Fentanyl and it’s analogs
Fentanyl is a synthetic opioid pain reliever used for treating severe pain. It is 50 to 100 times more potent than morphine and 40-85 times more potent than heroin (Fentanyl Drug Facts, NIH Drug Abuse). Even in small doses it may be deadly. On the street, fentanyl may be added to heroin making the mixture more powerful than heroin alone. Heroin addicts who are exposed to this mixture may not be aware of the fentanyl additive and as a result, users who have not developed tolerance to the fentanyl additive may overdose and die. The heroin-fentanyl mixture has resulted in a dramatic increase in overdose death.
Fentanyl is very inexpensive to produce and is extremely pure. Ingredients are typically imported into Mexico from China and the final product is then smuggled into the US. Many street drugs are adulterated with fentanyl and users are often not aware of what they are using. It is not rare for this high-risk behavior to result in overdose and death. As a precaution users need to understand that the extreme toxicity of fentanyl is a real danger. Users and others must be able to recognize the signs of overdose and carry and be able to use nasal Narcan when overdose is suspected. Signs of overdose include small pinpoint pupils, falling asleep or losing consciousness, weak breathing, choking or gurgling sounds, limp body, clammy skin and blue colored lips and nails (www.cdc.gov, accessed 8/1/23). Narcan needs to be administered quickly and in doses upwards of 2-4 times the amount of Narcan used to treat the typical opioid overdose patient. Even with high doses the lifesaving efforts may fail.
Fentanyl may be injected, smoked or taken by mouth. Fentanyl vapes, sometimes mixed with nicotine, are showing up across the country. Exposure and intoxication by secondary smoke (vapors), along with several deaths, have been reported. Fentanyl and Heroin vapes have been taken off of teens who had no knowledge of what was in the vapes.
In any form, fentanyl is readily disseminated into indoor/outdoor air as fine particles or liquid spray (aerosol) whenever the drug package is opened and handled. Fentanyl can be absorbed into the body through inhalation, oral exposure, or ingestion. Fentanyl is so dangerous that First Responders wear protective gear when assisting drug-overdose victims suspected of using any illicit drug. Extreme precautions are taken by First Responders to prevent exposure to Fentanyl, including:
- Always wearing nitrile glove when illicit drugs are present
- Changing gloves when they become contaminated
- Wearing respiratory protection when powdered drugs are present or suspected
- Avoiding procedures that may result in illicit drugs becoming airborne
- Not touching their face, eyes or mouth after touching any surface that may be contaminated, even if wearing gloves and wash hands with soap and water, not hand sanitizer, even after wearing gloves
Fentanyl is being laced in all other drugs, often in prescription drugs people recognize like, Percocet, Xanax, OxyContin, and Adderall. Marijuana joints have been laced with Fentanyl, as well as Ecstasy, Molly, Heroin, Methamphetamine and Cocaine. One should assume today that everything is laced with Fentanyl! These drugs may contain deadly levels of fentanyl, and the user wouldn’t be able to see it, taste it, or smell it. It is nearly impossible to tell if drugs have been laced with fentanyl, or any other drug for that matter, until the drug is tested. Fentanyl-test-strips are available, and users should use these strips to determine if their drug of choice is adulterated with fentanyl. Results are available in 5 minutes and can make the difference between life and death.
*Users need to be cautious even if the test is negative for Fentanyl, as test strips do not detect fentanyl analogs. And there have been a number of false negatives with the test strips. These test strips are not as reliable as testing from a laboratory.
Fentanyl Analogs
There are several fentanyl analogs (something that is similar or comparable to something else) on the street including acetyl fentanyl, furanyl fentanyl, and carfentanil. They are similar in chemical structure to fentanyl and may be detected in the urine using specialized toxicology testing. Carfentanil, the most potent fentanyl analog in the U.S., is estimated to be 10,000 times more potent than morphine (dea.gov. hq092216_attach.pdf).
- Acetyl Fentanyl: Acetyl fentanyl is a new and lethal drug and is becoming more popular among narcotic abusers. The drug looks similar to heroin and is being sold as heroin. Numerous deaths among intravenous users of this drug have been reported. The drug is available online and sold as a “research chemical.” Overdoses are treated the same as any opiate overdose. However, larger doses of rescue medications are often necessary.
- Carfentanil: This drug is marketed under the trade name Wildnil and used as a general anesthetic for large animals, i.e. elephants, rhino’s, hippo’s and bears. It is extremely potent and claimed to be 10,000 times more potent than morphine. It is a white powder and sold on the street as heroin, it can be mixed with Heroin and/or fentanyl, and pressed into pills as well. It is often added to heroin to make it more potent. It can be mixed with cocaine and sold as a “speed ball”.
- U-47700: Known as “pink” on the street is about 8X more potent than morphine and can be injected, snorted or ingested. Some people have “plugged” it by dissolving it in water and inserting rectally. It has been mixed with heroin and sold as heroin. The effects are short-lived, typically resulting in dangerous double dosing. It is corrosive to mucous membranes and sublingual administration is likely to damage the mouth. Vaporizing the substance damages the lungs. This was the substance found in fake Vicodin pills that killed the artist Prince.
