By Terry Gotham

If you follow the news about adulterants in the recreational drug supply, it’s easy to get overwhelmed with the news breaking every day. Last Friday, the medical examiner’s office of Cuyahoga County in Ohio disclosed that they’re on track to obliterate their overdose record from last year. With 187 heroin/fentanyl overdoses on the books since Jan 1st, if things don’t change substantially, they’ll blow past their 2016 total of 660 overdose deaths by over a hundred people. If you missed my last article, multiple types of fentanyl are now being found in overdoses & drug seizures. And I don’t mean one or two. 24 fentanyl analogs & metabolites were found in blood/urine in Ohio overdoses alone:

1-3-Methylfentanyl; 4ANPP; Acetyl Fentanyl; Acetyl Fentanyl 4-Methylphenethyl; Acryl fentanyl; AH7921; Alfentanil; Beta-Hydroxythiofentanyl; Butyryl Fentanyl/Isobutyryl Fentanyl; Butyryl Norfentanyl; Carfentanil; Despropionyl Para-Fluorofentanyl; Fentanyl; Furanyl Fentanyl; Furanyl Norfentanyl; Norfentanyl; ParaFluorobutyryl/4-Fluoroisobutyrylfentanyl; Para-Methoxyfentanyl; Remifentanil; Remifentanil Metabolite; Sufentanil; U-47700; Valeryl Fentanyl
~Research Update on Fentayl Outbreaks in the Dayton, OH Area, Boonshoft School of Medicine, Wright State University, 4/28/17

The growing pile of fentanyl-derived substances being found by law enforcement are being referred to as “fentalogs” for short by the substance abuse & toxicology communities. This means that the explosion in fentanyl-related overdoses is going to do nothing but climb. DEA samples from Georgia & Alabama have been found to have combinations of multiple opioids, including heroin, fentanyl, butyrfentanyl, and acrylfentanyl. This fucked up combination of multiple opioids has been dubbed “the Grey Death” by law enforcement officials & the media after the drug mixture started appearing in Ohio & Pennsylvania as well. In Cincinnati, the mixture includes U-47700, which, like W-18 of a few years ago, is seen as an opioid, but this has not been confirmed at the pharmacokinetic/receptor level yet. Also in Cincinnati, carfentanil is being found in in drug seizures alongside Grey Death mixture. Along with all of these pockets of multiple-opioid containing fentanyl seizures and commensurate overdose spikes, a confused panic has emerged within the news media. They’ve started calling fentanyl & fentalogs “Narcan Resistant” which is the most problematic statement I’ve heard in the world of harm reduction this year.

May 4, 2017 Scioto County, Ohio

Narcan Resistant Fentanyl Alert and Overdose Spike in Scioto County

A… https://t.co/uRuMcdSrPj

— PortsmouthCityH.Dept (@portsmouthhd) May 4, 2017

It’s problematic for a number of reasons. Making a declarative statement about a drug that has essentially no clinical, toxicology or animal model data behind it is the height of presumption. We simply do not know what side effects or secondary problems these fentalogs are responsible, or what acute or chronic use even looks like. While even the weakest fentalog is more potent than the strongest heroin, claiming that these substances are “naloxone resistant” is irresponsible and causes more problems than it solves. These substances are as problematic as the rest of the heroin out there, largely because many heroin seizures have been found to actually be multiple fentalog mixtures instead.

If you are using heroin in the USA, there is a high chance that your heroin isn’t heroin but is heroin+fentanyl or fentanyl or a fentalog.

— FtG (@forensictoxguy) April 26, 2017

Saying a drug is resistant to Narcan/Naloxone is easier than saying “We don’t know how potent these drugs are” but it totally obscures the issue and incites panic. People need more narcan when they’ve consumed more potent or more amounts of specific substances that are opiates or have been adulterated by opiates. But, there are no fentanyl analogues that have some type of inherent resistance to naloxone. That is simply fear mongering and causes more problems than it solves.

Both “the Grey Death” and “Narcan Resistant heroin” are topics that actually obfuscate the actionable stuff people needs to do. The Grey Death, especially as it’s been reported, neatly dovetails into the fentanyl news, classified as “Shit I don’t care about because I’m not a drug addict” for most people, even those who party hardy on the weekends. These are “IV drug use problems,” so ultimately, they’re not a problem if you see yourself as a recreational user of uppers & psychedelics, especially if you’re well to do. But, that is a category error of the highest order. Overdoses, stemming from cocaine that was adulterated with fentanyl or a fentalog have exploded in recent months.

This is a still from the snapchat video of a kid out in the Hamptons who overdosed on morphine thinking it was cocaine. In a suburb north of Vancouver, 9 overdoses & 1 cardiac arrest happened in 20 minutes one night. In Rhode Island, health department officials don’t believe cocaine or heroin in their state is clean anywhere.  Specifically, Linda Mahoney of the RI Dept. of Behavioral Healthcare, Developmental Disabilities & Hospitals, tested cocaine and heroin and found that fentanyl was “77% as likely to be found in cocaine as heroin.” That’s right, you’re almost as much at risk to be getting fentanyl when you pick up your gram for the party as when the junkie down the street gets his dime bag of black tar. While under 100 samples were tested, this pattern is being found all over the country. The CDC released a highlighted case report illustrating an incident in New Haven where 12 cocaine users were brought in presenting opiate OD symptomatology over a period of 8hrs. Three died, nine were admitted, 3 requiring intubation and one requiring a continuous naloxone drip. The “cocaine” only had trace amounts of cocaine, it being mostly fentanyl. Cleveland is beginning to see opiate overdoses from people who thought they were purchasing cocaine as well.

If you only take away one thing from this article, it should be that you need to test your cocaine. Every time. I don’t care how close you are with your dealer, I don’t care how much you brag to all your friends that your eight-balls are always a little heavy, I don’t care how long you’ve been snorting fat rails. As deaths rapidly overwhelm hospital systems in rural & suburban areas, these incidents will become ever more common. I have to stress, there are no field test kits currently available that can be purchased by citizens who aren’t emergency workers or law enforcement. While this is a problem for opiate users, if you test your cocaine with a home test kit and it tests positive for an unspecific opiate, you probably have fentanyl. This means that doing cocaine or opiates alone put you at risk for rapid inability to ventilate, leading to death by asphyxiation.

If this disturbs you to the point where you actually want to do something about it, the best way forward is to fight, at the state and local level, for safe injection facilities. These centers not only get heroin users into treatment faster, but also can test for fentanyl in cocaine and heroin far more effectively than can be done at the recreational or street level. Furthermore, call out sloppy rhetoric and comments made by the media & law enforcement. “Narcan resistant” will continue to be a meaningless term until we’ve done research evaluating the growing number of fentalogs and can provide correct dosing parameters to emergency response teams across the nation. We probably won’t be able to move the needle much when it comes to decriminalization or legalization under General Beauregard Sessions, but we can fight for safe injection facilities, needle exchange programs and to ensure that our friends party safe. That, in and of itself will save lives.