Around 2013, fentanyl started percolating in the United States street opioid supply, which was heroin-based at that time. Over the next few years it steadily pushed heroin out of the East Coast, and once the COVID-19 pandemic hit it rapidly did the same on the West Coast. As crackdowns have pushed the drug supply to evolve more quickly and chaotically, fentanyl has gradually begun showing up with non-opioid drugs.
Media and law enforcement, however, tend to describe it as an additive that predatory distributors mix into whatever they’re distributing—cocaine, meth, heroin, marijuana, vapes, pills that look like pharmaceuticals.
Fentanyl sometimes ends up in meth and cocaine supplies, probably not intentionally. This varies a lot by region and isn’t as common as most local news stories would have you believe, but is important to be aware of.
A pressed pill sold as Percocet or Oxycodone might not contain fentanyl, but you should assume that it does, if you don’t have the means to check. Same goes for anything sold as Xanax. A pressed pill sold as Adderall could conceivably contain fentanyl, but that would make it a pretty significant anomaly; what you should assume that it contains is meth.
We tend to fixate on whether something does or does not contain fentanyl, but that binary distinction isn’t what determines the risk. Someone opioid-naive who buys a fentanyl pressed pill that they believe to be real Percocet will still be okay if the amount of fentanyl in the pill is small enough. Conversely, someone who smokes what they know to be fentanyl pills off foil every day will be overdosing within minutes if they get one with more fentanyl than they were expecting.
Has fentanyl been found in marijuana? It has not. Periodically there are news stories or other vaguely credible-sounding claims to this effect, but none of them ever stand up to scrutiny. The one that got arguably the most traction was a 2021 statement from Connecticut health officials, announcing “the first lab confirmed case of marijuana with fentanyl in Connecticut and possibly the first confirmed case in the United States” and citing 39 incidents “where only marijuana use was reported but naloxone was required.” Later it turned out that this boiled down to a single case of minor, accidental cross-contamination among people who also used opioids.
You can immediately write off any claims of fentanyl being smoked with marijuana, or smoked with anything else using a combustion process rather than a vaping process. Fentanyl can’t be smoked with an open flame; it gets burned and rendered inactive.
A very small number of vapes appear to have tested positive for fentanyl. For one thing, this would probably happen with literally any physical object that school boards across the country started continuously testing for fentanyl. But the important takeaway is that the more credible claims involve vapes that had clearly been modified intentionally for personal use, not vapes that had been designed that way and marketed to children. You can still pick out any news story that describes a middle- or high-school student nearly dying from using a “fentanyl-laced vape”—even the stories circulated by elected representatives—and reliably find that it has either since been debunked or does not mention any actual laboratory confirmation of fentanyl, despite whatever the headline said. Usually the source for the claim is the student or their mom.
Naloxone works by binding to your mu receptors—the specific protein molecules that opioids also bind to—and kicking off whatever opioids might already be there. The clinical dose of naloxone, 0.4 mg/mL, is what’s usually sufficient to reach about 50 percent of your mu receptors, or enough to reverse an overdose. That’s why 0.4 mg/mL is the dose contained in a vial of generic intramuscular naloxone.
A Narcan nasal spray contains a 4-mg dose of naloxone. Intranasal administration can’t be directly compared to intramuscular, but it’s the less efficient of the two and so Narcan is designed to deliver more than the clinical dose. A 4-mg Narcan was more than enough for most heroin overdoses, is still more than enough for most fentanyl overdoses, and is also still more than enough for most overdoses involving fentanyl analogs, nitazenes, orphines and whatever novel synthetic opioids are found in the supply next. Naloxone’s effectiveness doesn’t change based on the opioid’s potency, since it acts on the mu receptors rather than on the opioids themselves.
When cops or well-meaning bystanders share stories about someone needing five doses of Narcan to wake up, and how this just shows how much more potent the supply is these days and how naloxone doesn’t cut it anymore, this almost always comes from the same mistaken assumptions about overdose reversal.
Naloxone takes two or three minutes to kick in, which is why it’s important to administer rescue breathing while you wait. But because the two minutes that you’re supposed to wait before administering a second dose can understandably feel like an eternity, especially to anyone not experienced in these situations, the temptation is often to pump in a second dose pretty quickly. Or a third dose, or fourth, or fifth, and so on until the person wakes up. When someone wakes up after a fifth Narcan, what you’re really seeing is the first dose kick in. All the extra naloxone did nothing to help, and for people with a physical tolerance to opioids it can precipitate withdrawal and put them at increased risk of overdosing again. At a proper dose, reversing an overdose with naloxone doesn’t require waking the person up at all.
