Addressing America’s Fentanyl Crisis

Image showing lethal doses of Heroin and Fentanyl With permission from Bruce Taylor/NHSP Forensic Lab Image showing lethal doses of heroin (left) and fentanyl (right)

Every day, 91* Americans fatally overdose on an opioid drug. It may be a prescription analgesic or heroin—4-8 percent of people who misuse painkillers transition to heroin—but increasingly it is likely to be heroin’s much more potent synthetic cousin fentanyl. In the space of only two years, fentanyl has tragically escalated the opioid crisis. This drug is 50-100 times more potent than morphine and able to enter the brain especially quickly because of its high fat solubility; just 2 milligrams can kill a person, and emergency personnel who touch or breathe it may even be put in danger. Unfortunately, many people addicted to opioids as well as other drugs like cocaine are accidentally being poisoned by fentanyl-laced products.

Although fentanyl is a medicine prescribed for post-surgical pain and palliative care, most of the fentanyl responsible for this surge of deaths is made illicitly in China and imported to the U.S. via the mail or via Mexican drug cartels. Its high potency and ease of manufacture make it enormously profitable to produce and sell. According to the DEA, one kilogram of fentanyl can be purchased in China for $3,000 to $5,000 and then generate over $1.5 million in revenue through illicit sales in the U.S. Thus distributors of illicit drugs are eager to adulterate heroin or cocaine powder with fentanyl or put it in counterfeit prescription drugs, such as pills made to look like prescription pain relievers or sedatives. Last month, for example, a wave of deaths in Florida was linked to fake Xanax pills containing fentanyl.

Deaths from fentanyl and a handful of other synthetic opioids tripled from 3,105 in 2013 to 9,580 in 2015, and those numbers are likely underestimates; some medical examiners do not test for fentanyl and many overdose death certificates do not list specific drugs involved. Thus far, New Hampshire has recorded the most fentanyl overdoses per capita; a NIDA-funded HotSpot study found that in 2015, almost two thirds of the 439 drug deaths in that state involved fentanyl.

Although most who fatally overdose on fentanyl are unaware of what they have taken, news of such fatalities has driven some people with severe opioid addictions to seek it out. Part of the cycle of an opioid use disorder is increased tolerance, causing diminished response to the drug, which leads users to seek products with higher potency so they can experience the euphoria they initially felt. Roughly a third of opioid users interviewed as part of the HotSpot study in New Hampshire knowingly sought fentanyl.

The fentanyl problem is already a high priority for policymakers. Last month, NIDA’s Deputy Director Wilson Compton testified before Congress on the science of fentanyl, accompanied by representatives from the DEA, the Office of National Drug Control Policy (ONDCP), the CDC, and other agencies. Diplomatic and law enforcement efforts to cut off the supply of illicit fentanyl and the chemicals needed to manufacture it will be important, but the emergence of very high potency opioids—which can be transported in smaller volumes—will make addressing supply increasingly difficult. Thus, a public health strategy to address the opioid crisis and overdose epidemic is more important than ever.

First, we must improve pain management and minimize our reliance on existing opioid pain medications. Second, treatment centers and healthcare systems must make much wider use of available, effective medications for opioid addiction (buprenorphine, methadone, and extended-release naltrexone). Third, the opioid-overdose reversing drug naloxone needs to be made as widely available as possible, both to emergency first responders as well as to opioid users and other laypeople who may find themselves in a position to save a life. In cases of fentanyl overdose, multiple doses of naloxone may be needed to reverse an overdose and additional hospital care may be needed. And all individuals who overdose on opioids need to be linked to a treatment program to prevent it from happening again.

Only by mobilizing healthcare systems to deliver effective prevention and treatment of substance use disorders, utilize naloxone to prevent and reverse overdoses, and develop safe effective treatments for the management of chronic pain will we be able end the current opioid crisis, as well as prevent it from happening again.

