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Decriminalize Fentanyl

A needle on a syringe among a variety of pills

Despite the hysterical media reports, fentanyl is not a poison that can kill you by looking at it. This is evidenced by its decades-long continued use for ongoing pain in a medical setting.

But the people who use it recreationally, the people overdosing and dying by the hundreds, are not using it in a medical setting, and they aren't taking pharmaceutical grade fentanyl.

The solution to the fentanyl overdose crisis, and emerging adulterants and substitutes for opiates, is not more criminalization. Instead, drug users need a safe supply of their drugs of choice, and support for personal efforts at self-control, whatever they may look like.

How We Got Here

Fentanyl is only the latest in opioid panics. The panic over oxycodone (OxyContin) has led to severe restrictions on doctors, pharmacists, and patients in pain management.

While this did indeed stamp out the quick prescription of opiates, primarily in hospital emergency departments, it also left patients with chronic pain and severe acute pain having to jump hurdles or settling for substandard care for their pain. Now, it is not uncommon for doctors to recommend ketamine, cannabis, or even mindfulness meditation for pain management rather than prescribe an opiate.

This, coupled with developments in Afghanistan and lawsuits faced by pharmaceutical companies, put a squeeze on the supply of opiates on the streets.

Enter Fentanyl

Fentanyl was actually first synthesized in the 1950s and approved for medical use in the late 1960s. Since then it had been used rarely for only opioid tolerant patients with extreme pain such as from cancer or surgery.

When the street opioid market contracted, dealers were looking for ways to make their opioids convincingly potent while using less product.

Fentanyl is upwards of 50 times stronger than morphine. There are several fentanyl analogues, each with their own potency, so it's hard to assert an exact potency for pure fentanyl. Because of this, it is nearly impossible to know what a given dose of street fentanyl will do before trying it.

While the propaganda is true that the equivalent of four grains of sand is enough to overdose, fentanyl is almost never found pure, and dealers generally try to get their dose weights close to weights their users are used to with other powdered opiates such as heroin.

The Difference Between Medical and Street Fentanyl

Pharmaceutical fentanyl is produced in a controlled laboratory or factory setting using carefully measured precursors and rigorous product testing to ensure a predictable dose. If dealers were able to supply pharmaceutical fentanyl to their clients, this would severely reduce deaths from ignorance of potency.

Street fentanyl finds recreational users in a variety of ways. Some fentanyl is procured from pharmaceutical sources and cut with other products and fillers. Some is synthesized in illicit labs that exist around the world and then cut into other products and fillers. In both cases, potency and dosage is a complete crapshoot.

If you can get fentanyl from a dealer that you can trust to procure from pharmaceutical sources and keep track of the potency of their final product, you may be able to nurse a safe fentanyl habit. Other than that, you're taking your life into your own hands.

Budding Alternatives

Due to its inherent risks, fentanyl may be on its way out. What is replacing it, however, may be worse for public health. Xylazine and tianeptine are slowly making their way into the street market as either adulterants or substitutes for opioids.

Xylazine is being found as an adulterant to opioids more and more. Used primarily as an animal tranquilizer, xylazine has many of the same effects as opioids. However, unlike opioids, they are not intended for long term use, and can cause long term users to develop lesions on their extremities. In addition, because xylazine is not an opioid, it will not respond to Narcan in the event of an overdose.

Tianeptine, more commonly known as gas station heroin, is not an opioid at the doses where it is used clinically outside the US. In its clinical use, it's an antidepressant. At high doses, however, it binds to mu opioid receptors causing an opioid effect. In the event of overdose, Narcan will have some effect, but it is complicated by the antidepressant properties of the medication.

This drug is popping up in gas stations and convenience stores across the country, hence the name. It's currently unregulated and drug users are seeking it out as a substitute for the risky supply of powdered opioids.

Gas station heroin is particularly pernicious because it is extremely physically addictive. Even at clinical doses, patients need to be very slowly weaned off of the medication when stopping treatment. At high doses, there is no medically recognized means of detox and users report that the physical severity of the withdrawal makes cessation impossible.

Tackling the Overdose Crisis

When it comes to the overdose crisis, we face numerous obstacles. Our drug supply is becoming less and less reliable, making it more risky to get high. As we have seen, this does not translate to fewer addicts but rather more dead addicts.

Tackling the overdose crisis requires a multi-pronged strategy that includes:

  • Opening harm reduction centers as a one stop shop for drug users looking to reduce drug risk to themselves and others

  • Establish a safe supply distributed by harm reduction counselors who work with users to gain control over their drug usage to use responsibly and reduce their consumption over time

  • Distribute free test strips for fentanyl, xylazine, and other adulterants in the opioid supply

  • Decriminalize drug dealing and manufacturing and establish industry standards for safe production and adulteration

  • Fund research on tianeptine abuse and detox

  • Create a matriculation process whereby former addicts can become paid harm reduction counselors


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