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.

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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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  • I really don’t know what to say about all this,except we were made in the Image of God, and really should be able to make our own choices for our bodies. Spirit is with us in what ever we choose, Its alright.

  • The war with drugs has always been a problem with the AMERICAN people. I don’t really know what to do about it, but take education on drugs serious, when it comes to our kids.

    • The DARE Program was supposed to educate kids, instead it appeared to introduce them to drugs. There is plenty of evidence that program did not work, yet they continued to do it to make money on the side. When kids see an adult lie to them, they tend to ignore it all.

  • I think everyone finds it easier to blame fentanyl than see the « white elephant » in the room! The real problem is that people who are users feel dienfranchized with the world, they can see a future, they have mental pain, anxiety, sadness, depression, too much pressure, loneliness, feeling like they cant keep up with Kardashians and other TV bubble heads. Of course fetanyl is nasty but real mental health issues need to be addressed to keep people engaged, loved, see an exciting fututre for themselves instead of horrible underpaid job and cared for. Therapy is expensive, carries stigmas, and often comes too late.Mental heal issues need to be nipped in the bud!

  • Folks , following All of the arguments about the opioid Problem only one sane conclusion keeps coming up–Legalize all of them with few restrictions get the hell out of our bodies and let us put in our bodies what we want to–
    Now tell me will you go out and get strung out on Heroin when it becomes legal- I sincerely doubt it !!!!!!!!

    • They did that in Portugal, and the death rates dropped. They also provided treatment. The US will remain beholden to the “Just Say No’ or “Pray it away” response to all of this.
      It looks like a lot of chronic pain patients chose death by suicide , over seeking out heroin or illegal drugs. These numbers have not been counted, by design.

  • We can blame the reaction to the “Opiate Crisis” for the prevalence of Fentanyl. Instead of going after the wholesalers, and pharmaceutical companies because they had paid off our policy makers, they went after pain patients. We can blame the AMA ad their lobbyists too, they decided to remain willfully ignorant of this topic, long before it became an “Epidemic.” They are still misinforming the public on the relationship between addiction and chronic pain. While people died from illegal Fentanyl, the media was going on about the dangers of prescription drugs. That was long after they were so over regulated that no Physicians were prescribing anymore for legitimate patients. At the same time they refused to fund any treatment for the addicted.
    This was a created “Crisis” and they are still misinforming the public. This is what Market Driven healthcare looks like! Follow the money!

  • Question if a client relapsed from Fentanyl in your treatment program what is clinical proctol to dis charging the individual

    • Why would there be a difference in any type of relapse the notion to relapse still would have been the same if he were to acquire his d.o.c.its still a conscience faction that an individual makes. I’m keen on this subject because I have struggled with opiate addiction for 8 years and still I go through the same thought process of everytime I slip and relapse. In the end its still a decision we make I must not understand the question I’m sorry if the response was not what you were looking for.

  • Tragically my wife and I just found our 26 year old daughter dead in her room
    Of what looks like a drug overdose laced with Fentanyl. We are still waiting for toxicology report.
    Fentanyl was not an issue when Oxycodin crushable pills were available. Obviously neither opiate is good but my rational is I would rather have my daughter alive with an Oxy issue than dead to fentanyl. I think the proper authorities need to reverse their decision so manufacturers can produce crushable Oxy . This just might knock Fentanyl out of popularity?

