In determining the signs someone is addicted to fentanyl, it’s best to start from ground zero: What exactly is this drug that gets so much media attention, and why in the world would anyone who has a problem with drugs actively pursue the use of a substance that’s so deadly?
Because make no mistake: It’s very deadly. According to the Centers for Disease Control’s (CDC) National Vital Statistics Report released in October 2019 , “In 2017, the drug most frequently involved in drug overdose deaths in the United States was fentanyl. Fentanyl also ranked as the most frequently involved drug in overdose deaths in 2016.” In fact, the report continues, fentanyl played a part in 29 percent of all U.S. overdose deaths in 2016, but that rate increased to 39 percent the following year.
Understanding why requires a deep dive into the history of fentanyl, it’s mechanism of action and its value as a drug of choice by addicts. And knowing the signs someone is addicted to fentanyl requires some additional perspective — what makes it so addictive, and why would any addict choose to dance with the devil, so to speak, when that particular deadly could very well kill them?
Signs Someone Is Addicted to Fenanyl: But, Why?
Simply put, choosing to purposefully pursue and use fentanyl is clearly a sign someone is addicted to fentanyl. A great many individuals whose deaths are linked to the drug don’t fall under this banner, of course — according to the CDC , “it is often mixed with heroin and/or cocaine as a combination product — with or without the user’s knowledge — to increase its euphoric effects.”
But what about those who purposefully seek out fentanyl? Granted, there aren’t a whole lot of fentanyl dealers on the streets, and by and large those who have a preference for the drug are, more often than not, employees of the medical profession who practice a method known as diversion, according to the news website The Daily Beast : “Thousands of doctors each year become impaired. Some are sufficiently compromised to harm patients most dramatically by diverting drugs, such as fentanyl, from the patient to themselves. The trick is simple enough—a syringe with an addictive drug is handed to a health care worker; he gives a little to the patient, a little to himself, and perhaps a little more to the patient.”
Medical-grade fentanyl may be more readily accessible to health professionals, but given its unpredictable and often deadly nature as an additive to street drugs like heroin, why would addicts actively seek it out? To rational individuals, that may not make sense, but nothing about addiction is rational. In a 2017 article about addicts in San Francisco actively seeking out fentanyl, reporters for Pew Charitable Trusts wrote , “For many of them, fentanyl is a high-value drug that, if used carefully, can prevent dope sickness and deliver a strong high for a fraction of the price of heroin … in San Francisco, the consumer preference for fentanyl and relatively low death rate likely stem in large part from the way the drug is marketed by dealers, said Phillip Coffin, director of substance use research at the city’s public health department. Fentanyl that is sold here is clearly labeled. It’s rarely disguised as heroin, as it is on the East Coast and in Appalachia. As a result, users who buy fentanyl know what they’re getting and, in most cases, take the necessary precautions, Coffin said.”
Simply put, it’s a matter of economics and tolerance that cuts to the very heart of what addiction is — not a matter of a specific substance so much as the desire for “more.” Even a “hot” batch of heroin laced with fentanyl isn’t necessarily something to be avoided: Many addicts hear that someone in their particular circle overdosed on fentanyl-tainted heroin and are immediately attracted to the idea of trying it themselves, not because they have a death wish, but because of a twisted sort of rationale. They won’t overdose, because they’ll know to be careful, but if it’s so potent that it killed someone, it has to be powerful stuff.
Addicts aren’t exactly flush with cash, and the brain’s ability to adjust to increasing dosages of opioids, the family of drugs that includes fentanyl, means that over time, the amount required not just to get high, but to keep from going into withdrawal sickness, keeps going up. Fentanyl, on the other hand, can be a game-changer, they believe: Something that’s cheaper and more powerful and, given the desperation that’s many addicts live in on a 24-hour basis, an alternative that seems, to their diseased minds, like a good idea.
Signs Someone Is Addicted to Fentanyl: So, What Is Fentanyl?
