The opioid crisis just keeps getting worse, in part because new types of drugs keep finding their way onto the streets. Fentanyl, heroin’s synthetic cousin, is among the worst offenders.

It’s deadly because it’s so much stronger than heroin, as shown by the photograph above, which was taken at the New Hampshire State Police Forensic Laboratory. On the left is a lethal dose of heroin, equivalent to about 30 milligrams; on the right is a 3-milligram dose of fentanyl, enough to kill an average-sized adult male.

Fentanyl, according to the Centers for Disease Control and Prevention, is up to 100 times more potent than morphine and many times that of heroin.

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Drugs users generally don’t know when their heroin is laced with fentanyl, so when they inject their usual quantity of heroin, they can inadvertently take a deadly dose of the substance. In addition, while dealers try to include fentanyl to improve potency, their measuring equipment usually isn’t fine-tuned enough to ensure they stay below the levels that could cause users to overdose. Plus, the fentanyl sold on the street is almost always made in a clandestine lab; it is less pure than the pharmaceutical version and thus its effect on the body can be more unpredictable.

Heroin and fentanyl look identical, and with drugs purchased on the street, “you don’t know what you’re taking,” Tim Pifer, the director of the New Hampshire State Police Forensic Laboratory, told STAT in an interview. “You’re injecting yourself with a loaded gun.”

New Hampshire, like the rest of New England, has been particularly hard hit by the opioid epidemic. The state saw a total of 439 drug overdoses in 2015; most were related to opioids, and about 70 percent of these opioid-related deaths involved fentanyl. The state has seen 200 deadly opioid overdoses this year so far, said Pifer.

Fentanyl was originally used as an anesthetic. Then doctors realized how effective it was at relieving pain in small quantities and started using it for that purpose. In the hands of trained professionals — and with laboratory-grade equipment — fentanyl actually has a pretty wide therapeutic index, or range within which the drug is both effective and safe.

The difference in strength between heroin and fentanyl arises from differences in their chemical structures. The chemicals in both bind to the mu opioid receptor in the brain. But fentanyl gets there faster than morphine — the almost-instantaneous byproduct when the body breaks down heroin — because it more easily passes through the fat that is plentiful in the brain. Fentanyl also hugs the receptor so tightly that a tiny amount is enough to start the molecular chain of events that instigates opioids’ effects on the body.

This tighter affinity for the opioid receptor also means more naloxone — or Narcan — may be needed to combat a fentanyl overdose than a heroin overdose.

“In a fentanyl overdose, you may not be able to totally revive the person with the Narcan dose you have,” said Scott Lukas, director of the Behavioral Psychopharmacology Research Laboratory at McLean Hospital in Belmont, Mass. “Naloxone easily knocks morphine off of the receptor, but does that less so to fentanyl.”

Matt Ganem, a former addict, explains the excruciating process of opioid withdrawal. Alex Hogan/STAT

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  • Your “lethal dose” amount of 30mg is WAY off – Studies have shown the average dose by users to get high is 50mg – 250mg, with 200mg being quoted as being the “minimum for a lethal dose” in some people.

    • I’m sure they mean someone who does not have a tolerance to the drug. That would not count as tolerances are different due to length of use, strengths, quality etc. So I am going to safely assume that it means 30mg could be a deadly dose to someone who has little to no tolerance to the drug.

