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Fentanyl Unpacked

Updated: Aug 18, 2023

Patients who “successfully” completed inpatient detoxification were more likely than other patients to have died within a year. The deaths from overdose in the group of patients who had successfully completed treatment is counterintuitive and illogical — unless it derives from loss of tolerance and consequent unpredictability of resumed drug use.

- National Institutes of Health (NIH), September 2022

As a mom who lost her son to fentanyl poisoning, it has been frustrating to me that the fentanyl crisis has been getting worse, not better.

While solutions are needed on all fronts, I will share one with great promise. First, consider these shocking facts:

  1. The US can’t keep fentanyl out of the country. Enforcement agencies confiscate less than 1%

  2. Fentanyl causes profound, varying degrees of brain damage

  3. Users quickly become dealers to fund their addictions

  4. Parents can’t keep it from kids since dealers are often other kids in schools

  5. Awareness of the risks posed by fentanyl is not widespread, and hundreds of thousands of young people died not knowing the danger of fentanyl

  6. TikTok, Snapchat & Instagram allow instant, anonymous delivery

  7. NIH reports detox and treatment have a failure rate of 91% & many die on their first relapse

  8. Treatment centers are using outdated treatment protocols based on heroin. A drug 100x more potent than heroin requires a whole new approach to treatment

So far, more than a million people have died in the opioid/fentanyl epidemic. Hundreds of thousands are trying to beat powerful addictions, and millions of loved ones have been devastated.

By comparison, on 9/11 the US lost nearly 3,000 lives. During the entire Afghanistan war, the US lost nearly 25,000 lives. Consider this:

  • 9/11: 2,996 US deaths

  • Afghan War: 24,995 US deaths

  • Vietnam War: 58,220 US deaths

  • World War 2: 420,000 US deaths

  • Opioids/Fentanyl: 1,000,000+ US deaths

In the 1990’s the first wave of opioid overdose deaths began, with a second phase that began in 2010. It started with pharmaceutical companies rapidly marketing them to doctors as non-addictive pain relief with full knowledge that they were highly addictive and lethal. People who got addicted to their legal prescription opioids found ways to buy the same prescription pills on the street. The street had eyes and saw that big demand exists for opioids. Enter China then the Sinaloa and Jalisco cartels.

In 2019 the STOP Act made it harder for China to send fentanyl pills and powders into the US, although they quickly modified the composition of it to evade regulations. Mexican cartels now buy the precursor chemicals and smuggle it into the US.

Government efforts now throttle pharmaceutical companies and doctors prescribing opioids. But now, we are badly losing the war on fentanyl.

Rates of overdose death by fentanyl are increasing at the rate of 27% year over year. It is hard to get clean data on fentanyl overdose v. overdose death statistics but at that rate, 150,000+ individuals will end their journeys here on earth this year. That number sounds so large it is hard to imagine but it means that 410 times each day we will collect their fallen bodies with human hands and all those who loved them will be forever grieving.

Narcan, the nasal spray that can reverse the effects of a fentanyl overdose, can save a person from respiratory failure. A myth exists that in drug overdose, only two outcomes are possible: a person will either live or die. A third outcome many fail to consider is that a person may survive with significant brain or body damage.

In 2019 the US blocked China from sending fentanyl directly into the US and blocked buyers from quickly ordering pills online. Those pills contained analogues like carfentanil, more deadly than fentanyl.

In 2022, when annual fentanyl fatalities in the US surpassed 107,000, the crisis started getting more press. But news stories often focus on one aspect of the crisis, which is more complicated.

This epidemic is much more complex than any other public health crisis, with many problem sets to solve. Any public health crisis takes time and well-coordinated resources. We don’t have a well-coordinated response.

Let’s try to unpack the situation further.

A bit of history is important to tie plants to the highly profitable disease of addiction. We can go back 8,000 years in history to the Sumerian tablets that reveal early prescriptions for opioids. With time, people figured out how to refine them, make them more powerful, manufacture, market, and sell them.

For thousands of years, indigenous people in South America chewed on coca leaves for energy. In 1885, John Pemberton, a pharmacist from Atlanta, Georgia, used cocaine in the form of an extract of the coca leaf to produce Coca-Cola. The “Coca” part of the beverage’s name came from the coca leaf and the “Cola” comes from the kola nut. Pemberton was looking for an alternative to using morphine for pain he endured from a saber wound in the US Civil War. Yes, Coca-Cola was invented by a drug addict.

Opioids from poppy flowers were used for thousands of years for pain treatment. Over centuries they evolved into addictive substances like heroin which were addictive. Later made into pain medications like oxycodone (OxyContin), hydrocodone (Vicodin), morphine, and other legal medications, these proved highly addictive and have killed hundreds of thousands of people. Drug companies such as Purdue, Johnson & Johnson, McKesson Corporation, Cardinal Health, CVS, Walgreens, and Rite Aid and their advisors such as McKinsey are responsible for fueling demand and causing countless, needless deaths for profit.

