How the Pandemic Helped Spread Fentanyl Across the US and Drive Opioid Overdose Deaths to a Grim New High

Yves here. This informative if disheartening article explains how specific Covid-induced changes in distribution of heroin and fentanyl, as well as reduced access to treatment programs, pushed overdose fatalities above what were already high levels.

By Andrew Kolodnym, Co-Director of Opioid Policy Research, Brandeis University. Originally published at The Conversation

For the past 20 years, I have been engaged in efforts to end the opioid epidemic, as a public health official, researcher and clinician. And for every one of those years I have looked on as the number of deaths from drug overdoses has set a new record high.

Yet even knowing that trend I was surprised by the latest tally from the CDC showing that for the first time ever, the number of Americans who fatally overdosed over the course of a year surpassed 100,000. In a 12-month period ending at the end of April 2021, some 100,306 died in the U.S., up 28.5% over the same period a year earlier.

The soaring death toll has been fueled by a much more dangerous black market opioid supply. Illicitly synthesized fentanyl – a potent and inexpensive opioid that has driven the rise in overdoses since it emerged in 2014 – is increasingly replacing heroin. Fentanyl and fentanyl analogs were responsible for almost two-thirds of the overdose deaths recorded in the 12 months period ending in April 2021.

It is especially tragic that these deaths are mainly occurring in people with a disease – opioid addiction – that is both preventable and treatable. Most heroin users want to avoid fentanyl. But increasingly, the heroin they seek is mixed with fentanyl or what they purchase is just fentanyl without any heroin in the mix.

While the spread of fentanyl is the primary cause of the spike in overdose deaths, the coronavirus pandemic also made the crisis worse.

The geographical distribution of opioid deaths makes it clear that there has been a change during the pandemic months.

Before the COVID-19 health crisis, the skyrocketing increase in fentanyl-related overdose deaths in America was mainly affecting the eastern half of the U.S., and hit especially hard in urban areas like Washington, D.C., Baltimore, Philadelphia and New York City. A possible reason behind this was that in the eastern half of the U.S., heroin has mainly been available in powder form rather than the black tar heroin more common in the West. It is easier to mix fentanyl with powdered heroin.

COVID-19 resulted in less cross-national traffic, which made it harder to smuggle illegal drugs across borders. Border restrictions make it harder to move bulkier drugs, resulting in smugglers’ increased reliance on fentanyl – which is more potent and easier to transport in small quantities and as pills, making it easier to traffic by mail. This may have helped fentanyl spread to areas that escaped the earlier surge in fentanyl deaths.

Opioid-addicted individuals seeking prescription opioids instead of heroin have also been affected, because counterfeit pills made with fentanyl have become more common. This may explain why public health officials in Seattle and elsewhere are reporting many fatalities resulting from use of counterfeit pills.

Another factor that may have contributed to the soaring death toll is that the pandemic made it harder for those dependent on opioids to get in-person treatment.

More than anything else, what drives opioid-addicted individuals to continue using is that without opioids they will experience severe symptoms of withdrawal. Treatment, especially with buprenorphine and methadone, has to be easy to access or addicted individuals will continue using heroin, prescription opioids or illict fentanyl to stave off withdrawal. Some treatment centers innovated in the face of lockdowns, for example, by allowing more patients to take methadone unsupervised at home, but this may not have been enough to offset the disruption to treatment services.

And maintaining access to treatment is crucial to avoid relapse, especially during the pandemic. Research has shown that social isolation and stress – which became more common during the pandemic – increase the chances of a relapse in someone in recovery.

In the past, one slip might not be the end of the world for someone in recovery. But given the extraordinarily dangerous black market opioid supply, any slip can result in death.

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  1. drsteve0

    Fentanyl, it’s in pain patches, pills and powders, oh, and in ‘China white’ lollipops, etc. Pretty common in prescribed form. Just wait till the smugglers and dealers discover the diminutive wonders of etorphine and Dog forbid, Carfentanil.

    1. drumlin woodchuckles

      Haven’t we had carfentanil in the illicit drug supply already from time to time? And hasn’t it all come from our great friend and valued trading partner China?

  2. Timothy Dutra, MD, PhD

    As a Forensic Pathologist, I concur with Andrew Kolodnym that illicit fentanyl has become the most common cause of opioid overdose deaths. However, I also believe that this is, at least in part, due to the decrease in availability of prescription opiates. Physicians and Pharmacists know they face increased scrutiny by State and Federal agencies, causing them to reduce prescribing and dispensing, even to chronic pain patients who need medication to continue their activities of daily living. The good thing about prescribed opiates is that the patient knows the dosage. Illicit fentanyl is not prepared for sale under controlled laboratory conditions, so there is great variability in the dosage of similarly appearing counterfeit pills.

    1. hemeantwell

      A side note: my wife and I have been surprised at how strong the Hulu show Dopesick is. Only two episodes in, but a good script and a strong cast are painting the Sacklers into one of the lower levels of hell.

