last, and just four years later, fentanyl was approved for use alone.\
The Fentanyl High
As fentanyl binds to the same µ (Mu) pain receptor as morphine, meperidine, and oxycodone, it’s not surprising that both the high and side effects are incredibly similar. Euphoria, relaxation, sedation, and pain relief are the ones that keep users coming back for more. However, they’ll also cause nausea, vomiting, dizziness, drowsiness, fainting, and seizures.
Overdosing on opioids is particularly dangerous as they affect the part of the brain that regulates breathing. Taking too much results in respiratory depression. In other words, it stops you from breathing, and you die.
Another complication associated with all opioids is Wooden Chest Syndrome. This is a particularly unpleasant condition involving prolonged contractions of muscles in the chest wall, resulting in rigidity that makes it feel as though the patient is made of wood. Unfortunately, it also means the lungs can’t expand, and the pressure is usually too great to ventilate effectively. Fentanyl causes a particularly high incidence of this deadly syndrome due to its extremely high potency.
The Part Played by OxyContin
Fentanyl wasn’t an instant hit with recreational drug users, mostly because heroin, which is 50 times weaker, was more than enough. Instead, it spent decades being prescribed legally as pain relief in the form of patches, sprays, pills, and even lollipops. As it’s such a potent opioid, most doctors reserve it for postoperative pain following a severe injury or as a cancer pain treatment. Tragically, this wasn’t the case for long due to a series of unfortunate and avoidable events.
The first step towards trouble began with the overprescription marketing of opioids, in particular, OxyContin by Purdue Pharma, in the US. When Purdue introduced the drug, they did so along with an aggressive marketing campaign, and all expenses paid symposia for over 5000 doctors, pharmacists, and nurses. They also targeted physicians known to prescribe opioids with a sales team of 671 and expanded their call list to 94,000. The company even sent doctors goody bags that included fishing hats, soft toys and CDs featuring the track “Get in the Swing with OxyContin”. True story.
At the same time, they worked on any doctors who were reluctant to prescribe the highly addictive pills with 20,000 educational programs designed to promote opioid use and get them to stop worrying about the potential risks. Sales representatives claimed the risk of addiction was “less than 1%”, a lie for which the company would later face criminal charges and a $634 million fine.
Equally as sinister was the starter coupon program they introduced for new patients. This entitled pain sufferers to a free, limited-time, 30-day supply. No different to a dealer providing the first hit for free. By 2001, 34,000 new customers had redeemed their free sample coupons, and hundreds of thousands were addicted. OxyContin sales had rocketed from $48 million in 1996 to $1.1 billion by the year 2000, and prescriptions for non-cancer-related pain soared from 670,000 in 1997 to 6.2 million in 2002.
Of course, the inevitable impact of overprescription was abuse and unintentional overdoses. In southwest Virginia alone, deaths related to opioid prescriptions increased by 830% between 1997 and 2003, and the problem soon spread nationally. Something had to be done, which leads us to step two on the journey to an all-out Fentanyl epidemic.
Around 2011, individual states began to crack down on opioid prescriptions, and the State of Kentucky passed House Bill 1, otherwise known as the pill mill bill. This intended to limit opioid prescriptions by requiring doctors to perform a full history and physical, educate their patient on safe use, provide only a short course, and obtain a report from a statewide prescription monitoring program for each opioid prescribed.
Sounds great, right? Unfortunately, according to the Iron Law of Prohibition, this had two effects. Firstly, it forced those addicted to the black market. People can’t suddenly give up a years-long opioid habit just because someone passed a bill. Secondly, the drugs became more potent because it’s easier to hide smaller things than bigger things. Why stick with trying to smuggle a lorry load of heroin across a border when you could sneak in a single package of fentanyl?
This leads us nicely to step 3. How did this relatively less serious oxycodone abuse explode into the most deadly overdose epidemic in American history?
Well, one of the issues with being an international drug supplier is that there’s a whole lot more gardening involved than there is hanging out on gold yachts and private jets. Manufacturing your traditional opioids requires fields of poppies, which need tending, watering, and patience. Fentanyl, on the other hand, is entirely synthetic; you can whip it up in a lab in no time. This makes it much cheaper to produce, even though it’s 50–100 times more potent.
Unfortunately for dealers, people had heard about the likelihood of fentanyl to, you know, kill you, so they were mostly happy to stick to oxy and, in more extreme cases, heroin. But, the profit margins weren’t as good, so suppliers got around the minor inconvenience of their customers wanting to stay alive by cutting their heroin, meth, crack, or whatever, with fentanyl. This allowed them to cut costs and didn’t water down their product like diluting it with laundry detergent, boric acid, or meat tenderizer would. They even started using the drug to produce fake pills which were dyed and made to look like standard prescription meds or much less dangerous party drugs.
