“Forever, the prevalence of what kinds of drugs people did was completely boring,” Alex Kral, an epidemiologist from the nonprofit health research institute RTI international, told Filter. He has been studying the drug market in San Francisco and elsewhere for 28 years. “For the first 22 years that I was doing that, it was the same.” No longer.
The drug market is now evolving so rapidly it can be challenging to fully grasp it before it changes yet again. The grim result is the body count, as consumption patterns change in the wake of the volatile supply, but not fast enough.
Reports of heroin adulterated with fentanyl began increasing, especially on the East Coast, around 2014. It was immediately identified as a causal factor in skyrocketing overdose rates. News headlines warned of fentanyl-laced heroin, emphasizing its place as a contaminant—not something people wanted to use.
Fentanyl was slower to hit the West Coast. While the East Coast traditionally had powdered heroin, sometimes sold in stamped bags as a method of branding, the West had black tar, the consistency of which made it harder for suppliers to mix in fentanyl. (Although given how challenging United States laws make drug checking, and the rarity of mass spectrometer testing, we can’t be sure of the earlier prevalence of fentanyl in the West Coast supply.)
Fentanyl pressed pills—specifically blue pills stamped with “M30,” colloquially referred to as “Blues”—have roared onto the scene.
Regions first affected by fentanyl saw a deceleration in overdose trends around 2018, perhaps as consumers adapted. “We’ve all learned how to use fentanyl on the Downtown Eastside [of Vancouver],” Dean Wilson, the harm reductionist who sued the government of Canada to allow its first safe consumption site, told Filter. He said the fentanyl found there is colored powder, as a way of branding. “Rainbow shit,” he called it.
Canada has had ubiquitous fentanyl prevalence for several years, but is now suffering from another adulterant that’s risky when mixed with opioids: benzodiazepines. “There’s very few people who die of a [pure] fentanyl overdose… We’re finding [benzos] are the killer now,” Wilson said. The US has not yet seen an equivalent, though the veterinary tranquilizer xylazine is found on the East Coast.
Just south of Vancouver, in Seattle and Portland, it’s a different story. Fentanyl pressed pills—specifically blue pills stamped with “M30,” colloquially referred to as “Blues”—have roared onto the scene since the onset of COVID-19. Their emergence—specifically the speed of the shift, and the fact fentanyl is being sold in a formulation to mimic pharmaceuticals—has alarmed everyone from harm reductionists to the Drug Enforcement Administration.
Through the “iron law of prohibition,” traffickers will always prefer the smallest and most readily-concealable product, with more potency by volume. Just as no one brewed beer during Prohibition, instead preferring hard liquor, heroin has now fallen out of favor.
US cross-border drug policy sped the transition, pushing Mexico, where the West’s black tar heroin mostly originated, to eradicate the cultivation of poppies. Poppy cultivation is fickle anyway, dependent on farmers and sensitive to climate change. Lab-made fentanyl provided an alternative that enabled vertical integration, easier transportation and increased profits. In the hyper-capitalistic unregulated drug market, fentanyl is now king.
The Mexican government, aligned with the DEA, continues its drug interdiction efforts. Heroin seizures are declining. In late November, by contrast, the Mexican Army found 61,000 “Blues” and 680 kilos of fentanyl powder in two back-to-back hauls, likely bound for the US. Customs and Border Protection seizures of fentanyl—the vast majority of which occur at border checkpoints—have increased precipitously since 2018. Fentanyl powder also comes through the mail from China; some, too, is manufactured in labs in the US, where much of the powder is pressed into pills.
Demand Is Shifting, Too
Fentanyl is no longer just a contaminant that consumers would rather avoid, but has become the drug of choice for many. Its form varies according to where you are: In San Francisco, it’s primarily colored powder rather than the Blues further north. But for the first time on the West Coast, since around 2020 depending on the city, it’s intentional fentanyl use.
Jon G (the name he goes by on the street) is a native Portlander in his 30s, currently having to live in a tent downtown. When he returned to using less than a year ago, it was on black tar heroin, he told Filter. But it quickly became harder to find. He first bought Blues for lack of an alternative, and now strongly prefers them.
“It’s like [heroin] isn’t cool anymore. You’ve still got one out of 10 people stuck doing black and walking around asking for it,” he said of the downtown Portland drug scene. “People are like, ‘man, nobody does that anymore. Get out of here!’”
Consumption patterns are changing as rapidly as the drug market, even if delays in adaptation cost lives. In October, Kral and colleagues published a study in Drug and Alcohol Dependence with remarkable results. Among people who inject drugs in San Francisco, the number of monthly injections dropped 89 percent from 2018 to 2020. As injections dropped, reports of people smoking fentanyl—heating it and inhaling the vapor, rather than smoking in the sense of combustion—increased inversely. Even people who had injected black tar heroin for years switched over to smoking fentanyl.
“Everybody down here was doing heroin. I would say probably nine out of 10 are doing Blues now.”
