“They say it’s fentanyl, but they honestly look like Perc 30s”: Initiation and use of counterfeit fentanyl pills

Abstract

Background Worsening of the overdose crisis in the USA has been linked to the continuing proliferation of non-pharmaceutical fentanyl (NPF). The recent wave of NPF spread in the USA has been fueled by an increased presence of counterfeit pills that contain NPF. This qualitative study aims to characterize the motivation and practices of counterfeit NPF pill initiation and use among individuals using illicit opioids in Arizona. Methods Between October 2020 and May 2021, semi-structured interviews were conducted with 22 individuals meeting the following eligibility criteria: (1) 18 years or older; (2) residence in Arizona; and (3) use of illicit opioids in the past 30 days and/or opioid use disorder treatment in the past 12 months. Participants were recruited through referrals by a harm reduction organization, craigslist ads, and referrals by other participants. Interviews were conducted virtually via Zoom. Qualitative interviews were transcribed and analyzed thematically using NVivo. Results Out of 22 participants, 64% were male, and 45% were ethnic minorities. Age ranged between 25 and 51 years old. Participants noted significant recent increases in the availability of counterfeit NPF pills (“blues,” “dirty oxys”) that were most commonly used by smoking. The majority indicated first trying NPF pills in the past year, and the first use often occurred in situations of reduced access to heroin or pharmaceutical opioids. Participant decisions to switch over to more frequent NPF pill use or to maintain some levels of heroin use were shaped by local drug availability trends and personal experiences with NPF effects. They were also influenced by conflicting views of social acceptability of pharmaceutical-like drugs, perceived harms of NPF in terms of overdose risks and increased difficulty of quitting, and perceived benefits of switching to the non-injection route of opioid administration (e.g., from injecting heroin to smoking NPF pills). Conclusion Our findings highlight the need for the implementation of novel policy, treatment, and harm reduction approaches to address the growing unpredictability of drug supply and NPF pill-specific risks, attitudes, and behaviors.

Illicit Non-Pharmaceutical Fentanyl and its Analogs: A Short Review of Literature

“…Over the past decade, there was emerging unpredictability and accessibility of NPF and its analogs. 6 There is still much to learn about the pharmaceutical properties and safety profiles of these analogs, which further exacerbates the emerging issue. Fentanyl testing strips have grown in popularity to help individuals with safer drug use practices, but they are considered illegal to use in outpatient clinics per the DEA; advanced and legal technology to detect NPF and analogs more easily and accurately is required.…”

“…As shown in Figure 1 , a recent study in Arizona found a dramatic increase in the availability of NPF attempting to mimic 30 mg oxycodone, popularly known as “dirty thirties” or “M-30 tabs”. 6 The similarities between these tablets and commonly used pharmaceutical drugs likely reduced the risk perception for people who use drugs, especially compared to heroin. Additionally, NPF is significantly easier to manufacture and distribute, leading to reduced prices in comparison to heroin and pharmaceutical opioids.…”

“…The most common form of heroin is black tar, which when available, had an increasing frequency of contamination with NPF. 6 Other possible perceived benefits to switching to NPFs, described in some qualitative research, are route of administration and familiarity to prescription opioid pills. NPF pills allowed users to transition from the injection route of opioid administration to smoking.…”

Fentanyl, Heroin, and Methamphetamine-Based Counterfeit Pills Sold at Tourist-Oriented Pharmacies in Mexico: An Ethnographic and Drug Checking Study

“…Counterfeit pharmaceutical drugs-especially those containing illicitly manufactured fentanyls (IMF)are playing an increasing important role in the United States (US) overdose crisis [5][6][7] . IMF and other synthetic opioids have transformed the risk environment for people who use drugs (PWUD) given their much higher potency and shorter half-life compared to other opioids.…”

“…They have also been driving a large relative increase in the overdose death rate of adolescents 7 , who are more likely to experiment with drugs they perceive as prescription pharmaceuticals relative to powders sold as heroin, or other drugs that are more stigmatized 14 . For the general population, there is a profound added risk of counterfeit prescription medications relative to other fentanyl-based illicit drug formulations, as pills purporting to be pharmaceuticals may be perceived as a lower-risk category of recreational drugs 6 , despite currently representing one of the most potentially lethal options for illicit drug use, especially because they may be more likely to be used by individuals with no tolerance to opioids. Although counterfeit prescriptions are described in the US illicit drug market-and it is well-known that a large portion of the IMF and methamphetamine that are pressed into counterfeit prescription drugs sold in the US originate in Mexico 15,16 -the prevalence of their consumption among PWUD in Mexico is not well-described in academic literature.…”