*Update: Overdose rates seen in 2018 are more than 115 a day

Dr. Nora Volkow, Director

Here I highlight important work being done at NIDA and other news related to the science of drug use and addiction.

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 America's Fentanyl Crisis

Thank you, Nora, for nailing the key issues in dealing with this problem. We absolutely must find better pain management drugs than the opioids that are the current standard of care. As long as opioids remain the most effective pain drugs available, it will be difficult to limit their use.

 There's nothing wrong with opioids!

This "epidemic" is the result of bad decision making over the course of the past two decades, some of which continues TODAY.

Drug companies were allowed to overadvertise, and doctors were able to overprescribe opioids FOR YEARS while the DEA was out chasing marijuana, A HARMLESS PLANT!

THEN, FIFTEEN YEARS AGO, buprenorphine was discovered to be effective at virtually eliminating the agony of withdrawal from opioids without providing a "high". There are some uneducated individuals who argue that it DOES provide a high. I guess a shot of beer could give some people a tiny buzz, but not someone who drinks a bottle of whisky a day. So it is with buprenorphine vs hard drugs.

Did policy makers rush this new drug out to the public to help the opioid crisis that was developing?
No. They did the OPPOSITE. They actually made it more difficult to get, by requiring a special DEA # for Dr's to prescribe it, THEN limited Dr's who could prescribe it to 100 patients, allowed only a 30 day supply, and prohibited refills. Then they forced pharmacies to comply with ratios, limiting the amount of buprenorphine they could carry, for the few pharmacies that even knew what it was.

This isn't a case of a "bad dog" its a case of a "bad owner".

And the "experts" sit here, scratching their heads, formulating plans, to end a crisis that could have been prevented, if not for the ineptitute of those who's BEST THINKING got us here.

 Reducing demand

There's an immediate need to revamp the current incarceration of addicts and change it to a rehabilitation program. The money could and should come from the drug companies that started this trend in the first place. Many of those currently hooked have been on some type of drug from an early age usually prescribed by the medical industry. It's no secret that the hamster wheel of Justice prevents those who want to or could drop the habit from successfully doing so. Probation fees, fines etc. Just make it more difficult and hopeless for people attempting Rehabilitation to get back to being productive members of society. Paraguay has a pretty successful philosophy which could be modeled in this country.

 Fentanyl Use

How can we impact legislation to change how we are treating frequent patients coming to ED and getting release within four hours if stable. Frequent admissions for drug OD needs to have mandated admission for treatment upon the third occurrence of OD specially when the patient had to be given NARCAN inhalation by EMS or other person, and how can we make Narcan more available and distributed to all EMS, police officers, schools, colleges. We are facing an epidemic and these are daily occurrences among young adults, and teens. Its time that we stop ostracizing substance abuse users, and address the problem a deadly chronic illness with devastating effects.


I was on Fentanyl for 41/2 yrs 125mcg every 48hrs for my chronic pain and was on oxycodone for eight years. I was taken off due to a change in wkr's comp drug testing policies that conflicted with the Dr. I was actually able to be active then, now I spend most of my time lying down just existing as all other conservative treatments before that didn't help with the pain. I'm not out there shooting up heroin or using any type of drugs nor do I have any desire to, the meds helped with my chronic pain but other than that they didn't make me feel good in any other way.

 Opioid / Treatment, Recovery / Buprenorphine

As a Recovered Alcoholic, who became Addicted to Opiates as a result of "Chronic Pain". It was untill a couple of close calls, that my Doctor stoped treating me & I was left to my own devices, which only led me further into trouble, I finally was left with just on option, after near over doses see this Doctor Who treated Chronic Pain With Suboxone,(who knew), left with only option I started Whats Known as MAT treatment, (Recovery For Me),since begining in 2006 I've stopped using Opiates All together ,Attend a Pain support Group, and reduced my dose of Bupernorphine to a transdermal patch which I change once a week. I now know there is an Answer, But Our Education is falling short, I have a Daily Reprive, And thats how I believe this Epidemic needs to be addressed.