When the musician Prince died of a fentanyl overdose in April of this year, it is likely he didn't even know he was taking the drug. Yes, he knew he was taking a drug, however, he likely believed he was taking a much less potent opioid, like morphine or oxycodone. Authorities say pills marked as hydrocodone have tested positive for fentanyl. It's a scene playing out all over the nation as more people seek out opioids and fatally encounter fentanyl. "Fentanyl is proving to be easy to produce and we are seeing it cut with other drugs—or substituted for them across the nation," says Jennifer Plumb, MD, a pediatrician with University of Utah Health. "However, it is much more potent and much more likely to cause an overdose."
As the opioid epidemic grows so does the spread of fentanyl. A new report in the Morbidity and Mortality Weekly Report shows the number of drug products testing positive for fentanyl rose 426 percent between 2013 and 2014 nationwide. In the same time period, the number of deaths related to synthetic opioids such as fentanyl rose 79 percent. In Ohio, which is considered a "high burden" state for opioid abuse, the number of deaths related to fentanyl has increased from four in 2007 to more than three thousand in 2015. "I am afraid the numbers are only going to go up, and that the next three to five years are going to be truly frightening," says Plumb, who also is the director of the Utah Naloxone project. "As the demand for opioids grows, fentanyl and other synthetic opioids will be used to fill orders by those who supply them."
Fentanyl is a synthetic opioid that is more than 50 stronger than morphine and 30 times stronger than heroin. Because of that, only a small amount is needed to produce a high. Unlike prescription opioids, it does not have to be stolen or taken from a hospital or pharmacy, but instead is brought in from China or Mexico where it is being manufactured. The potency and ease of access make it ideal for drug dealers—and dangerous for drug users. "With any illicit drug you do not know what you are getting," says Plumb. "However in the case of fentanyl, a user trying to achieve their regular high may unwittingly, and easily, take a deadly amount."
Fentanyl also has a faster onset, which increases its danger. A dose of heroin may take a period of more than 10 to 20 minutes to take full effect so an overdose can be detected. However, the time between taking fentanyl and a full respiratory arrest could be as little as three minutes. "Think of it as a slow speed crash versus a high speed crash," says Plumb. "In the slow speed crash you realize action will need to be taken. In the fast speed crash all you can do is watch the wreckage fly."
Reducing a fentanyl overdose is more difficult than reversing overdoses of other opioids. Naloxone is the gold standard when it comes to reversing an opioid overdose, but in the case of fentanyl several doses of the drug may be needed to have any effect. "Paramedics and other first responders may have enough naloxone on hand to reverse an overdose," says Plumb. "But it is unlikely the average household—even with a standard naloxone kit—would have enough to do so."
Fentanyl and other synthetic opioids are likely to continue causing deaths as the opioid epidemic grows. Efforts to stop this are something that Plumb hopes happen soon. "We need to treat this as a public health crisis. We need to act now to stop people from becoming dependent upon and addicted to opioids with better oversight of how they are prescribe them. We also need to work with law enforcement to get these frightening synthetic substances off the streets. And we need to increase access to treatment for those already addicted. It is critical that we act now."