Thanks to these strokes of capitalist evil, death by overdose ripped through the demographics. Middle-income women with back trouble, teenagers at festivals, and anyone who uses a dealer for medicinal or recreational drugs are now at risk of accidentally ingesting a lethal dose of fentanyl.
Between 2014 and 2015, fentanyl deaths in America shot up by 72%, to around 10,000. By 2021, the annual death toll had reached 64,000. An epidemic. Most of the victims had no idea they were even taking the drug.
Now, the obvious thing for the US to do would be to find the labs manufacturing fentanyl and shut them down. Unfortunately, though, it’s not that simple because the vast majority, and I mean almost all of it, is being produced in China.
In some cases, Chinese suppliers manufacture the main parts of the drug and then ship it to Mexico. There it’s assembled by drug cartels and smuggled across the border in the traditional ways. However, thanks to the joys of the internet and the failings of the US postal service, a new and innovative supply route has also opened up. Now, US customers can order a delivery of the deadly chemical straight to their door via the dark web. The convenience.
It works like this: companies in China fully manufacture the drug, remember it’s so potent that only small volumes are needed, and send it to someone posing as a legitimate chemical company in the US. As lab-to-lab deliveries of chemicals aren’t suspicious, most of the product gets through easily. From there, the U.S.-based lab can send out packages of the odourless fentanyl straight to the customer’s door, where they can press it into fake pills and kill a bunch of festival goers. Simple.
After two deaths in his area, Assistant US Attorney Matt Cronin decided to try out the ordering process for himself. After posting one message on the right site, “Hey, we’re interested in buying Fentanyl.” He received 50 replies, offering the drug in bulk and what they described as more powerful and, therefore, deadly analogues. One supplier, Gordon Jin, even offered custom synthesis—essentially drugs that don’t yet exist, or what Cronin calls “made-to-order poison.”
Sometimes, packages are intercepted, and the Chinese lab is identified, but unfortunately, US authorities are essentially powerless in China. They managed to track down Gordon Jin, a father and son team living in Shanghai, but without the Chinese government’s support, there was nothing they could do. When reporter Bob Anderson interviewed the father, Guanghua Zheng, he asked, “Will the Chinese government ever arrest you? Zheng replied, “The Chinese government has nothing to do with it.”
Stopping the Flow
Occasionally, though, some progress is made with China, and they have outlawed several fentanyl compounds. However, all suppliers have to do is alter the formula slightly, and they have a brand new, unregulated drug to ship.
Previously, China has implemented crackdowns on internet advertising, sales, and shipments. But, the effect has been minimal. For example, while their National Narcotics Control Commission was releasing a statement that said, “Currently, there is basically no information related to the illegal sales of fentanyl-class chemicals on websites within Chinese borders or pharmaceutical and chemical platforms,” a well-known vendor, Benjamin Chen, wasn’t even bothering with the dark web and just listed his synthetic drugs directly on Facebook. He was so accessible, and dedicated to customer service, that when one of his buyers claimed to have OD’d on his product, they messaged him and he paid for a Lyft to take them to the hospital.
This isn’t to say that China has had no success, though. In 2018, they raided a lab, seized 26 pounds of fentanyl, and arrested nine people, and in 2019, they officially controlled all forms of fentanyl as a class of drug, and committed to investigating manufacturing areas, enforcing stricter shipping regulations and creating special teams to investigate trafficking.
Regrettably, however, in August 2022, with fentanyl deaths still rising, China announced that they were ceasing all communication channels with Washington, including counternarcotics. A potentially catastrophic development, which could cause a new surge in fentanyl supply. Plus, as if this news wasn’t bad enough, officials are now seeing the drug coming out of India, too, creating what might be a very slow but ultimately life-or-death game of fentanyl supply whack-a-mole.
So what’s the solution if controlling supply isn’t an option? The best bet at the minute is harm reduction. This means accepting that it’s almost impossible to stop people from taking fentanyl, but it is possible to stop them from dying.
One way to reduce the staggering number of deaths is by making treatment for overdoses cheap and quickly accessible. This is the drug naloxone, an opioid antagonist that reverses the effects of an overdose, including wooden chest syndrome. Anyone can use the kit without training, which is great, but only if it’s available and affordable at the time of an OD. They currently cost around $100 at pharmacies but are free with insurance. However, users would need to think about overdosing in advance and carry it around with them.
The other strategy in the war against fentanyl overdoses is the use of rapid fentanyl test strips. These can detect fentanyl in any illicit drug purchased and only cost around $1. This has the potential to solve the problem of accidental fentanyl ingestion by those who’ve bought contaminated drugs from a dealer.
Ultimately, education is key. People need to be aware that any drug bought on the street could contain fentanyl; that rapid testing should be a habit; and that everyone should keep an overdose kit handy if they’re planning to take any illicit substance.
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