Along the wide spectrum of opioid users, there are those who fear fentanyl and those who are its fans, according to a recently published study led by Penn State University researchers. Understanding the mindsets of both kinds of users may be a key to reducing the damage done by the super-potent narcotic.
While some of the 30 users surveyed tried to avoid fentanyl — which is often mixed with, or sold as, heroin — most resigned themselves to using it, and roughly one in five preferred it, according to the study led by Katherine McLean, an assistant professor of administration of justice at Penn State Greater Allegheny in McKeesport, and Ashton M. Verdery, assistant professor of sociology, demography, and social data analytics at the University Park campus.
Those 30 users and the larger number (125) who filled out surveys for the study were largely united in one sentiment: They wished they knew what they were snorting, smoking or injecting.
Many talked of “the unpredictability of the illicit opioid market and how that unpredictability made it impossible for people to know what they were using and avoid overdosing, avoid getting ripped off, avoid withdrawal, avoid nodding off in a place in which they didn’t want to,” said Ms. McLean on Thursday.
The synthetic narcotic fentanyl has long been used as a powerful painkiller in conventional medicine. Illicit versions of the drug had periodically turned up in the heroin markets for years, but only became a consistent part of the mix in southwestern Pennsylvania from 2014 on.
Data from Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence and Westmoreland counties, gathered on overdosefreepa.org by the University of Pittsburgh School of Pharmacy, shows that from 2015 through 2018, fentanyl was involved in 2,464 fatal overdoses. That's 60 percent of the drug deaths in those counties — a bigger share than any other drug. (Heroin was implicated in 43 percent and cocaine in 32 percent. Most fatal overdoses involve more than one drug.)
During those four years, fentanyl's prevalence soared. Present in 29 percent of fatal overdoses in 2015, it was part of the mix in 72 percent in 2018.
That led Ms. McLean — who volunteers for the needle exchange organization Prevention Point Pittsburgh and worked in the harm reduction field in New York City — and Mr. Verdery to research fentanyl’s impact on the drug world. They focused on Allegheny County because it “had the highest rate of fentanyl-involved mortality among all [large] U.S. counties” in 2016, and trailed only New York and Chicago in the raw number of deaths from the drug, according to their report in the journal Substance Use & Misuse.
The researchers drew their subjects mostly from Allegheny County, with smaller numbers from Fayette, Greene and Washington counties.
Most of the subjects started using between the ages of 18 and 25, and had been on opioids for five years or more. A minority had personally overdosed to the point of needing medical attention, but a large majority had a family member or friend die from drugs. Many cited fentanyl as the culprit in a loved-one’s death.
You’d think that would deter people, and for a few it did. One study participant said that if he gets purported heroin that, upon inspection, looks more like fentanyl — which is subtly different in color and texture — he will “turn right around, take it right back.”
A similar number took the opposite tack. “Once you’ve used fentanyl you can’t do [heroin] anymore,” one participant said. “It doesn’t touch you.”
Some liked fentanyl’s quicker-than-heroin high, or the cost-effectiveness relative to much-more-expensive unadulterated heroin. Some thought that withdrawing from fentanyl was less severe than from heroin.
Most, though, accepted the risk inherent in a fentanyl-flooded heroin market, and Ms. McLean grew to understand that.
“I think the people that we talked to, they had a lot going on in their lives. They had a lot of risks, a lot of harms, that they were trying to ameliorate at various times in their lives,” she said. Caught in addiction in many cases, they feared going into withdrawal on the job, or while trying to care for children.
Many had countervailing fears of “nodding out” or overdosing in those circumstances. All faced the problem of rarely knowing whether they were buying “crappy” stuff that wouldn’t even stave off withdrawal, or super-potent fentanyl that would knock them out — perhaps permanently.
Stopping cold, though, was not an easy proposition. “Many of these people had been using for 5, 10 years, so they also have a routine,” said Mr. Verdery.
Some dealt with the routine-breaking uncertainty presented by fentanyl by developing a trusted dealer. Few used the fentanyl test strips, available from Prevention Point Pittsburgh, which can reliably detect even small amounts of the drug.
“They don’t tell you the concentration of the fentanyl in the [stamp] bag,” said Ms. McLean, but they are “certainly preferable to nothing.”
Cocaine users might consider the test strips, too, as there is persistent evidence of fentanyl infiltrating the supply of that drug. There’s also a rising tally of overdoses involving both cocaine and fentanyl.
“If you consider the population of people who use cocaine in this country, it’s much larger than the population of people who use heroin,” said Ms. McLean. And many cocaine users are “opioid-naive,” meaning a small amount of fentanyl mixed in could have outsized consequences, she noted.
Mr. Verdery said that in the coming months, the team will release a second paper on the origins of the addictions of the people studied. The perhaps surprising finding: Few started down the road to opioids with a prescription written to them. Most got a taste from pills prescribed to someone else, and then passed on by a friend or relative.
The biggest takeaway from all of their work, Ms. McLean said, is that people in addiction are not zombies lurching after the next fix, so to address their problems one needs to understand their complex processes and problems. “They are careful consumers, certainly not people who are wandering blindly," she said. But they are addicted to something that is "packaged by unknown persons in unknown quantities of unknown substances.”