Street fentanyl: Five dollars per death

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At left, the size of a fatal dose of fentanyl compared to a penny,. At right, a naloxone nasal spray overdose kit.

A couple weeks back I did a naloxone (Narcan™) training and distribution. I do a fair number of these and often ask two questions:

“How many of you have used Narcan to reverse an overdose?”

“Have you ever had it used on you?”

Because of my job as medical director for a mental health and substance abuse agency, I often give these trainings in high-drug-use settings and find that a third or more will answer yes to both questions. Some have saved relatives, friends, and spouses multiple times, and others will share their own near-death experiences. And by and large these are not suicide attempts, although those do occur with opioids.

Because I’m not a person who uses these drugs, I take the opportunity to learn. So, I ask, “How much is a bag of dope?” At a recent workshop the answer that came back stopped me cold. “$2.50. Because it’s probably fentanyl, I can get a bag for $2.50.”

With that simple statement, things became clearer. To start, the Drug Enforcement Agency and others have determined that a typical fatal overdose with fentanyl analogs, most from China, takes about 2 milligrams. This is the amount found in two bags of fake heroin or counterfeit oxycodone or hydromorphone pills. The price of death is $5.

That information brings other things into focus. Such as, with so much attention on the opioid epidemic and lots of people doing wonderful work to stem the tide, our numbers don’t seem to reflect our efforts. I’d argue that we have made progress, but with super-potent, highly addictive, and dirt-cheap drugs on the street, we’re in deep waters.

Let me clarify.

The numbers of dead continue to rise, but they do so less rapidly. We have significantly cut the number of prescriptions written for opioids. It’s important to remember that most misuse (about 70 percent) starts with pills, not with street drugs. Much of our current predicament is due to aggressive marketing of high-potency opioids by the pharmaceutical industry with buy-in from physicians and organizations that should have known better, such as the Joint Commission and the Institute of Medicine, which turned pain into the fifth vital sign, along with blood pressure, heart rate, temperature, and weight.

I’ve seen first-hand that the tens of thousands of doses of naloxone we distribute save lives… lots of them. It’s powerful to be in one small group and realize that a third of those people wouldn’t be there and another half dozen of their loved ones would also be dead if not for an overdose kit. The actual number of lives saved in Connecticut alone is in the thousands, possibly tens of thousands.

Efforts to educate the public have also made inroads. Most are now aware that the opioid epidemic is real and has crept into every town. In a week or two, I’ll give a talk on the subject at my local library (Woodbury). As happens at such events, I’ll meet parents sick with worry that they’ll find their child dead behind a bedroom or bathroom door. Worse still are those who’ve already lost someone and now fear for the life of another son or daughter. Knowledge is power, and the more information we get out, the more likely parents, teachers, coaches, first responders, law enforcement, and others will recognize the signs of a drug problem.

While the flow of these deadly opioids continues, it’s important to arm the public with up-to-date information, better access to care, and overdose kits. I keep one in my briefcase. While I’m not the parent of a teen or young adult, I’d recommend having two doses of naloxone in the medicine cabinet in every home. Most pharmacies in Connecticut can provide a quick training and dispense these without a prescription from your doctor. If you have family members who use drugs or are on prescribed opioids, get a kit. And agencies that work with people with substance-use problems should train their staffs and keep naloxone on site.

I hope you never have to use your overdose kit. But as a friend said, “It’s like a fire extinguisher in the kitchen. You’re not going to set your stove ablaze to see if it works, but when fire erupts, you’re damn glad it’s there.”

Finally, access to effective treatments for opioid-use disorders, while still a challenge, has improved. We have strategies and medications that work, though none are perfect. Relapses are common, but when people stay connected to treatment, devastating cycles of addiction break, and lives get back on track. It’s why I do this work. People get better. Recovery is real, and it’s wonderful to be a part of.

But I work with the living.

And a fatal overdose costs $5.


A list of pharmacies that can provide naloxone training and distribution is available here.

Charles Atkins, M.D. is a psychiatrist, author, chief medical officer for Community Mental Health Affiliates (CMHA) in New Britain, Waterbury, and Torrington, and member of the Yale volunteer faculty.  His most recent book on this topic is “Opioid Use Disorders: A Holistic Guide to Assessment, Treatment and Recovery.”


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