America is facing an opioid crisis. The statistics are staggering: According to the Centers for Disease Control and Prevention (CDC), more people died from a drug overdose in 2014 than any year on record, and the number of overdose deaths involving opioids nearly quadrupled since 1999. What’s more, drug overdose is now the leading cause of accidental death in the U.S.

Opioid and heroin abuse are destroying communities, breaking the hearts of families, and generating serious economic and healthcare burdens. But the situation is getting more complicated thanks to a new development within this already-threatening issue, and one that is still shrouded in many unknowns: synthetic drugs. Indeed, synthetic drugs are being developed and delivered to our markets with alarming speed and efficiency. The Wall Street Journal recently reported that the United Nations Commission on Narcotic Drugs estimates that new synthetic substances are emerging globally at an average rate of one new substance per week.

So, what do we know about these synthetic drugs, and how are they contributing to the opioid epidemic? Synthetic drugs, specifically synthetic opioids, are very often attempted replicas of drugs that were previously developed in legitimate pharmaceutical research, some of which are currently marketed, and some of which were abandoned by scientists years ago.

These emerging synthetic substances are resurrected in unregulated labs, most commonly in China and sometimes Mexico. They are frequently produced to be more powerful than other common designer drugs, like synthetic marijuana, and markedly more powerful than opiates and heroin. As a result, these chemicals, such as fentanyl and U-47700, have been the culprits behind a great number of overdoses in the U.S. this year. This is especially true of fentanyl, which was made famous as being the cause of popstar Prince’s tragic death in April. It is also suspected that synthetic fentanyl was behind the mass overdose in a rural West Virginia town over the course of one evening this summer, which also made national headlines.

In this article, we’ll explore the origins behind and patterns around fentanyl and U-47700, as well as what we can do to address this mounting problem.

 

Fentanyl: A powerful substance with increasing dominance

Fentanyl is the most potent opioid available for medical treatment, legally prescribed for conditions such as unrelenting chronic pain and advanced cancers. It’s a Schedule II narcotic under the Controlled Substances Act, signifying that it is easily abused and very addictive.

According to a report from Medscape, the drug was introduced into medical practices as an IV anesthetic in the 1960s. Today, in addition to being legally prescribed in the above-mentioned circumstances, it is also created in underground labs abroad and imported into the U.S. as a street drug. These compounds are subject to little or no regulation internationally, and thus pose great dangers to the people ingesting them.

Drug dealers are inclined to lace heroin with drugs like fentanyl to increase profit margins and market it as “good heroin” as their clients experience a more potent reaction with less drug. As a result, many heroin/opioid users are taking it unbeknownst to them. Some people do, however, knowingly use fentanyl, as it delivers an instant and powerful high, and is beloved by some individuals addicted to heroin and/or prescription painkillers who are seeking a heightened experience. Fentanyl is 50 times as potent as heroin, and the onset of respiratory depression is very fast. If you overdose on fentanyl, there is a much smaller window compared to overdose by heroin for revival by Narcan.

A recent Wall Street Journal article reported that in 12 states facing opioid and fentanyl crises (including New Hampshire, Massachusetts, and Ohio), more than 5,500 people have died of fentanyl-related overdoses between 2013 and 2015. This number is likely higher as individuals often perish from a cocktail of chemicals, making it unclear which exact one was the culprit; moreover, coroners and crime labs may not test for fentanyl specifically unless given direction or a reason to do so.

 

U-47700: An emerging danger

While fentanyl has been making headlines for its increasingly evident role in our opioid epidemic, there is another emerging synthetic drug that—while not yet as widely known or as abused as fentanyl—warrants our attention.

U-47700 dates back to the 1970s when scientists tried to create a pain-relieving drug that lacked dangerous side effects. In 1974, Dr. Jacob Szmuszkovicz of Upjohn Co. developed the U-47700 in a Michigan lab, where it was discovered to have more than seven times the strength of morphine. While it was never tested on humans, U-4770 was suspected to possess similar risks associated with opioids. The Wall Street Journal reports that pharmaceutical research efforts such as this, despite being abandoned, leave behind patents and scientific papers that can be replicated in labs. It is believed that U-47700 replications began in late 2014.

Since it emerged into the drug scene, we’ve learned that U-47700 is cheap, readily available, and can be purchased easily and anonymously online. Indeed, there are a collection of online vendors that sell U-47700 and other synthetic drugs, and they can be paid for via PayPal. The internet explosion and our online social connectivity make this drug extremely accessible.

