Illicit fentanyls in the opioid street market: desired or imposed?

Abstract

Background-Illicitly manufactured fentanyl and its analogues are appearing in countries throughout the world, often disguised as heroin or counterfeit prescription pills, with resulting high overdose mortality. Possible explanations for this phenomenon include reduced costs and risks to heroin suppliers, heroin shortages, user preferences for a strong, fast-acting opioid and the emergence of Dark Web cryptomarkets. This paper addresses these potential causes and asks three questions: (1) can users identify fentanyl; (2) do users desire fentanyl; and (3) if users want fentanyl, can they express this demand in a way that influences the supply? Argument/analysis-Existing evidence, while limited, suggests that some users can identify fentanyl, although not reliably, and some desire it, but because fentanyl is frequently marketed deceptively as other drugs, users lack information and choice to express demand effectively. Even when aware of fentanyl's presence, drug users may lack fentanyl-free alternatives. Cryptomarkets, while difficult to quantify, appear to offer buyers greater information and competition than offline markets. However, access barriers and patterns of fentanyl-related health consequences make cryptomarkets unlikely sources of user influence on the fentanyl supply. Market condition data indicate heroin supply shocks and shortages prior to the introduction of fentanyl in the United States and parts of Europe, but the much lower production cost of fentanyl compared with heroin may be a more significant factor Conclusion-Current evidence points to a supply-led addition of fentanyl to the drug market in response to heroin supply shocks and shortages, changing prescription opioid availability and/or reduced costs and risks to suppliers. Current drug users in affected regions of the United States, Canada and Europe appear largely to lack both concrete knowledge of fentanyl's presence in the drugs they buy and access to fentanyl-free alternatives.

Epidemiology of the U.S. opioid crisis: the importance of the vector

“…The high level of potency also helps to explain their lethality. According to law enforcement sources, fentanyl compounds are increasingly packaged and sold as “heroin” by drug dealers . Prices of the adulterated drug may be cheaper than heroin itself and the increased potency may even be a selling point, despite the clear risk for overdose .…”

“…A key question is how much do people who use drugs actively seek fentanyl versus how much is surreptiously added to the drug supply? While unintentional ingestion is certainly common, it appears that fentanyl is actively sought by some individuals who use drugs, and the high potency, as indicated by overdoses, may encourage the use of particular drug supplies . A study in New Hampshire interviewed people who use opioids about their practices and attitudes toward heroin versus fentanyl found that 25% specifically sought fentanyl or heroin laced with fentanyl over other opioids .…”

“…While many other users preferred heroin or a specific prescription opioid, the study found that alternatives without fentanyl were hard to obtain in their region. According to Mars et al ., evidence suggests that fentanyl has been added to the drug supply primarily because of supply‐led factors, that is, fentanyl augmented sometimes expensive and/or unavailable heroin and prescription opioids in a complex drug market. Given that how rapidly, and with such devastating effects, synthetic opioids have overtaken heroin and prescription‐type opioids, it is imperative that the public health community remains vigilant to market developments.…”

Addressing overdose risk among unstably housed women in San Francisco, California: an examination of potential fentanyl contamination of multiple substances

“…Study limitations include sampling from a single city, which limits generalizability to other locations, and a longer self-reported use period than drug detection periods. There was also no direct assessment of known fentanyl use as distinct from other opioid pain medication [30] for this secondary data analysis. Study strengths include longitudinal comparisons of both self-reported and mass-spectrometry toxicology-confirmed substance use, a focus on stimulant use, and a focus on women.…”

The opioid mortality epidemic in North America: do we understand the supply side dynamics of this unprecedented crisis?

“…Or rather, were the observed shifts in drug supply a response to existing domestic demand-side forces? Select examinations have sought to explore this question, including a 'three-wave' characterization of recent opioid supply, yet findings seem to primarily emphasize evolutionary developments in international illicit opioid production and distribution chains as the main drivers behind the opioid crisis unfolding in North America [21,22]. Substantial evidence supports the former perspective, namely that the recent 'wave' of toxic illicit opioid supply has emerged as an interrelated consequence within preexisting opioid demand and supply dynamics.…”