The American opiate crisis just gets worse. On the one hand, we have the lingering aftereffects of many years of often careless opiate prescribing, with the result being an entirely new population of substance abusers.
On the other, we have the compounding fallout of equally careless policy reactions designed to cut the newly dependent off from their doctor-suppliers—actions that frequently have the effect of sending the suddenly cut-off into the narcotics black market: heroin. Except, unlike the stuff coming from a pharmacy window, those pursuing highs in the black market don't get any sort of guarantee of purity or (relative) safety. They get whatever.
According to a new paper in the Annals of Emergency Medicine, that "whatever" increasingly consists of a highly dangerous form of "fake" or substitute heroin. The paper cautions that emergency room doctors can expect to see "an upswing in what on the surface appear to be heroin overdoses," but are actually overdoses related to the quasi-legal opiate acetyl fentanyl. The added danger comes from the fact that acetyl fentanyl boasts about five to 15 times the punch of heroin itself (40 times the punch, according to some sources); meaning, what looks like a standard dose of heroin is in actuality something like 10 equivalent doses of heroin.
What makes it worse is that an overdose victim (or those around them) may have no idea that something other than heroin is at work. So, ER docs would most likely go about administering the heroin antidote, naloxone—something of a wonder drug, boasting the ability to shut down an overdose within seconds, bringing someone back from the brink just as soon as they got there. Naloxone, however, doesn't have the same effect on an acetyl fentanyl overdose, which requires a much higher "megadose" of the drug to work.
Clever and well-informed drug distribution networks will likely take advantage of the 'analogue loophole.'
"Clinicians may initially attribute an overdose of acetyl fentanyl–contaminated heroin solely to heroin," the paper notes, "further complicating the issue because acetyl fentanyl would not be specifically investigated as the culprit, particularly if the event had already been attributed to heroin." They'd really only know after trying and failing to treat the OD with a standard naloxone dose, and then having success with the megadose. That gap might very well be lethal.
While acetyl fentanyl itself has never had any legitimate purpose, its discovery came alongside the development of its still more-powerful analog fentanyl, which is used as an anaesthetic and for the treatment of the extreme "breakthrough pain" experienced by some cancer patients. So far it's been considered more of a designer drug than a common street drug substitution, but reports of its use (and consequences) are sharply rising in the US. So far it's shown up as a heroin substitute in Pennsylvania, Rhode Island, and, more recently, several Southern US states.
Currently, as a fentanyl analog, the drug enjoys a "not-for-human-consumption" exemption, a particular grey area that keeps the drug from the same kinds of controls as heroin itself. "Clever and well-informed drug distribution networks will likely take advantage of the 'analogue loophole,'” the paper warns. "They may profit, in terms of decreased legal repercussions, from replacing or cutting a highly regulated drug with acetyl fentanyl."
"Though acetyl fentanyl would certainly be considered illicit when packaged for individual street sales, there are fewer risks in transporting and storing it compared with heroin," it continues. "Dealers may eventually mix heroin and acetyl fentanyl before selling the product to better deceive users (as suggested by most mortality reports also indicating the presence of heroin), but use of this stronger product reduces the amount of heroin needed to maintain their present level of distribution."
Finally, the paper notes that locking up acetyl fentanyl as a controlled substance is probably not the end. The potential for quasi-legal drug analogues is as unlimited as chemistry itself. The solution, according to the current paper's authors, is eliminating the loophole as a whole. "Though there may be logistic and regulatory challenges," they write, "the elimination of the exemption for products containing an analogue of a controlled substance when labeled 'not for human consumption' appears to be the most effective solution to the issue more broadly."