Since there is no in-person street dealer exchange that is seen with heroin and other drugs, some major barriers to drug use (arrest, violence at the dealer’s home, getting caught by family) are virtually eliminated. Moreover, using synthetic drugs essentially evades the law: Until classified by the Drug Enforcement Administration (DEA), they are technically “legal.” If a certain chemical combination is classified, the developers can slightly alter the compounds to make it “legal” once again.

U-47700 claimed its first life in May 2015 in Knox County, Tennessee. Like fentanyl, it causes severe respiratory depression. The medical examiner and labs involved in this case were unfamiliar with U-47700 and had assumed the overdose victim died from oxycodone. Today, more labs around the country know to look for the drug in overdose deaths and are taking actions to better screen for it. But the understanding of and testing for U-47700 is still very much in the dark compared to other substances. With most attention directed at heroin and prescription painkillers, and, as of late, fentanyl, U-47700 remains a lesser-known poison.

But that may not last for long. The DEA recently announced that they had added U-47700 to the list of Schedule I drugs, which went into effect on November 14th. They deemed it an “imminent threat to public health and safety.”

The combination of its low cost, easy access, and increasing numbers of people plagued by opioid addictions who are striving to find something stronger and faster means that U-47700 poses a major threat to society.

 

What can be done to address this danger?

  • Educate the professional community: Psychiatrists, social workers, interventionists, and others who treat individuals with substance use issues need to get educated about fentanyl, U-47700, and other emerging synthetic drugs. If we don’t know what we’re dealing with, we won’t know how to address it. Clinicians should also consider working with their patients to educate themselves about synthetic drug use and purchasing drugs over the internet. Opening this line of communication with patients could perhaps provide unique insights into this issue, and remind patients that their voice and role in this battle are deeply valued.
  • Educate our patients: While some individuals facing addiction may be well-versed in synthetic drugs, others may be unaware that they could be exposing themselves to these dangerous substances. It’s important that doctors have frank conversations with their patients about the risks posed by synthetic drugs, and what to look out for in online forums/markets and on the streets.
  • Share patient stories: We can understand the impact of synthetic drugs with our minds, but what about on an emotional level? It’s important that in telling the story of fentanyl and U-47700, we marry statistics with narrative. We need to share the stories of families who have been impacted by these drugs, and of individuals who have battled their addiction and came out on the other side. This is a small but important way to take action while the government ramps up their own efforts to address these substances.
  • Consider Narcan: Narcan is an opiate antidote; when a person is overdosing, Narcan (naloxone) can knock the opioids off of the opiate receptors in the brain and reverse an overdose. While the effect of Narcan on synthetic drugs is not totally understood, we do know that it can reverse overdoses caused by fentanyl. Communities that are enduring increased heroin abuse and overdoses, like the West Virginia town that experienced the mass overdose this summer, should arm not just EMT workers and physicians with Narcan, but “everyday” people in the community as well. Some physicians even train their patients to administer Narcan. With basic training, it is very easy to use. And it truly saves lives, giving us another chance to help get these individuals on the path to recovery.
  • Increase scientific research: We can’t get our arms around the true dangers of these drugs, and their potential impact on society, without research. Medical institutions, rehabilitation centers, and private addiction psychiatrists should consider participating in research around fentanyl and U-47700 use—including the transaction continuum, economic and social burdens, overdose rates, and long-term health effects.

Fentanyl and U-47700 are making our already frightening opioid epidemic more complicated, more complex, and more deadly. It’s time that we take the steps to get educated about and stimulate urgency around this issue. Only then will we see more meaningful action and real progress.

Shanthi Mogali, MD
Dr. Shanthi Mogali is the Director of Psychiatry at Mountainside Treatment Center. A graduate of Emory University School of Medicine Psychiatry Residency, Dr. Mogali is a double board-certified physician in General and Addiction Psychiatry. She is actively involved in opioid laboratory research and has co-authored a chapter on Treatment of Pain and Opioid Use. Her deep knowledge of the subject helps her drive advances in treatment at Mountainside, where she serves in a leadership role. Dr. Mogali is at the helm of creating topics and agendas for future psychiatric services as well as assisting in the establishment of the Medication Assisted Treatment Program. In partnership with the Medical Director, Dr. Mogali develops addiction education trainings and curriculums to keep all clinical staff abreast of the latest advancements in treatment.

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