In the fall of 1987, seven strangers at the Allegheny Country Rifle Club struck an agreement: They’d work together to start up a new drug network.
In the year that followed, they peddled “China White,” a white powder marketed as heroin. But produced in a laboratory using stolen chemicals and swindled prescription drugs, the substance was hundreds of times more potent, leading to the deaths of 18 people and as many as 60 nonfatal overdoses before the ringleaders were arrested in December 1988.
That white powder was the first analog of fentanyl recorded in Allegheny County, setting the stage for a variety of others to sweep into the region in the decades since — especially over the past two years.
Fentanyl is a synthetic opioid that is pharmaceutically used to treat severe pain, but it has become the most common drug involved in fatal overdoses nationwide. Its analogs are substances with similar uses and effects but different chemical compositions, leading some to be significantly weaker than fentanyl and others to be dozens of times stronger.
Fatal overdoses in Allegheny County have risen since 2018, with 2021 reporting the highest since record-setting 2017. Fentanyl analogs and other non-prescription synthetic opioids are becoming increasingly common across the county, with data showing that they were tentatively detected in 49% of fatal overdoses in 2022 — up from 21% in 2020. The county’s Office of the Medical Examiner has not yet completed toxicology tests on some of last year’s suspected overdoses, and expects to have that finalized by June.
Researchers fear that the proliferation of fentanyl and its analogs reflects a troubling nationwide trend: People no longer know the strength and composition of the substances they’re using.
“You don’t know the potency of it,” said Dr. Jeanine Buchanich, associate dean for research at the University of Pittsburgh’s School of Public Health and a professor within the school’s Department of Biostatistics. “You do become at-risk for having a potency higher than you wanted or intended, and then in that case, you’re very much at greater risk of overdose or death.”
Dr. Karl Williams, Allegheny County’s chief medical examiner, said that fentanyl and its analogs are among a range of substances contributing to overdoses across the county. “It’s rare to find a single drug,” he said. “They’re all mixtures — two, three, sometimes as many as nine different drugs through those stamp bags.”
‘The difference between life or death’
Nationwide, drugs are becoming increasingly adulterated, and this weighs heavily on people using substances, Buchanich said.
“They don’t always know what they’re on,” she added. “They know that it’s giving them this effect, but they don’t know exactly what it is.”
When fentanyl and its analogs are sold illegally in Western Pennsylvania, Williams said they’re often distributed in stamp bags. The stamp bags contain a powder form of the substances, which presents physical complications for the people packaging them.
“It’s not easy to get that perfect mixture when what you’re mixing is a solid,” said Jonathan Caulkins, a professor of operations research and public policy at Carnegie Mellon University. “You can have deaths caused by, in effect, an accident. They don’t realize there’s more in the bag than they thought.”
In January, Pennsylvania decriminalized fentanyl testing strips, which detect if fentanyl and many of its analogs are mixed into a substance. Although a step in the right direction, Alice Bell said this preventative measure is years too late and doesn’t address the current situation, since most testing strips can’t determine the quantity of fentanyl or analogs in a sample.
“At this point, we’re in such a crisis that I think we have to have a regulated, safe supply,” said Bell, the coordinator of the Overdose Prevention Project for the harm reduction nonprofit Prevention Point Pittsburgh. “People have to know what they’re getting.”
A lethal dose of fentanyl is equivalent to the size of a few grains of sand, and a lethal dose of its analogs can be slightly smaller or larger depending on their potency. For fentanyl and its analogs to trigger an overdose, they must be introduced into the bloodstream or mucous membranes — not simply touched — according to the National Harm Reduction Coalition.
The challenge of cutting fentanyl and its analogs into substances means that doses often vary from stamp bag to stamp bag. Because they’re such potent substances, Bell said that “a small difference in how much is in [a stamp bag] can be the difference between life or death.”
Treatment becomes complicated when substances of varying potencies are mixed together, particularly when adding fentanyl and its analogs to a substance makes it stronger than anticipated. If a person overdoses after using that substance, Buchanich said it’s difficult to determine how many doses of naloxone — a medicine used to rapidly reverse the effects of opioid overdoses — are necessary.
There are also consequences when the addition of fentanyl analogs to a substance makes it less potent than expected.
When people use opioids like fentanyl and its analogs, they develop a tolerance over time, meaning they need an increasingly higher dose to achieve the intended effect. They may take a larger dose if the substance doesn’t have the intended effect, increasing the risk of overdosing.
The rising prevalence of fentanyl and its analogs could additionally be leading people to choose to use a wider range of substances, Buchanich said.
In Allegheny County, the percentage of fatal overdoses involving both opioids and stimulants has steadily risen from 15% in 2014 to 48% in 2021, with 2022 expected to rise slightly higher. Buchanich suspects that people are using stimulants to counteract opioids’ depressant effects, which could put them at a greater risk of overdosing.
This creates an added challenge for treating people who have overdosed because, while naloxone can help reverse the effects of opioids, it’s ineffective against stimulants.
“You have poly-substance users, so you need to treat abuse problems for multiple different drugs,” Buchanich said.
A new round of whack-a-mole
The rise of fentanyl analogs isn’t groundbreaking when contextualized against the waxing and waning demand for illegal substances, said Dr. Jane Liebschutz, chief of the Division of General Internal Medicine at the University of Pittsburgh’s School of Medicine.