In 2021, the 8-mg Kloxxado nasal sprays hit the market and marked the beginning of the naloxone arms race. In the five years since then, the Food and Drug Administration has approved a 5-mg intramuscular autoinjector—meaning it delivers about 12.5 more naloxone than the clinical dose—a 10-mg nasal spray that launched earlier in 2026. It’s also moved beyond naloxone to a different, longer-acting opioid antagonist, nalmefene. The first nalmefene nasal spray, Opvee, has already been followed by a nalmefene auto-injector. And government contracts investing in nalmefene as a preventative measure for fentanyl nuclear war. And biased research inventing meaningless metrics that are supposed to justify any of this as necessary.
Technically, the US has three approved medications for opioid use disorder (MOUD). In reality, we have two MOUD that are shown to be safe and effective, and we have naltrexone. Methadone and buprenorphine (Suboxone) decrease overdose risk. Naltrexone’s labeling is required to carry a warning that it increases fatal overdose risk.
Naltrexone is commonly known by brand name Vivitrol, the injectable formulation touted in county jails and other correctional settings. While methadone and buprenorphine are opioid agonists, naltrexone is an opioid antagonist—like naloxone and nalmefene. It purports to work by blocking the effect of opioids, so that even if a patient tries to use opioids they won’t feel anything.
What this effectively does is reduce tolerance, which is why the FDA labeling has to warn that deaths have been documented “at the end of a dosing interval, after missing a scheduled dose, or after discontinuing treatment.” The warning about risk of fatal overdose from “[a]ttempts to overcome blockade” is similar to the warning carried by the two approved nalmefene products, Opvee and Zurnai.
Unlike methadone and buprenorphine, naltrexone requires detoxing prior to initiating the medication—going into withdrawal for at least a week, maybe two. That alone makes it a non-starter for a substantial portion of people at risk. A recurring theme with research supporting naltrexone’s efficacy is that it doesn’t count the people who tried to start the medication and weren’t able to get through the detox process, preferring to factor in only the cases where people did manage to onboard. Or it uses the framing that once detox is out of the way, “naltrexone is about as effective as buprenorphine,” which still isn’t true.
People stabilize on methadone and buprenorphine because those MOUD help manage cravings and withdrawal symptoms. But studies tracking naltrexone outcomes never show anything long-term. Conclusions that it reduces cravings come from short-term data, and any evidence of its efficacy is based on negative urine drug screens after a few weeks or at most a few months. This research is never concerned with what happens after that. The idea of naltrexone remains popular because it fits an abstinence mentality, it’s punitive and it’s an easy out for corrections departments. Not because it’s helpful.
As popular as it is to demonize syringe service programs (SSP), the arguments against them don’t see too much innovation. There’s the complaint that SSP increase “crime,” which is not true. There’s the complaint that they increase drug use, which is not true. The most substantive complaint is that they increase “syringe litter.” This is also not true.
Neighborhoods that open SSP are overwhelmingly associated with a decrease in publicly discarded syringes, for a few different reasons. They’re often more convenient than sharps-disposal bins in parks, which require people to make a separate trip just to have fewer syringes than before. They provide portable sharps containers that are small enough for people to carry around, and larger ones people can keep at home. And they employ peer workers who do daily walkabouts picking up any syringes they see on sidewalks or other public areas.
At the heart of the syringe litter myth is the suggestion that children are at risk of contracting HIV from stepping on a needle while playing at the park. This is an easy one to debunk: It has never happened. There has never been a single documented case of anyone, child or adult, contracting HIV from a publicly discarded needle. It’s just another myth.
The human immunodeficiency virus is very fragile and relies on our immune cells to survive. Once outside the body, exposed to air, it dries up and dies almost immediately. This is why the only confirmed HIV needlestick transmissions have all involved health care workers in hospital settings, and even then they’re extremely rare. For the public, transmission risk is limited to situations involving blood, semen, vaginal or rectal fluids, or breastmilk delivered directly to a mucous membrane or into the bloodstream.
The hepatitis C virus can actually live for several weeks outside the human body, but globally there have been maybe three documented cases of hep C transmission from accidental needlesticks in community settings; none in the US nor involving children. Hep C can be easily and painlessly cured with oral medication, and doesn’t begin to damage the body for years or even decades.
As often as the media runs stories about syringe litter, you might notice that the accompanying photos often show a syringe with the front and back cap still on, sterile as the day it was born, thoughtfully arranged in the middle of a ditch. I was going to make a joke about how eventually they’ll show one of those individually packaged 27-gauge 1 cc syringes still in its individual package, but this has already happened.
