Fentanyl is nearly always described with the following three words: Powerful. Synthetic. Opioid. Let’s look at these terms in reverse order. Opioid: Fentanyl belongs to the class of drugs called opioids, which are used to reduce pain. This category also includes morphine, oxycodone and heroin. Of these, fentanyl is one of the most potent, and is approved for medical use as a surgical anesthetic or for people with chronic pain (typically terminal cancer patients). Opioids reduce physical and emotional/psychological pain and can have a euphoric effect in high doses, which is why people sometimes misuse opioids. Synthetic: Unlike morphine and heroin, fentanyl is not derived from the opium poppy. Rather, it is a synthetic product, meaning it is “formed through a chemical process by human agency”; i.e. it is not derived from plants. This means that it can be produced quickly – it is not dependent on agricultural and harvest conditions. Since the supply is only limited by the availability of the precursor chemicals and the availability of people to make it, fentanyl is exceptionally cheap and easy to make compared to plant-based opioids. Powerful: Fentanyl is good at its job. It is a highly effective and efficient pain reliever. It is 50-100 times stronger than morphine. All the properties are amplified, so it takes a lot less fentanyl to get the same effect as morphine or heroin. That has many of implications, for instance: Just a tiny amount can be lethal, especially if you don’t have a tolerance to opioids. Fentanyl takes effect faster and wears off sooner, making it highly addictive and harder to kick. Standardized dosing in a pressed tablet requires precise measures of minute quantities, something that is not guaranteed by illegal suppliers. The difference between high and die is often a few milligrams, or roughly a few grains of salt.

There are two types of fentanyl you need to know about. Pharmaceutical-grade fentanyl is a legitimate medication produced by pharmaceutical companies that have developed advanced technology to control the quality and maintain the proper dosages of the end products. Pharmaceutical-grade fentanyl is tightly regulated and is safe when administered by professionals as prescribed. Deaths from overdosing on pharmaceutical-grade fentanyl are relatively uncommon and often involve misuse or tampering of medications. Illicit fentanyl is the black market version of the drug obtained or made by dealers and mixed into pills, other powders, blotter papers and liquids, etc. in “labs” with no quality controls. The risk of illicit fentanyl is two-fold. Illicit fentanyl, often made in Mexico, is not manufactured to the same quality standards as the pharmaceutical fentanyl commonly used for medicinal purposes. The potency of illicit fentanyl found in items sold in illegal markets can vary widely from maker to maker, or even from batch to batch, and the buyers don’t know the contents of what they are getting*. Fake pills are then being made, sometimes with inconsistent amounts of illicit fentanyl. Fake pills are illegally made in garages, basements, and other clandestine settings by unqualified drug makers who do not ensure the quality or consistency of the dose. When batches of fake pills are mixed, each pill may contain a different amount of illicit fentanyl making the dose of each pill impossible to predict. These products are not regulated and there is no way to ensure consumer safety. Because of this, use of illicit fentanyl is very dangerous. Illegally manufactured fentanyl is involved in the majority of U.S. drug deaths in recent years. *One of the other negative aspects of poor quality control is that at times, the “illicit fentanyl” is not actual fentanyl. Within an illicit fentanyl supply, there may be unreacted precursor chemicals, byproducts that form due to poor heating or stirring, etc. Also, the amateur chemists can change the ingredients (precursors) of the recipe to form “fentanyl analogs.” Pharmaceutical grade fentanyl is manufactured under strict, government regulated quality control standards so that precursor chemicals or byproducts that are left over from the synthesis process are removed as the final fentanyl product is purified.

A fentapill is a counterfeit prescription pill purposely made to resemble legitimate medicines, but instead is made of illicit fentanyl or an illicit fentanyl analog.

Samples of cocaine have tested positive for fentanyl and there are confirmed cases of users dying from consuming cocaine that contained fentanyl. This may be due to contamination or intentional mixing. This puts users at very high risk of fentanyl poisoning since it is consumed unknowingly.

In addition to being extremely potent, fentanyl has a very small therapeutic index. This means that the amount of fentanyl it takes to have an effect is almost the same as the amount it takes to kill a person. That is why fentanyl is so carefully dosed and closely monitored in medical settings. Illicit fentanyl also has a small therapeutic index, but it is manufactured without the necessary quality controls, so the potency of any given batch is an unknown variable. Combine this with improper blending when it is cut into powders and then pressed into pills, and you have a literal recipe for disaster: street drugs made with a potent, sensitive raw material that is unevenly distributed within the end product.

