Deadly fentanyl hybrids and substitutes could fuel 2023’s opioid crisis

As 2022 comes to a close, the U.S. opioid crisis — now more than two decades old — rages on.

According to the U.S. Centers for Disease Control and Prevention, more than 108,000 Americans died from drug overdoses in the last 12 months, the highest on record, and many more remain caught in the throes of addiction. While there have been some bright spots along the way — the number of drug overdose deaths slowed compared to prior years, more healthcare providers are prescribing medically-assisted treatment than ever before, and the opioid-reversing drug naloxone is becoming more mainstream — new challenges await. 

The drug trade continues to evolve, and the U.S. must continue to evolve with it. Fentanyl, a synthetic opioid more than 50 times more powerful than heroin, remains the key driver of the drug crisis, continuing its devastating romp through communities across the country, and is increasingly found mixed with other illicit substances, including heroin, cocaine and methamphetamine. While chronic drug users initially shied away from fentanyl due to the short-lasting “high” and risk of overdose, many now purposefully seek it out after building up a tolerance to the powerful narcotic.  

Meanwhile, casual drug users unaccustomed to fentanyl continue to find ever-more potent varieties in counterfeit pills. The U.S. Drug Enforcement Administration has found that 6 out of 10 fentanyl-laced fake prescription pills contain a potentially lethal dose of fentanyl, a 50 percent increase from last year. While they are most often made to look like oxycodone 30-milligram pills — commonly known as “blues” or “M30s” — drug traffickers are likely to exploit the ongoing Adderall shortage by creating counterfeit ADHD medication containing fentanyl, methamphetamine or other substances.   

This has important implications for drug users and first responders, who may encounter deadly substances in new places and need to administer multiple doses of naloxone to reverse drug overdoses. The government’s recently launched non-fatal overdose tracker will be critical to identifying shifts in the drug trade and formulating the appropriate response; for example, by issuing public safety alerts and surging resources to the hardest hit areas. 

The U.S. will also need to step up efforts to monitor the emergence of new illicit substances in the drug supply. Drug traffickers in Philadelphia have already introduced “tranq dope” — an unholy mixture of fentanyl and xylazine, an animal tranquilizer linked to severe skin ulcers, wounds and amputations, among other complications — into the drug supply. Drug traffickers will also continue to promote new products such as isotonitazene and U-47700 — two synthetic opioids with similar effects as fentanyl — to diversify their offerings and increase market share. Meanwhile, there is increasing evidence opioid users are turning to cheap, potent and abundant methamphetamine to offset some of the effects of fentanyl. 

This reinforces the need for policymakers to quickly advance legislation to address gaps in drug prevention, harm reduction and treatment, including efforts to improve access to telehealth, methadone and naloxone. Additionally, Congress must permanently schedule fentanyl-related substances under the Controlled Substances Act to ensure law enforcement retains the tools they need to effectively target these deadly substances and protect public health and safety. Finally, policymakers must develop comprehensive, evidence-based strategies to maximize the billions of dollars flowing to state and local governments from opioid settlement funds, recognizing there is no “one-size-fits-all” approach.   

And then there’s the issue of supply. While it’s hard to imagine any significant, near-term breakthrough in U.S. relations with China and Mexico — the largest suppliers of synthetic drugs to the U.S. — Washington must seize every opportunity to stop the flow of these deadly drugs at their source — ideally, through enhanced cooperation, but, if necessary, through more aggressive political, diplomatic and economic measures. 

The opioid crisis stands among the most destructive events in American history and perhaps the least understood. And yet, the U.S. is better prepared to tackle this crisis than ever before. The year ahead — and the years to come — present an opportunity for the U.S. to leverage all the emerging tools and lessons learned to alter the course of this national tragedy. The American public deserves nothing less. 

Jim Crotty is the former deputy chief of staff at the U.S. Drug Enforcement Administration.