  • i have 3 main symptoms of withdrawal or rather 2…there might be 4 or even more i don’t really notice because of the way i am in general…like depression and anxiety, etc…is normally always going to be present with me. I’ve had those problems all my life. I’ve also always had trouble sleeping for different reasons. I have a wild imagination, and have had auditory hallucinations since I was a child always making it difficult to sleep. Insomnia from withdrawal is different though, like I don’t get any sleep at all. None… I’ve gone 5 days straight before I get MAYBE an hours rest after a really hot bath. I don’t sleep though. I might get my first 2 hours sleep after a full week or so. idk.. going beyond this point is really iffy because it’s really hard to get much further than this. I’m not even at the hard part yet. First come the muscle aches, which start immediately before anything else normally like might get them within the same day i take any kind of opiate. these are pretty common I hear. They aren’t so bad at first, but they get worse and worse every day until it feels like all the muscles inside are continually burning…tightening…but it’s not like I’m working out. I get the impression it’s the feeling of muscle atrophy. Eventually it’s happening to my entire body and even my face. I remember feeling like i had these 2 giant ass pulsing veins burning up leading from my neck through my cheeks to my ears.. what is it.. the “Masseter” is the muscle right there lol that I assume was going through atrophy during withdrawal. That’s what kicks in first…anyways…muscle aches. normally doesn’t take long for it to start, and it starts off really subtle like it’s not at all that bothersome for the first day, but i still might not be able to sleep it depends…especially on the second symptom i get, which is the worst of them all in my experience. Crazy thing about it is, I normally LOVE this feeling. I used to go out of my way to get the feeling all the time…I remember talking to people about it a long time ago when it was still relatively an unknown subject and most people had no idea what I was talking about. Saying I get “goosebumps” is taking it lightly. These aren’t any ordinary chills, they are painful, especially in combination with the fiery muscle aches. The trillions of ice cold spikes and needles piercing over all of my skin in consistent waves. They don’t just come and go, they are constant. ALWAYS. When one wave ends, another one begins, and they go all over my body, no matter what I’m wearing, how hot it is, and when I’m in sweats it is that much worse my god can the chills hurt like hell is freezing over while my muscles burn in atrophy. At first, I thought, hey maybe if I just get warm, they’d stop, right? No, that’s not how it works apparently. That’d just make me sweat, making the chills hurt even worse than they were before. It seems the only thing that really helped was a hot bath…and my god was discovering it practically a religious experience for me. I still got chills in the hot bath…like just as constantly, but it seemed they didn’t hurt as bad, and the muscle aches are practically unnoticeable when soaking in a hot bath. On their own, neither of the symptoms would be all that bad, like it isn’t THAT painful, I mean it is, but…but those extra cold needle chill waves that leave goosebumps(i have goosebumps permanently basically is what im saying) in combination with the fire of the muscle aches i just assumed was the reason for my insomnia. I just thought it was impossible to sleep through that, I mean I don’t think anyone would be able to it’s rough. it sucks. Either way, I think the insomnia is its own symptom as well, because when my other 2 main symptoms steadily start to pass, i still go sleepless and would only get 2 hours of sleep every 24 hours or so at most. idk how long that lasts…oh i almost forgot another thing idk if i’d call it a symptom, but it feels liek time moves so very slowly. I remember soaking in a bath at a friends house, and watching the clock on his wall and thinking it was broken or something, because it felt like i was staring at it for a good five minutes where the second hand just kept flicking back and forth on the same second. idk if it’s boredom or just being so withdrawn it’s impossible to enjoy anything life has to offer so much so that it feels time is frozen still and i’m just stuck there.

    I just watched that video about the “science of withdrawals” and wanted to add my own personal experience. Mine seems to be a bit different from others I’ve heard personally…

  • Our sons and daughters, family members and friends never deserved to die from an overdose like they did, and they never meant to.

    I have never been ashamed to tell people the truth about my sons cause of death. However, I must admit that during those first moments after death was confirmed I thought of telling people it was from cardiac arrest only because I was concerned about what he would want people to know and how he would want to be remembered by those who didn’t know about his addiction. Then I thought “hell no!”, people talk and are going to find out anyway then think I am ashamed of my son.

    Everyone has at least one major problem of some sort that alters life in one way or another. The way I feel about it is that drugs are not who users are or were, it is/was only THEIR PROBLEM. Those with addictions have many other sides to them. They are mothers, fathers, brothers, sisters, sons, daughters, friends, etc. They are/were people with hopes and dreams and who are/were fully capable of giving and receiving love. They have/had personality beyond the addictive personality. They are or may have been highly intelligent, artistic, comical, giving, loving and so on, … they are/were so many things to so many people with so many different qualities about themselves. A drug problem does not make a person any less than anyone else. I’ve always hated the word “addict” because the label sounds like that’s all there is/was to the person or that it’s the first and foremost thing about them. It just stands out and takes over the person. However, I do understand that in a group like Narcotics Anonymous that stating you’re an addict is a way of feeling you have something in common with all the other people there in recovery. But I do think that repetition can be brainwashing into making someone think that’s what they are before anything else.

    If you read this and have struggled or you are now struggling with an addiction, please, please think of yourself as more than your drug problem because you are way more than that. You are a beautiful soul in a very stressing and complicated world. Perhaps it all started as a way of coping with something, or it may have been a prescription for pain that got out of hand. Whatever the reason please be kind to yourself. Look in the mirror and repeat to yourself “I am” and list all the positive things about yourself. Never let this past or present problem make you lose your self-worth.

