Five years ago, British Columbia saw a change. People who use drugs in the Canadian province started overdosing in higher numbers, as fentanyl arrived into the unregulated opioid supply. The province—which recently asked the Canadian federal government for the ability to decriminalize drugs—saw a record 1,716 illicit drug-related deaths last year. Finding heroin or other unregulated opioids without fentanyl or its analogs in the mix has become near-impossible there.
“It’s not like we all jumped up one day and grabbed picket signs saying ‘We want fentanyl.’ It infiltrated our drug supply,” said Erica Thomson, executive director of the BC/Yukon Association of Drug War Survivors.
In BC, and elsewhere in North America, heroin has functionally, and by degrees, been supplanted as the major unregulated opioid. Heroin is holding on in some regions. But a future exists where it has practically disappeared under waves of far more potent synthetic opioid receptor agonists—and without radical policy changes, it’s unlikely to end with fentanyl.
In BC, pretty much nobody can find fentanyl-free heroin in person, Thomson, who has lived experience with drugs, told Filter. Some people may be able to find it on the dark web, but even there, it is increasingly rare. In a strange turn of events, she said, mixtures of heroin and fentanyl have become one of the safer options on the market—assuming proper testing has been performed—compared to a batch whose only active ingredient is fentanyl. “It’s safer than most right now.”
It’s not just BC and Canada. Heroin has basically disappeared from New Hampshire, for example, and Ohio and West Virginia are heading that direction as well, said Bryce Pardo, a drug policy researcher at RAND Corporation and previously at the University of Maryland.
Pardo has written extensively about the rise of fentanyl. He had an article published in the International Journal of Drug Policy (IJDP) on the topic in January. The research saw Pardo and his colleagues pore over US drug-seizure and overdose data, to get a sense of the extent of this issue, why it is happening, and what it means for buyers, sellers and policy makers.
It’s not that people who use drugs necessarily want fentanyl (although some people, of course, do). According to Pardo, in many cases, consumers have little interest in fentanyl when it first reaches the market. But heroin’s share of the market is growing smaller and smaller, and fentanyl and its kin are increasingly the only remaining options.
“The likely trend is that more potent opioids are going to displace currently available and traditionally used opioids.”
This shift fits a preexisting pattern, as Pardo noted. Opium use dates back at least as far as ancient Mesopotamia. But in 1803, German scientist Friedrich Sertürner isolated pure morphine—one of the constituent active compounds of opium—from the legacy drug. Morphine became popular in the following decades, and in some places remains so. Smoking opium remained popular well into the late 19th century, but gradually declined.
In the wake of the US Civil War, which ended in 1865, around 400,000 people who had been treated with morphine were estimated to have developed addictions. Around this time, scientists began to hunt for an alternative.
In 1874, British chemist Alder Wright made heroin from morphine while looking for this alternative. Much stronger than its ancestors, heroin replaced morphine, and stuck around as the world’s mangum opiate into the 21st century. But by the mid-2010s, things were changing fast in North America and beyond.
“The likely trend here is that more potent opioids are going to displace currently available and traditionally used opioids that are of a plant-based origin,” Pardo told Filter.
The role of policy in helping to produce such changes is described by what’s known as the “Iron Law of Prohibition.” As researchers Leo Beletsky and Corey S. Davis described this phenomenon in a 2017 IJDP article: “…efforts to interrupt and suppress the illicit drug supply produce economic and logistical pressures favouring ever-more compact substitutes”—that is, increasingly potent drugs.
The three countries that grow the biggest opium poppy crops—Afghanistan, Myanmar and Mexico—are now growing less and less, Pardo said. In Mexico, for example, demand for raw poppy has decreased. Prior to 2017, a kilo of opium paste would sell for $1,480. After fentanyl changed the game, that value hit a low of $315 in 2018. Illicit drug-producing organizations in Mexico have since moved into fentanyl.
Fentanyl isn’t a new substance, having first been synthesized in a lab in 1960 by the Belgian company Janssen Pharmaceuticals. The drug has important medical uses, including for COVID-19 patients in critical condition. Some also theorize that fentanyl reached illicit North American markets long before the modern overdose crisis.
In the 1990s, a powerful substance known as ”China White,” sold as heroin, came onto the scene, and was linked with thousands of overdoses. Some modern researchers and harm reduction advocates suggest that this substance may have contained fentanyl, or one of its analogs. However, Pardo noted, fentanyl only became a household name with the rise of global e-commerce and the Chinese pharmaceutical market (a connection that racist politicians have exploited). And its impact is well documented.
According to the Centers for Disease Control and Prevention, for the 12 months leading up to May 2020, 81,000 reported drug overdose deaths occurred in the US. This was a marked increase from the previous 12-month reporting period, and, the CDC notes, synthetic opioids appear to be the primary driver.
Per the Iron Law, fentanyl’s very high potency—which the DEA reports as between 80 and 100 times that of morphine—means it is active in much smaller quantities than heroin, and smaller quantities can be hidden and smuggled more easily.
Above all, the cost is perhaps 1 percent of what it costs to produce heroin, Pardo estimated.
It is also relatively easy to produce. There is no need, as with heroin or other plant-derived opiates, to wait for poppy crops to mature. Instead, fentanyl and other synthetic opioids can be made in small labs with fewer people than would be needed to grow and process crops, maximizing profits by cutting the cost of labor.
These labs are much easier to conceal from law enforcement than poppy fields and their processing facilities. And their locations aren’t restricted to remote areas or to regions where poppies can be grown, allowing for shorter, cheaper supply chains. A meth and fentanyl lab busted by law enforcement last October, for example, stood on the outskirts of Mexico City.
