243 ‒ The fentanyl crisis and why everyone should be paying attention | Anthony Hipolito

KEYPOINTS

• 01

  Fentanyl is dosed in micrograms, and street pills are off by orders of magnitude

  Peter explains that hospitals give morphine in milligrams (1–5 mg IV) but fentanyl in micrograms. About 100 µg is a typical dose for something like a colonoscopy, and even clinicians occasionally over-sedate someone by misjudging sensitivity by 25–50 µg. Deputy Anthony Hipolito says about 2 mg can kill. Illicit manufacturers can match colours and stamps perfectly, yet they are off by as much as 'a dose of a thousand' on the active ingredient: far beyond a lethal dose, 'you might as well have cyanide'.

• 02

  The crisis grew out of prescription opioids

  Hipolito dates widespread opioid addiction to around 2010–11, when some pain-management doctors prescribed oxycodone, Vicodin and Percocet recklessly and patients went 'doctor hopping'. As an Austin police interdiction sergeant along I-35, he began seeing fentanyl around 2017–18, mostly ordered on the dark web from China and shipped through FedEx, UPS and USPS. Mexican cartels now dominate the trade.

• 03

  Accidental overdose is now the leading killer of young adults

  By Peter's reading of the last 12 months of CDC data, someone in the US dies of an accidental overdose roughly every five minutes, more than 100,000 a year, excluding suicides. Hipolito estimates about two-thirds involve fentanyl. In 2021, fentanyl was the number one killer of Americans aged 18–45, and he expects the 2022 data to push the lower bound down to 13 or 14. Ten years ago Peter would have said only two things threatened people under 40, car accidents and suicide; now accidental overdose dwarfs both, making them 'rounding errors'.

• 04

  Call it poisoning, not overdose

  Most victims are not trying to get high on fentanyl or end their lives. They believe they're taking Xanax to sleep, Adderall to study, a Percocet, or cocaine. Hipolito says six in every 10 counterfeit pills contain a potentially lethal dose. By his estimate, street cocaine is laced 90–99% of the time, and most users survive only because a given dose happens not to be lethal: 'Russian roulette'.

• 05

  Seizures show the explosion in supply

  Fentanyl seizures went from about 200,000 to 1.5 million to 4.1 million to almost 10 million over 2018–2021. Border agents are thought to intercept only 5–10% of narcotics. Because it is synthetic and needs no poppy fields, fentanyl is cheap compared with a kilogram of cocaine or heroin, and smugglers use methods that can evade X-rays and drug dogs.

• 06

  Dealers are targeting younger kids

  Hipolito says the DEA believes cartels are deliberately pursuing younger buyers to create long-term customers. 'Rainbow' or candy fentanyl looks like sweets and is smuggled inside real Skittles or Nerds boxes. Sales happen on Snapchat, Instagram and Facebook, and on encrypted apps like Telegram and Signal where messages disappear. In Hays County, the most recent death was a middle school student.

• 07

  How fentanyl kills

  It suppresses breathing. As breathing slows, heart rate falls, and death can come quickly while the person feels euphoric. Surveillance footage Hipolito shows students includes a passenger who waited 20–25 minutes before calling 911, delays that cost lives.

• 08

  Narcan works, but street doses may need many

  Naloxone reverses opioid effects. Hospitals use it after an accidental fentanyl overdose of, say, 120–125 µg. In Hays County, a single dose often isn't enough: one teenager needed 15 doses. All deputies there carry it. It is sold without a prescription at pharmacies such as Walgreens and CVS, and the federal government will mail it.

• 09

  Policy is unresolved; the 'why' matters most

  Peter notes Portugal decriminalized personal possession and reports one of Europe's lowest overdose rates, while Oregon and British Columbia are trying similar approaches. He says he hasn't decided where he stands and worries it may be a band-aid. Both agree the root question is why someone needs the drug, whether that's anxiety, insomnia or academic pressure, and without answering it the person won't get help.

• 10

  Stronger opioids are coming

  Peter says he has heard that the FDA deeply regrets approving the medical opioid sufentanil because it 'makes fentanyl look weak'. Hipolito warns that manufacturers are altering molecular structures to create compounds stronger than fentanyl, and that a 'super Narcan' is being developed in response.