Published January 2023*
Where and how might one encounter fentanyl, and how risky is each scenario?
Many Americans are being directly and indirectly impacted by fentanyl. Reports of overdoses and poisonings are seemingly everywhere. Its prevalance leads to questions: Is fentanyl a safe medicine or a deadly poison? What are the risks? How do I keep my loved ones safe?
Fentanyl is a synthetic opioid that is safely used in medical settings for pain relief every day. However, because it is cheap, potent, and relatively easy to make, a black market version of fentanyl has percolated into the street drug market. This illicitly manufactured fentanyl (IMF)** is now the primary contributor to the recent, unprecedented spike in drug related deaths.
People can encounter fentanyl in many different settings, and the risk of overdose or poisoning in each setting is variable. Given everything known about today’s fentanyl landscape, the Expert Fentanyl Response Team has organized various potential scenarios (or encounters) into three types, followed by context and consensus about the relative risk of overdose or poisoning.
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*Please note: The landscape of fentanyl use and its presence in the US drug supply is dynamic. Due to economic or other factors that can impact overall risk, the fentanyl patterns emerging today may not be what’s seen in the future. This report was written in January 2023 and aims to equip individuals with knowledge about the current landscape of fentanyl in the United States.
**In this overview, illicitly manufactured fentanyl refers to fentanyl and all of its analogs currently found in street drugs.
3 KINDS OF FENTANYL ENCOUNTERS
A note on methodology: This resource was authored by the Expert Fentanyl Response Team (EFRT). The contents of this overview is informed by an assessment of the following questions:
Taking into account the chemical properties of fentanyl and what we know about toxicology and human biology, is the scenario technically possible?
Considering economic incentives in the illegal drug market, is the scenario likely?
Is there any data that confirms that the scenario has actually occurred?
PHARMACEUTICAL FENTANYL IN A MEDICAL SETTING
Many people encounter fentanyl in the hospital for pain relief. In this setting, fentanyl is often administered through an IV or a shot (fentanyl skin patches or lollipops can also be prescribed to consume in safe doses at home). Pharmaceutical fentanyl is produced by manufacturers in sterile facilities and in compliance with stringent quality control measures enforced by government regulations. This commercial version of the drug is precisely dosed, which allows medical professionals to properly administer it to patients.
Physician and Alchemist Paracelsus (1493–1541) is credited with saying, "All things are poison, and nothing is without poison; the dosage alone makes it so a thing is not a poison." This has evolved into the shorter, “The dose makes the poison,” now a common maxim in the world of toxicology. When properly manufactured and carefully administered, fentanyl is a highly effective opioid medication, whose benefits far outweigh its risks.
MANUFACTURED FENTANYL IN STREET DRUGS
Fentanyl that people encounter outside of medical settings – in, for example, fake pills sold on the street or in heroin or cocaine – is known as illicitly manufactured fentanyl. This version is produced in unregulated “labs,” which results in random, variable dosage. Illicitly manufactured fentanyl has been involved in the majority of US drug deaths in recent years. There are several different ways an individual may encounter illicitly manufactured fentanyl, listed below in order of highest to lowest risk.
VERY HIGH RISK
IN COUNTERFEIT PRESCRIPTION PILLS (ACCIDENTAL)
IN COCAINE (ACCIDENTAL)
IN MDMA (ACCIDENTAL)
IN METHAMPHETAMINE (ACCIDENTAL)
IN HEROIN (ACCIDENTAL)
DRUG OF CHOICE (INTENTIONAL)
IN THC GUMMIES OR OTHER EDIBLES (ACCIDENTAL)
IN MARIJUANA FLOWER (ACCIDENTAL)
In this overview, the terms marijuana and cannabis are used interchangeably.
IN VAPE CARTRIDGES (ACCIDENTAL)
PERFORMING CPR ON AN OVERDOSE VICTIM
HANDLING FENTANYL PILLS
TOUCHING FENTANYL POWDER
INHALING FENTANYL DUST
There have been media reports about people inadvertently encountering illicitly manufactured fentanyl and experiencing overdose symptoms from casual or second-hand contact. Below are a few scenarios that have been reported – in each of these cases, relative risk of experiencing an overdose is very low.
CASUAL EXPOSURE TO
ILLICITLY MANUFACTURED FENTANYL
To take effect, fentanyl must enter the bloodstream and penetrate the blood/brain barrier. Here are the four ways that fentanyl can enter the bloodstream, listed in order of bioavailability (roughly, rate of absorption).
Directly into the bloodstream (injection/intravenous catheter)
Via the mucous membranes (snorting, smoking*)
Via the stomach/liver (swallowing)
Transdermal (via a prescription skin patch)
*The term ‘smoking’ refers to the practice of indirectly heating fentanyl and inhaling the vapors.