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America’s Heroin Supply Is Changing — and Becoming Deadlier

Maybe officials should start telling users what’s in the supply, instead of waiting until they show up in the morgue, some researchers argue.
(Photo: Drew Angerer/Getty Images)

(Photo: Drew Angerer/Getty Images)

Fentantyl, the synthetic opioid nearly 50 times more potent than heroin, continues to spread across America.

A powerful opioid painkiller that people can get as a prescription, fentanyl is also a black market drug. In its illicit form, fentanyl is most likely made in clandestine labs, then shipped into the United States, according to federal data. There have been reports that fentanyl and certain chemicals are making their way into the heroin supply in parts of the U.S., including Baltimore and some counties in Massachusetts.

Fentanyl can be produced cheaply, as a dry powder, and then mixed in, imperceptibly, with white-powder heroin. Even small amounts of these lab-made drugs can prove lethal, especially if users aren’t aware of its presence in their heroin. “There’s been such a horrifying level of death around users,” researcher Sarah Mars says. “So many people we spoke to have lost friends and acquaintances and family members, just recently, to overdoses.”

Mars is a project director for Heroin in Transition, a study funded by the National Institutes of Health and carried out through the University of California–San Francisco. To track America’s changing heroin supply, Mars and her teams visit cities where overdoses have spiked, interview heroin users about their experiences, and observe the heroin itself. Mars says that, in some cities, heroin users report urine tests showing no traces of heroin, but only fentanyl or other synthetic drugs — a fact that had been unknown to the users themselves.

Mars’ work is a crucial bridge between the federal drug-control data, which talks about trends nationwide, and the experiences of people on the ground facing this new threat. Pacific Standard talked with her about what they’ve found, and what it means for combating overdoses in America.

How has heroin in America changed recently?

Since the late 1990s, there’s been this division in the country. West of the Mississippi has been black-tar heroin and east of the Mississippi has been powder heroin. The black-tar heroin is sourced from Mexico and the powder heroin has been sourced from Colombia. But, recently, this has been changing, and there are reports of powder heroin coming from Mexico into the East Coast and a lot of fentanyl and other synthetic drugs in the heroin supply, particularly in the powder heroin supply, because it’s easier to mix it in.

At the street level, those dealers often aren’t aware [there’s fentanyl in what they’re selling]. They may not be responsible for what’s been added to it further up the supply chain.

So things are very much in flux, which is why we are studying them.

What do we know about fentanyl?

It’s so much stronger than heroin. It’s difficult to use safely when it hasn’t been mixed in a consistent pattern because such a tiny amount can make such a huge effect.

What are heroin users telling you about what they’re seeing?

Long-term users are saying that, in the last three to five years, the color, the effect, the intensity, and the duration of the drugs they’re taking have changed. That coincides with when these synthetic drugs started appearing in the heroin supply.

How are people reacting to these changes?

People’s responses vary a lot. Some people want heroin that they believe has fentanyl in it. They want the intensity and the euphoric rush and they’re willing to take the extra risk, but not everyone wants that kind of excitement. Some people want the long duration of heroin that you don’t get with fentanyl. They want a safer effect. They’re going to try to avoid fentanyl as much as possible.

Heroin in Transition’s lead scientist, Dan Ciccarone, has talked about having officials test the drug supply, and then tell emergency responders and users what’s in it.

It makes sense, really. Dan used the analogy of a contaminated lettuce outbreak. So if you had contaminated lettuce in the food supply, you wouldn’t just go around testing dead bodies. You would try and find the source of the contaminated lettuce. But the drug supply approach is still testing the dead bodies and not trying to find the source of the outbreak.

There’s not enough information coming back about the testing that’s going on in real time. A lot of the testing information that’s available to public health has a long lag time.

How would officials go about this testing?

There’s testing of police seizures. There’s testing a user’s own supplies. There’s lots of different approaches. There’s no one single model, but certainly more up-to-date information about what’s circulating would be helpful, not least to emergency workers because there have been reports that, with fentanyl, people are needing many more shots of Narcan. [Editor’s NoteNarcan is the brand name for naloxone, the overdose-reversing drug.] Knowing what’s in the supply is important because then you can supply the right strength or number of doses to those working with overdoses.

Are there any arguments against testing the drug supply for users?

One of the things people might say is, “Well, if you tell people that there’s fentanyl, they’ll just all flock to it.” But that’s not what we found in our data. A lot of people we’ve spoken to don’t want it, or want to know how to use it cautiously.

This interview has been edited for length and clarity.