When I began using heroin on the West Coast in the late 2000s, it came in the form of a sticky black chunk that left a brown residue on my fingertips and smelled heavily like vinegar. “Black tar” heroin was its most common street name.
Not long into my use, the doses and prices dramatically changed. Where once I was paying $20 for a gram, I was now paying that same amount for a “point”—a 10th of a gram, smaller than the tip of my finger.
The potency had changed, too. Half of one of those points was enough not just to stave off the withdrawal that I would experience if I didn’t use an opioid daily, but to get me very high for hours. Taking a quantity as large as a “20-bag” would have killed me.
This was years before media outlets began to report findings of fentanyl in street heroin supplies, but word of fentanyl, and a whole new level of potency, was already in the mouths of heroin users.
By now, if you read the news at all, you’ve heard about fentanyl. How this powerful, short-acting opioid, used in medical settings for anesthesia and pain relief, has—in its illicitly manufactured form—become more and more prevalent in unregulated supplies of heroin and other drugs across North America. And you know that fentanyl has been linked with high and sharply increasing rates of overdose deaths.
“The problem is consent.”
“Some people call fentanyl ‘evil,’ especially coming from a place of being traumatized by their own, or a loved one’s, disordered use,” acknowledged Avi, a community-based harm reductionist in Eugene, Oregon, who has experience of using licit and illicit opioids, including fentanyl. “I understand this…[but] I cannot agree and find that reductive. Pharmaceutical-grade fentanyl has been an important breakthrough for high-threshold pain. And using outside of the medical institution isn’t innately wrong either. The problem is … consent.”
In many areas, fentanyl has saturated the supply to the point that it’s virtually impossible to procure heroin or other opioids that don’t contain fentanyl or its analogues. In others, it’s hit or miss—creating a dangerous guessing game out of the use of drugs that many people can’t go without.
This supply shift has multiple impacts beyond the headline death rates. Put together, they call for one solution above all: Offer people access to tested, regulated and safe drug supplies. Until that happens, people who use opioids, and who seek treatment or safer options, face a variety of underreported and dangerous complications.
When I eventually went to treatment, I didn’t pop positive for fentanyl on my drug test. That doesn’t mean much: I don’t know if they tested for fentanyl, since it has to be tested for specifically. But based on what I would experience later, I don’t think there was fentanyl in those black-tar points; perhaps they were just cut less, or contained something else. Fentanyl is difficult to mix into black tar, which is one reason it has been less prevalent in the West.
By the time I began using IV opioids regularly again in 2019, the street market had completely changed. I was also in Florida by then, which likely contributed to the difference. Reports of fentanyl adulteration had been popping up around the country, but particularly on the East Coast, where it had always been available to some degree in the form of “China white.”
This time, my dope came in baggies of powder—either white or tan or occasionally tinged a lovely but disturbing lavender color. It was so strong that I almost overdosed off a pinpoint of powder cooked down in water the first time I tried it, and spent the night vomiting like someone who was opioid-naive. I didn’t develop an addiction again right away, but when I did, and when I was finally able to access evidence-based treatment, my drug test this time came up positive for fentanyl.
I’ve previously written for Filter about my experience with precipitated withdrawal, after I attempted buprenorphine induction a little over 24 hours after my last fentanyl use, as I had many times with heroin in the past. I expected that, as fentanyl is a short-acting opioid, 24 hours would be more than enough time. It wasn’t.
“Fentanyl has a very high lipid solubility, so in comparison to things like morphine or heroin it will cross over your blood-brain barrier … very quickly and then crosses back out very quickly. It’s known to have a very fast onset but short duration,” explained Ryan Marino, an emergency medicine physician and medical toxicologist in Cleveland. “That means it’s picked up in peripheral tissues, not just fat and adipose tissues but different organs and stuff, where it’s not really having effect per se but whole body stores can be increased.”
Marino, who created the viral Twitter hashtag “WTFentanyl,” aimed at dispelling myths, emphasized that, due to a lack of rigorous research data on people who regularly use illicit fentanyl, a lot of this information is coming from inferences, observations and patient anecdotes.
In Canada, physicians are able to prescribe a conventional opioid alongside measured microdoses of buprenorphine … [this] is illegal in the United States.
But it suggests to him that for some people, the time needed to successfully induct on buprenorphine is much longer than it is for more typical short-acting opioids like heroin or morphine. Microdosing methods offer some promise, by allowing fentanyl users to take tiny doses of buprenorphine over time, thus building up the levels of the drug in their system gradually instead of pushing out all the fentanyl at once.
In Canada, physicians are able to prescribe a conventional opioid alongside measured microdoses of buprenorphine to help keep their patients comfortable during induction, but co-prescribing buprenorphine for addiction and a conventional opioid is illegal in the United States. And those pre-measured buprenorphine microdoses aren’t available either.
This is a potentially deadly problem, because buprenorphine is one of two highly effective pharmacotherapy treatments for opioid use disorder available in the US. The other, methadone, doesn’t share the risk for precipitated withdrawal, but frequently requires, thanks to US regulations, daily in-person dosing at clinics that can be difficult or impossible to access for some. While buprenorphine comes with its own restrictions and barriers, patients can typically pick up weekly or monthly doses from a pharmacy.