    It is coming up on 6 months since I lost my beautiful son. It’s so hard because for a little over 29 years not one day passed that I didn’t see or talk to him and now it’s been almost half a year since I’ve seen his face or heard his voice. I talk to him on and off every day. Getting no reply is the hardest thing ever. I will never move on but since there’s no choice but to go forward I will help others who are battling an addiction. My college education was focused on substance abuse counseling. I do not agree with the way addiction is handled in America—almost all the way around, from cops and court to some of the types of help. And good luck in some states for those who do not have insurance or a family member who can and is willing to pay! My son tried to get help just months before he died and was tuned down from several places.

    I’m still messed up and trying to heal but I’m also trying to put something together a little at a time to do my part. What we are doing in the US is not working, it’s just getting worse. We have to do better! NC had the death by distribution act signed into effect. I feel this will cause more deaths in the long run because who is going to make a 911 call to help someone who has overdosed when they fear they could be charged, especially if they were also using with the person. Always some crazy, useless law and more punishment. Where is the love in all this? Why are they not coming up with something that can actually help people instead? Why are they not looking at the effectiveness of Portugal’s way of treating addiction? Drugs and addiction rakes in a ton of money. I say the life and wellbeing of people with this disease and their family’s wellbeing is way more important. I’m determined to advocate for something better than what we have. Some people say drug use is a choice. It may have been at first but after addiction sets in the choice is no longer there. This doesn’t mean it can’t stop. But it will take a lot of caring and support.

    I wish you all peace and love.

    • Thank you for a beautiful and well written piece. You said everything and more that I have tried to say since the death of our son in 2017. We have been in hell for 2 years and the treatment we received, like you said, has been horrible. All you said and more. One thing I might add is our son’s doctor had him on Oxycodone, Valium, and Ambien. Doctors are also a big part of this problem and I havent seen much as to their part in this epidemic. Our son hated how he felt but was unable to stop. Peace and healing to you as well. The grief will never end but I will keep doing everything in my power to get justice for our son and our family. Florida is a horrible state as far as this crisis and it’s been a nightmare trying to deal with them. Prayers and peace for you and everyone else that has lost a loved one.

    • I feel your story. Of course your son hated it!! No one means to become addicted to drugs, ruin their life while also making it hard on their family, and even die from an overdose one day. You will never get over the grief you feel but only get through it the best you can day by day. My son often told me how much he hated the need to use. He felt guilty because he knew how it was affecting him and the entire family. He had 3 children who he loved and adored but he still used. Never let anyone tell you that if he hated it bad enough or cared enough for himself and family then he wouldn’t have used drugs; it’s not that simple.

      North Carolina is as horrible as Florida. Doctors would not help my son. The cops we had to deal with never made it any easier for us while going through so many moments of crisis when he would find himself in trouble. They actually made things worse in lots of ways, which caused even more stressful situations for my son, but also for the whole family. Stress causes and increases use of drugs.

      Sending someone who has an addiction to jail or prison never made much sense to me. It is downright cruel. My son was caught with drugs and sentenced to a year in prison at the beginning of 2017. After his release I learned about the abundance of drugs in the prison system and all the petty little programs designed to cost the least amount of money that never work. My son was spending the weekly money we sent on suboxone strips. I never knew until his release. He was shown how to soak the strips in a spoon of hot water until melted down so he could then snort the water up his nose. I heard about a few guards who brought drugs in as well as how a supervisor on the road crew would have an inmate score drugs for him and let the inmate acquire and carry drugs back to the prison.

      Our system is so screwed up!!! Why send anyone to jail or prison!! Oh yea, because it generates a lot of money for people who just don’t give a damn, and the system knows about things that are going down in there. I’m not out to bash anyone, I’m just speaking truth. The reality of this epidemic is overwhelming in all areas.

      Within 5 months of release, he overdosed once, in which narcan saved his life. He tried to stay clean but could not get any help without insurance or cash. It was way too expensive, much more than buying drugs to calm withdrawals. There was no narcan to save him later. He lay there while people in the house robbed him and waited for a long period of time before calling for help. The only reason they made the call is because where he was they had to.

      We all have stories that are similar in many ways but that also have different circumstances in them. My story is a long and horrible one that I’m not ashamed of and would love to talk about but no one wants to listen. We should all support each other and find a way to keep in touch to vent our stories. If others would like to, I’m all in. However, I do not like or use Facebook.

