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How illicit fentanyl and an ‘increasingly toxic drug supply’ drive overdose deaths

Without reliable access to naloxone or testing equipment, people who use drugs are condemned to "play Russian roulette," experts say.
A plastic bag of assorted pills and prescription drugs dropped off for disposal sits in a container during the Drug Enforcement Administration (DEA) 20th National Prescription Drug Take Back Day at Watts Healthcare, on April 24, 2021, in Los Angeles.
Overdose deaths continue to rise every year in the U.S., and experts say it's due to an "increasingly toxic drug supply." But innovative harm reduction tools can help save lives, experts say.Patrick T. Fallon / AFP via Getty Images file
/ Source: TODAY

People who use drugs are increasingly facing a new challenge, a drug supply that is less predictable and more dangerous than ever before: Deaths due to synthetic opioids, which users may not know are in their drugs, are on the rise, and last year, U.S. overdose deaths hit an all-time high, according to the Centers for Disease Control and Prevention.

But people who use drugs don't have enough access — or access at all — to the things that could save their lives, experts in addiction medicine and harm reduction say.

"We are in an abysmal place, with the most deaths we've ever had every single year for probably the past five years. And COVID has only exacerbated that," Dr. Kimberly Sue, medical director for the National Harm Reduction Coalition, told TODAY.

Now, addiction medicine and harm reduction experts say, it's way past time to widen access to the few tools we have, like test strips, naloxone and overdose prevention centers, and to consider implementing new and innovative options to keep people alive.

Illicit fentanyl is driving overdose death rates

Polysubstance use is the use of more than one drug at a time, even unintentionally, according to the CDC, such as using heroin or cocaine that's cut with illicit fentanyl. And it's this type of drug use that's fueling U.S. overdose deaths — especially among people of color, according to a July report from the CDC.

Between 2019 and 2020, drug overdose deaths increased by 30%, and the increase was even higher among Black and Indigenous people. "Polysubstance use and the increasing proliferation of (illicitly manufactured fentanyl and fentanyl analogs) in the drug supply have exacerbated the surge in overdose deaths," the CDC reported explained.

Looking at overdose deaths involving synthetic opioids (including illicit fentanyl) specifically, rates increased more than 56% from 2019 to 2020, when more than 56,000 people died from this type of overdose; in 2018, the number of deaths involving illicit fentanyl and similar substances was 18 times higher than in 2013, according to another CDC report.

"Fentanyl is not inherently poisonous. What makes fentanyl different is its potency," Dr. Brian Hurley, president-elect of the board of directors of the American Society of Addiction Medicine, told TODAY. "It's a super high potent opioid ... and the rise in illicit fentanyl is driving overdose rates in the U.S. more than any other substance."

Fentanyl, a synthetic opioid, is more potent than heroin, per the CDC. And while many people safely receive prescription fentanyl in a medical setting for advanced cancer pain, for instance, when illicit fentanyl is lurking in other drugs, its potency makes the combination of drugs more likely to cause an overdose, Dr. Bobby Mukkamala, chair of the American Medical Association’s Substance Use and Pain Care Task Force, told TODAY.

"It's one thing if it's a prescription opioid-related issue because that's a very known quantity and known concentration," he explained. But with illicit drug use, "the unpredictability of what they're putting in their body is what makes this so deadly," he said.

So why is there fentanyl in the drug supply at all?

Multiple factors — including the effects of drug prohibition and the disruption of trafficking routes and production during the pandemic — are likely converging to bring more and more potent drugs into the supply, Ryan McNeil, Ph.D., associate professor and director of harm reduction research at Yale School of Medicine, told TODAY. A 2017 study in the International Journal of Drug Policy compared the illicit fentanyl market to the alcohol prohibition era of the 1920s.

In a sense, the emergence of illicit fentanyl and fentanyl analogs is partly because “the U.S. has been so successful” at criminalizing illicit drug manufacturers, Taleed El-Sabawi, Ph.D., assistant professor of law at Florida Internal University, told TODAY. To get around laws that make specific substances illegal, illicit manufacturers are incentivized to make drugs that are just different enough to avoid prosecution, she said.