- Furanyl Fentanyl: This designer version of fentanyl is mass-produced in clandestine labs in China and smuggled into the United States. It has no approved medical use and is not approved for human consumption. It is 5X more potent than fentanyl. It has been encountered as a single substance as well as in combination with other drugs including heroin, fentanyl, butyryl fentanyl, and U-47700. This potent drug has killed hundreds of people throughout Europe and the US. Ingesting the powder may cause seizures. Treatment centers report that abusers do not respond to normal medical treatments. Higher doses of methadone are required to detoxify the user.
Newest synthetic opioids on the streets
Nitazenes
Nitazenes were developed by commercial pharmaceutical companies in the 1950’s as synthetic opioid candidates. This class of drugs has a chemical structure similar to Fentanyl but is not Fentanyl. Because of the similarity, it binds on the same Opioid receptors that Fentanyl does. These compounds are thought to be 20 times more potent than Fentanyl. Clandestine labs learned about the Nitazenes family and began production for recreational use by 2019. Since then Isotonitazene has been implicated in over 200 drug-related overdose deaths in Europe and North America but their presence is likely under-detected because many testing facilities are not set up to test for the drugs (Pergolizzi et al. Cureus, June 2021.doi 10.7759/cureus40736)
The arrival of any new drug or intoxicant into the illicit drug supply creates tremendous burdens for first responders and emergency healthcare providers as they encounter the first overdose cases without the benefit of knowing much about the pharmacology, toxicology, or potential use or interactions of these novel agents. The problem is compounded by the fact that many street drug users may not be informed or aware of exactly what substances they have taken.
Nitazenes are specifically developed to be cheap, easy to manufacture, and highly intoxicating. There are no quality, purity, or manufacturing standards. Even if street drug buyers understand they are buying heroin mixed with nitazenes, the quality and quantity of the nitazenes would likely not be disclosed. In theory, the effects of some nitazenes can be reversed by naloxone(Narcan) but the high potency and impurities of the nitazenes might limit Narcan’s effectiveness.
Many of these new substances are metabolites of the parent drug. N-Desethyl Isotonitazene from Isotonitazene and N-Desethyl Etonitazene from Etonitazene and are listed online as not for human or animal use. (see below)
- Isotonitazene is the most persistent and prevalent new opioid in the U.S. today. It has been found in “fake” Dilaudid pills, sold as a brownish powder similar to brown heroin, and put into capsules. Isotonitazene is derived from a powerful opioid called etonitazene and is about 60 times more potent than morphine. When etonitazene became illegal the molecular structure of etonitazene was altered creating Isotonitazene, a schedule 1 drug in the US. Illicitly using the drug will very likely lead to addiction. It is available on the illicit drug market and mixed with cocaine is deadly.
- N-Desethyl etonitazene was detected by the Boulder County Coroners in Colorado mid-2023 making it the first time law enforcement has found proof of the drug’s presence in the United States. It is considered to be 10 times more powerful that fentanyl. In this case the victim had ordered Quaalude’s, a hypnotic sedative used as a recreational drug, online and did not know they were laced with etonitazene. N-pyrrolidino etonitazene has been found recently in Canada. It’s known on the street as Pyro.
Xylazine and Fentanyl (TRANQ)
The combination of Xylazine and fentanyl, called TRANQ, is used to prolong the effects of fentanyl and lengthen its euphoric effects. Overdose deaths linked to Tranq have spread across the United States. Most overdose deaths linked to Tranq also involve combinations of cocaine, methamphetamine, heroin, benzodiazepines, alcohol, gabapentin, methadone, and prescription opioids. The combination of Xylazine and Meth, or Xylazine and Cocaine, are known as speedballs on the street.
Xylazine is a non-opioid sedative, muscle relaxant and analgesic for veterinary use but is also used to adulterate and potentiate the effects of heroin/fentanyl. Its use first emerged in Puerto Rico and has spread to mainland US where it is combined with heroin and Fentanyl. The combination may be swallowed, inhaled, snorted or injected and results in profound CNS depression and decreased blood pressure, respiratory rate and heart rate. It should be suspected when opioid overdose is accompanied by profound hypotension and very slow heart rate not responsive to naloxone(Narcan). There is no antidote and intense supportive care is required. Skin wounds, known as abscesses, lesions, and necrosis, are becoming prevalent with opioids mixed with xylazine, and ER’s across the nation are seeing an increase in infections. These are not the types of wounds commonly seen with injecting drugs. These sores are developing on skin far away from injection sites, and people are reporting wounds from smoking and snorting xylazine laced substances. The death rate from overdose of this combination is said to be about 30%.
*Narcan does not respond to Xylazine alone. Since it is often mixed with other opioids it is recommended to use Narcan and hope it catches. They also do not test for Xylazine, so it flies under the radar and true data on deaths is lacking. When mixed with meth or cocaine, it acts like a speedball. Sedation comes quickly and death can occur. New Xylazine test strips are available from harm reduction sites, health departments, and other groups in the US. But again, these test strips are not 100% accurate. And they only test for Xylazine! It won’t tell you if Fentanyl or another drug is in there.