However, a recent study published in Harm Reduction Journal warns that change is coming. Reviewing data across three key countries, the authors chart a potentially dangerous turn in South American drug markets. Synthetic opioids, ketamine and Tusi (known as “pink cocaine,” but typically including a mix of synthetic substances) have all rapidly increased in popularity—on a continent where harm reduction services, especially for opioids, are sorely lacking.

According to the study’s lead author, Ignacio Bórquez of New York University’s Grossman School of Medicine, these new trends are a stark departure from the traditional local drug supply.

“What we’ve been seeing since, I would say, 2010 onwards in Latin America is the emergence of synthetic drugs.”

“Latin America and the Caribbean really have a history using cannabis and cocaine,” he told Filter. “[T]hey’re locally produced, so they’re very cheap. A gram of cocaine is around $10 in Latin America—here in the US, it’s $100.”

Bórquez and his team compared multiple data sources, including forensic analyses, law enforcement seizures and surveys of people who use drugs, to get a pulse on substance use in Brazil, Chile and Colombia. Clear trends quickly emerged.

“What we’ve been seeing since, I would say, 2010 onwards in Latin America is the emergence of synthetic drugs. Particularly in the party scene, things like MDMA, ketamine,” Bórquez said. “And then we’ve also been seeing seizures of synthetic opioids and some evidence of diverted opioids from pharmaceuticals.”

In Chile, the volume of ketamine seized annually by law enforcement rose by over 5,000 percent from 2017 to 2023, and that trajectory was corroborated in Chilean wastewater analysis. Oral samples from Brazilian nightclub attendees also showed ketamine use rising—often along with cocaine, in the combination known as Tusi.

The data tell a similar story for opioids. According to a nationally representative Chilean survey, opioid use has nearly quadrupled since 2002. While fentanyl is not a major factor in Chile or Colombia, law enforcement seizure data do show a rise. In addition, other synthetic opioids, including nitazenes, are being manufactured in Brazil.

“We are a continent torn by violence … because with crops like cocaine or cannabis, you really need territorial land.”

Globalization and online connectivity have propelled these new substances’ popularity, with rapid distribution available on social media platforms like the gay dating app Grindr. And relative to the region’s traditional plant-based drugs, these new options require far fewer resources to produce.

“We are a continent torn by violence … that has been very linked to drug trafficking and drug production, because with crops like cocaine or cannabis, you really need territorial land,” study co-author Francisco I. Bastos, of Brazil’s Fundação Oswaldo Cruz, told Filter. “And with these new substances we’re looking at, they don’t need that.”

In part because South America has not faced a major overdose crisis, the continent’s harm reduction infrastructure is vastly underdeveloped. Citing the Global State of Harm Reduction 2024, the authors note that of the 34 countries in this region, only three have syringe service programs, and only four offer opioid agonist therapy. Naloxone is also largely inaccessible.

The solution, however, is not simply to import North American and European harm reduction models, because South American patterns of drug use remain very different. While these new substances are on the rise, they still represent a minority of drug use, which continues to be dominated by stimulant smoking and concurrent alcohol use. Injecting remains largely taboo.

Bórquez loses sleep at night thinking about how to adapt harm reduction models like supervised consumption sites to communities in South America.

“It would need to be a place where stimulant use, which is very different from opioid use, could be contained in a non-harmful way,” he said. “[Y]ou’re not gonna have 30 people using stimulants together in a room … it’s hard to think of a [harm reduction] service for people who use stimulants and alcohol.”

“It is a very different balance from the US. The US is the largest producer and importer of opioids in the world … Brazil is on the other side of the balance.”

Meanwhile, attempting to combat synthetic opioid diversion by restricting importation of medical opioids would threaten the availability of these substances for their clinical uses, such as pain relief for cancer patients and palliative care.

“If we just put pressure on the supply, we cannot have medicines for the people who need the medicine,” Bastos explained. “It is a very different balance from the US. The US is the largest producer and importer of opioids in the world, so there are opioids for everything—opioids for cancer patients, opioids for the streets. Brazil is on the other side of the balance.”

Yet there are still many promising paths forward. The authors highlight drug checking, overdose prevention training and naloxone accessibility as relevant harm reduction services. They also suggest increasing investment in nonintrusive surveillance, such as local wastewater monitoring programs, to stay abreast of this rapidly shifting market and target harm reduction efforts accordingly.

“[These efforts] will be essential to mitigate future harm and prevent another synthetic drug epidemic from taking hold in the Americas,” the study concludes.

Photograph of Rio de Janeiro by Rafael Rabello de Barros via Wikimedia Commons/Creative Commons 3.0

The post South America’s Drug Supply Is Rapidly Becoming More Synthetic appeared first on Filter.

O-DSMT is the primary active metabolite in tramadol, a synthetic opioid approved by the Food and Drug Administration to treat moderate to moderately severe pain. Tramadol is a prodrug, which in this case means it’s an oral medication that’s essentially inactive until it hits the liver and is metabolized by enzymes that convert it into the O-DSMT. While people who use drugs often crush and inject oral medications to get a stronger and quicker effect by introducing them to the bloodstream directly, that doesn’t necessarily work with a drug that still has to go through the liver first.

Tramadol has been in Schedule IV of the CSA since 2014. While it’s considered a “weak” opioid receptor agonist, O-DSMT is a more potent agonist. Codeine works similarly—it’s a weak opioid agonist until liver enzymes break it down into morphine, a more potent agonist. The central nervous system stimulant Vyvanse is another common prodrug, with limited effect until red blood cells convert it into dextroamphetamine.

