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When you buy street drugs, you can never be entirely sure of what you’re getting. Photograph: stockex / Alamy/Alamy
When you buy street drugs, you can never be entirely sure of what you’re getting. Photograph: stockex / Alamy/Alamy

Street opioids are getting deadlier. Overseeing drug use can reduce deaths

This article is more than 7 years old
Maia Szalavitz

Crackdowns on prescriptions are sending addicts to find a fix in the street. But drugs there are more often being made with rapidly fatal doses of fentanyl

As health officials battle increasing mortality associated with heroin and prescription opioids, an even more dangerous group of street drugs has appeared on the scene. From Seattle to Syracuse, authorities are reporting a spike in overdoses of fentanyl, an opioid 25 to 50 times stronger than heroin; in Canada, four pounds of a drug called W18, which is 100 times stronger than fentanyl, were recently seized.

These drugs — which act so quickly that they can be used in anesthesia— are now being made in clandestine Chinese and American labs. Fentanyl and similar derivatives are then sold either as heroin, in the form of fake Oxycontin pills, or scarily, sometimes even in pills made to look like anti-anxiety medications such as Xanax.

The problem has caught law enforcement officials and politicians off guard. But to anyone who has studied the history of drug policy, it was completely predictable.

It’s known as the “iron law of prohibition” or, as activist Richard Cowan, who coined the phrase, put it: “The harder the enforcement, the harder the drugs.” It’s been demonstrated throughout the history of drug policy: the more authorities target a class of drugs, the more potent and dangerous the versions on the street become. Under alcohol prohibition, bootleggers preferred to sell whiskey and gin, not beer and wine; during the cocaine years, dealers switched from selling powder that was used typically for snorting to selling crack, which can only be smoked, a much more addictive way of using the drug.

From dealers’ business perspective, then, switching to fentanyl makes total sense: the smaller the amount needed to get high, the tinier each package is and the lower the risk of getting busted. But from a public health perspective, it’s a disaster.

At least prescription drug misusers who get pharmaceuticals from doctors receive drugs of a known dose and purity, far from the case with street heroin or pills. When users substitute street fentanyl, it can cause an overdose so quickly that there is little time to intervene and save a life. (Pharmaceutical forms of fentanyl exist, but the kind found on the street tends to be illegally produced). While heroin overdoses tend to take several hours before they are deadly, fentanyl can kill so fast that people often die with a needle still in their arm.

Further, it’s only luck that so far, flawed manufacturing hasn’t introduced a batch laced with MPTP into the streets. A known neurotoxin which can be made accidentally when trying to synthesize certain types of fentanyl, MPTP causes rapid-onset Parkinson’s disease, destroying the brain’s dopamine neurons. It often “freezes” victims in place, leaving them conscious but unable to move or speak. In the 1980s, at least six California heroin users suffered this horrific fate, and hundreds of others may have been exposed, which increased their risk for late-life Parkinson’s.

This explosion of dangerous, unregulated drugs won’t cease unless the policies that encourage them do; cracking down on doctors who prescribe opioids without boosting treatment for addicts will only grow street-drug demand. The only intervention that has been repeatedly proven to cut the mortality from opioid addiction by 50% or more is indefinite maintenance with another opioid, typically buprenorphine or methadone.

If we’d immediately expanded maintenance treatment when the medical crackdown began, the street market that provides heroin and fentanyl almost certainly wouldn’t have grown as quickly. And while Barack Obama recently proposed regulations that will allow doctors to prescribe buprenorphine to more patients, he has actually made doing so subject to increased red tape and has not touched the sclerotic bureaucracy that restricts methadone to highly isolated clinics. This must change.

Secondly – and here, more progress is being made – increased access to the overdose antidote, naloxone, is needed. Many states are now making this nontoxic drug available over the counter, and the Obama administration is funding programs to get it into the hands of more first responders, friends and family members of drug users. But to stop fentanyl deaths, naloxone needs to be cheap and everywhere: there should be a national campaign to put a few vials in every first aid kit in the country, to help whether a toddler gets into grandma’s pills or a teenager begins a potentially deadly experiment.

Finally, there are two ways to help cut the death toll among the highest risk users, those who either refuse or cannot access maintenance treatments and who are often homeless and mentally ill. The first and most well-researched is to provide what are known as “supervised injecting facilities” (Sifs), places where users can go to take their drugs under the watchful eyes of medical professionals.

Research on the Insite Sif in Vancouver, Canada, for example, showed that after it opened in 2003, the overdose death rate in the immediate area fell by 35%, compared to only 9% in areas nearby without such a facility. And a review of the data on Sifs in Europe, Canada and Australia found they do not increase injection rates, but they do cut HIV, reduce overdose deaths and get people into treatment.

A second approach would be to offer drug testing services – not the kind that test users’ urine, but the kind that shows what’s in the substance itself. This way, if “heroin” or “Oxy” actually contains fentanyl, at least users would know the risk they face – and there is a chance to talk them out of taking it. This has not yet been well-researched for opioids, but it is widely used to test “club” drugs, with groups like DanceSafe offering test kits online and at raves and festivals to help people avoid dangerous chemicals sold as MDMA (ecstasy).

There are ways out of the opioid crisis, but it cannot be curbed simply by tightening access to legal supplies. Now that demand is moving to the black market, some cities are already beginning to see violence and turf wars similar to those that accompanied the early marketing of crack during the 1980s war on drugs, which was not previously part of today’s opioid problem.

A market will always arise where there’s a demand; the real answer is to prevent and treat addiction, not drive people from dangerous legal drugs to even riskier illegal substances without any way to ensure their safety.

More on this story

More on this story

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  • Two arrested after death of teenage girl who took ecstasy

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