Guidance for Handling the Increasing Prevalence of Drugs Adulterated or Laced With Fentanyl

Fentanyl and its analogs are the primary drivers of deaths related to the opioid overdose crisis and are responsible for the “third wave” of the opioid epidemic (3). Fentanyl has become ubiquitous in the illicit drug supply across the United States and can be used knowingly or unknowingly. It is often added to or replaces other drugs, including opioids such as heroin and nonopioids such as benzodiazepines, and is added to drugs that are consumed by smoking. Fentanyl has also been found pressed into counterfeit pills that are sold to people who may believe that they are buying authentic prescription medications (e.g., oxycodone or Xanax). The effect of fentanyl and its analogs is at least 50 times stronger than the effect of heroin (4). The unintended use of fentanyl, especially by people who have not built a tolerance for opioids, has led to a spike in drug overdose deaths across the country. The potency of fentanyl is such that even people with a history of drug use, opioid use disorder, and high tolerance can easily miscalculate dosage and experience a fatal overdose. Overdose by fentanyl can occur by ingestion, inhalation, or injection but not by exposure through skin (5).

The high potency of fentanyl may require multiple doses of naloxone to reverse an overdose. Because fentanyl and its analogs tend to produce profound rigidity in the diaphragm, chest wall, and upper airway (i.e., wooden chest syndrome) within a narrow dosing range, routine administration of naloxone may not successfully reverse respiratory depression without airway management. Buprenorphine induction can be difficult in the case of fentanyl use, but microdosing buprenorphine can be a good option when fentanyl is the main drug of use.

Black, Hispanic, and Indigenous people with opioid use disorder may be disproportionately affected by opioid overdose (6). The number of opioid overdoses increased during the COVID-19 pandemic. Potential contributors during the pandemic include the closure of treatment centers and harm-reduction programs, decreased access to naloxone, physical isolation preventing bystander rescue, mental health stressors, financial instability, and changes to drug supply networks. In this article, we discuss guiding principles and offer recommendations for remediating the impacts of the rising rate of drugs adulterated or laced with fentanyl.

We endorse four principles to address the escalating fentanyl crisis embedded in the ongoing opioid epidemic. First, pursuing an incremental approach to behavior change (i.e., harm reduction) is the essential and primary principle that should be applied when implementing efforts to address the consequential impacts of fentanyl exposure and use. Centered on “meeting people where they are, but not leaving them there,” the goal of harm reduction is not abstinence, but reducing the risks involved with drug use and improving the health of people who use drugs before death by overdose makes recovery impossible. Most patients seeking help for substance misuse are not initially trying to achieve abstinence. According to the stages-of-change theory, only approximately 20%–30% of these patients are actively making a change (7), yet many substance use disorder programs are designed for that group. Such a system risks losing the opportunity to significantly improve the health and function of the other 70%. Meeting people where they are, delivering motivational enhancement, and setting goals for incremental change and gradual engagement, rather than solely for abstinence, make sense to guide care. Recovery is almost always an incremental process. Some improvement is better than no improvement, and safer use and reduced use of opioids are valuable interim steps. Persons should not be denied ongoing treatment when they have reduced their drug use but have not achieved complete abstinence. The recommendations discussed below offer a range of specific and effective harm-reduction interventions.

The second principle is that engagement always precedes treatment. Programs should strive to offer whatever information or services, such as testing for fentanyl, a person with substance use challenges is open to receiving and encourage them to come back for a follow-up visit.

Integrated care is the third principle. Many people who use drugs may be seen in primary care before receiving specialty treatment. Even if they are identified as having a substance use challenge and are open to a referral, not enough treatment programs are available to treat all persons in need. The provision of interventions needs to move upstream in the cascade of care to improve initiation of and engagement in treatment. Additionally, inequity in access to health care persists in the United States, and many communities do not have access to treatment at all. The most effective intervention to treat individuals with opioid use disorder is induction onto a medication approved by the U.S. Food and Drug Administration (FDA), such as methadone, buprenorphine, and extended-release injectable naltrexone. Medical settings (e.g., internal, family, pediatric, psychiatric, and obstetric medicine), whether inpatient, outpatient, or emergency department (ED) services, provide an opportunity to screen patients and intervene, and peer support specialists and recovery coaches can maintain engagement and foster transitions between treatment settings.

Vigilance about the common problem of fentanyl-adulterated illicit drugs is the fourth principle. Clinicians, program staff, and the people they serve should all assume that street drugs are contaminated with fentanyl and that any overdose involves fentanyl until proven otherwise.

We offer the following recommendations for remediating the impacts of the rising rate of drugs adulterated or laced with fentanyl. As recommended by the U.S. Preventive Services Task Force (13), all health care providers should be incentivized to periodically screen patients for use of illicit substances by using validated screening survey instruments. All health care providers should promote and increase access to harm-reduction services and supports. People who use drugs should be advised to assume that any illicit drug contains fentanyl until proven otherwise, be provided with naloxone and educated on how to administer it, and be given FTSs wherever possible and be encouraged to use them regularly. Additionally, they should be advised to test an illicit drug that they have not used before and advised to take an initial, highly diluted microdose of an illicit drug on the assumption that it contains fentanyl and could cause overdose.

Laboratory companies and health care systems should include fentanyl on all comprehensive drug screen panels to increase the ease of its detection. The Centers for Medicare and Medicaid Services (CMS) should prioritize approving one or more point-of-service tests for the presence of fentanyl in blood, urine, or saliva that do not require sending the sample to a certified laboratory (i.e., CLIA-waived tests), and all states should make FTSs legal for over-the-counter sales.

Additionally, hospitals should be incentivized to initiate medications for opioid use disorder and provide people with FDA-approved medications when they seek help, including during ED visits and before hospital discharge after an overdose. Interns, residents, and fellows in EDs, internal medicine, psychiatry, obstetrics, and pediatrics receive inadequate education and are unprepared to identify persons at risk for fentanyl overdose and to meaningfully and collaboratively intervene to substantially influence outcomes. Health care organizations, including primary care clinics, should give performance feedback to individual clinicians and programs on rates of initiating induction of medication-assisted treatment and referral to opioid use disorder treatment.

Furthermore, communities should better integrate the immediate induction of buprenorphine treatment (urgent management) in EDs and hospitals after overdose with continuing services in substance use treatment programs. Communities should also better integrate health care treatment and services with the criminal legal system (14) and increase access to prearrest diversion programs that encourage treatment in lieu of incarceration. Participation in these programs should not require proof of abstinence. Moreover, communities should increase access to evidence-based treatment in jails and prisons, including follow-up and linkages to community-based care and treatment. The highest risk for overdose occurs in the days and weeks after incarceration ends; all persons leaving incarceration should be advised of their increased overdose risk and be provided with naloxone, FTSs, and linkage to care in the community.

Finally, legislation is needed to eliminate restrictions on buprenorphine prescribing and to decriminalize possession of morphine. Federal law and CMS regulations should include safe-harbor provisions related to using contingency management for substance use disorders. Contingency management is an evidence-based and highly effective treatment strategy (15).

Overall, remediating the opioid overdose epidemic requires an incremental harm-reduction approach that engages with persons who use drugs. Continued vigilance about fentanyl adulteration is imperative from providers and those who use illicit drugs.