Spread of Illegally Manufactured Fentanyl in the US

"Historically, there have been a number of US overdose events where a fentanyl was implicated [14▪▪,15▪]. However, the wave of overdose deaths attributed to illicit fentanyls since 2013 is unprecedented. The current rise of fentanyls is considered a positive supply shock, i.e., a supply driven more than demand-driven event [16]. Evidence for this includes: fentanyls are generally sold as ‘heroin’ i.e., fentanyl-adulterated or substituted heroin (FASH) [17,18]; wholesale distribution of FASH [19] and related overdose is regionally distributed with the Northeast and Midwest most affected followed by the South [20–22]; these are illicit products not diverted pharmaceuticals [19]; early on there was mixed desirability for FASH [17,18,23,24]; and there is market incentive in that dose-for-dose fentanyl is cheaper to produce than heroin [3,25]. The reasons why fentanyls were introduced during the current surge is complex; one argument, based on prior episodes, is that they replace heroin during periods of relative shortage [16,26]. In The Future of Fentanyl and other Synthetic Opioids, Pardo et al. highlight a confluence of supply side factors to explain the rise of fentanyls, e.g., more-efficient synthesis methods, internet communication and commerce, and out-paced regulatory environments in source countries e.g. China [27▪▪].

"The fentanyls problem is spreading. Globally, fentanyls have been detected or implicated in deaths in Europe, esp. Estonia, Latvia, and Sweden [27▪▪]. Canada has been particularly hard hit by fentanyl-related overdose [28]. The spread of fentanyls is also happening in the USA. From 2014 to 2017, the fentanyls problem was initially regionally isolated to the US Northeast and Midwest, followed to a lesser degree in the South [20,22]. However, from 2017 to 2018 the region that had the highest relative change in overdose rates due to synthetic opioids was the West [5▪]. Examining CDC data, Shover and colleagues found the share of US synthetic opioid overdose deaths attributable to seven western jurisdictions more than tripled from 2017 to 2019 [29▪▪]. Supply side data also support increasing fentanyls supply, esp. in the form of counterfeit pills, to the West [30]. And the supply is diversifying from China and Mexico to include India as a source country [31▪]."