In toxicology, the lethal dose for a substance is referred to as the LD50, or median lethal dose, which is the amount that is needed to kill 50% of a sample group. Toxicologists point out that it is impossible to determine a precise LD50 for opioids because tolerance builds in lab subjects as the dose is increased. In other words, the lethal dose for any opioid is a moving target, technically speaking. The DEA says that 2 milligrams (mg) of dry powder fentanyl is a “potentially lethal dose.” This general statement makes the point that a small amount can be deadly. In fact, the actual amount of fentanyl that will cause death varies depending on the person’s weight, whether they have used opioids before, their metabolism, their general health, and more. The amount of fentanyl that will kill a 110-lb person who has never ingested opioids will be different than the amount that will kill a 220-pound opioid dependent user. Therefore, a “lethal dose” may not cause death to everyone who consumes it. Conversely, a person could die from an amount of fentanyl that is less than the “lethal dose” of 2mg.

Illicit fentanyl is an ideal raw material for drug dealers. It is cheap to get and extremely potent. Because it is potent, only a tiny amount of powder is needed to make large quantities of drugs, making it easy to hide from law enforcement and extremely profitable to sell. Money is the biggest driver of illicit drug sales. Trying to get real prescription pills from the pharmacy to the street is difficult and risky. Pressing out a fake oxy is easy and costs the maker just pennies per pill. If an oxy sells for 40 bucks on the street, almost 100% of that goes in the dealers’ pockets. Apply that math to a batch of 5,000 or 10,000 pills and you can see there is A LOT of money to be made by the dealers up and down the supply chain. Let’s look more closely at how fentapills get into the buyer’s hands. The people making the pills usually sell them to other dealers, who sell them to other dealers, and so on, many times before the deadly pills are sold to the buyer. Whether the pills are made in Mexico or in the U.S., it is highly unlikely that the people making the fentanyl powder and fentapills, or the higher-level dealers, even know that their product has killed someone. They have made their money and moved on. Buyer beware: even a trusted friend does not know what is in the drugs they are giving you; they cannot test the dosages of their pills and have no way of backing their claim that the pills they are offering are safe. Not all fentapills contain a lethal dose, so many people take a fake pill, assume it was real and then get comfortable taking another. This creates demand, especially since fentanyl is so addictive. This is another feature that dealers like – dependent customers are repeat customers, and that market segment is growing.

Illicit fentanyl is synthesized by combining and mixing specific raw materials (precursor chemicals) in the proper ratios. The precursors are highly regulated in the U.S. but relatively easy to acquire from makers in China and India since they have other legitimate uses in chemistry and are not as tightly regulated there. Manufacturing pharmaceutical-grade fentanyl requires the use of special equipment and conditions, but clandestine labs can make much lower quality illicit fentanyl with no special equipment. Making fentanyl is not dependent on climatic conditions, seasons, or weather, which means that fentanyl can be made quickly and in large quantities - anywhere at any time.

Beginning around 2014 China was the primary source of illicit fentanyl powder coming into the U.S. and Mexico, shipped directly through postal and shipping services. Drug traffickers based in the U.S. and Mexico then cut the illicit fentanyl powder into heroin and other drugs or pressed it into counterfeit prescription pills. In May 2019, under international pressure, the Chinese government banned the production and sale of fentanyl analogs, leading to the significant reduction of the amount of illicit fentanyl being shipped directly from China to the U.S. and Mexico. Since then, Chinese vendors have shifted their manufacturing to precursor chemicals, selling them to the Mexican cartels via online networks. Currently, most of the fentanyl in the U.S. illicit drug market comes across the southern border from Mexico. Mexican Drug Trafficking Organizations (DTOs) manufacture fentanyl using Chinese precursors and smuggle it north in powder or pressed pills. With pressure being put on the Chinese supply chain, India and Mexico have become emerging sources of fentanyl and precursor chemicals, and the DEA expects the number of countries producing these precursor chemicals to increase. DTOs are likely poised to take a larger more significant role in the production and the supply of fentanyl and fentanyl-containing illicit pills to the United States. We can expect that illicit fentanyl production and precursor chemical sourcing will become increasingly global as time goes on. (Source: DEA)

An analog is a compound having a structure similar to that of another compound, but differing from it in respect to a certain component. Some fentanyl analogs have been created by pharmaceutical companies for legitimate medical use. Others have been developed by illicit drug traffickers to get around drug laws. Wikipedia currently lists 84 different fentanyl analogs, and new fentanyl analogs are still being formulated. Not all fentanyl analogs have the same potency. For instance, carfentanyl is 100 times stronger than fentanyl (and 10,000 times more potent than morphine).

