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Research: Is illicit fentanyl desired by or imposed on opioid users?

Recently, illicitly produced fentanyl, and fentanyl analogues, have been rapidly emerging in countries all over the world. Fentanyl is usually disguised as heroin or prescription pills, which results in increased overdose mortality. This phenomenon can be explained by reduced expenses and risk to heroin sellers, heroin shortages, buyer preferences for rapid acting, strong opioids, and the increased popularity of darknet marketplaces. A recently published research paper addresses these possible explanations and tries to answer three important questions: (1) can users precisely identify fentanyl and differentiate it from other drugs?; (2) do users really desire fentanyl?; and (3) if users really desire fentanyl, do they express this desire in a way that affects supply?

Let’s take a look at how the paper attempts to answer these questions.

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Can users precisely identify fentanyl?

Most of the research studies centered on this question have been conducted in the US, where users are utilizing multiple techniques to identify fentanyl in their heroin supply. These techniques include embodied effects of the drug, drug color as dry powder and in solution, and taste. Users also obtain information from dealers and from peers’ experiences. Users often describe fentanyl’s effects as short acting with a rapid and powerful onset, which correspond to the drug’s pharmaceutical properties.

In Canada, tested drug users were unaware that they had been exposed to fentanyl while using heroin, even though this usually changes as users become more aware and experienced over time. This is further complicated by the fact that there are currently synthetic opioids in circulation, such as U47700, which can be mistaken for fentanyl.

Adding fentanyl to heroin supply usually takes place at a wholesale level. As such, with regional distribution, retail dealers usually have no knowledge regarding the content of the products they sell. Thus, users often take dealer’s claimed knowledge with considerable skepticism. However, some users claim they can avoid fentanyl via loyalty to a reliable dealer.

Point-of-use testing, which is namely associated with drugs such as MDMA, has also become a possibility with fentanyl test strips. Even though these strips can reliably identify fentanyl, they are not capable of detecting its concentration or differentiating between various fentanyl analogues with different potencies.

Do users really desire fentanyl?

Previous research studies have proven that users prefer to purchase the strongest available heroin, even if it is known to be of low purity, to the point that some users seek heroin known to be associated with overdoses. Nevertheless, in the present fentanyl wave, with its high mortality rate, US studies indicate that attitudes have somehow polarized as some users ask for fentanyl despite its associated risks, while others tend to avoid it.

Some users describe fentanyl as a drug that has a more powerful onset or “rush” than heroin, bringing them back to an opioid euphoria lost to drug tolerance. Another group of users favored a heroin/fentanyl cocktail with heroin providing a prolonged effect, complementing the intense rush induced by fentanyl. For those using drugs that block opioid effects, such as buprenorphine, fentanyl’s ability to bypass this enables users to experience the opioid’s effects. Others don’t like to experience fentanyl’s effects, with its increased overdose risks. Fentanyl’s short duration of action is also reported as a disadvantage rendering it less cost-effective. Among some heroin addicts, fentanyl’s high potency has furthered their opioid tolerance, making sole use of heroin insufficient to meet the demands of their addiction, which makes them prefer fentanyl over heroin, regardless of their prior preference.

If users really desire fentanyl, do they express this desire in a way that affects supply?

Street based heroin buyers usually discuss drug quality, potency, availability, and other features along their quest to acquire heroin. Information as well as rumors spread more or less efficiently according to the drug distribution in question. A study that examined heroin sales in two US based cities proves that in a street market with several sellers, buyers can obtain and act upon information concerning drug quality more easily and quickly than buyers who purchase from dealers operating via cellphone communications.

On the other hand, drug dealing via dark web marketplaces is associated with different methods of opinion and information sharing. Darknet market customers are capable of comparing the prices of products sold by different vendors, reading user reviews, and leaving their very own feedback. A user who wishes to purchase fentanyl rather than heroin can find it advertised as such under multiple product listings and in a myriad of delivery systems including powder, nasal sprays, pills, etc. Nevertheless, drugs sold on darknet marketplaces as heroin have been also found to be adulterated with fentanyl.

Due to the frequency of dependence on opioid use and the barriers associated with access of darknet marketplaces, it is unlikely that enough drug users are purchasing fentanyl this way to significantly affect fentanyl supply and its mixing with heroin supplies. Moreover, if darknet market fentanyl purchases were more common, one would expect a wider distribution and less common adverse consequences associated with its use.

The unpredictable and sporadic appearance of various fentanyl analogues in various parts of the US, suggests that user preference is not the main determinant, instead suppliers are using whatever seems convenient or minimizes legal risk. Regulation of analogues is more or less reactive, and once controlled, newer unregulated substitutes appear on the market.

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