Jon is no exception. He has struggled on and off with opioid addiction for over a decade. For the vast majority of that time, he injected. When black tar dried up and he was forced to buy Blues to stave off withdrawal, he knew not to inject them. He smoked them off of aluminum foil, and found it worked well for him.
He had plenty of experience of using opioids in this way, thanks to an earlier shift in the supply. Right as the availability of OxyContin plummeted under government restrictions around 2008, many Portlanders who had grown a taste for them seamlessly switched to smoking heroin (myself and Jon included). As tolerance grew, many people later switched to injection as a method of economization (myself and Jon included).
Jon sees parallels between that change and today’s, while stating that the current transition is “at least twice as fast as back then.”
Shifts in supply—then a reduction in OxyContin, now a reduction in heroin—end up provoking monumental shifts in demand through increased tolerance. After his first few involuntary Blues purchases, Jon attempted to return to black tar heroin. He suddenly found that he could hardly stay well, much less get high from it. For him, that cemented the switch to fentanyl. Reliable drug-market data are notoriously scarce, but anecdotal reports, along with a constant stream of massive law enforcement seizures, indicate that Jon is far from alone.
“I’ve never seen so much growth as rapidly as Blues,” Jon said. “For the most part, everybody down here that I knew was doing heroin. I would say probably nine out of 10 of them are doing Blues now.” Just about all of them are smoking, he added.
“It’s going to cut down on a lot of infections and abscesses.”
Asked whether he perceives the switch to smoking fentanyl as a net positive, his answer reflected the complexity of his situation.
“There’s positives and negatives for me with the Blues. The positive about it, versus mainline heroin, is I’m not poking myself all day,” he said. “I don’t have track marks … I don’t have to worry about misses and I don’t have to worry about having clean needles.”
“Honestly, it’s just faster and convenient,” he continued. “In the morning, I can roll over and spark the lighter, inhale and I’m well. Heroin, I’m having to cook it, get cotton, draw back and try to hit. Then what if this arm doesn’t work and I have to switch over to my leg, and all the other stuff. So, that’s one good thing, it’s going to cut down on a lot of infections and abscesses.”
But the downsides are nearly as numerous, he explained. Rapid increases in tolerance and the need to use much more frequently concern him, and were a factor in how rapidly he lost both employment and housing after he started using again. Previously, he could use heroin in the morning and then work an eight-hour shift without issue. But with fentanyl’s shorter half-life, he finds he needs to use every four to five hours, which proves disruptive. He cannot even sleep through the night, instead waking up in withdrawal. According to Jon, those consequences were outweighed, if barely, by the fact he no longer injects.
Anecdotally, overdosing from smoking Blues is reported more rarely than with injecting, but it can happen. Overdose rates continue to climb in the West.
Aaron, a 33-year-old Portlander who recently stopped using opioids, felt frustrated by the market switch to Blues. He still preferred heroin, he said, in part because of the longer duration of its effects.
“[Blues are] like heroin crack,” he told Filter. “You get stupid high stupid fast, and 20 minutes later you’re left looking for more.” Much to his dismay, he was living in a Christian recovery house at the time of the interview.
Counterfeit Pharmaceuticals
Despite rare consensus from people who use drugs, researchers and law enforcement that unprecedented shifts in the drug market have major implications for people’s lives and health, the US government seems to have altered its drug interdiction strategies little. In late September, it announced the results of a two-month operation to combat counterfeit pills: seizures and arrests. With annual drug war expenditures in the billions, US drug overdoses have increased 500 percent since 2000.
This current phase of fentanyl—its replacement of heroin and smoking’s replacement of injecting—will produce myriad unpredictable downstream consequences that we don’t yet know. We saw similar results after government-enforced underprescribing of opioids meant that regulated, known-dosage pharmaceuticals became scarce, to the detriment of pain patients and drug users alike.
People turned to street drugs with volatile purity and overdosed by the thousands—an outcome not entirely unanticipated by the architects of a policy allegedly designed to save lives. Today, prescription opioids are involved in a very small proportion of deaths (less than 2 percent in Oregon, according to data from Oregon Health Authority) and fentanyl kills orders of magnitude more than OxyContin ever did; counterfeit pharmaceuticals, on the other hand, are increasingly prevalent.
Dean Wilson in Canada described “pressing into pills as a more American phenomenon.” Sources in Mexico confirm that despite large seizures there, counterfeit pharmaceuticals are unheard of for personal consumption. Counterfeit pills have been seized in massive quantities in Seattle, Portland and Los Angeles; in the Bay Area, it is mostly fentanyl powder.
Despite years of record-breaking fentanyl-involved deaths, the DEA (which provided information and materials but declined Filter’s request for comment) put out its first public safety advisory on the drug on September 27, 2021:
These counterfeit pills have been seized by DEA in every US state in unprecedented quantities. More than 9.5 million counterfeit pills were seized so far this year, which is more than the last two years combined. DEA laboratory testing reveals a dramatic rise in the number of counterfeit pills containing at least two milligrams of fentanyl…
Fentanyl pressed pills (colloquially referred to as “pressies”) are sometimes presented as opioids—but they can also appear to be Xanax and other benzodiazepines, posing additional dangers to people who aren’t expecting to use opioids and may have no tolerance.
