Fentanyl, a synthetic opioid exponentially stronger than morphine, has transitioned from an unwanted contaminant in the illicit drug market to a sought-after substance among people who use drugs (PWUD).
This shift underscores a critical change in drug use patterns, motivations, and the associated demographic and socioeconomic factors contributing to its rising preference.
Highlights:
- Fentanyl’s Potency: Fentanyl is 50 to 100 times more potent than morphine, making it a highly effective but also dangerous analgesic.
- Demographic Shifts: Intentional fentanyl users tend to be young, male, and predominantly White, with a high incidence of substance use patterns and precarious living situations.
- Motivations for Use: The motivations behind intentional fentanyl use include its greater potency, ability to delay withdrawal symptoms, lower cost, and increased availability.
- Treatment Challenges: The unique pharmacological properties of fentanyl pose significant challenges for traditional opioid use disorder treatment strategies, necessitating novel and adaptable treatment approaches.
Source: Frontiers in Psychiatry (2024)
What is Fentanyl? (Basic Overview)
Fentanyl is a synthetic opioid, renowned for its potency, which is estimated to be 50 to 100 times more powerful than morphine.
Developed in 1960 by Dr. Paul Janssen, fentanyl has been widely used in medical settings for its effective pain management properties.
It belongs to a class of medications known as opioid analgesics, which work by binding to the body’s opioid receptors, predominantly found in the brain, to reduce pain sensation.
Mechanisms of Action
Fentanyl primarily exerts its effects through the activation of the mu-opioid receptors in the central nervous system (CNS).
This action not only alters the perception of pain but also affects areas of the brain responsible for emotional regulation, leading to feelings of euphoria.
However, this same mechanism can depress respiration, especially at high doses, which is the primary cause of opioid-related overdose deaths.
Medical Uses
In the medical realm, fentanyl is utilized for its fast-acting and potent analgesic effects, making it a critical tool for managing severe pain, including breakthrough cancer pain.
It is also employed in anesthesia as a part of surgical procedures to help with pain mitigation and to induce a state of sedation.
Fentanyl is available in several forms, including injections, transdermal patches, and lozenges, each tailored for specific clinical scenarios and patient needs.
Non-Medical Use & Abuse
Despite its therapeutic benefits, fentanyl’s high potency also makes it a drug with a high potential for dependence and abuse.
Non-medical use of fentanyl often involves seeking out its powerful euphoric effects. In some cases, individuals start using fentanyl non-medically after developing a tolerance to other opioids.
The illicit market for fentanyl has grown, with the drug being mixed into heroin or other street drugs, often unbeknownst to the user, which significantly increases the risk of overdose and death.
Major Findings: Who Uses Fentanyl Illicitly (Non-Medical)?
Tsang et al. reviewed the landscape of intentional non-medical fentanyl use among people who use drugs (PWUD), aiming to grasp the scope of its voluntary consumption, demographic variances, motivations behind use, and the emerging patterns of its consumption.
Through a detailed analysis of 41 peer-reviewed studies, the research brings to light significant findings regarding who is using fentanyl intentionally, why they are choosing this highly potent opioid, and how their consumption behaviors are characterized – below are the major findings.
1. Demographic Characteristics of Fentanyl Users
Young, Male, Mostly White: The review established that individuals intentionally using fentanyl tend to be young, predominantly male, and White. This demographic trend points towards specific social and cultural contexts that may influence the drug use patterns within these communities.
Socioeconomic Factors & Living Conditions: The research also shed light on the precarious living situations of fentanyl users, with a significant number experiencing homelessness, higher rates of unemployment, and incarceration. This correlation suggests that beyond individual choice, structural and socioeconomic factors play a significant role in the drug use landscape.
2. Motivations for Fentanyl Use
Potency & Cost-Effectiveness: One of the primary reasons behind the intentional use of fentanyl is its high potency and lower cost compared to other opioids. Users are seeking a more intense experience or a longer-lasting high, which fentanyl provides due to its chemical properties.
Delaying Withdrawal: Users also reported seeking fentanyl to delay the onset of withdrawal symptoms, a critical factor for those with heavy dependency on opioids. This indicates a cycle of use where the motivation is not only the high but also the avoidance of withdrawal discomfort.
3. Patterns of Use
Injection as Preferred Method: The review found that injection is the most common route of administration among intentional fentanyl users, which raises significant public health concerns due to the risks associated with injecting drugs, including transmission of infectious diseases and overdose.
Polysubstance Use: Fentanyl users often consume the drug in conjunction with other substances, including heroin, cocaine, and methamphetamines. This polysubstance use pattern complicates the clinical management of overdose and withdrawal, increasing the risk of fatal outcomes.
High Incidence of Overdose: The data revealed a disturbingly high incidence of overdose among fentanyl users, attributed to the drug’s potency and the practice of mixing it with other substances. This underscores the critical public health challenge of addressing fentanyl use amidst the broader opioid crisis.
Intentional Non-Medical Fentanyl Use Among People Who Use Drugs (2024 Review)
This systematic review aims to evaluate the evidence on intentional non-medical fentanyl use among people who use drugs (PWUD), by summarizing demographic variance, reasons for use, and resulting patterns of use.
