What is fentanyl?

The powerful painkiller is the leading cause of overdose deaths in America.

(Video by Luis Velarde and Peter Stevenson; Animation by John Parks/The Washington Post)

Fentanyl, a powerful painkiller developed nearly 60 years ago, has triggered the deadliest drug epidemic in American history. Synthetic opioids like fentanyl have claimed the lives of more than 67,000 people — more than the number of U.S. military personnel killed during the Vietnam, Iraq and Afghanistan wars combined.

One of the greatest dangers of fentanyl is its potency. A few grains of the drug can cause an overdose. Deaths from the drug began to climb in 2013, when traffickers began to mix street heroin with illicit fentanyl. In just a few years, fentanyl began to rival heroin as the deadliest opioid in the United States, prompting the Centers for Disease Control and Prevention to issue a nationwide public health advisory. The alert received little national attention.

Here is what you need to know:

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What is fentanyl?

Fentanyl is a man-made opioid used to manage severe pain. It is typically administered to cancer or surgery patients. The drug was created by a Belgian physician in 1960 and approved for use as an anesthetic in 1972. Pharmaceutical fentanyl is reserved for patients who experience powerful pain that requires a stronger opioid dosage, and most patients who receive fentanyl have already been taking some type of opioid.

Fentanyl is up to 100 times more powerful than morphine and up to 50 times more powerful than heroin. Fentanyl can produce feelings of euphoria similar to heroin. The drug can also cause reduced blood pressure, sedation, dizziness and respiratory depression, according to the Drug Enforcement Administration. Pharmaceutical fentanyl comes in patches, sprays and lollipop-like lozenges. Illicit fentanyl is a white, powdery substance and can be pressed into counterfeit prescription pills.

What makes fentanyl so dangerous?

It takes about 2 milligrams of fentanyl to overdose. Fentanyl also can be combined with street drugs like heroin or cocaine. In some instances, drug users have no idea that fentanyl has been added. More recently, drug dealers have been selling straight fentanyl, which is more profitable for them.

Fentanyl analogues — or chemical variations of the drug — pose a major problem to law enforcement. Chemists can tweak the analogues to make versions of fentanyl that are not banned by law. Thus begins a game of cat and mouse: Federal officials race to identify and ban the analogues while chemists continue to make new ones.

What is being done to address the crisis?

Many police officers and paramedics carry naloxone, a drug that can help reverse an overdose. Naloxone can be injected into the body or used as a nasal spray. It works as an antidote, blocking the effects of opioids and helping restore breathing.

Pharmacies are now stocking the nasal spray. Naloxone is available for purchase without a prescription in 46 states. Public health departments, including the CDC, have encouraged more access to naloxone for first responders. In one study, opioid deaths in 19 Massachusetts communities dropped by 11 percent after the state implemented a naloxone distribution and education program.

Yet municipalities still have trouble accessing the drug, partly because of the cost. Narcan, the commercial name for naloxone as a nasal spray, can cost between $70 and $150. But the injectable version, known as Evzio, can cost around $4,000.

Learn more on how first responders use Narcan:

What do you do if you come into contact with someone who is overdosing on fentanyl?

If you suspect someone is experiencing an overdose, the CDC recommends the following:

1. Call 911 immediately.

2. Administer naloxone, if available.

3. Try to keep the person awake and breathing.

4. Lay the person on their side to prevent choking.

5. Stay with him or her until emergency workers arrive.

How many people have died as a result of fentanyl overdoses?

The United States has experienced three major waves of opioid deaths. They began in the late 1990s, when Americans increasingly began to overdose on prescription painkillers, such as OxyContin and Vicodin. The next wave began in 2010, when addicts turned to heroin as supplies of prescription opioids dried up. Beginning in 2013, fentanyl overdoses started to skyrocket.

In 2016, fentanyl surpassed heroin as the opioid most responsible for overdose deaths. That year, 19,720 people died of overdoses related to synthetic opioids, most of which involved fentanyl. In 2017, synthetic-opioid overdoses rose to 28,869.

Which parts of the country are most affected?

Most of the deaths are concentrated in the Northeast and Midwest. Some of the highest tolls have been recorded in New Hampshire, West Virginia, Massachusetts, Ohio, Maryland, Rhode Island, Maine, Connecticut, Kentucky and Washington, D.C.

The first signs were detected in the spring of 2013 in Rhode Island with a sudden increase in overdose deaths at the state morgue.

Where does illicit fentanyl come from?