Many modern medicines emerge from simple plants. Through years of refinement and testing in science labs some experiments result in cures for diseases. Others create addictive substances. For drug cartels or multinational pharmaceutical companies, addiction is big business and addiction is a big win. US addicts manage to pay for $150B+ every year for their drugs, costing taxpayers more that $1 trillion dollars a year to combat.

Once addicted, patients sometimes survive their disease but die from their opioid addictions. When cut off from legal medications, people often buy what they think is similar on the street, which now contains fentanyl. Cheap to produce in China, it is easy to ship the precursor chemicals to Mexico, where it gets pressed into anything, often blue- or rainbow-colored pills that look like candy. Due to its highly addictive quality, it gets mixed into most other street drugs too, including weed, cocaine, meth, and literally any street drug.

Street fentanyl is synthetic, with no plant origin. Pure chemistry. A hundred times more potent and addictive than either morphine or heroin, fentanyl is one unforgiving drug.

Or biological weapon.

Fentanyl ranks up there with most lethal things a person can ingest or inhale, like anthrax, sarin or botulinum. As far as most addictive substances, a person’s physiology changes to demand more after one single dose. After three doses, many become unreachable, fixated only on getting more. Fentanyl is a trap door into a very dark place few can escape. When people try to resist and override cravings, their bodies respond with agony to the point many describe as so painful they feel like they will die. In their addictions many believe they need it to survive. Fentanyl is a black hole that sucks in anyone, it does not discriminate.

The US is only able to capture about 1% of the fentanyl coming in. I recently participated on a DEA panel with Homeland Security, DOJ, and the amazing San Diego Team 10, where I learned that despite our best efforts, fentanyl is just flooding in.

Our agencies believe these groups are at risk: unsuspecting people who think they are taking a different benign substance such as weed but it may be laced with fentanyl, unsuspecting people fooled by counterfeit opioids such as Percocet, people who first got addicted to opioids by doctors who now turn to street drugs, people who like to experiment with new drugs, people in chronic pain and people who are flat out seeking fentanyl itself and don’t care what it is mixed with. Now we can add a new group seeking “Tranq” (xylazine mixed with fentanyl), despite the fact it contains fentanyl, causes skin lesions and that overdose can’t be reversed by Narcan. Blend in the US mental health crisis, teenage depression rates, and soaring suicide trend. It begins to mushroom into a fog of users and reasons people take fentanyl.

Covid obscured the fentanyl crisis. Covid victims died of respiratory failure. Fentanyl victims died of respiratory failure. Some hospitals received higher payments for Covid patients, so the incentive to classify a death as Covid was present. Without a specific toxicology report that a doctor ordered, and someone had to pay for, we will never know how many deaths classified as Covid were caused by fentanyl. It could have been 10 or 100,000.

According to NIH for those suffering fentanyl addiction, detox and treatment is failing at a rate of 91%. Also, according to NIH in 2022, “Patients who “successfully” completed inpatient detoxification were more likely than other patients to have died within a year. The deaths from overdose in the group of patients who had successfully completed treatment are counterintuitive and illogical — unless it derives from the loss of tolerance and consequent unpredictability of resumed drug use.”

If the fentanyl relapse rate is so high, almost guaranteeing treatment failure, with 7,30,30 or 90 days of treatment which was decided the necessary length of time based on heroin addiction long ago, why aren’t insurance companies paying for longer treatments with better outcomes? If fentanyl is 100 times more powerful than heroin it doesn’t take a genius to know that the treatment for that substance addiction requires its own protocols.

Treatment is expensive and the value remains vague to insurers. Relapse means the insured person must go back through treatment again, starting from detox. I know a 37-year-old woman who has been to treatment 35 times for fentanyl, for example.

Body brokering is a real thing in the treatment community, it is called the rehab shuffle. Some treatment facilities who rely on insurance payments to operate discharge patients when their benefits run out, hand them cash, sometimes thousands of dollars, and tell them on their way out to call as soon as they relapse to get right back in for more treatment. Most treatment centers are for profit companies and many master the insurance game for revenue.

By offering short lengths of treatment for people in high acuity addiction, health insurance companies can prolong addiction, which leads to other serious medical conditions that cost insurance companies more money.

Elliot is as smart as he is kind as he is handsome. At 21, he has spent more than half his life in drug rehabs. By now a walking encyclopedia on street drugs, their histories, chemical compositions, and interactions, he said, “As a fentanyl and opioid addict hoping for recovery, I’m horrified by the chemical. I’ve been resuscitated from opioids 45 times and around 40 of those times I had quite a lot of fentanyl in my system. When using, I know where I end up and who it affects, and I’ve already done too much damage to those I love.

Elliot taught me that fentanyl test strips fail at a high rate because, when scratched against a round pill, they often miss the part of the pill that contains fentanyl. Imagine an aspirin or small vitamin. Inside it, hidden somewhere are two grains of salt, perhaps not on the surface. A test strip may or may not scratch the part of the pill that contains fentanyl. That same amount of fentanyl, two tiny grains of salt, can kill someone.

Curing the body of physical addiction to the substance does not cure the brain of damage.