“It’s like whack-a-mole,” she said. “You get something, and then something else pops up.”
A decade ago, fentanyl was a rarity in Allegheny County — detected in just 5% of fatal overdoses in 2012 — and its analogs had disappeared without a trace years earlier. Heroin was the most common substance involved in fatal overdoses, supplanting prescription opioids.
Two years later, fentanyl’s meteoric rise changed everything.
As fentanyl was increasingly cut into local drug supplies, fatal overdoses across the county reached unprecedented levels, peaking with 835 deaths in 2017 — of which 73% involved fentanyl, according to the county’s overdose dashboard. The percentage of fatal overdoses involving fentanyl has continued to climb in the years since, accompanied by the growth of fentanyl analogs.
Williams said the most popular fentanyl analogs detected across the county over the last five years are acetyl fentanyl, which is less potent than illegally manufactured fentanyl, and para-fluorofentanyl, which has a similar potency to illegally manufactured fentanyl.
“There’s no rhyme or reason — nationwide or in any area — why one particular analog shows up or the other doesn’t,” Williams said.
Buchanich said the steady emergence of fentanyl analogs is the natural next step in the cycle of producing more potent substances for the lowest price.
“What we used to see for a while was just prescription opioids,” Buchanich said, “then just heroin. Started becoming heroin adulterated with fentanyl and then more fentanyl than heroin. Now, adulterated fentanyl with fentanyl analogs.”
The cycle ensnares people using substances by making them dependent on stronger and stronger doses, leading to more demand for highly potent substances like fentanyl analogs.
From an economic standpoint, creating synthetic opioids like fentanyl and its analogs benefits drug producers and traffickers because it provides them with an alternative to the laborious process of farming and transporting heroin.
“Synthetic opioids cost less per gram, and they are more potent,” Caulkins said. “When the supply chain switches from heroin to synthetic opioids, it is just reducing its costs.”
In recent years, recipes for producing fentanyl and its analogs have become easier to find online and replicate, which may be contributing to their rising prevalence.
“The whole world has developed over the last 25 years, and now there’s a lot of people in a lot of places that know enough chemistry to do these synthesis reactions, particularly now that there are some that are simpler than what was in the past,” Caulkins said.
The path to ‘keep folks alive’
Caulkins said law enforcement is experiencing greater difficulty curtailing supplies of fentanyl and its analogs because the process of creating these substances has grown so decentralized. People can now import the precursor chemicals for creating fentanyl and its analogs, and as the equipment to finish synthesizing these substances has grown simpler, more laboratories have cropped up.
“At this point, it’d be very hard to shut down enough labs to make the fentanyl go away,” Caulkins said.
Buchanich said anyone using illegally produced opioids should carry multiple doses of naloxone — in case they overdose after using a substance stronger than anticipated — and avoid using without another person nearby. She also recommended that first responders, law enforcement officials and health care providers be continually provided with training on substance use and harm-reduction principles.
“You have to keep folks alive to get them into recovery,” Buchanich said. “Harm reduction helps to do that.”
Williams’ office is currently conducting research to analyze the quantity of substances detected in stamp bags across the county, funded through a grant from the University of Pittsburgh School of Pharmacy.
“To know the exact levels of each of the drugs — nobody else in the country is doing that,” Williams said.
Williams’ research is set to end soon, and as of late February, he was unsure if the grant funding would be extended.
Buchanich said this sort of testing could especially help to identify the effects of new fentanyl analogs coming into the region. “Then we can look into the potency [and] understand what may be happening to substance users and first responders who have contact with it,” she added.
Liebschutz added that until the root causes driving people to misuse substances — such as poverty and unemployment — are addressed, the cycle of peddling increasingly potent substances will continue pressing forward.
“The analog problem is just part of this bigger issue,” she said. “It’s just a continuation of the same issue that we’ve been experiencing in our country for a long time.”
This story was fact-checked by Abigail Nemec-Merwede.
This reporting has been made possible through the Staunton Farm Mental Health Reporting Fellowship and the Jewish Healthcare Foundation.
- The Pennsylvania Harm Reduction Network assembled a resource guide to help people connect with services for overdose prevention, safer substance use and recovery.
- Prevention Point Pittsburgh provides syringe services, wound care and management for people using substances. Call 412-247-3404 or email firstname.lastname@example.org.
- The Never Use Alone Hotline is run by volunteers who have lived experience with substance use disorders. The volunteers stay on the phone with callers as they use substances and contact emergency medical services if the caller becomes unresponsive. Call 1-800-484-3731.
- Pennsylvania’s Acting Secretary of Health and Physician General issued a standing order that allows anyone at risk of experiencing an opioid-related overdose — and their family and friends — to obtain naloxone at their local pharmacy. People can also have naloxone mailed to them for free.
- Pathway to Care and Recovery provides Allegheny County residents with services including peer support and linkage to recovery programs. Call 412-325-7550 or email email@example.com.
- The Pennsylvania Get Help Now Hotline assists people in finding nearby providers of treatment for substance use disorders. Call 1-800-662-4357.
- Onala Recovery Center offers services for recovery including connections to certified recovery specialists, daily group meetings and free Narcan and monthly trainings. Call 412-471-8797 or email firstname.lastname@example.org.
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