The news that actor Michael K. Williams died of an accidental overdose involving the synthetic opioid fentanyl highlights the toxicity of the drug supply in the U.S.—and the heightened dangers people face when they use drugs again after taking a break, experts say.
Williams, the beloved actor who played Omar Little on HBO’s The Wire and hosted Black Market on VICE TV, was found dead Sept. 6 in his Brooklyn apartment. He was 54. On Friday, New York City’s chief medical examiner said Williams died of acute drug intoxication due to a combination of fentanyl, p-fluorofentanyl, heroin, and cocaine.
Williams had been open about using drugs like cocaine in the past and had told the New York Times in 2017, “Addiction doesn't go away… It's an everyday struggle for me, but I'm fighting.” Earlier this year, on Marc Maron’s WTF podcast, he said, “You know, relapse to me is part of my story and, you know, but I’m living good today, you know. All’s we got is today.”
His death comes in the midst of a drug poisoning crisis in North America in which heroin is increasingly being replaced with fentanyl, a much more potent opioid, up to 100 times stronger than morphine. In 2020, the U.S. had its worst year on record for fatal overdoses, with 93,000 deaths, more than 60 percent of which were linked to fentanyl.
Fentanyl is also being found cut into other drugs, including cocaine. The Drug Enforcement Administration released a public safety alert Monday about an influx of fake prescription pills containing meth and fentanyl; the agency said it has seized 9.5 million counterfeit pills this year so far, more than the last two years combined.
“This is literally a mass poisoning. There's no other way to describe it,” said Dr. Ryan Marino, a medical toxicologist. “People can go out and buy heroin, and if they get something that isn't heroin and die from that, that meets the definition of poisoning.”
Using opioids such as heroin again after taking a break has always been dangerous because a person’s tolerance can go down quickly. The deaths of actors Phillip Seymour Hoffman and Cory Monteith of Glee were linked to recurrent heroin use.
But Marino said it’s much more dangerous with fentanyl flooding the drug supply. In many places, particularly along the East Coast, it’s nearly impossible to find heroin.
“When people use (opioids) over time, they need more and more to get the same effect and that’s the tolerance… If people go back to using the same amount and they've lost some of their tolerance, it's going to set them up for an overdose because their body is not physiologically where they were before they stopped,” he said.
“I’ve seen people who have used heroin for decades… and now that it's being cut with fentanyl, fentanyl analogs, other synthetic opioids, and other compounds, [they] will experience an overdose.”
Marino said when heroin was still widely available, it generally would be around 50 percent pure. With fentanyl, it’s about 1 percent of raw fentanyl and the rest are cutting agents, he said, so if someone messes up by even adding 1 percent more fentanyl, that batch’s potency will double.
Fentanyl analogs, drugs designed to mimic the effects of fentanyl but with a slightly different molecular structure, are also becoming more common in the illicit drug supply. In part, that’s because drug sellers are trying to avoid the classification of their drugs as illegal. (The analog parafluorofentanyl found in Williams’ system was originally developed by Janssen in the 1960s; it is stronger than fentanyl.)
Although drugs that are “substantially similar” to controlled substances in the U.S. are also prohibited, the language around that is vague enough that drug sellers will keep trying to make different synthetic drugs that could potentially fall in a grey area.
“It prompts drug sellers to get more creative and more diverse in their holdings to try to avoid any one bust from taking down their entire supply chain,” said Claire Zagorski, program coordinator at the Pharmacy Addictions Research and Medicine Program at the University of Texas at Austin.
Zagorski said once drug sellers move away from plant compounds, like heroin, which comes from poppies, and into synthetic drugs, “the sky is the limit.”
Fentanyl analogs can also yield a drug seller more profit for less risk, because they can be sold in smaller but more potent batches.
“It's a sad thing to say, but if we flooded the market with black-tar heroin, our death rates would go down,” said Chad Sabora, co-founder of Sana Lake Recovery Center in Missouri, which treats people with substance use disorders.
Besides unpredictable potency, Sabora, who has been in recovery for over 10 years, said fentanyl analogs are harder to metabolize, which makes it more difficult for people to detox or go on prescription drugs that help alleviate withdrawal symptoms, like Suboxone.
He said the U.S. needs drastic drug policy reform, including universal health care, widespread access to syringe exchange programs, and heroin-assisted treatment. He also said systemic issues like poverty, racism, and trauma need to be addressed.
Programs in Canada and Switzerland offer prescription heroin for people who have a substance use disorder.
“We either devise a safer delivery system that will reduce people's chances of dying or we let people die needlessly,” Sabora said. “What we have now is beyond scary and we don't know what's going to come next because we keep repeating the same mistakes.”
Zagorski said Williams’ death is “horribly sad,” especially considering what an important figure he was to many people. She said his death is a reminder that anyone can be susceptible to poor drug policy.
“Any time I see a celebrity who dies of an overdose, dies of a drug poisoning from this inconsistent supply, it's really telling,” she said. “Even people with more money, more visibility, more resources than most Americans—when those people are also dying of drug poisoning... it really says something about the tremendous inaccessibility of safe drugs.”
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If you are going to use drugs, do not use them alone, and carry naloxone—which can reverse opioid overdoses. You can get naloxone at https://nextdistro.org/. Make sure that someone with you knows how to use naloxone.
If you are going to use drugs alone, you can call the Never Use Alone hotline at 1-800-484-3731, and someone will stay on the line with you while you use.
You can also get fentanyl testing strips, to test your drugs for the presence of fentanyl, available through dancesafe.org. However, these strips aren’t foolproof.
Sabora also recommended going slow when using drugs and staggering your use.