The Next Wave of the Opioid Epidemic

Newer, more powerful opioids are here—and they're killing more Americans than ever.

The Next Wave of the Opioid Epidemic

Opioids are powerful and addictive painkillers that can create a sense of euphoria—and stop your breathing—and their abuse is on the rise.

According to a preliminary report released by the Centers for Disease Control and Prevention in August 2018, an estimated 72,000 Americans died as a result of a drug overdose in 2017 (more than 49,000 of which were caused by opioids). This represents a significant increase from the 62,632 drug overdose deaths reported in 2016 (of which more than 42,000 were caused by opioids). 

These climbing numbers have public health experts alarmed. 

The changing crisis
In years past, the opioid epidemic was dominated by heroin and prescription medications, but other drugs have crept in. Dealers are mixing powerful and dangerous new compounds, such as fentanyl, with heroin in a quest for greater profit.

“Heroin and prescription opioids, those are the base elements. What’s changed is what they’re mixed with,” says Mark Cardillo, LCSW, behavioral health program director at Tampa Community Hospital and its addiction recovery center in Tampa, Florida. “That can change rapidly based on what’s available to the dealers and what they can concoct. A lot of time they’re doing it to stay one step ahead of the Drug Enforcement Administration (DEA).”

Here’s what you need to know about the potent, dangerous new opioids being mixed with heroin and sold on the black market.

Stronger and deadlier
Chris Green, a police officer in East Liverpool, Ohio, had just returned to his station after a traffic-stop-turned-drug-bust in May 2017 when a fellow officer noticed some white powder on Green’s shirt. Green brushed it off with his hand and soon fell ill, slurring his speech and finally, collapsing. That powder was fentanyl, an opioid estimated to be 50 to 100 times more potent than morphine. (Green made a full recovery.) 

Clinically, fentanyl is used to treat severe or post-surgical pain, and usually comes as a lozenge, skin patch or injection. But, according to Cardillo, when you mix it with heroin, you get a product that’s up to 50 times stronger than heroin alone—and less expensive.

“If you’re mixing fentanyl with heroin, profits go up and costs go down,” says Cardillo. “A kilogram of fentanyl costs $4,000 to $5,000 but on the street you can profit $1.4 or $1.5 million. If you’re diluting your heroin with it but still calling it heroin, it costs less for you to make and you make more money.” Dealers are starting to realize that fact; law enforcement encounters with fentanyl jumped from 5,343 in 2014 to 13,882 in 2015.

Fentanyl is increasingly being combined with cocaine, as well, though it's not clear whether the mixing is intentional—for "speedballing" purposes—or accidental. While it's believed the vast majority of cocaine does not contain the opioid, overdose deaths involving a blend of the two drugs have risen in certain areas. In Connecticut in 2012, for instance, a mix of cocaine and fentanyl factored into two deaths. Five years later, in 2017, the combination caused 220 deaths.

For some dealers, 50 times stronger is not strong enough. Carfentanil is one of the newer substances found mixed with heroin at the scene of overdoses. It’s chemically similar to fentanyl—but about 100 times stronger—and is the strongest commercially used opioid. It’s too powerful for humans; instead, it’s typically used as a tranquilizer for elephants and other large mammals.

What else is out there?
Fentanyl and carfentanil get a lot of press, but there are lesser-known and equally deadly additives out there. U47700, also known as "pink," is one. The DEA classified it as a Schedule I drug in 2016, which means it has a high potential for abuse, no medical treatment and no safety protocols. Like fentanyl and carfentanil, it’s sometimes mixed in with heroin in order to give dealers and their customers more bang for the buck.

Finally, there's gray death. Sometimes found in concrete-like chunks, it’s usually a combination of heroin, fentanyl, carfentanil and U47700. “Even touching the stuff can cause people problems,” says Cardillo. “The biggest problem with gray death is you have to use three or four times the amount of naloxone to bring someone back. That’s how potent it is.” Naloxone, or Narcan, is a drug used to stop overdoses by blocking the effects of opioids, triggering instant withdrawal and jump-starting breathing.

Naloxone, or Narcan, is a drug used to stop overdoses by blocking the effects of opioids, triggering instant withdrawal and jump-starting breathing. It's often used by emergency personnel, though everyday Americans increasingly have it on hand. In April 2018, the Surgeon General issued an advisory asking more people to keep naloxone around, especially if they're currently taking opioids or are at high risk of coming into contact with people who may overdose.

From the lab to the street
Fentanyl and carfentanil can be purchased on the black market in the US or online from overseas distributors. “A lot is produced in China,” says Cardillo, “but China has stepped up a little in terms of what they’re outlawing.” The country banned carfentanil in March 2017. “Mexico is where most operations have moved,” says Cardillo. “The cartels can be pretty sophisticated in how they produce drugs. They can create labs.”

This mix of cheap overseas and illicit stateside production helps dealers stretch their batches of heroin, reaching more people. As a result, more become addicted, more develop a tolerance to ever-more-potent synthetics, and more die. Between 2015 and 2016, overdose deaths from synthetic opioids more than doubled from 9,580 to 19,413.

“The synthetic opioids are supposed to create a more intense, long-lasting high, but there are a lot of risks,” says Cardillo. "To get into an addict’s mind, figure out why they’re willing to take it, that’s tough. Their brain chemistry changes and they’re not thinking of the consequences.” 

One of the biggest tragedies is that opioid users aren’t necessarily even looking for these synthetics. “I’m not positive that they even know what’s in there,” says Cardillo.

Fortunately, authorities are responding. The DEA has distributed warnings about fentanyl, carfentanil and other synthetics to law enforcement officers around the country, and the National Institute on Drug Abuse is working on a more effective national response for health officials, law enforcement, and people who are addicted. If you or someone you love has a problem with opioids, contact the Substance Abuse and Mental Health Services’ national helpline at 800-662-HELP.

Medically reviewed in January 2019.

More On Substance Abuse and Addiction

Protecting Children from the Opioid Epidemic


Protecting Children from the Opioid Epidemic
The old saying “curiosity killed the cat” dates back to the middle of the 16th century. And the idea “cats have nine lives” may predate that. Some bel...
Pregnancy and Opioid Addiction


Pregnancy and Opioid Addiction
Alicia Keyes craved root beer floats while pregnant with her second child, Genesis; Victoria Beckham was marmalade-crazed while carrying daughter Harp...
How to Treat Substance Use Disorders


How to Treat Substance Use Disorders
Seeking substance use disorder treatment is a difficult step, but can also be one of the most important and best steps to take. Only 1 in 10 individua...
How Is Substance Abuse of Prescription Drugs Treated?


How Is Substance Abuse of Prescription Drugs Treated?
If you're addicted to prescription drugs, the treatment is similar to what doctors use for alcohol or illegal drug addiction, says addiction specialis...