They might as well be playing Russian Roulette.
It doesn’t matter if you’re talking about a teenager chasing a higher high or a mega star trying to soothe chronic pain. The counterfeit pills they may be reaching for are more deadly than ever, experts say.
Why? One word: fentanyl.
“Synthetic fentanyl showing up in the street drug supply is an enormous game changer,” says Carol Falkowski, CEO of Drug Abuse Dialogues, a group that helps track drug trends for the National Institute on Drug Abuse. “It means anybody who purchases illegal drugs can unknowingly be taking fentanyl, which is 100 times stronger than morphine.”
All it takes is a dose of fentanyl the size of three grains of sand to kill.
Fentanyl powder is cheap and easy to obtain on the dark web, experts warn, making it attractive to those manufacturing it into pill form mixed with other drugs.
Those counterfeit drugs are sold on the street, and usually dangerously usually labeled as something less potent. Even forensic scientists can’t tell whether some of the pills sold on the street are counterfeit or not just by looking at them. That’s how good the counterfeiters have gotten at making the illicit drugs.
Those who take fake prescriptions likely have no idea if fentanyl is inside, or how much.
“They should be known as a kill pill,” Falkowski says.
Prince Rogers Nelson’s death may turn out to be the most famous example of the dangers posed by counterfeit fentanyl. Pills found in his Minnesota home were reportedly marked as hydrocodone, but when tested the pills turned out to have fentanyl in them. No one has said if Prince took those pills. But he did die of fentanyl toxicity, according to the autopsy report.
Fentanyl is an opioid. Its effect on the body is exactly like heroin, or any other opiate-based medication. But fentanyl is 50 times stronger than heroin, up to 100 times stronger than morphine. It is stronger than any prescription painkiller on the market.
“All opiates are just oral heroin. There is no difference to the body,” Minneapolis emergency medicine physician Chris Johnson says.
Tracking and taxing the epidemic
The drug that killed Prince is showing up in counterfeit form across the US with devastating effects.
Long before Prince died of a fentanyl overdose, the Drug Enforcement Administration was preparing a document to share with law enforcement around the country. It was a warning. Weeks after Prince died, the document was published, and titled “Counterfeit Prescription Pills Containing Fentanyls: A Global Threat.”
“Prince is the most notable and famous person who tragically died from an opioid overdose. But we are seeing it in every town in Minnesota.” U.S Senator Amy Klobuchar, who represents Minnesota, told CNN.
Senator Klobuchar authored a bill that would require states to monitor the prescription of powerful painkillers and co-authored another which proposes taxing pharmaceutical companies and using those funds for treatment of opioid addiction.
“We must go even farther,” Sen. Klobuchar says. “We need more funding for treatment and better prescription drug monitoring programs. Because of the fact states like Florida don’t even share their information across state lines. There is no way to monitor who is taking what across state lines.”
The problem in her state isn’t as bad as some states such as Ohio or Florida, which have been hit hardest by the illicit fentanyl epidemic, according to CDC statistics. But attention has focused on the state following the death of Prince, one of its most famous native sons.
Drug overdose deaths have quadrupled in the past 15 years in Minnesota, according to the state’s Department of Public Health.
“In 2015, more than half of the drug-related deaths were related to prescription medications rather than illegal street drugs,” the health department’s report says. 216 deaths were associated with opioid pain relievers and 114 with heroin.
Drug overdoses now kill more Americans across America than car crashes, data from the Centers for Disease Control data shows.
How did we get here?
Minneapolis Dr. Chris Johnson, who has testified about the opioid problem to the Food and Drug Administration, points his finger at doctors and pharmaceutical companies for the epidemic sweeping the country.
They were hawking prescription opioids with abandon, he says.
“There was a push by the pharmaceutical industry and their paid physician advocates that pushed opiates saying they aren’t as addictive as we thought,” Johnson says. “So they can be used for back pain and other daily pain. They influenced government bodies to emphasize pain management as the doctor’s responsibility.”
He sighs, and says something he knows some will find distasteful, even shocking, coming from a doctor.
“If the cartels could, they would shake the hand of the medical industry and thank them for creating this new business,” Johnson says.
He explains how someone who was given Percocet for back pain for years may turn to illegal alternatives if doctors stop prescribing because of increased scrutiny or if prescriptions become too expensive for a patient.
That’s where cheaper heroin, or the counterfeit pills laced with fentanyl may come into play now, he says.
“They are increasingly desperate for opiates to make them feel normal again, then they make that jump” [to illicit drugs], Johnson says.
But Dr. Mark Willenbring, a psychiatrist at Alltyr substance abuse clinic in St. Paul, Minnesota, puts the blame squarely on regulators.
“The real blame is on regulatory authorities. Those regulating pharmacy practice in Florida. They let these huge pill mills operate freely in Florida,” he says. “There was no monitoring. The regulatory agencies let this be a free for all.”