Fentanyl manufactured in clandestine labs has been traced to Mexico and China, according to the DEA. In January, U.S. Customs and Border Protection officers in Arizona reported their agency’s largest fentanyl bust ever: 254 pounds seized at a checkpoint on the southwestern border. The drug, along with 395 pounds of methamphetamine, was hidden in the false-floor compartment of a truck carrying cucumbers. The driver was a 26-year-old Mexican national, according to authorities.

Some of the illicit fentanyl made in Chinese labs is sent to the United States in small packages through the U.S. postal system or overnight shipping companies, making it difficult to detect. The Department of Justice announced its first indictment against Chinese fentanyl manufacturers in October 2017, when officials in North Dakota charged two Chinese nationals with selling fentanyl over the Internet. The department alleged that one of the suspects operated at least two chemical plants capable of producing tons of fentanyl and fentanyl analogues.

Does fentanyl go by any other names?

Fentanyl can be called many street names, including Apace, China Girl, China Town, China White, Dance Fever, Goodfellas, Great Bear, He-Man, Poison, and Tango and Cash, according to the DEA.

Can fentanyl be absorbed into the skin?

This is a common myth and should be clarified. The risk to emergency responders is “extremely low,” according to the American College of Medical Toxicology (ACMT) and the American Academy of Clinical Toxicology (AACT).

Their current position states: “To date, we have not seen reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids.”

Andrew Stolbach, one of the lead authors of the ACMT statement and a Johns Hopkins medical toxicologist and emergency physician, said fentanyl does not pose a risk to first responders who take basic precautions.

“Fentanyl is absorbed very poorly through the skin,” Stolbach said. “For routine precautions, simple nitrile gloves are more than sufficient. If powder does get on the skin, washing it off with water is sufficient.”

Daniel Ciccarone, a heroin expert and professor at the University of California who has handled fentanyl in his field research, said casual exposure is not a concern.

“There’s a lot of drugs on the street that police, paramedics and other first responders are responding to,” Ciccarone said. “We don’t see a lot of those first responders who did collapse on the streets come back with positive toxicology reports of fentanyl.”

Michael J. Moss, a toxicologist and the Utah Poison Control Center’s medical director, led the writing of the ACMT and AACT’s position statement and said first responders or family members shouldn’t assume that just being around fentanyl will make them sick.

“Fentanyl is potent, though it is very unlikely — extremely unlikely — that anyone would be exposed from incidental contact, and we don’t want people to be afraid to take care of someone who might have overdosed because they think fentanyl could be around,” Moss said.

Is naloxone a prescription drug? Is it available over the counter?

Yes, naloxone is a prescription medication, but depending on your state, it can also be purchased without a prescription at a pharmacy. Naloxone is available for purchase without an individual prescription at CVS pharmacies across the country except for Hawaii and Wyoming. Walgreens also offers naloxone without a prescription.

The medication can be administered in either a nasal spray or through an auto-injector. CVS offers a discount on Narcan, the brand name for the nasal spray, for uninsured customers.

In recent years, the Food and Drug Administration and the U.S. surgeon general have called for expanded access to naloxone for first responders and community organizations. In Washington, D.C., Mayor Muriel E. Bowser (D) recently announced a plan to provide more than 50,000 naloxone kits to patrol officers, community organizations, opioid users and residents who know anyone at risk of an overdose.

Who, how and what is required for fentanyl production?

It’s important to note there are two types of fentanyl: medicinal and illicit. Medicinal fentanyl is prescribed to patients who experience extreme pain. It’s distributed by pharmaceutical companies and goes by the names of Actiq, Duragesic and Sublimaze.

Illicit fentanyl is created by illegal labs or drug traffickers. Drug users purchase illicit fentanyl on the dark web, and some of it flows through the U.S. postal system. Most of the illicit fentanyl that comes into the United States is from China, according to a report from the U.S.-China Economic and Security Review Commission. It can also be smuggled into the country across the southern border, and most of the seizures happen at ports of entry.

Fentanyl is a synthetic opioid. No plants are required to produce it. It is man-made and mimics the effects of opiates like opium and morphine.

Belgian physician Paul Janssen developed it in a lab in 1960, and the FDA approved it in 1968. When fentanyl was created, it was the most potent opioid in the world. Janssen’s team intended for it to be used as a painkiller that can be administered through an IV. Now, the drug is available in a pill, spray or patch.

More questions?

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Julie Vitkovskaya

Julie Vitkovskaya is a projects editor for The Washington Post who focuses on innovative storytelling and enterprise stories. She was previously the operations and digital editor for foreign and national security. She joined in 2015 after spending two years in South Korea working at an English-language newspaper as a Princeton in Asia fellow.

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Originally published March 13, 2019.