A pressed pill, as the name implies, is a tablet made using a pill press machine. Pill presses can be found online and are cheap and easy to purchase. Drug traffickers use molds (or dies) with common brand marks to press pills that look exactly like pharmaceutical prescription pills (we call these fentapills). They start by mixing filler powders and dyes with illicit fentanyl powder. This dry mixture is then run through the pill press - compacted into tablets and stamped with commercial markings in a single step. Black-market pill pressing operations lack sufficient quality controls, so the dosage varies from pill to pill and from batch to batch. As a result, the potency of any given street pill is impossible to know. This, combined with the fact that they look like safe commercial medications, is what makes fentapills so dangerous.

The exact number is impossible to calculate, but we can make an educated estimate based on some informed assumptions. The DEA reports having confiscated 9.6 million counterfeit prescription pills in the first nine months of 2021. U.S. Customs and Border Patrol (CBP) is on pace to confiscate 12,000 lbs. of fentanyl in 2021, a number which includes both powders and pills. We can’t say how much of the powdered fentanyl will be cut into heroin and cocaine, versus how much will be pressed into fentapills. Experts think that the authorities only stop about 5-10% of the drugs that are smuggled into the country. Applied to the quantities cited above, we conservatively estimate that between 250-500 million fentapills are in circulation in the U.S. at any given time. Again, this is just our estimation.

Yes. In fact, there are documented cases of people dying after ingesting just ONE HALF of a fentapill.

As fentanyl deaths continue to rise, there is momentum behind promoting Fentanyl Test Strips (FTS) as part of a harm reduction strategy. The most widely distributed FTS is the Rapid Response Fentanyl Test Strip manufactured by BTNX. These FTS are designed to detect several common fentanyl analogs in urine; they were not designed to test pills. The Harm Reduction community has adopted “off label” uses for the BTNX FTS and actively promotes their use (with significant disclaimers) for testing heroin, cocaine, meth and MDMA. There is strong evidence that FTS detect fentanyl in liquid samples with a high degree of accuracy. However, there are limitations specific to testing fentapills that reduce their usefulness. Because of the chocolate chip effect*, you cannot test a portion of a pill and be sure that the rest of the tablet or batch is free of fentanyl. You must dissolve everything that is to be consumed prior to testing. Because of uneven mixing, a common problem in illicit pills, you cannot test one pill from a batch and assume that the other pills in the same batch do not contain fentanyl. FTS detect the presence of several fentanyl analogs, but do not measure the amount or the potency. FTS do not detect all fentanyl analogs. Improper dilution can result in a false negative result. We do not know if FTS can or will detect the other synthetic opioids that drug traffickers are already using to make fake pills, like nitazenes. Because of these limitations, FTS do not guarantee safe use of illicit pills. *Because the fentanyl is never evenly distributed throughout the base powder mixture, part of the pill might have no fentanyl while the other part has a lot. Once the pill is pressed, the components are locked in place. This is called the chocolate chip effect.

No. See question #13. There is no such thing as a street pill that has been tested, since that would require dissolving, testing, drying and re-pressing the pills. Sadly, there are dealers making this false claim in order to reassure their customers. Do not believe them. If you buy pills online or on the street, you cannot know what they contain, no matter what anyone tells you. There currently is no test that will guarantee that a pressed pill does not have fentanyl in it, or even that it has a ‘safe’ amount of fentanyl in it. The only way to ensure that you are getting a safe pill is to get it directly from a pharmacist in a bottle with your name on it. Fentanyl test strips (FTSs) are regularly promoted by the harm reduction community as a way to reduce the number of overdoses. Fentanyl test strips do not test for all fentanyl analogs, were not created to test pills (they were created to test urine), and their accuracy with pills has not been established; therefore, the use of FTS does not guarantee the safety of pills. We discourage the consumption of ANY illicit pill. Any time a person consumes an illicit pill in the age of fentanyl, they risk dying. That being said, those fighting substance use disorders who are willing to take the potentially fatal risks that come with consuming illicit pills can reduce their chances of overdosing by using FTS.

