Addressing the fentanyl threat

Richard Frank and I have a piece on the fentanyl threat to public health in the current New England Journal of Medicine. I am still stunned by the incredible percentage of current opiate OD deaths that involve fentanyl and related substances.

Fentanyl, a powerful synthetic opioid, poses an increasing public health threat. Low production costs encourage suppliers to “cut” heroin with the drug, particularly white powder heroin sold in the eastern United States. Fentanyl also appears as a prevalent active ingredient in counterfeit OxyContin (oxycodone) tablets. The result is that fentanyl plays a major role in rising mortality due to heroin or opioid overdose. It poses a serious overdose risk because it can rapidly suppress respiration and cause death more quickly than do other opioids

More here.


Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect,, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

8 thoughts on “Addressing the fentanyl threat”

  1. Harold: I have a couple of questions here.

    First, are you aware of how many fentanyl overdoses are occurring in people who have migrated to illicit opioid use following initiation of opioid use with prescription painkillers? Are there unintended consequences to policies which tighten prescribing rules for narcotics, such that opioid-experienced individuals seek other sources for opioids when their legal access is curtailed? As many states pass laws with prescription limits, how should they factor in these considerations?

    Second, are there significant numbers of fentanyl overdoses occurring in opioid-naïve people? The Feb. 3 MMWR reported on a cluster of overdoses in New Haven where fentanyl was used to cut cocaine powder, where the affected cases had cocaine metabolites in serum and urine, as well as levamisole, a previously known cocaine adulterant, but not opioid metabolites other than norfentanyl. If fentanyl becomes an adulterant in non-narcotic street drugs, that would expose an especially high-risk population to lethal overdose. Is this a widespread phenomenon?

    1. The cross-sectional time series analyses suggest that tightened rules are not correlated with OD deaths. It's possible that these laws both help and hurt at different points in the life cycle of use.

  2. Wasn't it some kind of fentanyl gas which Putin used on the hostage theater crowd, which involved a lot of deaths?

  3. The ultimate in harm reduction would seem to be to provide high quality drugs free of charge to anyone who wants them, as well as free treatment for those who want that. Also free mental health treatment for people who are at risk for becoming addicted.

    1. This is what Vancouver does — heroin injection service, supervised consumption rooms, needle exchange, naloxone, lots of free treatment.

  4. And it's not as if this hasn't been known for decades. (I recall a published study of fentanyl abuse among medical personnel from roughly 25 years ago that discussed the advisability of allowing people back into narcotic-access positions after they had successfully completed rehab. The problem with doing that, according to the study, was that in roughly a third of case the first sign of relapse was a fatal overdose.)

    Will the common knowledge that fentanyl is effectively more of a poison than a narcotic decrease its illicit use or increase it?

    1. Doubt it. Look up "krokodil russia". It's an opioid that …. well, basically if you get hooked on it, you're dead in a year (or something like that). The article I read was …. stomach-churning.

  5. Dr. Pollack,

    Maybe this is completely off-topic. But: I wonder why there hasn't been any effort I've ever heard of, to simply remove these opioid-based painkillers from the market? Is the harm that would be suffered by bona fide pain sufferers *really* so great that it would outweigh the harm being suffered today by addicts who got addicted due to (e.g.) Oxycontin? I read that 11% of adults in the state of Kentucky (was it?) were prescribed opioid painkillers last year.

    I'm not trying to understate the harm that real pain patients would suffer. But there is a very real harm being suffered by society right now, from these painkillers. And of course, I don't pretend that Purdue Pharma (and others) wouldn't fight tooth-and-nail. But I've never even -heard- of such an effort.

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