Why Heroin Users Aren't As Afraid of Deadly Fentanyl As They Should Be

The killer heroin was sometimes sold under the brand "Scumbag."

Heroin brand names are often devised with a morbid sense of humor. A few recent examples I've come across include "Obamacare," "Jim Jones " and "Walking Dead." In the case of Scumbag, however, the name should have been taken as a warning about the kind of person who manufactured it: The drug may have been responsible for as many as 35 deaths over the course of five days in Philadelphia last month.

In the past, that fact might have been a marketing bonanza for Scumbag dealers—a signal that their stuff was potent, or at least definitely not a placebo. Experienced users with a high tolerance might have been drawn to it because powerful heroin that will easily kill a newbie is, for some addicts, the only thing strong enough to do more than stave off the next withdrawal.

But the proliferation in recent years of street fentanyl and related derivatives—which can be hundreds of times stronger than morphine and are generally sold either as heroin or in counterfeit prescription pills—may be starting to change that calculus. And that has important implications for how America combats drug overdose in the years to come.

According to the DEA's 2016 National Heroin Threat Assessment, between 2013 and 2014 alone, overdose deaths linked to synthetic opioids (predominantly fentanyl and derivatives) rose by 79 percent. before 2013, the New York City Department of Health and Mental Hygiene had found that less than 3 percent of overdose deaths in America's largest city involved fentanyl and similar synthetics. But in 2016, they were implicated in nearly half of all cases. In Philadelphia, fentanyl deaths have risen an incredible 636 percent in just two years.

Jeff Deeney, a social worker in Philadelphia who is himself in recovery from heroin addiction, has seen the spread of fentanyl harm his clients. "The biggest challenge for me was to really punch through this idea that the game has changed," he says. "This is the 'crying wolf' thing. Everybody had heard in past, with crack, you smoke it once and you're addicted for life and all that bullshit. Everyone thinks they've seen it all before."

This cynicism doesn't come from nowhere: Every time the media discovers a new "drug epidemic," journalists get quotes from experts saying that this time, it's really different and the new stuff truly is more potent, more addictive, and deadly than anything that has come before.

Here's neuroscientist Roy Wise of Concordia University in Montreal, quoted in the New York Times in 1988, near the height of hysteria about crack: "If I knew that my daughter was going to try either heroin or crack, I'd prefer that she try heroin,'' he said. "In the case of crack, the only solution I've got a lot of faith in is not starting to use it in the first place."

Now here's NPR two years ago, quoting a police chief who's actually nostalgic for crack:

When every fashionable new drug is always presented to the public as unbelievably awful, if a truly nightmarish substance does come along, users might not believe it—at least, not until many people around them are dead. But fentanyl really is that bad: Crack didn't actually account for that many overdose deaths, and even during the times in the past when heroin was especially popular, it never reached fentanyl's level of mortality.

"The medical system hasn't applied the same rigor and standards to talking about drug addiction as it has for everything else," says Sarah Wakeman, medical director of the Substance Use Disorder Initiative at Massachusetts General Hospital and assistant professor at Harvard Medical School. "We haven't informed the public in an accurate way."

Wakeman notes that teens who are told that weed will inevitably lead to disaster can simply stop believing official information when they see the real world falsify these claims—which makes it harder to stop them from doing dangerous drugs. "People are inured to fear tactics because they think you're trying to scare them straight," adds Deeney.

Another way using fear to try to reduce addiction can backfire is through policing. As Deeney told Philadelphia magazine at the time, many of the Scumbag overdose deaths took place in the wake of a crackdown on street markets. Users had actually been trying to avoid Scumbag, according to him.

"The cops had shut literally every other corner down," Deeney tells me. "It created a huge funnel and shunted all these people to the one corner where they were selling it."

So what can make people with opioid addiction reject brands that boast super high potency rather than chase them? Simple experience, for one. "Everyone is being touched by this and death is a bit less hypothetical when your friend or partner just died," says Wakeman.

But there's also another critical factor, which is the pharmacology of fentanyl-like drugs. Fentanyl is legitimately used for surgical anesthesia, with good reason: it knocks you out cold, almost instantaneously. If you want complete oblivion, that's one thing.  But in my experience of covering addiction for nearly three decades—and having struggled with addiction myself—most users want to feel better, not feel nothing. What's the point of taking drugs if you don't consciously get high or feel relief? And if you are lying unconscious on the street, you're highly vulnerable.

"The fentanyl high is sloppy," Deeney says. "They call it 'sleep cut.' It puts you right out." It also lasts for a much shorter time than heroin does, with users reporting that at most, they get a few seconds of high, lose consciousness—and then, if lucky, wake up with withdrawal sickness an hour later. It doesn't have what users call the "legs" or long-lasting four to six hour high of heroin.

Daniel Raymond, policy director of the Harm Reduction Coalition, observes that a shift away from seeking the strongest heroin possible towards actively avoiding fentanyl may come with experience. "It's almost like a community level adaptation," he says, "At first fentanyl might seem like it makes more sense—if you can stretch it out longer by dividing it into smaller doses, there's [perceived] benefit from that. But then when you see that it's hard to calibrate the dose and people are OD'ing and people close to you are dying, that shifts it from adaptation to avoidance."

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This month, in order to try to help drug users reduce risk related to fentanyl, the Harm Reduction Coalition will launch a pilot research program offering test strips that can determine the presence of fentanyl and survey those who decide to try them about how they use such information. The group doesn't yet know whether this will be helpful, of course. Will people just discard bags that test positive for fentanyl—or will they try to avoid overdosing by using smaller doses? Will the test provide accurate information, or will it miss too many potentially harmful but new synthetics and fail to reduce harm?

"That's why we're doing the survey," says Raymond, who adds that the test strips seem to be able to pick up not just fentanyl, but at least some derivatives. Still, this doesn't clarify the dose present, which obviously makes a huge difference. "Is that useful or actionable information?" he wonders. "Are there risks of false positives or negatives or of a false sense of security?

"We don't know that yet, so we're hoping to at least learn something," Raymond says.

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