“It’s this constant battle to be one step ahead of the law enforcement agencies,” said El-Sabawi, who is also an addiction and public policy researcher at Georgetown University’s O’Neill Institute for National and Global Health Law. And, as a result, people who use drugs are taking substances “that may affect them in a different way,” El-Sabawi said, adding that they may not have the tools to even know what they’re taking.

“What we effectively have is an increasingly toxic drug supply,” McNeil said. And it’s one that’s characterized by fentanyl of varying potency, as well as “new adulterants entering the supply that increase the likelihood of all of these complications (such as overdoses and deaths) that we’re incredibly concerned about,” he said.

People can't always know what's in their drugs

At a time when people are faced with a changing and increasingly dangerous drug supply, many people don't have access to tools that could help them determine what's in their drugs, the experts said.

“People are buying something, they have no idea what it is, and being forced to consume it because they have an opioid use disorder,” Sue explained. “We really relegate them to playing Russian roulette.”

For example, people in New Jersey may be using drugs that came through Philadelphia or New York City, so Caitlin O’Neill, co-director of New Jersey Harm Reduction Coalition, keeps tabs on what community members in those nearby cities are seeing.

“On the ground, a lot of times, (the only tool we have) is word of mouth or it’s trial by error, unfortunately,” O’Neill, who uses they/them pronouns, told TODAY. “We can’t just leave people to that.”

Even for experienced drug users, it can be nearly impossible to stay safe: "I'm still losing a lot of friends ... many, many people," Phoenix Beck McGreevey, a research associate in Vancouver, Canada, told TODAY. "And these are not naive drug users. These are people who have access to all possible harm reduction available."

A variety of tools can help combat rising overdose deaths, experts say

To help reduce overdose deaths, experts say, we need a variety of tools, including making substance use disorder treatment options more available for those who qualify, as well as exploring and increasing access to harm reduction tools.


Naloxone is a drug that "rapidly reverses an opioid overdose" by knocking opioids off the brain’s receptors, according to the National Institute on Drug Abuse. It's typically administered via a nasal spray or injection into the muscle or veins, or under the skin. A 2018 national study found that states' enacting laws that increase access to naloxone cut opioid overdose deaths by 14%, according to NIDA.

After losing their partner to an overdose in 2014, O’Neill decided they would always have naloxone. “I’m always the person with Band-Aids in their pocket, and I’ve always got a dose of Advil on me,” they said. “I’m going to be the one that carries naloxone.”

Both the AMA and ASAM agree that naloxone is a lifesaving tool that should be made more available.

Access to testing equipment

Fentanyl test strips are another on-the-ground solution, and they're especially helpful when checking drugs one might not expect to have fentanyl in them, like cocaine or methamphetamine, according to the New York City Department of Health.

But, these days, people who use opioid drugs generally assume there's going to be fentanyl (or another potent adulterant) in whatever they're using, McNeil said. In those settings, it's not a question of whether or not there's fentanyl, it's a question of how much — a question that test strips alone can't answer. Plus, fentanyl test strips are only legal in 13 states, TODAY reported previously.

Instead, it would be more useful to have access to higher-quality testing equipment "for people to come in and find out — to the molecule — what’s in their bag,” O’Neill said, pointing to the mass spectrometry program at Chicago Recovery Alliance as an example.

Through testing programs like this, organizations can sample what's circulating in a community and keep people in the area better informed without each individual having to get their drugs tested. But that equipment can easily cost tens of thousands of dollars, Sue said.

“It’s on my wish list,” O'Neill laughed. “All I want for Christmas is a mass spectrometer.”

Currently, experts can get information on the contents of drugs circulating from seizure data through law enforcement or coroner data from people who overdosed, Hurley said. But both tend to lag behind what people are using in real-time and are “an indirect picture of what people are actually purchasing on the street,” he said.

ASAM doesn't have a formal recommendation on the use of mass spectrometry, Hurley said, but "from my perspective, it's intuitive that if someone's going to use drugs, you would want them to know what they're using."

