Fentanyl: The Deadly Consequences

1. Introduction

Fentanyl, a synthetic opioid, is an extraordinarily potent drug that is devastating communities across our Nation. One potentially lethal dose of fentanyl is only 2 mg—less than a gram of sugar. But Mexican drug cartels, who obtain the precursor chemicals from China, package fentanyl by the kilogram – about the size of a cantaloupe. A kilogram of fentanyl has the potential to kill up to 500,000 people (DEA, 2022). As a direct result of the failed border strategy of the Biden Administration, a staggering amount of it is flooding into every American community. In fiscal year 2022, enough fentanyl was caught crossing the border to kill 3.3. billion people – or every American 10 times over (CBP, n.d.).

Fentanyl has recently become known as the “silent killer” because it is frequently being mixed (cut or laced) with other drugs unbeknownst to the buyer. In the U.S., news stories hit the headlines every day announcing another tragic death of a young American who died taking a drug laced with fentanyl. Unsurprisingly, synthetic opioid-deaths (largely driven by fentanyl) surged by over 20% in 2021, killing over 71,000 Americans. The U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Administration estimates that 9.5 million Americans abused opioids in 2020—the latest data available from the National Survey of Drug Use and Health (SAMHSA, n.d.). Total drug overdose deaths since 1999 have topped 1 million (HSOAC, 2022).

The U.S. is experiencing a public health crisis because of the volume of illicit fentanyl that has made it into our country through the southern border. The fentanyl-related deaths are a tragic illustration that every state is a border state—though too few have drawn that connection. Fentanyl is everywhere and Americans need to be aware of its prevalence and the dangers associated with consuming it, whether intentional or not. Therefore securing the border is the most vital step that must be taken to halt the infiltration of fentanyl into communities. Serious, actionable steps must also be taken for stricter prosecutorial measures to disarm the cartels and their couriers, who are making millions of dollars from fentanyl sales. Additionally, the federal scheduling of fentanyl needs to be revisited and state and local educational efforts on the harrowing dangers of drugs need to be amplified. 

2. Dangers of Fentanyl

Through the Controlled Substances Act (CSA), Congress created five schedules to designate federally regulated substances taking into account medical use, potential for abuse, and safety (21 U.S.C. 812). Drugs that are classified as Schedule I have a high potential for abuse, no currently accepted medical use in the U.S., and  a lack of accepted safety for use of the drug (21 U.S.C. 812(b)(1)). At the other end of the spectrum, a Schedule V drug has low potential for abuse, and there is currently medically accepted use for treatment in the U.S. Further, abuse of a Schedule V drug may lead to limited physical or psychological dependence compared to Schedule IV substances (21 U.S.C. 812(b)(5)).

Fentanyl, which was developed in 1959 as an intravenous anesthetic, is currently a Schedule II drug (DEA, 2020). Under the CSA, a Schedule II drug has a high potential for abuse, has a currently accepted medical use in the U.S. with severe restrictions, and abuse of the drug may lead to severe psychological or physical dependence (21 U.S.C. 812(b)(2)). Fentanyl is 50 times more potent than heroin and 100 times as potent as morphine (DEA, 2020). The drug was designed to be fast-acting for non-extended periods of time, and its typical uses included the treatment of extreme pain, usually during or after surgery, or for late-stage cancer pain. In the 1990s, fentanyl skin patches were developed under the brand name Duragesic with the intent of being used as treatment for chronic pain for patients who developed a physical tolerance to opioids (Stanley, 2005). Soon after, fentanyl in lozenge, lollipop, tablet and nasal sprays followed for similar medical purposes (Stanley, 2005).

Consistent with a Schedule II designation, the potential for misuse or accidental ingestion of fentanyl, including prescription, is extremely dangerous. The ease of delivery methods contributes to the potential abuse of fentanyl or other products laced with fentanyl. For example, not long after Duragesic came to the market, reports of deaths due to overdoses of children and animals with patches accidentally stuck to them began to proliferate (PNNL, n.d., Stoecker, 2016). In 2013, the FDA issued a safety advisory requiring color changes to writing on skin patches to “prevent accidental exposure to the patches, which can cause serious harm and death in children, pets, and others. Similar changes are being requested for the generic fentanyl patches,” (FDA, 2013). Janssen discontinued the manufacture of Duragesic on June 30, 2020, yet generic versions of the patches are still produced (Drugs,.com, 2022).

Despite the potential for misuse, only a small fraction of deaths attributed to fentanyl overdoses today involve prescription forms. The relatively stagnant raw number of prescription-related fentanyl fatalities over the past few years seemingly indicates that the safety measures in place in controlled medical settings are generally effective. Instead, the vast majority of deaths involve illicitly manufactured synthetic fentanyl. Of the estimated 107,622 overdose deaths in 2021, 71,238 (66%) were due to synthetic opioids, primarily fentanyl (DOJ, 2022). The percentage of drug overdose deaths involving a synthetic opioid has increased dramatically since 1999 (Figure 1). The Centers for Disease Control and Prevention called the year 1999 the “first wave” of the U.S. opioid crisis because of the rise in prescription opioid deaths (Figure 2). The year 2010 is considered the “second wave” due to the rise in heroin deaths (Figure 2). There was a significant uptick in this percentage in 2013 during what is called the “third wave” of the U.S. opioid crisis (Figure 2). Those totals pale in comparison to present-day as synthetic opioid-involved overdose deaths in 2020 are 18 times higher compared to 2013.

Figure 1. National Drug-Involved Overdose Deaths*, Number Among All Ages, 1999 – 2020

Figure 2. Three Waves of Opioid Overdose Deaths

3. Today’s Fentanyl: Manufactured in China, Smuggled by Mexican Cartels

As explained above, the deadly fentanyl that is plaguing American communities is part of the illicit drug trade that is trafficked over the southern border. In 2019, Customs and Border Patrol (CBP) reported that “a majority of the illicit fentanyl in the United States is manufactured in clandestine labs in China and possesses strong opioid properties that make it an attractive drug of abuse” (CBP, 2019). The Drug Enforcement Administration’s (DEA) data gathering points to China as the origin of nearly all fentanyl trafficked into the U.S. Figure 3 (below) details/ the variety of ways the drug is illegally shipped directly into the U.S. or through Mexico and Canada, where it is then smuggled across the border (DEA, 2020). The high demand for opioids in the U.S. is enabled by cartel-controlled ports in Mexico, and our now unsecure border. This results in an attractive profit opportunity for Chinese manufacturers of illicit fentanyl. To illustrate the high demand, CBP reportedly seized 31 kilograms of fentanyl in 2015, and 1,154 kilograms in FY2019 (Myers, 2019).

Figure 3: Fentanyl Flow to the United States 2019 (Source: DEA)