People need to know they or their loved one is at higher risk of death after detox and treatment than before. Trained companions are game-changing because someone must compensate for the damaged part of the brain until it heals. Addiction causes job loss, damaged relationships, and frontal lobe damage that controls executive functions like memory, planning, problem solving, emotional control and performing tasks. Basic things like eating, sleeping, and taking medications on time are challenging. Getting a driver’s license back, cleaning up a financial mess or getting a job require support.

Detoxing at a treatment center is expensive. Detoxing at home is difficult. Traditional seven-day detox regimens often fail. Free clinics can offer step-down medications to ease the severe withdrawals, but users need to be free of the substance for 24 hours+ to tolerate them. Depending on the amount of fentanyl a person was using, it can take up to nine days for a person to tolerate step-down medications, and the withdrawal symptoms are so fierce and painful that many people fail in their efforts to step down and go back to using. How sad it is to know these people who fail at detox are better off than those who do complete detox and treatment.

If fentanyl is a war, who do we fight? Chinese pharmaceutical companies? Mexican drug lords? Dealers and distributors? Users who are dealing to support their addictions? Rappers and influencers who glorify it? Social media apps that allow for easy access to drugs? Fighting multiple opponents usually results in loss. Could we follow battlefield strategy: go after the leader, strategically plan the defense, and always keep the opponents in sight? Not really. It is not a war with multiple enemies, it is many enemies with many agendas.

Scientists are trying to come up with vaccines against fentanyl and understand the genetic roots of addiction, cyber security and AI are helping Homeland Security intercept huge cargo ships in places like Fiji full of fentanyl from China. The Department of Justice is prosecuting dealers with the crime of murder, Border Patrol added thousands of agents and media coverage is helping a bit more.

This past weekend I attended a conference hosted by another mom who lost her son to fentanyl. Her foundation sponsors scientific advances in the disease of addiction. Speakers presented from Johns Hopkins, Yale, UCLA, Mount Sinai Hospital, Scripps and other institutions. Their work is important, yet slow. I was invited by a third mom who also lost her son, who now works warning school kids about the dangers of street drugs. If it is a war against fentanyl, moms, top scientists, middle school kids, filmmakers, investigative journalists, and many other civilians need leadership.

In my three years of trying to understand the crisis and help save lives I stumbled onto something very promising. I will explain how I did that.

After my son died, I went through grief counseling with Jay Westbrook, who was recommended to me by the San Diego DA, Terri Perez. I met Terri working closely with Homeland Security, DEA, San Diego Team 10 and local police over a period of two years to win two murder convictions against the dealer who poisoned both my son and his girlfriend who died days apart. Fortunately, they caught that dealer, Darin Andrew Lee, as he was casually carrying enough fentanyl across the border to kill 22,000 people.

Jay then referred me to a charitable organization called Red Door Life, which treats trauma, mental health and addiction and has one of the top trauma clinicians in the US, Bernadine Fried. I recovered, and my other son recovered there as well.

I asked the founder, Alex Shohet, why they didn’t run more centers in more locations, and he said they can’t because they are not seeing that treatment for fentanyl is working well, and he was testing out models to improve outcomes. He explained that only in cases where at risk fentanyl clients leave their treatment with a trained companion are they proving successful long-term outcomes. In fact, almost all have succeeded over a period of eleven years. The problem is that few people can afford treatment and fewer still can afford to pay companions $40-$60 per hour, or $1,000 per day.

I learned that Alex has seen a lot of what isn’t working in treatment and built a totally different approach with Red Door Life to improve treatment outcomes and prevent overdose death. A successful high-tech executive, entrepreneur, experimenter, and recovering addict himself, he reinforced two points; 1) addicts become stigmatized and isolated 2) addiction is the opposite of connection. Support matters, community matters and in his centers, many times companions have been the difference between life and death.

A light bulb went off for me. With 30 years’ experience building enterprise training in all modalities, I knew how to migrate the existing training program online and remove the barriers, optimizing:

  • Sound instructional design: the program was originally designed in partnership with one of the largest US university systems. An award-winning eLearning, website and app development firm now ensures highest quality training

  • Time tested and proven: Since 2006 Evergreen Fund has trained 50+ companions and provided services to more than 200 clients in early high acuity addiction, primarily fentanyl

  • Designed for everyone over 16: Any family member, roommate, neighbor, church member, coworker, teacher, can be a companion. Professional care providers can earn certification. All groups are encouraged: organizations, associations, schools, universities, hospital systems, a.

  • Easy: Designed to be intuitive, engaging, easy to grasp and retain, placing tools at the learner’s fingertips

  • Affordability: While some may charge for their services, most learners are unpaid volunteers who want to help someone fully recover

  • Service: In its new format, intended for the public, “The United States Recovery Companion Certification” (USRCC) will be free of cost to individuals in need

Given the magnitude of the fentanyl crisis, it is hard for most people to know how to help.

Support this urgent, lifesaving project. Evergreen Fund needs talent, charitable donations, sponsors, and promotion to get this training to all those in need.

My son died a day after being released from a premiere treatment center. My family had no idea he was at higher risk of death when he came home than when he went in. We thought since he “graduated” and was released that he was safe. This amazing training, USRCC, will save many like him.

Dedicated to the memory of Bennett Rhodes.


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