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What is the chemistry?

Fentanyl is a synthetic opioid, easier to produce than most opioids because it doesn’t require access to fresh opium poppies. It is also among the most potent of drugs, up to 50 times stronger than heroin and 100 times more potent than morphine. Some of its many analogues, such as carfentanil, are even more potent—as much as 10,000 times stronger than morphine.

Because there are innumerable ways to “tweak” the basic fentanyl formula, the drug is difficult to regulate effectively: it’s easy for illicit manufacturers to claim their formulas aren’t technically illegal.

What is the history of the drug?

Originally developed as an intravenous anesthetic in 1957, fentanyl was first sold under the trade name Sublimaze. Starting in the mid-1990s, other means of administration began appearing—skin patches, lollipops, tablets, nasal and under-the-tongue sprays—and such slow-release options made the drug increasingly popular for easing severe pain in terminally ill patients. Fentanyl is a Schedule II drug under U.S. law, meaning it can be prescribed for medical use but also has high potential for abuse.

In 2007, fentanyl first appeared as a street heroin additive, an illicit use that has become common—and deadly.

What are the side effects?

Fairly common side effects from taking prescribed fentanyl include darkened bowel movements, heavy perspiration, coughing, chest pain, blurry vision, dry mouth, chills, increased thirst, lightheadedness, aching back or side, tingling in extremities, muscle cramps, mood swings, sore throat, and tinnitus.

Less common side effects—which should always be reported to the prescribing doctor—include severe stomach pain, loss of muscle coordination, pounding headache, hallucinations, seizures, body tremors, and irregular heartbeat.

How was it intended to be used?

Fentanyl is prescribed primarily in cases of severe and incurable pain, typically in a hospital setting. Cancer patients who have been declared terminal are frequent prescription recipients. Some fentanyl versions are used as large-animal tranquilizers because potent doses are inexpensive.

Fentanyl and its analogues are so potent that professionals handle them only under extremely controlled conditions. Law-enforcement officials investigating suspected fentanyl labs often use the same hazmat protection that’s standard for toxic chemical spills.

How is it used illicitly?

Because fentanyl is typically prescribed in patch form to patients who feel any pain relief would be an improvement, fewer addictions start as legitimate prescriptions than with many other drugs. There’s a bigger risk if prescriptions are furnished in the easily consumable, easily alterable pill form. Someone really desperate for a stronger, faster effect might heat a patch to make it release fentanyl faster, or rip it open to get to the whole dose at once.

More commonly, illicit fentanyl is purchased as a street drug—either alone or as part of a heroin mix—and snorted, injected, or taken as a pill. Sometimes it’s used to saturate blotter paper, which is then placed under the tongue.

What are the signs of illicit use?

Symptoms of addiction include: bouts of euphoria and drowsiness, lethargy, loss of interest in old activities, slowed breathing, difficulty walking, pinpoint pupils, shakiness, dizziness, itching, slurred speech, and swelling in the limbs.

Symptoms of withdrawal include: chronic irritability, chills, heavy perspiration, insomnia, dilated pupils, diarrhea, and anxiety.

Symptoms of overdose include: sudden collapse, lips turning blue, “gurgling” breathing, frothing at the mouth, stiffening muscles, slowing heart rate, and disorientation. When you call 911, make sure to say if you think it’s fentanyl that caused the overdose—because the drug is so potent, it requires a stronger-than-standard anti-opiate dose to minimize harmful effects.

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