After that viral video with the San Diego County Sheriff’s Department deputy in 2021, the online harm reduction community got the rare satisfaction of rallying around a talking point—you cannot overdose from touching fentanyl—and seeing the media actually take notice. A lot of news stories will now add some kind of disclaimer when referencing passive exposure, though this remains pretty hit or miss. You can’t overdose from skin contact. You can’t overdose from breathing in fentanyl molecules floating around in the air; fentanyl has a very low vapor pressure and barely releases any molecules into the air anyway. You can’t overdose from any other kind of passive exposure. The public is now moderately more aware that there is no such thing as secondhand fentanyl overdose. However, like everything else in harm reduction, this development has not made it into the prison system.
US prisons and jails have a completely different drug supply than the free world. There is fentanyl, but the mainstays are generally synthetic cannabinoids (K2; Spice) meth, Suboxone, tobacco and strips, a catch-all term for the ubiquitous strips of paper soaked with what could be anything, but is often synthetic cannabinoids or household solvents like insecticide. In recent years, many facilities have seen synthetic cannabinoids and/or strips replace meth or other contraband similarly to the way fentanyl replaced heroin in the outside drug supply.
Countless press releases and Facebook announcements have described how corrections officers required Narcan (multiple doses!) and were hospitalized following exposure to dangerous synthetic cannabinoids and other drugs concealed in incoming mail. This does not mean the officers were harmed. It does not mean the officers were ever in harm’s way. It does not even necessarily mean the officers were exposed to any drugs. It means that officers gave themselves Narcan and took themselves to the hospital. Synthetic cannabinoids are not opioids and are not affected by Narcan, but the whole situation is so far beyond logic that we don’t have time to stop for this.
The only one of these incidents that’s ever cited actual harm was in 2024 at USP Atwater, when mailroom supervisor Marc Fischer reported feeling ill and then died at a hospital about two hours later. Initially the cause of death was undetermined, pending toxicology, which gave media outlets across the country an opening to run headlines about “possible fentanyl exposure.” The Merced County Sheriff’s Office did not respond to Filter’s February 2025 coroner records request, which is fine because a week later documents filed in US District Court for the Eastern District of California revealed that the cause of death was a heart attack. Neither the AP nor the Los Angeles Times nor any other media outlet that ran a “possible fentanyl exposure” headline ever published anything further. The Bureau of Prisons, Correctional Peace Officers Foundation and various other agencies continue to honor Fischer’s memory by not acknowledging the autopsy, and praising his sacrifice in the line of duty while handling synthetic drug-soaked mail.
There is no evidence to suggest that secondhand exposure to synthetic opioids or cannabinoids poses any kind of risk. Many corrections officers know this, since they’re the ones bringing in most contraband drugs anyway. But they continue to bravely share their stories, and Occupational Safety and Health Administration investigations conclude that mailroom staff need head-to-toe personal protective equipment and HEPA-filtered biosafety cabinets, and federal corrections officers unions use those findings to call for the expansion of digitized mail-scanning.
And that’s what all of this is really about: understaffing and the nationwide push to privatize prison mail services, and cut incarcerated people off from receiving physical letters. Along with in-person visitation, and book donations, and any other “privilege” whose physical form can be replaced with a digital service conveniently offered by a handful of for-profit contractors. More than three out of four people incarcerated in US prisons no longer have access to physical mail.
At this moment, somewhere in the US another corrections department is drafting another press release breathlessly recounting how over the weekend one or more officers were hospitalized following exposure to deadly synthetic drugs, and pleading for Congress to recognize that no one should have to risk their life just to do their job of opening other people’s mail. Media and legislators will circulate it with no scrutiny whatsoever. To date, there are no confirmed reports of any corrections officers ever having been harmed by exposure to drugs in the mail.
Opioid overdose is potentially fatal because opioid molecules can bind to the brainstem receptors that regulate breathing; the mechanism of death is respiratory depression. Meth, like synthetic cannabinoids and various other stimulants like cocaine, doesn’t have any particular mechanism of death that accompanies overdose in the same way.
Stimulant overdose, or overamps as they’re sometimes called, don’t necessarily produce stereotypical symptoms like paranoia or hyperactivity. Often they make people fall asleep. Occasionally they might cause seizures. But then they resolve, and that’s that. The harms tend to come from exposure to law enforcement, rather than the physical ordeal itself.
Meth-involved overdose deaths in the US began rising more noticeably around 2019, peaking in late 2023 before starting to gradually drop back down; the same trajectory as fentanyl-involved deaths, but less drastic. It’s clear that more people are using meth compared to a decade ago, which means more people have meth in their system at the time that they die. But it’s not quite clear that meth is what’s causing them all to die, at least not on the scale being suggested by the media.