So fentanyl and its chemical relatives are attractive to illicit producers in many ways. Above all, the cost of producing them is perhaps 1 percent of what it costs to produce heroin by growing, harvesting and processing poppies, Pardo estimated. “It’s a combination of economics and pharmacology as well as globalization,” he said.
According to Pardo, some regions may resist a fentanyl future to a degree. In the US, heroin has traditionally taken two forms: a white powder and a black or brown tar. Largely, the white powder has been more popular on the eastern side of the Mississippi River, while black tar has been more popular in the West. It might be harder to mix fentanyl in with the tar. But, he noted, other substances containing fentanyl are found almost everywhere.
Despite fentanyl’s potency, it’s not a first choice for many consumers, for reasons that go beyond the deaths and harms associated with the drug. Fentanyl is relatively short-acting, for instance. According to Pardo, a heroin “high” usually lasts around four-to-six hours. Fentanyl lasts around half that time. So people using fentanyl can expect to need to dose more frequently.
“Many of us miss heroin. Fentanyl doesn’t have the legs that heroin did.”
This largely fits with what Thomson has seen among her peers in BC. Fentanyl isn’t generally a desired drug, she said, both because of its relatively short high and the dangers when it comes unexpectedly and in an unknown amount.
“Many of us miss heroin, and heroin is very different from fentanyl, in the way it makes you feel,” she said. “It doesn’t have the legs that heroin did. Good heroin, I used to be able to get eight hours without needing to inject again. With fentanyl, you’re chasing it. You’d be lucky to get two hours.”
But a dime bag containing only fentanyl and filler will typically cost the same as a dime bag containing pure-ish heroin, despite the differences in potency and duration. It’s another source of increased profits for producers.
Pardo added that this also has the potential to drive more needle use. In an effort to stave off withdrawal symptoms, some people may inject the shorter-acting drug more times in a day, which could result in more needle sharing and higher risk of blood-borne disease transmissions. People may also end up resorting more often to illegal means to make enough money to purchase drugs more frequently. “It’s going to have ripple effects throughout the policy environment,” he said.
More potent opioid receptor agonists may also complicate provision of medications for opioid use disorders. For instance, research suggests that a single administration of naloxone might not cut it for stronger opioids. We may need more potent overdose reversal drugs in the future, Pardo said.
In another worrying trend related to fentanyl’s prevalence, Thomson said that in BC, it’s not uncommon to see less scrupulous sellers using a pill press to make fake prescription drugs—sold as, and looking like, opioid painkillers or even benzodiazepines—with fentanyl as the active ingredient. It’s something that researchers and harm reductionists have noted in many places.
“We are trying very, very hard to warn people about any types of pills, pill presses,” Thomson said. “If you have an oxy, it’s most likely contaminated.”
Though “fentanyl” regularly makes headlines, many novel fentanyl derivatives regularly find their ways into legacy drug supplies. Pardo noted that a relatively new class of potentially even more potent synthetic opioids called nitazenes—the best known of which is isotonitazene—is also reaching markets. This has so far only happened on a very small and uncertain scale. But given illicit markets’ inherent dynamism, it hints at how, in the future, fentanyl itself could be supplanted.
According to Patil Armenian, associate professor of clinical emergency medicine at University of California San Francisco Fresno, it’s hard to say just how powerful synthetic opioid and similar drugs may end up in the future. “I don’t think we know one way or another,” she said.
“If you don’t look for something, you’re not going to find it.”
What we do know is that new synthetic, opioid receptor-binding compounds are regularly discovered in licit and illicit labs around the world. Some are bound to be more potent than others, and many remain in obscurity. Those created in unregulated labs aren’t exactly getting medical trials before release.
Doctors, harm reduction organizations and police aren’t generally testing for them, both because they don’t know precisely what to look for and because they often lack the specialized equipment to pick them up.
“If you’re just looking for fentanyl, that’s all you’re going to find,” Armenian told Filter. “You won’t find fentanyl analogues. If you don’t look for something, you’re not going to find it.”
As heroin’s stock in the global drug market decreases, innovations in drug policy and harm reduction work are much needed, Pardo said, with drug-war supply-side interventions “increasingly a fool’s errand,” although there is value in working to identify the most dangerous formulations out there and spreading awareness.
Prescription heroin and other safe supply programs, safe consumption sites, expanding access to drug-checking kits, mobile methadone clinics, telemedicine and easing restrictions on buprenorphine prescribing should all be on policymakers’ agenda.
“These kinds of innovative solutions need to be put on the table, even if they’re unpalatable to some,” Pardo said. “What we’re doing is just not going to be enough.”
Back in BC, Thomson has started a heroin “compassion club.”
And then, given the role of prohibition in promoting ever-more potent drugs, there’s the question of dismantling prohibition itself. That has, to a degree, been on policymakers’ agenda in places like Oregon, which passed Measure 110 to decriminalize drug possession, and Canada, which has seen escalating calls for full decriminalization.
Back in BC, Thomson has started a heroin “compassion club.” Somewhat akin to the Dallas Buyers Club, it is a collection of like-minded individuals and groups. When one member finds a line on pure (or relatively pure) heroin, the members all buy in, and the batch is shared. This effort to keep each other safer “creates community.” The group also provides support to members who want to quit opioids, she said.
After years of an escalating opioid-involved overdose crisis, now exacerbated by the COVID-19 pandemic, it’s clear that fresh ideas are needed.
“If we had stopped the bleed a long time ago,” Thomson said, “and found ways to use these [controlled] substances when they were closer to being plant-based, and not synthetic and adulterated, it would be a better world, that’s for sure.”