How to kill opioid addiction, fast
Opioid medications bind to the areas of the brain that control pain and emotions, driving up levels of the feel-good hormone dopamine in the brain's reward areas and producing an intense feeling of euphoria.
As the brain becomes used to the feelings, it often takes more and more of the drug to produce the same levels of pain relief and well-being, leading to dependence and, later, addiction.
In June, the Food and Drug Administration requested that Opana ER manufacturer Endo Pharmaceuticals pull the drug from the market. It was the first time the agency has asked that a opioid pain medication be pulled "due to the public health consequences of abuse." Endo announced in July that it would pull the drug.
After an investigation, the FDA restricted the use of codeine and tramadol in children under 12 and recommend against their use in children between 12 and 18 years of age. Additionally, the FDA has warned breastfeeding mothers not to take these medications due to the risk of serious adverse reactions in breastfed infants.
CNN's Chief Medical Correspondent Dr. Sanjay Gupta has reported on recent research that shows today's typical heroin addict starts using at 23, is more likely to live in affluent suburbs and was likely unwittingly led to heroin through painkillers prescribed by his or her doctor.
According to the CDC, deaths from overdoses of prescription drugs and heroin continue to be the leading cause of unintentional death for Americans, rising 14% from 2013 to 2014.
The type of fentanyl usually associated with overdoses is bought on the street in powder or pill form and is often mixed with heroin in a clandestine lab to increase the high it produces. Street names include Apache, China girl, goodfella, jackpot, murder 8, TNT and Tango and Cash.
Patients are warned not to break, chew, crush or dissolve extended-release tablets because the rush of oxycodone into the system could cause serious health problems, including overdose and death.
Though highly addictive, oxycodone is not thought to be as frequently abused as hydrocodone. OxyContin, Percocet, Percodan and Tylox are some trade-name oxycodone products.
As with most opioids, mixing medications, drinking alcohol or taking other meds that contain alcohol, or using street drugs while taking morphine, increases the risk of breathing problems or other serious, life-threatening side effects.
The most common brand name is Demerol, which comes in both tablet and liquid forms. It is usually taken with or without food every three or four hours as needed for pain.
As with all opioids, meperidine can cause drowsiness, so never drive a car or operate machinery after taking it until you know how you will react.
Liquid hydromorphone holds the dubious honor of being frequently mistaken for morphine in hospital "wrong drug" medication errors because of the similarity of the names and appearances.
Methadone has many of the same side effects as other opioids, including weakness, headache, nausea and vomiting, stomach pain, sweating, difficulty urinating, mood changes and vision problems, and difficulty falling asleep or staying asleep.
However, if abused by crushing and snorting or injecting, it can suppress breathing and cause dizziness, confusion, unconsciousness and death.
Subutex, the brand name for buprenorphine, is taken as a tablet placed under the tongue and allowed to dissolve.
The brand Suboxone is a combination of buprenorphine and naloxone, an opioid antagonist. Antagonists block the opiate receptors in the brain, keeping the narcotic from creating the high abusers crave.
Willenbring spends his days working with patients struggling with substance abuse.
“I have patients that range in age from 17 to 72,” he says. “We are seeing something we have never seen before in the US.”
He says the demographics of who is addicted to heroin have changed dramatically.
“Traditionally heroin addiction has been a problem associated with middle aged black men about 43 years of age,” Willenbring says. “Those statistics have gone back for decades. Now its predominantly young, white people.”
He is very clear. Not all substance abuse problems are the same. He describes how his patients feel when they are addicted to opiates and then suddenly taken off them.
“What it means it that you can’t experience ordinary pleasure. Every day is a gray day. You have no energy. You have no motivation,” Willenbring says. “You have a low grade case of the flu all the time. Your bones and joints ache. And your brain is constantly screaming ‘I want more opioids.’ It doesn’t get better over time.”
When it comes to treating opioid addiction, Willenbring says the science is clear and there is agreement on the one treatment that works, fast. You replace what is deficient in the brain.
“The only proven effective treatment is replacement maintenance therapy or methadone,” Dr. Willenbring. “What I tell my patients is you can no more will your brain to produce more opioids than you can will your pancreas to produce more insulin.”
But the psychiatrist is deeply concerned the current uproar about opioids may do more harm than good if the focus is only on stopping prescribing pills.
“Right now the biggest crisis I am seeing is people with severe disabling chronic pain who are summarily and arbitrarily taken off of them,” Willenbring says. “It ruins their lives. I think we are going to see a lot of suicides.”
Carol Falkowski says the solution to the opioid epidemic, and the growing threat of fentanyl will take work, not just words, from many different sources. And the medical community, law enforcement, government officials, pharmaceutical companies and regulators must act now.
“Whenever a new drug trend appears on the horizon there’s a lot of hand-wringing and ‘Oh my, this is awful,’” Falkowksi says. “When it comes to counterfeit fentanyl pills there is no overstatement going on, there’s no exaggeration, there’s a clear and present danger.”