US death investigations are a mess. Depending on the state, they might be carried out by medical examiners, elected county coroners or local law enforcement. In Nebraska, for example, cause of death is determined by prosecutors. In most California counties, the coroner is also the sheriff. Forensic pathologists are still required to sign off on the death certificate, but there are only a few hundred of them in the whole country and many jurisdictions now use forensic pathologists who aren’t board-certified. In Canada and other wealthy countries full autopsies are considered standard for suspected overdose deaths, but in the US they’re rare. Where not mandated by state law, they’re pretty much reserved for cases where law enforcement could potentially use the evidence to prosecute someone, or the family could afford a private one.
In suspected overdose cases, the death investigation often consists of toxicology and an external examination—medical history plus a long look at the body and any evidence found at the scene. None of these can reveal a heart attack, or heat stroke, or pneumonia. But they can reveal meth, and even without fentanyl that’s all that’s needed to wrap the investigation, particularly for people who die without housing. No available medical history? Well, clearly their medical history is that they used meth.
“If they had a heart death, I think [any meth] is going to get attributed as a cause of death. Because that is the bias of the system,” a toxicologist who signs off on drug death reports told Filter in 2023. “It’s like: Here’s someone that was found in a tent, we can’t contact their next of kin, we did a [urine drug screen]. They’ve got meth in their system; keep it moving. We’re not going to do an autopsy.”
Some research has suggested that meth is linked to about two out of three US deaths among people without housing. Local-level studies have found similar patterns in places like California and Oregon.
Deaths attributed to just meth, with no fentanyl present, tend to be among people who were over 45 and had a history of cardiovascular disease. To which chronic meth use may have contributed, but it wouldn’t have been the only thing. When a non drug-user dies from a heart attack in a hospital, we say they died from a heart attack—not from a sedentary lifestyle or refined carbohydrates. When a meth user dies from a heart attack and they weren’t in a hospital, their cause of death was a heart attack. But we might say it was meth, if drugs were the only thing we checked for.
No matter how much we sensationalize fentanyl and its potency, after hearing about it for so many years the public has somewhat acclimated to the idea. So fentanyl headlines lose their power, and the only way for media outlets to combat this is with something even more potent than fentanyl.
First it was fentanyl analogs, followed by nitazenes and most recently orphines. All have the potential to be more potent than fentanyl (as well as less potent, not that this is of interest to anyone). The problem with news outlets pouncing on each novel synthetic opioid (NSO) as it hits the supply isn’t so much that they misrepresent the potency; it’s that they misrepresent the prevalence. Each NSO is presented as a harbinger, like behind the first couple of reports is a dam about to break, unleashing the substance that will replace fentanyl the way fentanyl replaced heroin. That will usher in the next wave of the overdose crisis all on its own.
Outside of North America the emergence of NSO could have a very different significance, if fentanyl hasn’t already saturated the opioid supply the way it has here. But at the moment, there’s no real reason to think that any fentanyl analogs, nitazenes or orphines are poised to overtake fentanyl in the US supply. Some of them, like carfentanil or cychlorphine, have become more recognizable names, but we’re still talking about substances linked to a very small portion of overdose deaths, and that’s including the cases where they were detected at all not just the ones where they were detected alone or determined to be the cause of death.
Most of these substances arrive mixed in with fentanyl—though some are occasionally found on their own—and aren’t really distinguishable from fentanyl, from a user perspective. Health departments will take whatever one or two talking points exist , which are probably just the location where it was detected and how many times more potent than fentanyl it’s supposed to be, and stretch them over a public bulletin that doesn’t help the public do anything differently. There’s a NSO in the supply. It’s been detected six times, in these two states; you can’t test for it and it’s not distinguishable from fentanyl. You should still use naloxone and take the precautions you were taking for fentanyl. This kind of thing is for the benefit of website traffic and re-election campaigns, not the public.
Not all recent additions to the supply are interchangeable. Xylazine and medetomidine, both non-opioid veterinary tranquilizers, have come with distinct complications and forced harm reduction groups to evolve overdose response protocols around each of them specifically. NSO have certainly reshaped how we criminalize the supply, but they haven’t really reshaped the supply itself. Even carfentanil, which has been in the US about as long as fentanyl and remains the most potent opioid we know of, has ebbed and flowed at the edge of the supply and never grown into something with a market of its own. None of them have.
No matter how potent, a substance can’t really be more deadly than fentanyl if it isn’t causing more people to die.