And Mukkamala agreed: "Knowing if something is laced with fentanyl is the first step," he said. "Knowing how much fentanyl is just an evolution of that same desire to know so that people are not putting something in their body that's going to kill them." 

Overdose prevention centers

Another way to save lives, research shows, is overdose prevention centers, also called supervised consumption or safe injection sites. These are places where people can go to use drugs while being supervised, typically, with sterile equipment, and if someone has an overdose, staff on site are trained to take care of them, NBC News previously reported.

Mukkamala said the AMA is "very much in favor" of the use of overdose prevention centers.

For one thing, the sites allow people to use drugs in a way that is much safer, he said. But they also "give us an opportunity to have a conversation" about whether they have naloxone at home and whether they're interested in treatment. "We can have that conversation in that moment, in a nonjudgmental way," Mukkamala said.

ASAM's policy on overdose prevention sites is that "health departments should be empowered to set up, pilot and test overdose prevention sites so that we can learn how they work," Hurley said.

While there are more than 200 sites like these around the world, according to the Transform Drug Policy Foundation, there are only a few operating legally in the U.S. The two OnPoint NYC centers in New York City averted 125 overdoses in two months of operation, according to recent research published in JAMA Open Network.

Buprenorphine, methadone and "safe supply"

There are medication treatments approved by the Food and Drug Administration to help treat substance use disorder, such as buprenorphine and methadone, Sue said. But many people still face challenges in accessing those medications — and only a small fraction of people with addiction actually receive treatment, Hurley added.

"We need to scale up treatment options for people, and that includes options that are approved, for example, for opioid use, that aren't available in the U.S. but are evidence-based and available elsewhere," McNeil said. 

He pointed to the use of different forms of prescription heroin — diacetylmorphine, slow-release oral morphine or injectable hydromorphone — that are available in other countries, such as Canada and Switzerland. The idea is that providing a "safe supply" of drugs with a predictable dose will make overdoses and deaths less likely, he said.

"These aren't available here," McNeil said. "And, frankly, that should offend every person in this country concerned with addressing this crisis because it's taking away tools that have been shown to be effective."

On the other hand, Hurley countered that the U.K.’s prescription heroin program, which has existed for decades now, only reaches a few hundred people. And the medications available in the U.S. today — buprenorphine and methadone — are longer-acting, so missing a dose won’t send someone into withdrawal as quickly. In that way, the currently FDA-approved medications are a better, more practical option for most people with opioid use disorder than prescription heroin, he argued.

ASAM doesn't have an official policy on including drugs like diacetylmorphine as an option for treatment, Hurley said. But the organization "would want to follow the science and show (the medications) can be effective in the settings where they're used."

Is it time for more innovative approaches?

“No one recovers if they’re not alive. We want people to be alive for long enough to be able to actually access treatment and recovery."

Dr. Brian Hurley, American Society of Addiction Medicine

While some people may see these harm reduction tools as at odds with traditional addiction treatment methods, the experts TODAY spoke to said the two approaches can complement each other well.

“No one recovers if they’re not alive,” Hurley said. “We want people to be alive for long enough to be able to actually access treatment and recovery."

In March, the Biden administration released new plans to increase funding for various ways to reduce overdose deaths, including increasing access to harm reduction tools like fentanyl test strips and naloxone. But when reports earlier in the year suggested the Department of Justice might explicitly allow overdose prevention centers, a group of 14 Republican senators signed a letter opposing the idea.

The truth, McNeil said, is these options are probably never going to be popular politically, but they’re evidence-based, and "at the end of the day, political leaders need to step up and do what’s right to keep people alive,” he said. 

Substance use disorders are medical issues no different than, say, diabetes, Mukkamala explained. "But there's a huge stigma related to substance use disorder," and that stigma fuels restrictions on things like naloxone, which can actually save lives, he said.

“That’s what people should get angry about: We have the solutions to stop overdose deaths, and we do not use them because we’re too busy moralizing about drug use,” El-Sabawi said. To her, the solutions include drug testing, access to a safer supply and harm reduction efforts that specifically involve people with experience using drugs.

"People who use drugs are all around us," O'Neill said. "And, just like anybody else, they want to live to see their next day whether or not you agree with their choices."