Marino described a modified version of microdosing, using measurements created from the buprenorphine doses available in the US—one that doesn’t involve co-prescribing another opioid—as a way of legally inducting fentanyl-dependent patients onto buprenorphine in the US. But it’s still not a widespread practice here, and while some patients can induct onto buprenorphine from fentanyl within hours or days without issue, those who can’t are often left in the hands of care providers who don’t know how to treat them.
Underreported complications arising from the opioid-supply adulteration stretch far beyond buprenorphine induction—for example, to withdrawal in general. The lipophilic properties of fentanyl—its tendency to combine with, or dissolve in, fats—make it essentially function, in some people, like a long-acting opioid in the body, but not in the brain. This means they will experience the analgesia and euphoria of fentanyl for short lengths of time, but may still experience extended withdrawal.
She was hospitalized for withdrawal-related dehydration between days four and eight.
Avi, for example, described being acutely sick from withdrawal for about two to three weeks after discontinuing fentanyl use. She was hospitalized for withdrawal-related dehydration between days four and eight. She reported having used heroin cut with fentanyl for about eight months, and also suspects that it may have been cut with benzodiazepines—a phenomenon that Marino has also been aware of on the West Coast. Benzodiazepines are known for producing severe, sometimes fatal withdrawal in people on high doses who are suddenly cut off.
Avi’s experience raises another point about sheer uncertainty. “Fentanyl kind of showed up as this unknown, originally unwanted thing,” said Marino. “We really don’t know what else is in the drug supply that we could be attributing to fentanyl and could actually be from other opioid derivatives. There are other fentanyl analogues that could have lipid effects and solubility… There could also be other things we are not detecting readily.”
And then, there are the people who don’t intend to use an opioid at all.
“Last year, I overdosed on some fentanyl-contaminated cocaine,” recounted Jes Cochran, executive director of the Never Alone Project, a drug-user led harm reduction organization in Indianapolis. “I’m not a never-opiate user … but the prominence of [fentanyl] in [methamphetamine] and cocaine supplies here … we’ve found it in MDMA and pressed pills too of course, is alarming for those of us who not only aren’t using opioids regularly (if at all) but it’s also bogus as fuck. Like if I want to go fast, I don’t really want a system depressant in the mix.”
“When you have well-meaning policy making pharmaceutical-grade opioid access near-impossible, the illicit market is flooded with customers,” added Avi, referencing crackdowns and restrictions on opioid prescribing. “Some of them may enjoy fentanyl, or certain fentanyl analogues. Others may not. The bottom line is, all of these people would prefer to have a clear understanding of the contents of their drugs … None of these people are getting that agency.”
Fentanyl required countless injections a day to keep myself stable, and my tolerance built fast.
When I was using in Florida, I knew enough to know that heroin didn’t look like white powder but fentanyl did. So I knew what I was consuming (although I couldn’t actually test for it—harm reduction programs didn’t exist in my county, so any supplies I needed I had to buy myself online, and fentanyl test stips were a luxury I couldn’t afford).
But I didn’t know its strength, I didn’t (and still don’t) know what it was potentially mixed with, and I certainly didn’t know what impact it would have—how different the experience of using and stopping would be from heroin.
Nor had I requested it. During the height of my addiction to heroin, I spent $40 on myself per day, and that was only for a few months. Most of the time, I could get by just fine on $10 or $20 if I needed to. But fentanyl required countless injections a day to keep myself stable, and my tolerance built fast. It wasn’t long before I was spending $50 on myself per day. The day before I quit, I did $200 worth of fentanyl in one 24-hour period. That’s a long way from almost overdosing on a pinhead of powder—but it only took a few months to get there.
The criminalization of drugs has always fostered a lack of transparency and consent for people who use them. But the rise of fentanyl and its analogues both reflects and has created a market volatility, accelerated by the COVID-19 pandemic, that demands immediate, actionable change.
From teens dying after trying what they thought was a pharmaceutical pill that turned out to be pressed with fentanyl; to people with opioid use disorder struggling to detox or induct on evidence-based medicine; to users of substances with radically different effects being forced to experience opioid sedation against their will—in any other field of health, such risks and harms would be seen as evidence of intolerable policy failures.
Even for people who do want to use fentanyl, the instability of the supply and inability to appropriately gauge doses creates circumstances in which even the most cautious are risking overdose. The situation was created by crackdowns on heroin trafficking, meaning more of the same won’t solve it. Nor will these issues go away on their own.
Which brings us back to the clear and urgent need for the safe supply of opioids that could, at a stroke, remove many of the worst harms.
As Marino pointed out, “We had good treatment protocols for heroin and withdrawal … Now we are having new issues because the drug supply changed so much. We can only really expect the supply to continue changing at an accelerated pace, so our treatments are going to continue to be inferior if we don’t address the drug supply. If we could standardize that or make it safer, that would probably help a lot more issues than trying to scramble on the back end.”
Photograph of heroin powder via Drug Enforcement Administration/Public Domain