Published May 23, 2024 | Originally published on MedicalXpress Breaking News-and-Events
Now that smoking has replaced injecting as the most common way to consume fentanyl, UCSF researchers have uncovered an increased risk of fatal overdose from the residue that accumulates in smoking equipment.
The researchers found that people both shared fentanyl resin and consumed it accidentally. This may be increasing the risk of overdose, especially among those who use the equipment to smoke other drugs, like methamphetamine, and have not developed tolerance to opioids like fentanyl.
"The risk of overdose when sharing smoking devices with fentanyl resin could be seen as analogous to the risk of shared injection paraphernalia and HIV transmission," said Daniel Ciccarone, MD, MPH, Justine Miner Professor of Addiction Medicine at UC San Francisco in the Department of Family & Community Medicine, who is the first author of the paper. "Harm reduction-based and culturally attuned education campaigns need to be rapidly advanced to address this new risk."
The paper is the first to explore fentanyl resin as a key contributor to overdose and appears May 22 in PLOS ONE.
Smoking fentanyl is rising locally and nationallySan Francisco reached an all-time high of 806 deaths in 2023, with 653 from fentanyl. Nationwide, the number of fentanyl deaths declined modestly in 2023, dropping from 76,226 to 74,702; but they remain high, and fatal overdoses from psychostimulants, including methamphetamine and cocaine, are on the rise.
In recent years, mirroring national trends, fewer people in San Francisco have been injecting fentanyl and more have been smoking it. But the beliefs and behaviors surrounding this development have not been well understood to date.
To conduct the study, the researchers observed people in their own environment in 2022, conducting face-to-face interviews with 34 participants who were recruited from syringe service programs.
They asked about the progression of the participants' substance use, as well as their modes of use, experiences with overdose, and the changes they had observed in the local drug supply. The interviews were supplemented with daily field notes, video-recorded smoking sequences, and photography of drugs and equipment.
The researchers observed that fentanyl was extremely cheap, as low as $10 a gram; and most people used foil to smoke it, although glass bubbles, bongs, and dabbing devices were also popular. The quality of the fentanyl varied, and people had no apparent method to determine it. Participants could gauge potency upon inhalation, however, and they had developed techniques to regulate their dose. Several participants reported frequent use, up to one or more grams a day.
Shared equipment poses significant dangersIt was both the difficulty of injecting and the fear of overdose that motivated people to start smoking fentanyl instead. Smoking was also more social, and people shared equipment, drugs, and information. The researchers were surprised to find that this caused participants to reflect on the changing risk environment for people with varying opioid tolerances and to develop strategies to protect others.
Early during fieldwork, the researchers observed an interaction in which a random person attempted to borrow a glass pipe from a participant, who vehemently refused. The participant explained that the pipe had been used for fentanyl and did not want to share it with someone who only used methamphetamine. Smoked fentanyl and methamphetamine residues look similar, and the equipment used often overlaps.
"The overdose risk arises when there is a potential mismatch between the potency of the residual drug and the recipient's tolerance," Ciccarone explained.
While some participants took precautions to prevent others from using their smoking equipment and overdosing on the residues, the shared smoking culture still poses increased risks, particularly given high consumption rates.

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Published May 14, 2024 | Originally published on NIH News News Release Monday, May 13, 2024

Over 115 million pills containing illicit fentanyl seized by law enforcement in 2023NIH-supported study highlights increasingly dangerous illicit drug supply, risk of pills not coming from a pharmacy.
Law enforcement seizures of illicit fentanyl increased dramatically in number and size between 2017 to 2023 in the U.S., especially in pill form, according to a new study funded by the National Institutes of Health’s (NIH) National Institute on Drug Abuse (NIDA). The number of individual pills containing fentanyl seized by law enforcement was 2,300 times greater in 2023 compared to 2017, with 115,562,603 pills seized in 2023 vs. 49,657 in 2017. The proportion of fentanyl pill seizures to the total number of fentanyl seizures more than quadrupled, with pills representing 49% of illicit fentanyl seizures in 2023 compared to 10% in 2017. The study also found a significant increase in the number and weight of fentanyl-containing powder seizures during this time.
“Fentanyl has continued to infiltrate the drug supply in communities across the United States and it is a very dangerous time to use drugs, even just occasionally,” said NIDA Director Nora D. Volkow, M.D. “Illicit pills are made to look identical to real prescription pills, but can actually contain fentanyl. It is urgently important that people know that any pills given to someone by a friend, purchased on social media, or received from any source other than a pharmacy could be potentially deadly – even after a single ingestion.”
Although fentanyl seizures were historically less common in the Western U.S., this analysis found that this region now accounts for most of law enforcement seizures of fentanyl overall, as well as total weight of fentanyl seized. The proportion of fentanyl pill seizures compared to the overall number of fentanyl seizures was also highest in the West, with 77.8% of all law enforcement seizures of fentanyl in the West being in pill form in 2023. These data emphasize the need for continued monitoring of regional shifts in the fentanyl supply, to help inform targeted prevention and public health responses.
In 2022, over 107,000 people died of a drug overdose, with 75% of those deaths involving an opioid. The overall rise in overdose deaths is largely attributable to the proliferation of illicit fentanyl, a synthetic opioid. Illicit fentanyl is highly potent, cheaply made, and easily transported, making it extremely profitable. Fentanyl is about 50 times more potent than heroin and a lethal dose may be as small as two milligrams.
While some people knowingly consume fentanyl, many people do not know if the drugs they plan to use contain fentanyl. This is especially true of illicit counterfeit pills, which are often made to resemble prescription medications such as oxycodone or benzodiazepines, but really contain fentanyl. Recent studies have reported a dramatic rise in overdose deaths among teens between 2010 to 2021, which remained elevated well into 2022 according to a NIDA analysis of CDC and Census data. This increase in deaths has been largely attributed to widespread availability of illicit fentanyl, the proliferation of counterfeit pills containing fentanyl, and the ease of purchasing pills through social media.

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