Fentanyl

DEFINITION: Fentanyl is a highly potent opiate analgesic with biological effects indistinguishable from those of heroin.

ALSO KNOWN AS: Apache; the bomb; China girl; China white; dance fever; friend; goodfella; jackpot; murder 8; perc-a-pop; poison; tango and cash; TNT

STATUS: Legal in approved formulations as an anesthetic and analgesic; other formulations and uses are illegal

CLASSIFICATION: Schedule II controlled substance

SOURCE: Synthetic opiate analgesic with no natural sources. Similar to but more potent than morphine. Illegal formulations are either produced in underground laboratories or smuggled into the United States.

TRANSMISSION ROUTES: Legally administered by intravenous, transdermal (patch), and transmucosal (lozenge) routes; illegal formulations taken intravenously, snorted, or smoked

History of Use

The powerful opioid known as fentanyl was first synthesized in a medical drug research laboratory in Belgium in the late 1950s. The original formulation had an analgesic potency of about eighty times that of morphine. Fentanyl was introduced into medical practice in the 1960s as an intravenous anesthetic. Subsequently, two other fentanyl analogs were developed for medical applications: alfentanil, an ultrashort-acting analgesic (of 5–10 minutes), and sufentanil, an exceptionally potent analgesic (5–10 times more potent than fentanyl) for use in heart surgery. Fentanyls are used now for anesthesia and analgesia. The most widely used formulation for medical uses is a transdermal patch for relief of chronic pain, although illegal black market fentanyl is often transported and sold in liquid or powder form.

Illicit use of fentanyl first occurred within the medical community in the mid-1970s. Among anesthesiologists, anesthetists, nurses, and other workers in anesthesiology settings, fentanyl and sufentanyl are two of the agents most frequently abused. Potential abusers have ready access to these agents in liquid formulations for injection and can divert small quantities with relative ease. Transdermal patches cannot be readily adapted for abuse. The fentanyl lozenge has been diverted to illegal use. On the street, the lozenge is known as perc-a-pop.

More than one dozen analogs of fentanyl have been produced clandestinely for illegal use outside the medical setting. Beginning in the mid-2000s and comtinuing in subsequent decades, fentanyl abuse emerged as a serious public health problem. Fentanyl-laced heroin or cocaine powders became the drugs of choice for some drug abusers and also became popular as a way for dealers to increase the potency of their drugs while cutting back on costs. In the 2010s, fentanyl played a major part in the drastic spike in overdose deaths due to opioid abuse, as the drug was often mixed with heroin or cocaine. Its potency means that users who are unaware of the mixture can easily overdose.

Beginning around 2013 and accelerating in subsequent years, the sharp rise of fentanyl-related overdose deaths contributed to the growing opioid crisis. The National Institute on Drug Abuse (NIDA) estimated that deaths involving synthetic opioids other than methadone, usually fentanyl, numbered 70,601 in 2021, a drastic increase over the number of these deaths in the early 2010s and a clear sign that fentanyl had come to account for a large share of fatal overdoses. According to the National Center for Health Statistics, 2023 deaths in the US from drug overdoses totaled 107,500; of the 81,083 deaths caused by opioids, fentanyl was responsible for over 92 percent of them. Still, this marked the first time since 2018 that annual overdose deaths decreased in the US.

Despite the growing role of fentanyl in the opioid crisis, the drug continued to be used in clinical settings. It also was explored as an agent for carrying out lethal injection in cases of capital punishment, in part due to the growing difficulty for states to source drugs for this purpose. In the fall of 2017, Nevada announced it planned to use fentanyl as part of a multi-drug combination to carry out an execution, prompting considerable controversy. However, in 2018 that plan was delayed when pharmaceutical companies objected to the use of their products as other elements of the drug cocktail and brought a suit against the state. Nebraska also announced its intention to incorporate fentanyl in an execution, and this time a pharmaceutical company's effort to block the use of another drug was dismissed by a judge. With the legal path cleared, Nebraska became the first state to carry out a lethal injection using fentanyl in August 2018, executing convicted murderer Carey Dean Moore. In 2022 Nevada announced it planned to use a unique drug cocktail containing fentanyl in an upcoming execution.

Effects and Potential Risks

The biological effects of fentanyl are indistinguishable from those of heroin, with the exception that illicit fentanyl analogs may be hundreds of times more potent. Short-term effects of fentanyl abuse include mood changes, euphoria, dysphoria, and hallucinations. Anxiety, confusion, and depression also may occur. High doses or long-term use may impair or interrupt breathing due to respiratory depression. Unconsciousness and even death can occur. Fentanyl's extreme potency can make it dangerous or even fatal to handle without proper protective equipment.

The 2000s and 2010s saw a sharp increase in fentanyl use, as well as related overdoses and deaths. For example, in 2014 twenty-eight people died over a span of two months in Philadelphia due to the use of fentanyl-laced heroin. Police seizure of illegal drugs containing fentanyl tripled between 2013 and 2014; there were 942 fentanyl-related cases in 2013, compared with 3,344 in 2014. In 2015 the Drug Enforcement Administration (DEA) issued an alert about the spike in fentanyl-laced heroin. The problem was originally thought to be concentrated on the East Coast, but in April 2016 a spate of overdoses in the Sacramento area of California (thirty-six overdoses with nine deaths in a single week) showed that the problem was nationwide and growing. Notably, the drug used as a painkiller was responsible for the April 2016 death of the musician Prince. Fentanyl abuse and related overdose deaths continued to increase in the 2020s as fentanyl became responsible for the majority of fatal opioid overdoses in the US.

With the rise of the opioid crisis, law enforcement and health care organizations began to press for wider availability of the overdose medication naloxone, also known as Narcan. The medication is effective in reversing the effects of overdose, though some critics claim it encourages drug users to use more recklessly, as they know they can be revived in case of overdose. Some jurisdictions have also explored implementing supervised injection sites, where drug users can administer drugs without fear of police prosecution and in the presence of medical personnel, to help prevent overdose deaths. While such plans draw much criticism, proponents have suggested that the potency of fentanyl and its analogs meant that drastic steps were necessary to limit mortality. Furthermore, such facilities could help reduce the risk of infections such as hepatitis C and HIV, both of which are associated with intravenous drug use. During the late 2010s and early 2020s US government agencies, including the DEA, had begun taking steps to crack down on illegally imported black market fentanyl. Meanwhile, a small number of Republican elected officials in the US, including Arizona congressman Paul Gosar, publicly endorsed using the death penalty to punish individuals convicted of selling or distributing fentanyl.

In 2021 New York City became the first American city to establish supervised injection sites. However, repeated efforts to pass legislation permitting such facilities in California failed. By 2023 Rhode Island had also authorized the establishment of safe injection sites and other states, including Colorado, Nevada, and New Mexico, had begun considering opening such sites. Still, despite efforts to contain the opioid epidemic, the US continued to see high numbers of fatal overdoses from fentanyl and other drugs at that time, and law enforcement agencies continued to seize large amounts of fentanyl.

Bibliography

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