    • Steve, Very sadden by the loss of life of your daughter.
      The illicit drugs have been coming into the US since the Vietnam war if not before.
      History Channel has excellent segment War On Drugs.
      Fentanyl & Carafentyl & Heroin are coming into the USA by the tons. NY had a bust with enough Fentanyl to kill the population of NY & NJ 11 times over.
      CDC and a HHS panel realize this is not a prescription by physician issue any longer an one gentleman Richard Lawhern on Twitter @Lawhern1 that has information that prescription opiates or opioids are not connected to illicit use. You can also find my Twitter @Bobbygos under media of another chart from Lawhern & CDC shoeing the decline in prescrption opioids and dramatic increase in illicit opioids.
      The USCG missed 500 trafficking incidents in 2016 because of the lack of equipment and man power. 2017, Trump cut the USCG budget.
      Ret CIA operatives since the Vietnam war have stated “The USA has a cash flow addiction. Remove the cash flow and the use of illegal drugs will decrease or stop.”
      I think you have a good idea however there is such a bigger picture and I don’t see illicit opioids going away.
      The problem some Doctors are having is not prescribing enough pain management for injuries or radical procedures like back surgery or neck surgery which is a form of torture.
      We are seeing an uptick of chronic pain patients including veterans that have been responsible patients with their pain medication being lumped into the drug addict groups suddenly removed from pain management and abandoned. Therefore some killed themselves.
      The propaganda broad brush to a multilayer pain management system is hurting functional patients that contribute to themselves and society.
      Now the fight is for the chronic patient that is responsible and doctors not being afraid to prescribe a pain medication without worry of the DEA or CDC knocking on their doors.
      I know this doesn’t bring your daughter back however you can have sense of the BIG picture. Your not alone.

    • I am so sorry for your loss. The powers that be decided to outlaw all of the Pain Medications with no thought as to the number of deaths. They are still quibbling about treatment programs, long after the supply of Prescription Pharmaceuticals were cut off. They are still running a false narrative about the prescription drugs as people die from Fentanyl, and street drugs. They are still in denial and chose to turn to industry insiders rather than facts and science.

    • Why would there be a difference in any type of relapse the notion to relapse still would have been the same if he were to acquire his d.o.c.its still a conscience faction that an individual makes. I’m keen on this subject because I have struggled with opiate addiction for 8 years and still I go through the same thought process of everytime I slip and relapse. In the end its still a decision we make I must not understand the question I’m sorry if the response was not what you were looking for.

  • I have to be honest when I lived in Nh. I was arrested 9 times in two years with fetenoyl . Or meth and fetenoyl or herion and fetenyl I had to leave Nh to get help because the nh has no free help judges and courts are jokers and they givr no help only a 28 day rehab setence. I cant pay for it no one checks if i went I believe they want us to die

  • Mk your correct it is mainly a white man’s drug. The spanish, Mexicans , Dominicans mainly are cashing in.
    The Nh. System is letting the whites use and die. They know if they overdose they’ll be let go. Probation lets them use. Judges don’t do anything but a 28 day rehab like joel wrote 26 times in 28 day. that no one makes sure they go or complete. If their caught selling small amounts of fetenoyl or caught with it they get 30 days or less. This is a joke and my friends the users know it. Other countries I know a guy that has been in a six year rehab so far with out a known release date. The dealers overdosed on purpose to avoid being held for 30 days. The judges are idiots. Their wrecking society. Maybe their karma will give each of them a close family member addict. We need trump as Governor. Then he would have a closer look into this insanity in NH. THE capitol city has 6 to 8 overdoses every day. manchester has over 10. West Virginia has more deaths because of all the remote areas , can’t get to save them. Nh. Is a drug den. No one should be proud to live there. Live free and die. Holds true dealers and users are free no long term rehab like 3 to 6 or more year rehabs and the rest Die. Keep doing what your doing Nh. Now 46 percent of your population has an addiction. Wait soon more will be an addict than are not.
    This includes alcohol. Nh sells the most alcohol than the hudge states with millions more people, their more druggies and alcoholics in nh. Live free the druggies or let them die

    • It should all be completely legal and controlled that way you know exactly what your getting if your an adult and to dumb to know the consequences then it is your fault to make. If you die I hope you had insurance or a freind to cremate your ash! What could be the harm a nation of junkies? or a nation of open minds who say its a drug that could kill you or kill your pain either way its your decision to make. We do not need other hypocrites telling us what to do especially politicians. The reason its not legal is because too much money is made on the black market and other legitimate businesses running off the illegality of it just to keep that percentage of the population down and the other percentage up in terms of control over you. If you are a junkie either quit or tell you representatives you want to live your life the way you want and to make it all legal.

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