Fentanyl is a synthetic opioid that is used to treat patients with severe pain, often in post op surgery, and in patients living with chronic pain. Fentanyl, like morphine and other opioids, works by binding to the brain’s opioid receptors which can cause feelings of euphoria and pain relief. If opioids like fentanyl are consumed too frequently, the brain will adapt to this use and it will require larger doses of the drug to achieve the same level of pain relief and other feelings. Over time, this can lead to increased opioid tolerance and in some cases, Opioid Use Disorder (OUD). However, fentanyl is different from many other opioids in that it is a synthetic opioid, meaning it is produced using chemical synthesis. The unique chemical structure created during the chemical synthesis makes fentanyl much easier for the brain to absorb resulting in a stronger and more rapid onset of the drug.
Fentanyl has legitimate benefits when taken appropriately in a medical setting but it can also cause serious harm. When politicians and law enforcement officials talk about fentanyl, they are typically referring to illicitly produced fentanyl that is consumed recreationally; sometimes knowingly and sometimes not. This illicitly produced fentanyl is what has caused the dramatic increase in U.S. drug overdose deaths over the past decade.
From the mid 1990s until roughly 2013 (a time period referred to as the “first wave” of the opioid epidemic1) legal opioids like OxyContin were severely overprescribed in the U.S. leading many Americans to develop OUD while killing tens of thousands each year. Efforts to curb the number of opioid prescriptions circulating in the U.S. resulted in many people, who had become dependent on prescription opioids, turning to heroin, a readily available and less expensive, but more dangerous alternative. From 2013 to 2015 (the “second wave”) heroin use increased as did fatal drug overdoses which reached around 52,000 in 2015. Then the “third wave” began and fentanyl flooded the market dramatically increasing overdose fatalities in the U.S. resulting in the over 100,000 annual drug overdose deaths the country experiences today. Fentanyl quickly overtook heroin and prescription opioids as the leading cause of drug overdose deaths in the U.S. So what makes this particular drug so dangerous? Here are a few reasons that we will discuss in more detail:
To demonstrate this concept, a team of journalists from Reuters purchased the lab equipment and chemicals required to set up a large fentanyl production operation. The team spent around $3,600 on equipment and chemicals (which were shipped directly to them in Mexico) and estimated that they could produce around 3 million fentanyl pills with a street value of $3 million.
Fentanyl is easy to produce as it really only requires an inexpensive, unsophisticated, homemade “lab” and a handful of chemicals, called precursor chemicals, that are mixed together to produce the fentanyl product. The precursor chemicals required to produce fentanyl are cheap and can be easily purchased (often from China) and received via standard mail delivery services. Once the chemicals are in hand, a fentanyl producer can create large quantities of the product in less than a day.2 To demonstrate this concept, a team of journalists from Reuters purchased the lab equipment and chemicals required to set up a large fentanyl production operation. The team spent around $3,600 on equipment and chemicals (which were shipped directly to them in Mexico) and estimated that they could produce around 3 million fentanyl pills with a street value of $3 million.3 Because fentanyl is so cheap and easy to make, the financial incentive for suppliers is large, and the barrier to entry is low, allowing the supply of fentanyl to grow quickly.
The common fentanyl supply chain begins with Chinese criminal networks shipping fentanyl and other drug “precursor” chemicals to other countries where the drugs are ultimately produced. In the case of fentanyl, Chinese criminal groups export the precursor chemicals to cartels in Mexico.4 These cartels control the bulk of fentanyl production operations and then smuggle the drugs across the southern U.S. border. An estimated 90% of fentanyl that makes it into the United States is smuggled across the U.S. - Mexico border through legal ports of entry.5
Since most fentanyl production occurs outside of the U.S., law enforcement agencies must engage in cooperative counternarcotics operations with Mexico and China, a feat that is complicated by the changing dynamics of international relations. Additionally, since the chemicals can be shipped virtually anywhere and the labs are easy to stand up, even if law enforcement shuts down a production lab, another one can pop up within 24 to 48 hours.6
Because it is difficult for U.S. authorities to impede the fentanyl supply chain, a significant quantity of fentanyl is able to enter the U.S. market each year. DEA fentanyl seizures more than doubled from 2021 to nearly 15,000 kilograms in 2023 yet overdose deaths continued to rise. However, it is not only that the supply of this product is extremely widespread, but the product itself is much more dangerous than prescription opioids or heroin.
While all opioids have the potential to cause harm, fentanyl is distinct because its chemical structure makes it extremely powerful, roughly 50-100 times more potent than morphine, and has a more rapid onset.7 An individual can overdose on fentanyl with a dose as small as 2 milligrams (mg)8 (for comparison, a Domino sugar packet contains around 3,500 milligrams of sugar). Furthermore, because of the extreme potency, reversing the effects of a fentanyl overdose could require multiple doses of naloxone. When fentanyl first entered the U.S. drug market on a large scale, around 2015, opioid and heroin users were not accustomed to the potency of this new drug and since such a tiny amount can result in a lethal dose, many people began overdosing from this new, unpredictable drug. Additionally, fentanyl users tend to use the drug many more times in a given day as compared to heroin users which increases their risk of experiencing an overdose.9
Since illicit fentanyl is commonly produced in crude, unregulated, labs the quantity of fentanyl in any given dose can be impossible to know. For example, the DEA has found counterfeit pills containing as low as .02 mg of fentanyl and as high as 5.1 mg of fentanyl (over two times the average lethal dose). Furthermore, in a sample of seized fentanyl pills, 42% contained at least 2 mg (a potentially lethal dose) of fentanyl. People who purchase illicit fentanyl have almost no way of knowing what quantity of the drug they are consuming with each ingestion and since the potential lethal dose is so small, even a tiny deviation in production can result in a fatal overdose.10
Additionally, because of its low cost and high potency, fentanyl is often mixed in with other drugs such as cocaine and methamphetamines to increase the effect of the primary drug at a lower cost to the supplier. Other times, fentanyl is sold under the guise that it is another drug and therefore, some people ingest fentanyl completely unintentionally thinking it is an entirely different drug. These people, consuming fentanyl unknowingly, likely don’t have any tolerance built up towards fentanyl and are therefore more likely to overdose on a smaller quantity of the drug.
An overprescribing boom in the 2000’s created strong demand in the United States for prescription opioids. This demand for controlled, expensive, prescriptions gave way to cheaper illicit heroin around 2013 which in turn gave way to even cheaper fentanyl in around 2015. But fentanyl is different from other opioids. It can be produced in crude labs without expensive equipment or a chemistry PhD. Production is easy to set up and the small dose size makes it easier to smuggle across borders undetected. It is often mixed with other drugs in irregular quantities which makes it nearly impossible for someone to know how much, or even if, they are consuming fentanyl. Most notably, fentanyl is much more potent than its counterparts, up to 100 times as potent as morphine, and has a much more rapid onset. As little as 2 mg of fentanyl can be considered a lethal dose and naloxone, a drug that reverses the effects of an opioid overdose, must be administered quickly and potentially multiple times to save someone from a fentanyl overdose.
Fentanyl is not going to disappear from the illicit U.S. drug market and potentially even more dangerous combinations of fentanyl and other drugs such as xylazine are beginning to appear more regularly in the U.S.11 Protecting people from powerful, fast acting opioids like fentanyl is an extremely difficult task but this is where the Resilient System can make an impact. By automatically monitoring for and detecting signs of a potentially fatal overdose, the Resilient System can immediately administer lifesaving naloxone as soon as trouble is detected. The system is an effective way to overcome the high potency and rapid onset that makes fentanyl a uniquely destructive opioid.
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