Counterfeit phamaceutical pills containing fentanyl, heroin and methamphetamine are being sold out of Mexican pharmacies catering to customers from the United States, as a new academic preprint, which I co-authored, details. Crackdowns on pharmaceuticals have profoundly altered drug-market dynamics in the US, ultimately leading to the proliferation of fentanyl-based counterfeit pills known as “Blues” or “Dirty 30s.” The startling finding that counterfeit offerings are not only expanding to include meth and heroin, but being sold out of Mexican pharmacies, is a logical extension of preexisting trends.
Since at least 2020, counterfeit pills have become the dominant illicit opioid in many US cities’ drug markets. They pose heightened risk to people who believe they are consuming genuine pharmaceuticals and don’t have opioid tolerance. As such, they’re a major contributor to surging rates of adolescent overdose.
Medical tourism is meanwhile a burgeoning industry, as the US remains a global outlier in the unaffordability of its health care costs as they continue to rise. Just over the Mexican border, whole neighborhoods service Americans who border-hop in search of medical and dental care, as well as cheaper prescription drugs.
Of the “oxycodone,” 30 percent was counterfeit—of which the majority was fentanyl-based.
Our research team conducted an experiment by entering 40 pharmacies in selected neighborhoods across four tourist-heavy cities in northern Mexico, and asking for oxycodone, Adderall and Xanax. The pharmacies were chosen for being independent, non-corporate establishments that appeared to cater to US tourists, and all the transactions were conducted in English.
Fourier-transform infrared spectroscopy (FTIR) and immunoassay-based testing strips were then utilized to test the purchased pills for benzodiazepines, fentanyl, methamphetamine and amphetamine.
A whopping 82 percent of “Adderall” purchased across the pharmacies (eight out of 11 samples) was actually meth, pressed to look like a 30mg Adderall pill. Of the “oxycodone,” 30 percent (eight of 27 samples) was counterfeit—of which the majority was fentanyl-based. Surprisingly, given heroin’s virtual disappearance from many North American markets, three of the “oxycodone” samples were heroin-based counterfeits that tested negative on fentanyl test strips. All of the pills purchased as Xanax, however, were presumed to be authentic after drug checking.
Altogether, 11 of the 40 pharmacies visited were found to be selling counterfeit pills.
The numbers of drug or medical tourists buying pills from these pharmacies, or when exactly counterfeits became available there, are unknown. But the researchers identified both genuine and counterfeit oxycodone being sold near each other, and utterly indistinguishable from one another except by advanced drug-checking methods.
“For the pills that contain heroin, it’s not even something you could pick up with the standard harm reduction advice to use fentanyl test strips.”
“The alarming thing about these findings is that people probably think they are getting a pill with a known strength, known ingredients, and then it turns out to be something much stronger,” Chelsea Shover, PhD, of UCLA and the senior author of the research, told Filter. “Ultimately this increases risk of overdose.”
The presence of heroin-based counterfeits additionally stretches the typical harm reduction advice of “check your drugs” to its limits. “For the pills that contain heroin, it’s not even something you could pick up with the standard harm reduction advice to use fentanyl test strips,” Shover said. “So that is both alarming and a unique strength of using the FTIR spectrometer alongside test strips.”
But virtually no one who uses drugs has access to this technology. Though heroin is less potent than fentanyl, the unknown dosage in a counterfeit pill can just as easily lead to overdose.
Another alarming finding are lower-miligram counterfeits that are more likely to be consumed by less experienced drug users, or simply a tourist with a toothache: “Percocet” and even “Vicodin” were found to be counterfeit. (While our research team identified counterfeit Vicodin that was simply tramadol, an LA Times investigation, published on February 2, detected fentanyl-based Vicodin counterfeits.)
