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Pharmaceutical fentanyl is a synthetic opioid, approved for treating severe pain, typically advanced cancer pain.¹ It is 50 to 100 times more potent than morphine. It is prescribed in the form of transdermal patches or lozenges and can be diverted for misuse and abuse in the United States. or Fentanyl, also spelled fentanil, is a highly potent synthetic opioid primarily used as an analgesic.

However, most recent cases of fentanyl-related harm, overdose, and death in the U.S. are linked to illegally made fentanyl.² It is sold through illegal drug markets for its heroin-like effect. It is often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge—to increase its euphoric effects.

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Drug dealers have used fentanyl analogs as an adulterant in illicit drug supplies since 1979, with fentanyl-related overdoses clustered in individual cities.

The modern epidemic of fentanyl adulteration is far broader in its geographic distribution, production and number of deaths. Overdose deaths roughly quadrupled, going from 8,050 in 1999 to 33,091 in 2015. From May 2020 to April 2021, more than 100,000 Americans died from a drug overdose, with over 64 percent of these deaths due to synthetic opioids like fentanyl and its analogs.

Illicitly manufactured fentanyl is internationally synthesized in China, Mexico and India, then exported to the United States as powder or pressed pills. Additionally, the emergence of the dark web, an encrypted and anonymous corner of the internet that’s a haven for criminal activity, has facilitated the sale of fentanyl and other opioids shipped through traditional delivery services, including the U.S. Postal Service.

Fentanyl is both sold alone and often used as an adulterant because its high potency allows dealers to traffic smaller quantities but maintain the drug effects buyers expect. Manufacturers may also add bulking agents, like flour or baking soda, to fentanyl to increase supply without adding costs. As a result, it is much more profitable to cut a kilogram of fentanyl compared to a kilogram of heroin.

Unfortunately, fentanyl’s high potency also means that even just a small amount can prove deadly. If the end user isn’t aware that the drug they bought has been adulterated, this could easily lead to an overdose.

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As an emergency physician, I give fentanyl as an analgesic, or painkiller, to relieve severe pain in an acute care setting. My colleagues and I choose fentanyl when patients need immediate pain relief or sedation, such as anesthesia for surgery.

But even in the controlled conditions of a hospital, there is still a risk that using fentanyl can reduce breathing rates to dangerously low levels, the main cause of opioid overdose deaths. For those taking fentanyl in nonmedical settings, there is no medical team available to monitor someone’s breathing rate in real time to ensure their safety.

One measure to prevent fentanyl overdose is distributing naloxone to bystanders. Naloxone can reverse an overdose as it occurs by blocking the effects of opioids.

Another measure is increasing the availability of opioid agonists like methadone and buprenorphine that reduce opioid withdrawal symptoms and cravings, helping people stay in treatment and decrease illicit drug use. Despite the lifesaving track records of these medications, their availability is limited by restrictions on where and how they can be used and inadequate numbers of prescribers.

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Other strategies to prevent overdose deaths include lowering the entry barrier to addiction treatment, fentanyl test strips, supervised consumption sites and even prescription diamorphine (heroin).

Despite the evidence supporting these measures, however, local politics and funding priorities often limit whether communities are able to give them a try. Bold strategies are needed to interrupt the ever-increasing number of fentanyl-related deaths.

Fentanyl works directly on opioid receptors in the central nervous system and reduces feelings of pain by interrupting the way nerves signal pain between the brain and the body.

It is available in several formulations in different strengths, including patches, lozenges, tablets that disintegrate in your mouth and sublingual (under the tongue) tablets. Fentanyl is also given by injection for severe acute pain or as part of anaesthesia before surgery.