The rumors are out there, maybe even whispers in your waiting room. The news is flooded with tales of the opioid epidemic and more increasingly the drug fentanyl. A quick Urbandictionary.com search tells us that fentanyl has many nicknames including china white: defined by a site user as “a pure/raw or high grade heroin, mixed with the powerful synthetic painkiller, fentanyl. Combined, these two create a very very high grade painkiller.”

Let’s start with the basics. What is fentanyl? The DEA Drugs of Abuse Resource Guide states, “Fentanyl is a potent synthetic opioid drug approved by the Food and Drug Administration for use as an analgesic (pain relief) and anesthetic. It is approximately 100 times more potent than morphine and 50 times more potent than heroin as an analgesic.” It is prescribed under trade names such as: Actiq, Fentora and Durogesic. It was first used clinical as an intravenous anesthetic under the trade name of Sublimaze in the 1960s.

And where are we now: Dr. Nora Volkow, on her NIH blog recently wrote, “Although some users seek out fentanyl, it is often ingested unintentionally. It is commonly used to adulterate heroin as well as counterfeit prescription pain pills and sedatives that are purchased on the street. Increasing numbers of overdose deaths among cocaine users may also be related to fentanyl-adulterated cocaine. Because it is so highly potent, fentanyl is more easily smuggled into the country, and because it is so cheap to produce, drug traffickers have increasingly turned to fentanyl as a profitable product.”

The New York Times recent article on drug smuggling adds to the topic, '“This is what makes the opioid crisis so unique and dangerous,” said Peter Vincent, who led ICE’s international operations during the Obama administration. “Traditionally, law enforcement has focused on large quantities of drugs like marijuana and cocaine. But very small amounts of opioids can bring tremendous profits.”'

Exactly what type of profits are we talking about:

The Minnesota Department of Health states:

Fentanyl sales are much more lucrative than heroin. A kilogram of heroin is purchased for approximately $6,000 and sold for appropriately $80,000. A kilogram of fentanyl is purchased for approximately $6,000 and sold for approximately $1.6 million. The reason for this vast difference in pricing is that the potency of fentanyl is so great, that it is cut into heroin and other drugs, to expand their volume.

The previously quoted New York Times article quotes similar figures stating, “The going market wholesale price for a kilogram of cut fentanyl is about $80,000, and can be turned around and sold for a profit of about $1.6 million, according to the Drug Enforcement Administration. That is about 20 times more profitable than heroin.”

All good and well for generalized national data. But ever wonder about your hometown or where your practice is located? Enter StreetRX. Based off of crowdsourcing principals it allows users of the site to anonymously report prices paid for prescription and illicit drugs, creating a searchable database of drug pricing. A quick fentanyl search showed prices ranging from $80 for a fentanyl 50 mcg/h patch in Cape Girardeau, Missouri to $125 for the same patch in Topeka, Kansas down to $30 in Indianapolis. Heroin prices on the site ranged from $30 for a gram of black tar in Santa Ana, California to $70 for the same drug descriptor in Fort Worth, Texas.

So where is fentanyl coming from and how is it getting into the US?

The underlying belief is that only a small amount of pharmaceutical fentanyl is being diverted from the legitimate market, with China being the primary source of illicit fentanyl. The U.S.-China Economic and Security Review Commission recently released report examines how “China’s illicit chemical production and inefficient U.S. and international counter narcotic efforts” created the stark increase in fentanyl-related deaths.

“China is a global source of fentanyl and other illicit substances because the country’s vast chemical and pharmaceutical industries are weakly regulated and poorly monitored,” the report states. “Chinese law enforcement officials have struggled to adequately regulate thousands of chemical and pharmaceutical facilities operating legally and illegally in the country, leading to increased production and export of illicit chemicals and drugs.”

While some of the fentanyl travels directly to the United States from China, other shipments come in from China to Mexico (and to a lesser extent) Canada before making its way eventually to the U.S.

In a January 2018 press release, U.S. Senator Charles Schumer stated, ‘In FY2017, more than 81 pounds of fentanyl and other synthetic opioids were seized via international mail and private carriers. In New York, approximately one million pieces of mail enter the JFK International mail facility each day, roughly 60 percent of the nation’s international mail. According to reports, seizures of fentanyl at the JFK International mail center increased from 7 in 2016 to 84 in 2017, all from China.”

Fentanyl, due to it’s potent nature, is hidden in small quantities in packages of all shapes and sizes, small business envelopes, or packages sometimes claiming to be clothing or generic household items. Homeland security officials at JFK intercepted a teddy bear in January loaded with 18 grams of fentanyl. The intended recipient had ordered the drugs from overseas on the Dark Web and had paid for them using Bitcoin.

“The mail is now a central front in the whole fight against drugs,” said Richard Baum, the acting drug czar, told USA TODAY during a Sept. 8, 2017 visit to the facility.

Fentanyl has been called the number one drug threat in the opioid epidemic. The statistics continue to show its impact is far and wide as overdose deaths attributed to its use continue to rise.

New legislation on several levels are attempting to address the issue. Stay up to date on fentanyl related issues by subscribing to the AffirmHealth blog.

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Cover Photo Source: https://www.cdc.gov/drugoverdose/pdf/pbss/PBSS-Report-072017.pdf