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Once feared, illegal fentanyl is now a drug of choice for many opioid users

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One of the deadliest street drugs, illegal fentanyl, has gone from being a covert killer people often hope to avoid to one that many drug users now seek out for themselves.

The shift to intentional use of fentanyl underscores a worrying trend in the country’s ongoing opioid epidemic, experts say: that a growing number of people have become so tolerant of opioids like heroin that they are turning to the synthetic compound, which 50 times stronger.

Until recently, the intentional use of fentanyl was mostly confined to the West Coast, but in recent years addiction specialists across the country have seen an increase in the use of the drug.

“Two years ago I would have thought this was crazy,” says Dr. Akhil Anand, a psychiatrist at the Cleveland Clinic who specializes in addiction. Now, Anand said, he sees many more people in Ohio seeking illegal fentanyl as their drug of choice.

In medical settings, fentanyl is used to treat patients with severe pain, such as those who have just had surgery. Fentanyl patches on the skin are sometimes prescribed for severe pain at home.

But fentanyl first entered the illicit drug supply about 10 years ago, especially in areas east of the Mississippi River. The white powder looked like heroin, but was much cheaper. Drug dealers began mixing the two drugs to increase their heroin stocks. Fentanyl also started showing up in non-opioid drugs, such as cocaine and fake versions of prescription pills.

The shadowy addition of fentanyl to the illicit drug supply has caused lethal overdoses skyrocket among users unaware they were taking such a strong drug. In 2021, fentanyl was involved in the vast majority of overdose deaths, according to the National Center for Health Statistics.

Mary Ward, president of the McLeod Addiction Center in Charlotte, North Carolina, has noted the shift toward a preference for fentanyl in her home state. “Some people thought they were buying heroin on the street, and it turned out to be fentanyl,” Ward said. “They ended up liking it more.”

Alex Kral, an epidemiologist from Berkeley, California who studies illicit drugs at the nonprofit research institute RTI International, said he has heard from users that once they start using fentanyl, it is very difficult to start using heroin again because they none the same high.

In addition, experts said, people are increasingly moving from injecting fentanyl to smoking it.

“My prediction would be that smoking fentanyl will be the norm within a year” among those using the drug alone, said Dr. Daniel Ciccarone, a professor of family medicine at the University of California, San Francisco.

Ciccarone said the shift from injecting to smoking could be seen as harm reduction in that it eliminates the risk of spreading infections through shared needles, including HIV, hepatitis C and bacteria that can cause heart infections.

“It’s nice not to have to use or inject your veins, and so a lot of people would rather not do that,” Kral said. “I think we’re going to see more and more people smoking fentanyl than they are injecting it.”

Others were concerned that because smoking fentanyl is easier and often more appealing than injecting it, it could lead to more widespread use. And there is no data to suggest that smoking fentanyl reduces the risk of fatal overdoses.

“I don’t know if we’re in a place where we can say, ‘Hey, maybe you should smoke it instead,'” says Dr. Kris Kast, clinical director of the Addiction Consult Service at Vanderbilt University Medical Center in Nashville. “It would be hard for me to have the confidence to recommend that to anyone.”

While a fentanyl overdose can be reversed with naloxone, the drug’s high potency means more naloxone is needed to counteract it, both Anand and Ward said.

The drug also causes a shorter duration of the high than other opioids, meaning users need to take the drug more often to avoid withdrawal.

“Usually by the time someone switches to fentanyl, someone has to take it pretty constantly throughout the day to feel normal, not to withdraw,” Kast said. “As they transition to fentanyl, they will need to use it more often to manage that withdrawal.”

And for fentanyl users who are being treated for their addiction, doctors must prescribe higher doses of drugs such as suboxone and methadone to control their withdrawal symptoms.

“Because fentanyl is so potent, patients have more physical withdrawal symptoms,” Ward said. “We’ve seen an increase in the amount of medication we’ve had to prescribe for some patients to keep them stable.”

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