    • Give me a sec. I had to take a minute. A few steps back from where I’m sitting. I started crying and I was so choked up I couldn’t finish reading the final paragraph of your comment. I really hate the way the U.S. handles drugs, the USDA and FDA are completely biased and a result of self-serving capitalism. They list these things off as poison right…one of which, by the way, was the very foundation on which the United States was built. Then if you’re caught with enough of the wrong thing, you’d might as well have raped and murdered an entire family. I think at one time people were getting life in prison just for having a single hit of acid on them. If I’m not mistaken people are STILL in jail for marijuana distribution in states that have legalized it. The FDA was built from prejudice, and all that can be built from prejudice is-you guessed it-more prejudice. As if DARE did anything but spread misinformation about would-be lucrative product that has absurd regulations. That’s just the tip of the ironic iceberg. It’s correct to be cautious, but to serve entire generations prejudices of product is going to create schisms in social hierarchy. That should be OBVIOUS, but that’s not even the real problem. Think about how much it costs to get a doctor to tell you what prescriptions you can and can’t take if you get sick or hurt. Most drugs are inexpensive and easy to make, lucrative drugs like opioids are INCREDIBLY cheap. I mean, they are no kidding the oldest drug known to man. I mean it makes sense right? Why wouldn’t it be. But here, in the U.S. you GOTTA get a prescription from a doctor, where you GOTTA go to college to get your credentials. All this debt has been built up through prejudiced bullshit we just accept like that’s just how it’s supposed to be, but ask a child what they think. An innocent child, who knows no prejudice might be wiser than the average man on the subject. Ask them why is the doctor so expensive? Why is it they know what drugs do what? Why are the specialized schools so expensive? Why do we need these signatures of “authenticity”? Is it really the truth? The whole truth and nothing but the truth? Even in their confusion, I’m sure they’d eventually be able to gather we’re all fools at the very least. Opium is the oldest, most important, heavily used medicine on the planet since ancient times, but what about a methadone or suboxone clinic? I just got back from one, and the drugs including the doctor’s appointment(nothing but a signature from literal monkeys considering the handwriting) cost me 300$ for just TWO WEEKS, and NO insurance pays for this kind of medicine. Trust me we looked for insurance. There’s always some kind of catch, some rule in place, that looks like it basically just means “no, this is how we make our money back off the dead[we killed] and impotent[we jailed] on the street.” There are “plans” but they are totally up to the individual doctor’s discretion whether or not you’re worthy of a payment plan. I mean I don’t want to point any fingers because I don’t think any one person is at fault. The blame rides on everyone’s shoulders for being so prejudiced and allowing all this prejudice to fly as if it’s normal. People just shrug it off like that’s the way it’s supposed to be. Why stop here when we can talk about everyone’s favorite thing to talk about…by [PC]themselves. Every single election without fail is like watching a boxing match. Their grandiose visions are more comparable to some useless ad that’s just a label on the butt of their trousers because it’s impossible to deny whoever looks worse at the end of the match is the one that loses. Who cares about the person running the country, as long as it’s not THAT person, right? As if any one of us can judge. It’d be one thing if we were all running for it, but we aren’t. It’s not supposed to be a popularity contest with votes kept personal. I’m not on the ballot am I? *looks around shiftily* Humans are naturally compelled to the truth, it’s that simple. And if it matters THAT much, nobody would even care where it came from, they’d might as well have said it themselves. Nobody cares who said what first. It’s not like you can put a price tag on freedom.

    • Parents NEED to start raising HELL and calling anybody and everybody that gave these drugs to our children. I call police, news media, board of health, Governor, Attorney General, Congressman, DEA, and in and on. No doctor should EVER get away with treating my son less than a HUMAN BEING in cahoots with the crooked lawyer trying to get as much cash in their pockets without giving a damn about my son!! And let’s don’t even go to the crime scene where if the cops had any kind of IQ they would have figured out the person at the crime scene was INVOLVED and they treated it as natural causes. Florida needs to get on the ball and start prosecuting these pill mill doctors and anyone caught selling fentynal resulting in death should go to prison for LIFE. It’s murder, they know someone will die, and they should pay. I will keep calling and making noise until THE DAY I DIE TO GET JUSTICE FOR OUR SON!! All this opioid talk and lip service is worthless and it’s time for ACTION!!

  • Wow. Yes. This is the answer. If people believe that they are being granted a future then they will step up. I wish this was the policy worldwide!

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