United States law enforcement first encountered O-DSMT in 2011. In the 15 years since then, it’s been identified a total of 148 times, primarily through seized drug samples rather than through post-mortem toxicology reports.

“The threat of serious injury to the individual and the imminent threat to public safety following the ingestion of O-DSMT persists,” the notice states. “Because not every forensic laboratory has the capacity to test for O-DSMT, it is likely that encounters of O-DSMT are underreported.”

This is probably true, but just in the sense that you could say that about any substance. O-DSMT is in the National Institute of Standards and Technology mass spectral reference library, the master list of known chemical substances that forensics labs work off of, but it wouldn’t be detectable through certain basic tests like drug panels that aren’t designed to detect O-DSMT specifically.

The hard data about fatal overdose comes from a handful of report from Sweden in 2009.

The DEA stated that law enforcement has encountered O-DSMT “in various forms, including as a solid powder, pressed into pills or tablets, in a capsule, as a semi-solid paste/slurry, and in liquid formulations.” 

The notice states that O-DSMT was “found as the only drug” in 118 of those encounters, and in the rest was “co-reported with various other substances,” including kratom. The language is similar to how we often describe fatal overdose, in terms of whether post-mortem toxicology identified one substance versus multiple substances, but here the DEA is just referring to seized drug samples.

It also probably means very little that O-DSMT has been co-reported with other substances, because different labs have different definitions of what that means. A 2019 National Forensic Library Information System report on tramadol explained that, for example, a bag of tramadol found with a bag of heroin could be logged as one item, so a “drug combination” might mean powders found mixed together or it might mean “counts of separate drugs reported together in the same item.”

The DEA also stated that O-DSMT has been “found to be mixed with the kratom plant as determined by packaging material and the confirmation of both O-DSMT and [active kratom metabolite] mitragynine in toxicology results of individuals.” This is also slightly misleading, because two substances being in someone’s system at the same time doesn’t always mean they’d been consumed together.

The post DEA Plans Emergency Ban for O-DSMT, Active Compound in Tramadol appeared first on Filter.

“Synthetic opioids pose serious risks for federal agents and first responders,” DHS stated in its announcement. “The risks include inhalation exposure to lingering toxic aerosols of fentanyl and ultra-potent opioids like nitazenes, which are up to ten times stronger than fentanyl.”

This is the third edition of the MQL, and the first to include nitazenes. Despite the announcement’s misleading characterization of their potency, the MQL itself doesn’t spend that much time on nitazenes.

Historically, law enforcement has been preoccupied with two main routes of so-called passive exposure: skin contact and inhalation. The MQL gets one of these more or less right, noting that skin contact with fentanyl is unlikely to lead to any adverse effects. Fentanyl is really not conducive to absorption through the skin membrane, which is why prescribed transdermal fentanyl patches have to be worn for such a long time.

“Synthetic opioid exposure can occur via several different routes; however, inhalation is the exposure route of greatest concern for emergency responders,” the guidance states. “While synthetic opioids can penetrate the skin, they do so slowly as compared to inhalation and injection routes.”

This, however, is a pretty egregious mischaracterization. DHS is conflating passive, accidental exposure with methods of direct consumption. First responders are not accidentally injecting themselves with fentanyl, nor are people deliberately using fentanyl by rubbing it onto their skin. Despite what DHS is implying, breathing air while standing somewhere in the vicinity of fentanyl is not the same thing as snorting a bag of fentanyl, which is why one of these will introduce fentanyl into your bloodstream and one will not.

Inevitably, DHS does endorse nalmefene-based products.

Though local law enforcement across the country rely heavily on colorimetric field tests that are notorious for false positives, DHS does correctly note that these aren’t reliable without confirmatory testing.

“Colorimetric test kits for opioids may give false positive results in the presence of common interferants, such as sugar and Excedrin,” the MQL states. “The use of a more definitive test, such as IR or mass spectrometry (MS) to verify the identity of a drug is recommended.”

In addition to being highly subjective and readily misinterpreted, the tests tend to identify opioids more accurately when they’re not mixed with other substances, which is almost never how they’re found in street-level samples. Not that this guidance will make highway patrol any more inclined to send their seized drug samples out for expensive mass spectrometry testing at a lab.

The MLQ correctly notes that naloxone is the standard antidote medication for synthetic opioid overdose, which is something; it’s become a common law enforcement refrain that naloxone doesn’t work on fentanyl, nitazenes and such. Inevitably, DHS also endorses nalmefene-based products, which have recently emerged as alternatives despite the fact that they offer no established benefits compared to naloxone and substantial risk of harm. 

“Intranasal nalmefene is a competitive, reversible opioid receptor antagonist with a longer duration of action than naloxone,” the MQL states. “Nalmefene nasal spray was approved for use by the FDA in reversing opioid overdoses in 2023 … and an autoinjector of nalmefene was approved in 2024.”

The danger posed by Indivior’s nasal spray Opvee and Purdue Pharma’s autoinjector Zurnai is that they can induce unnecessarily long precipitated withdrawal in people with a physical dependence on opioids; for everyone else, the experience of being administered nalmefene versus naloxone is probably about the same. While nalmefene’s continued existence in overdose-response products is detrimental to public health education, if those products have to go somewhere it might as well be to the federal agents who want something to self-administer whenever they think they’ve been exposed to fentanyl floating around in the air.

Image (cropped) via Indiana Department of Health

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