Myths around law enforcement officers overdosing by being in the presence of fentanyl or by merely touching it—you cannot—inspired policies that restrict testing.
Experienced drug users know when they buy a blue M30 that it is not oxycodone, but fentanyl. But others don’t know this; If you google “blue round M30,” you’re told that this pill is a 30 mg oxycodone. Smoking requires multiple “hits” off the foil to fully consume one pill, which can be spaced out to slow the pace. Swallowing it doesn’t allow for such pacing, even if the nature of fentanyl means that swallowing is much lower-risk than crushing and preparing them for injecting, as some people are doing.
While “protecting the children” has been the justification for decades of punitive drug policy that mostly harmed Black and brown people, adolescents are especially vulnerable to counterfeit pills. The DEA started a campaign “One Pill Can Kill” that tries (in a fear-mongering way) to inform that pills purporting to be pharmaceuticals frequently contain fentanyl.
Yet federal law enforcement data are unreliable. Large seizures of counterfeit pills are initially documented as “oxycodone,” despite the fact no one has 60,000 pills on a prescription. Myths around law enforcement officers overdosing by being in the presence of fentanyl or by merely touching it—you cannot—inspired policies that restrict testing.
No one can say for certain whether or not pills are actually fentanyl, it can only be “presumed fentanyl.” Many substances aren’t lab-tested until they go to trial, which is exceedingly rare in a justice system that relies on plea deals. Whether a pill is fentanyl or one of its many analogues, and in what purity, remains largely unknown despite the obvious harm reduction applications of this information. Law enforcement maintain the resources and machinery of the War on Drugs, failing to apply them to public health purposes.
Evolving Challenges
People’s initiation into opioids used to be primarily through nonmedical use of pharmaceuticals. As the supply of those fell, more and more people were initiated through heroin. Following that trend, the nation may expect to see people’s drug-of-first-use switch to fentanyl. That is likely already happening, even if data don’t yet show it—drug-use data collection operates on a lag, and the pandemic complicated it further. It’s a dangerous transition, as fentanyl is more potent and presents a higher overdose risk, especially for the opioid-naive.
The shift towards fentanyl seems to be less harm reduction than it is harm shifting. Any shift away from injection and towards other routes of administration reduces harms, especially related to infection. But counterfeit pharmaceuticals and wildly volatile formulations of fentanyl and its analogues are creating more risks, and in different demographics.
Traditional harm reduction, born out of the 1980s AIDS crisis, has focused on syringe provision. That strategy may need to be adapted, as people who exclusively smoke their drugs are less likely to walk into an exchange and be offered other services. Fentanyl also causes issues with buprenorphine induction, as it is partially lipid soluble, and reports of precipitated withdrawal have been heard from coast to coast.
Innovations in our responses must move as rapidly as the shifting drug market if we are to prevent mass death.
In November, the CDC released data showing that overdoses exceeded 100,000 in a one-year period for the first time in history. Traditional public health research methods falter in the face of such rapid transitions. Overdose data are delayed by months or more. Quantitative data can miss emergent trends and consumption patterns. Naloxone remains in shortage nationwide.
People on the ground, closest to the issue, are best placed to identify emerging problems and solutions.
Fentanyl seizures have reached record levels, outpaced only by overdose deaths. But the public remains focused on the crisis of 15 years ago, the one whose policy response brought us to our current state of affairs. The drug supply has innovated but responders of all kinds are using the tactics of a bygone era. Injection drug use is decreasing, but overdoses are increasing. Safe supply programs and safe consumption sites can certainly help, but need to be set up in the right ways.
The United States is in the midst of the most rapid drug market shift in history, caused by both supply and demand changes. Innovations in our responses must move as rapidly as the shifting drug market if we are to prevent mass death.
Back on the streets of downtown Portland, Filter asked Jon G if he would prefer free heroin or free Blues. He answered immediately. “Blues. Definitely Blues.” Shortly after our interview, he was admitted to the hospital with what he reported to be acute kidney failure of unknown cause.
Photograph of Jon G holding a smoked Blue by Morgan Godvin
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Morgan Godvin is a writer from Portland, Oregon. She founded Beats Overdose, a harm reduction provider for the music and entertainment industry. She is a research associate with Health in Justice Action Lab and a councilmember on Oregon’s decriminalization Measure 110 Oversight and Accountability Council. She was formerly incarcerated.
Kristen Gonzalez, MPH, is a harm reductionist from rural Terrebonne Parish, Louisiana. She is a Marine Corps veteran and directly impacted by overdose. A refugee of climate disasters, she now lives in Portland, Oregon and works as a substance use program manager at a nonprofit. She is a member of the United Houma Nation.
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