Opioid overdose deaths continue to rise. A 2015 DEA report showed a greater than thousand-fold increase in fentanyls —potent synthetic opioids— showing up in intercepted drugs. This, more than anything, fuels our worsening crisis.

The economics and pharmacology of fentanyl are game changers. Word on the street is buyer beware. What’s sold as heroin is probably fentanyl. What looks like a Xanax, Oxycodone, or Ativan could also be fentanyl.

This story has been brewing for a few years. As a medical director and opioid taskforce member, I became aware of fentanyl as it popped up repeatedly in autopsy reports I review as part of my day job. But the issue grew clearer when a young woman in recovery told me why fentanyl is so attractive.

“If you and your friends hear on the news that there’s killer dope in Willimantic. You’re taking a road trip. That’s the dope you want.” And no, she and her friends are not suicidal. They’re chasing a high that has become elusive for the user who’s developed tolerance.

The jaw dropper came when another one of my committee members, also in recovery, laid out an ugly truth. ” You have to understand the economics of fentanyl. That’s what this is about.”

Here’s a word problem to illustrate:

For under $4,000 you can purchase a kilogram of fentanyl, about the size of a brick, from China. It’s 100 times more potent than heroin. So, a milligram of fentanyl equals 100 milligrams of heroin (an average bag).

A kilogram contains 1,000 grams, each of which contain 1,000 milligrams.

So, a four-thousand-dollar kilogram of fentanyl yields one million doses.

A pill press on eBay runs several thousand dollars. The fentanyl is then cut and pressed to look like Oxycodone, Roxicodone, Vicodin, and even nonopioids such as Xanax, Ativan, and Klonopin.

The pills wholesale for $5 each. Or $5 million gross. But the final price will run between $10-$20 per pill, which leaves plenty of meat on the bone for the street dealer.

Alternatively, the fentanyl is bagged and packaged as heroin. A ten-bag bundle in Hartford runs about $35. In this scenario the dealer grosses $3.5 million per kilogram of fentanyl.

Profits like these push the price to the end user ever lower. New consumers, such as high-school students, with limited funds find fentanyl products cheap and plentiful. What was once a rare commodity is now an entry-level option.

While we seek longer-range solutions, we must face the current reality and focus on saving lives.  Anyone who purchases drugs on the street needs to know that they are likely getting fentanyl —this includes a pill from a trusted friend who swears it’s from a doctor.

Naloxone (Narcan) in adequate quantities and doses should be in the hands of drug users, first responders, family members, high school coaches, school nurses, and anyone who is likely to encounter an overdose. If you live with a teen, I recommend you have it in the house.

Drug users need to buddy up and know that they won’t get arrested if they call 9-1-1 when they help someone who has overdosed. And while supervised drug-use settings are distasteful to some, they save lives. We should have them.

But finally, there’s the shimmer of a silver lining. After an overdose reversal, there is often a tiny window where a person will contemplate treatment. Oh my God, I almost died. It’s in that fleeting moment that you can save and help transform a life if you offer and deliver the right treatment—which relies on immediate access to opioid-replacement therapies such as methadone or buprenorphine (Suboxone and others). Barring such an in-the-instant response, you’re left with a person in debilitating opioid withdrawal.

They need their next dose. They need it soon. And it may be their last.

Charles Atkins, M.D., is a psychiatrist, author, and the chief medical officer for Community Mental Health Affiliates a multi-site behavioral health and substance abuse agency in New Britain, Torrington, and Waterbury. He is a member of the volunteer faculty at the Yale School of Medicine.

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