As for the meth-based counterfeit Adderall, the unknown dosing and lack of quality controls in production are cause for concern. A pill purporting to be 30mg Adderall could contain anywhere between trace amounts and huge doses of methamphetamine. (Meth, it should be noted, is an approved medication for the treatment of ADHD in the form of Desoxyn; principal health risks come from the unregulated supply and unknown dosage.) Clandestine pill presses open up the potential for cross-contamination, especially risky if fentanyl makes its way into a pill bound for a person with no opioid tolerance.
The research team asserts that Mexico does not capture accurate drug-use or overdose data, and that the scope and impact of these phenomena on either domestic or tourist populations are therefore unknown.
Opioid use among the Mexican population remains low, however. Addiction rates (other than alcohol use disorder) are a fraction of those seen in the United States. The few cities that do see high rates of opioid use are along the border, and people who use opioids are predominantly deported from the United States, where they often began their use. According to ethnographic accounts of drug-use patterns in Mexico, people most often consume goma (black tar), china (fentanyl/heroin) or cristal (meth). Mexican citizens are relatively unaccustomed to pharmaceutical opioids, and pain is undertreated in the country.
Our findings should be treated as an artifact of America’s dysfunctional relationship with drugs in general, and pharmaceuticals in particular.
So it seems reasonable to hypothesize that Americans are the main recipients of the counterfeit pills in these pharmacies. Tourists should beware of the likelihood of getting a substance much riskier than what they thought they were buying. Mexican law is clear: You need a prescription for controlled substances, and if you purchase even genuine pharmaceuticals without a prescription, the transaction is illegal. The illegal nature of these transactions leaves them inherently unregulated, increasing the chances of counterfeiting. In all, it is a minefield.
Our research findings should be treated, too, as an artifact of America’s dysfunctional relationship with drugs in general, and pharmaceuticals in particular.
The vacuum left when opioid prescribing plummeted by nearly half in a decade—thanks to unprecedented levels of government meddling in medical practice—was swiftly filled by the illicit market. More recently, Adderall shortages have threatened the prescriptions of millions of Americans accustomed to pharmaceutical amphetamine.
If sanctioned pipelines of pharmaceuticals dry up, it affects not only the people who were prescribed that medication, but also the people who bought those pharmaceuticals “diverted” onto the illicit market. When the opioid-involved overdose crisis was first identified in the mid-2000s, government officials decried 10,000 opioid-related deaths per year. Slashing opioid prescribing—ostensibly an effort to reduce the death count, although some of the policy’s architects were well aware of the potential consequences—saw deaths skyrocket. Both chronic pain patients and people using pharmaceutical opioids without prescriptions were pushed towards illicit opioids—first heroin, and later fentanyl.
The shift to counterfeit pharmaceuticals wasn’t immediate. It took a number of years for the illicit market to accommodate consumer preferences for pharmaceutical-style opioids, but accommodate them it did.
With Adderall, it’s happening faster. As the current scarcity reaches its peak, counterfeits are already in mass production. Journalist Christopher Moraff shared his testing of meth-based “Adderall” in Philadelphia’s drug supply on January 30.
The adderall shortage is now spreading to methylphenidate drugs like ritilan. Meanwhile counterfeit 30mg pressed adderall are popping up in Philly- this one showing a presumptive positive for meth. pic.twitter.com/0zstOn6r7d
— Christopher Moraff (@moraffreports) January 30, 2023
Without the kind of drug policy changes that the US government refuses to even contemplate, there’s no going back from an environment in which counterfeit pills—not inherently riskier than what’s already on the market, but posing great danger to those who take their branding at face-value—are the norm.
The cornerstone of America’s “partnership” with Mexico against illicit drugs is that the US will work on demand reduction if Mexico tackles supply reduction. Mexico has recently arrested several more bosses of trafficking organizations, each time spawning more spasms of the violence that has raged in the country since 2006, but never reducing supply. The US has utterly failed to reduce demand. The price of both meth and fentanyl continues to fall despite inflationary pressures. Now, America’s voracious drug consumption is finding new ways to encroach onto Mexican soil.
Photograph of counterfeit oxycodone pill via the Drug Enforcement Administration