The goal is to inform the development of effective intervention approaches, identify settings for interventions, and pinpoint critical areas for future research.
Methods
- Search Strategy: The search was conducted using a combination of free text keywords and MeSH and non-MeSH keywords, across four databases: Ovid MEDLINE, Embase, Web of Science, and PsychINFO, covering literature up to May 2021.
- Inclusion Criteria: Human studies on the intentional use of non-medical fentanyl or its analogues in individuals older than 13 were considered. Only peer-reviewed original articles in English were included.
- Study Selection: Following de-duplication, 4437 studies were screened, with 132 selected for full-text review, resulting in 41 studies included in the review.
- Data Extraction & Quality Assessment: Two independent reviewers extracted data using a standardized table. The Newcastle-Ottawa Quality Assessment scale, among other tools, was used for quality assessment.
Findings
- Demographics: Fentanyl users tend to be young, male, and predominantly White.
- Use Patterns & Motivations: Many are motivated by fentanyl’s greater potency, delay of withdrawal symptoms, lower cost, and greater availability. Injection drug use and experiences of overdose are common.
- Socioeconomic & Health Outcomes: Intentional fentanyl use is associated with precarious living situations, severe substance use patterns, and extensive overdose history. There is a clear need for alternative treatment approaches for opioid use disorder and withdrawal management in this population.
Limitations
- Heterogeneity of Studies: The included studies varied significantly in design, focus, and quality, making it challenging to conduct a meta-analysis or draw uniform conclusions.
- Specificity on Intentional Use: The review focused solely on intentional non-medical use among PWUD, excluding those with opioid use disorder who might not use fentanyl intentionally, which might limit the generalizability of findings.
- Recent Studies Only: The review was limited to studies available up to May 2021, potentially missing recent developments in fentanyl use patterns.
Why Research Intentional Non-Medical Fentanyl Use?
Understanding the dynamics of non-medical fentanyl use is crucial for multiple reasons, both from a public health perspective and for the formulation of effective interventions.
Its infiltration into the illicit drug market, sometimes unbeknownst to users, has led to a sharp increase in overdose deaths.
However, a segment of the population intentionally seeks out fentanyl for its potent effects, posing unique challenges and opportunities for substance use management and policy formulation. Here are the key rationales for researching non-medical users of fentanyl.
1. Addressing the Overdose Crisis
Overdose Risk: Fentanyl is 50 to 100 times more potent than morphine, making the margin for overdose very narrow. Understanding who is using fentanyl intentionally and why can help tailor overdose prevention strategies to be more effective, recognizing the increased risk this group faces.
2. Protecting Public Health
Targeted Harm Reduction: By identifying the demographics, motivations, and usage patterns of intentional fentanyl users, interventions can be more accurately designed. For instance, programs offering testing strips for fentanyl or supervised consumption sites can be better promoted and situated in communities with higher rates of intentional use.
Treatment & Recovery Programs: Insights into the socioeconomic conditions and preferred consumption methods of non-medical fentanyl users inform the development of tailored treatment programs, which may need to differ from traditional opioid use disorder treatments given fentanyl’s unique properties and the user’s motivations.
3. Drug Policy & Regulation
Regulation & Law Enforcement: Understanding the scope and nature of intentional fentanyl use assists in crafting laws and policies that effectively target the illegal supply chain without exacerbating the risks faced by users. It also helps in balancing law enforcement approaches with public health initiatives.
Funding & Resource Allocation: Detailed knowledge of the intentional fentanyl user population aids governmental and non-profit organizations in allocating resources more efficiently, ensuring that funding is directed toward interventions that address both the supply and demand sides of the fentanyl issue.
4. Stigma Reduction
Reducing Stigma: Public narratives around drug use can often be simplistically negative, contributing to stigma. Research that sheds light on the complex reasons behind intentional fentanyl use can help humanize users, reduce stigma, and encourage a more empathetic and effective societal response.
Education & Awareness: Disseminating findings from such research can inform educational campaigns targeted at at-risk populations, emphasizing the dangers of fentanyl use and offering guidance on seeking help. It can also educate the broader public, leading to greater support for harm reduction and treatment-focused policies.
Conclusion: Understanding Non-Medical Fentanyl Users
Understanding non-medical users of fentanyl is critical for multiple reasons, providing the foundation for this research’s rationale.
Firstly, fentanyl’s high potency makes it inherently dangerous, significantly increasing the risk of overdose and death among users.
Secondly, intentional use reflects underlying social, economic, and psychological factors that require comprehensive public health and policy responses.
Thirdly, recognizing the demographic and behavioral patterns of fentanyl users can guide targeted interventions, harm reduction strategies, and the development of treatment programs tailored to the needs of this population.
Moreover, understanding motivations behind fentanyl use, such as its cost-effectiveness and potency, can inform educational campaigns and prevention efforts.
Finally, this knowledge contributes to the broader effort to combat the opioid crisis, aiming to reduce the harm caused by fentanyl and other opioids through informed, evidence-based strategies.
References
- Paper: Systematic review on intentional non-medical fentanyl use among people who use drugs (2024)
- Authors: Vivian W L Tsang et al.