Most people in the United States know what fentanyl is. They know that a tiny amount of fentanyl can kill you. They know that it can often be found mixed in with other drugs, specifically, in prescription pills sold on the street. They know that people have overdosed after buying what they thought was oxycodone or Vicodin, when the pill was mostly fentanyl. Public awareness about fentanyl has led to years of drug education campaigns and the passage of strict laws regarding its possession, distribution, and sale. But what is happening in the drug supply moves a year or two ahead of policy.
Let’s take a step back and first define what the drug supply is. This refers to what is in the drugs that are being bought and sold on the street across the United States. What is in the drug supply can vary depending on the region in the U.S., but broadly, we are starting to see a few trends.
We can ascertain what is in the drug supply primarily through a few ways: by testing drugs that are seized by law enforcement, by community testing where people voluntarily submit their own drug samples for testing, and by blood toxicology screening in the aftermath of an overdose. Community testing is an efficient and quick method to know, because it allows us to get closer to a real-time understanding of what exactly is in a substance and what that substance may be sold as.
People who buy and use substances can also tell us a lot about the drug supply. They can let us know how potent it is, what symptoms they are experiencing, and what these drugs are being called on the street. The Substance Use and Mental Health Administration (SAMHSA), up until earlier this year, used to run the Drug Abuse Warning Network (DAWN), which would collect information from drug- and alcohol-related emergency department visits to report on emerging trends, including drug combinations and slang terms. This system has been discontinued.
While Americans know about the risks of using fentanyl, there are emerging trends that are becoming concerning.
1. The presence of veterinary sedation drugs
You may have heard of xylazine. This is a veterinary drug that is used to sedate animals, but it is showing up often mixed in with fentanyl and causing prolonged sedation as well as skin ulcers. Xylazine has caught the attention of the federal government—Congress has proposed legislation looking to schedule the drug.
Now, a new drug, metomidine, is showing up in the supply and is causing concern. It’s much more potent than xylazine and so may cause prolonged sedation and stronger withdrawal symptoms.
2. The presence of nitazenes
These are opioids that are much more potent than fentanyl. As a result, they require more doses of naloxone than a fentanyl overdose would. Already, there have been deaths associated with nitazenes, and they have been appearing in the drug supply across the United States. Nitazenes began to appear after stricter controls on fentanyl were implemented in 2019.
3. Polysubstance overdoses
In 2022, more than half of all fentanyl related overdoses also involved a stimulant like cocaine or methamphetamine. People could be using these drugs together, or these could be drugs that are adulterated with fentanyl. Overdoses involving stimulants and fentanyl are of particular concern for older people. Recent research shows that overdoses involving fentanyl and stimulants increased 9,000 percent over the past 8 years for adults over the age of 65. This may also be driving the increases in overdoses for Black men over the age of 55.
Policymakers often respond to the overdose crisis with simplistic narratives. Fentanyl is killing people, so target the source of the fentanyl—with more money for interdiction efforts and harsh penalties for possession and distribution. However, as we have seen, the reality is far more complex and dynamic. By the time laws are passed targeting fentanyl, another drug has appeared to fill the void. This is what some researchers refer to as a game of “whack-a-mole.” We can keep hitting the mole with the mallet, but new drugs will continue to pop up—often worse than the drugs that preceded them. This is a failed approach.
It’s important to continue to do research on emerging drugs and stay alert and aware so we know how to best manage the symptoms. But a narrow focus on drugs as unique threats can create the impression that these are problems that can be addressed just by eliminating the specific drug. More of our time and efforts could be better spent on the people who are affected by the overdose crisis—what do they need to not just survive this crisis, but to live and thrive? The more we do to address the “demand” side (aka the lives of the people who use drugs), the less we will have to worry about the “supply” side.