    2. Mike

      Amazing to think this. At first sight I think a lot of people (me included) intuitively would agree to apply increased scrutiny on the prescribing of opiates and think that is the right/good thing to do. I agree with your analysis though that we may now be paying the price for putting the nations supply of “good” product on hold. All around this whole situation is very sad and there doesn’t appear to be any national strategy in place for this. I know various local municipalities trying to provide safe injection sites but that may be a moot point if all the product is fentanyl, I suppose it at least gives them a chance to get narcan.

  3. Ed Burkett

    It would seem to me that unless we can solve/fix all the problems of our culture and economy we ought to leave a path for those in ultimate despair to leave this life. I suppose good Republicans could point out that firearms offer the politically correct solution. But opioids offer the sleep from which you never awake. I would hope that they remain available for those in desperation.

    1. clarky90

      …….eugenics………. After many experiences during the 20th century, I had imagined that we, collectively, had concluded (FI, Treblinka, Solovki, Rwanda, The Killing Fields…..) that genocide (Overt or covert) was not a progressve, high-minded or an educated response to …….

    2. Mike

      That’s a pretty fatalistic perspective. I think all of these problems are solvable but we have to clean house in the government and get honest people in there to do work. Everyone can still try and provide support to someone affected by addiction. Your perspective would suggest someone who thinks the strong will survive and to leave the week behind. I used to think that way until one of my dear family members developed an addiction from opiates after a severe injury. I’m convinced a vast majority of people have the capacity to get addicted to these substances. At least at this point with doctors prescribing less, theoretically there should be less people entering this addiction meat grinder. So that leaves the option to try and help these people or let them die off as you are suggesting.

    3. RA

      I tend to agree with you but most will think you are bitter, insane or criminal, or something like that. Why?
      Because the preservation of any human life is viewed as a sacrosanct given.

      For me, as far back as the mid-70s I felt that people were becoming an infestation on earth and it was clear to me that the only real solution to our growing massive problems was significant culling of our herd. There were then and are way too damn many people.

      The sacrosanct view that each and every human life must be protected has always been the norm. Back then there arose the group MADD (mothers against drunk driving). I thought about it and decided drunk driving was a minimal and random culling of our herd, so I supported DAMM (drunks against mad mothers) both because it seemed rational to me and also it was more fun.

      Can’t remember when I got to understanding and believing CO2 in the air and greenhouse effect. Probably mid-80s or so.

      So now there are a whole lot more of us on earth and it seems we enjoy comfort and mobility if we can achieve that. That makes us burn stuff. Not good for climate change.

      So we are told we must fix the problem by moving the source of the energy we consume from gasoline in our cars or gas in our furnaces to whatever they do at that place where they make electricity.

      In my experience people like to be comfortable. Burning stuff either locally or remotely makes us comfortable. Changing our ways and rearranging our lifestyles and locations will be a last ditch survival attempt.

      So in my view, long term survival requires a big reduction in human population. Continued climate change will accomplish that but may kill off most other life forms too.

      Covid-19 made an attempt but looks like we mostly beat it back before it made an effective dent in our over population.

      To the original post, I’m good now but I have seen the possibility that I might want to check out in the next several years. How to do that? I could get a pistol but that’s very messy and ugly for who ever finds me and then has to clean up. So I thought it might be nice to have a small amount of fentenal in my freezer. But I have no idea where to get it. And how would I know it is real. Not an easy thing to test.

      Uhhm. Just a thought. What would sactrosanctimonious mean?

      1. RA

        Oh, I forgot the sacrosanct exception in our scheme of protecting all lives.
        Insert this after my first paragraph…

        Unless you are in the military and are unlucky enough to have your life terminated. But then, at least you are unquestionably a ‘Patriot’!

      2. aletheia33

        not to worry, RA!
        in several years, volunteering for the culling is likely to be easier than it is now.

  4. Sue inSoCal

    I’m late to the party on this, but I can’t take Kolodney seriously, even though he controls the horizontal and vertical of pain control for babysitting the US. Yes, I understand the criminality of the pill producers. Otoh, addicts will be addicts. I can kill myself legally with alcohol if I see fit. Alcohol and Tylenol will whack your liver pretty good in combination. Responsible intractable pain patients following responsible physicians’ advice did not cause the opiate crisis. Pain prescriptions are at an all time low now, but fentanyl from China is killing people at a record pace. Cui bono? Decriminalize.

  5. roxan

    I recall there were strong rumors of the CIA flying drugs from Cambodia during Vietnam, and cocaine from S. America. There is a good wiki about it that cites sources. I suspect many people have a thumb in this pie…. Meanwhile, actual sick people–even cancer patients–get no help and merely asking for a pain referral may result in your dr dropping you. I would guess, there are a few desperate pain patients risking their lives buying dope in Kensington. If you are suicidal, probably pretty easy to get dead there, too.

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