Fentanyl is being integrated into almost all forms of street drugs. In some cases dealers purposely add fentanyl to their drugs to reduce costs, enhance the effect of an existing drug, hook their customers, or all three. Remember, it’s a business and it’s all about making as much money as possible. In some cases, the presence of fentanyl is the result of contamination from traffickers handling multiple drugs in unclean environments or mixing several different powders with the same equipment. Widespread Fentanyl Contamination: Fentanyl has been widely detected in all of the street drugs listed below: Fake Pills, including but not limited to: Percocet Oxycontin Norco Xanax Vicodin Valuim Other: Heroin Cocaine MDMA (Ecstasy, Molly) Methamphetamine Drugs to Watch: Marijuana Vape Pens Adderall made of methamphetamine Fentanyl in Marijuana: There are reports of fentanyl powder being detected in marijuana, but these are difficult to confirm and there is no evidence that this is currently a widespread practice. In most cases the most likely cause is accidental contamination. We have not identified any instances of people dying from fentanyl poisoning after smoking marijuana. Toxicology experts maintain that dying from smoking fentanyl laced marijuana is highly unlikely, given that fentanyl ignites and burns off at a much lower temperature than the marijuana flower. This is why fentanyl is sometimes “smoked” by heating fentanyl powder on foil and inhaling the vapor. Fentanyl in Vape Cartridges: There are reports of vape cartridges being filled with fentanyl, but these are not widespread. We have not identified any instances of people dying from fentanyl poisoning after vaping fentanyl using a vape cartridge. Some people argue that vaping fentanyl is not possible because the fentanyl is destroyed before it reaches the temperature when it becomes a vapor. We do not believe this is true. A research article entitled Fentanyl vapor self-administration model in mice to study opioid addiction describes research that shows where ”mice readily self-administered fentanyl vapor, titrated their drug intake, and exhibited addiction-like behaviors, including escalation of drug intake, somatic signs of withdrawal, drug intake despite punishment, and reinstatement of drug seeking.”

The terms “poisoning” and “overdose” are both used by the CDC, medical examiners and law enforcement professionals to describe drug related deaths. So, from a governmental reporting standpoint, fentanyl deaths are indeed called both “poisonings” and/or “overdoses”. However, these terms are not always used consistently between organizations, making the reporting of “poisonings” and “overdoses” complicated and sometimes inaccurate. We think the language we use to describe drug deaths should be updated to accommodate recent developments brought on by the emergence of fentapills. An overdose occurs when a person ingests too much of a known substance, resulting in either illness or death. Fentapill deaths are different. The consumer is being deceived. Many people ingest a fentapill believing they are taking a legitimate prescription medication such as oxycodone or Percocet. They typically ingest the recommended dose of their intended drug - a single pill - and die from fentanyl toxicity. Because of the deception, such a death is most accurately classified as poisoning. Updating the language is necessary to address the problem appropriately. The solutions we have historically applied to the opioid “overdose” crisis do not apply across the board in the age of fentanyl and fake pills.

There a few main contributors to the large increase in deaths from illicit fentanyl: Supply- The amount of fentanyl being sold by drug dealers has increased dramatically since it was introduced into the illicit drug supply in the early 2010s. We estimate there are millions of fentapills currently in circulation in the U.S., more than ever before. Social media has also made these cheap fake pills much more accessible to anyone who wants them. Deceit- A major factor in fentanyl deaths is the fraudulent way that it is marketed and sold. Whether fentanyl is consumed in pill form or in other street drugs, dealers don’t always disclose that their product contains fentanyl, even if they know it does. Dealers often make their products with fentanyl and pass it off as a more familiar and less potent substance. Potency- Fentanyl is extremely potent and lethal in very small amounts. Illicit fentapills are not made with high quality controls, so many of the street drugs and fake pills being offered by dealers are deadly and the consumer bears the risk. These combined issues have caused the number of deaths from fentanyl to skyrocket in recent years.