To understand where fentanyl comes from, let’s turn back the clock to the 1950s, when Dr. Paul Janssen, who established Janssen Pharmaceutica in 1953, set out to create “potent, effective, rapid-acting analgesics to treat the many pain problems of the time”  by experimenting with the molecular structure of the drug meperidine, which was a key component alongside morphine for pain management at the time.
However, the two drugs struggled to act effectively on the central nervous system, according to “The Fentanyl Story,” first published in The Journal of Pain : “They began working with meperidine, rather than morphine, as the parent molecule in the production of newer and better compounds because it was much less complex a molecule and thus easier to manipulate.” Over time, their manipulation of meperidine’s chemical structure led to the creation of a group of narcotics that was more effective at crossing the blood-brain barrier, making them faster-acting in terms of pain management.
- Phenoperidine was synthesized in 1957 and was “25 times more potent than morphine and more than 50 times more potent than meperidine in most animals in which it was tested”  At the time, it was the most powerful opioid ever discovered and was marketed in Europe, where it still is used intermittently today.
- In 1960, Janssen scientists created fentanyl, “more than 10 times more potent than phenoperidine and 100 to 200 times more potent than morphine in most animal models.” Although it registered the quickest onset of action and the “highest therapeutic index” for pain ever measured in an opioid, it was also discovered that when administered orally, it lost 60 to 70 percent of its potency, meaning that intravenous injection was the best method of delivery.
Fentanyl revolutionized anesthesia, according to the 2014 work “The Wondrous History of Anesthesia ," and medical professionals began to experiment with it in conjunction with other IV drugs “in attempts to create a type of total intravenous anesthesia in the 1960s and 1970s.” The U.S. Food and Drug Administration was hesitant to give fentanyl broad approval, however, because of concerns that it was too powerful, and the first U.S. drug to contain fentanyl — Innovar, approved in 1968 — was a compound that also included the tranquilizer droperidol.
However, advances in medicine and anesthesiology quickly made fentanyl a better high-dose opioid than morphine at producing unconsciousness for patients undergoing cardiovascular surgery and other procedures, and in the 1980s, particularly 1981 when the patient expired, fentanyl use began to increase dramatically : “The marked increase in fentanyl usage throughout the world in the 1980s resulted in a number of events that would further improve the popularity of fentanyl, lead to other fentanyl-like compounds, increase the use of other opioids, and begin an entire new field of novel opioid drug delivery development.”
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Fentanyl Gets Supercharged
Given the powerful effects of fentanyl, pharmaceutical and chemical companies began to experiment with fentanyl in wildly different settings than medicine, including wild animal immobilization and anti-terrorism efforts. Some of the fentanyl analogs developed in 1974 include sufentanil, five to 10 times stronger than fentanyl and 500 times stronger than morphine; and carfentanil, “approximately 10,000 times that of morphine and 100 times that of fentanyl” and “intended for large-animal use only as its extreme potency makes it inappropriate for use in humans.” 
Around the same time, Johnson & Johnson — which had absorbed Janssen — was contacted by the Azar Company to develop fentanyl as a pain management tool. The result was the transdermal patch Duragesic, which brought new levels of relief for sufferers of chronic pain and individuals who had undergone invasive and traumatic surgeries: “Duragesic proved to be one of the most successful analgesic pharmaceutical products ever developed, with sales in 2004 (its last year of patent life) exceeding $2.4 billion,” according to “The Wondrous Story of Anesthesia.” 
Throughout the 1980s, companies began to produce a number of different fentanyl-related medications, from child-friendly Oralet lollipops to nasal sprays to sublingual tablets — but the drug’s power has raised concerns over the years as well, according to “The Fentanyl Story” : Overdoses was first recorded as early as 1972, shortly after its approval, mostly through “misuse and illicit uses.” FDA approval of Oralet was “held up for months in 1993 because of concerns about the possibility of unintentional overdoses of fentanyl.” And in a 2006 study by a group of researchers reported in the Journal of Addictive Diseases , fentanyl was even detected “in cardiovascular surgery operating room air … like tobacco, second hand opioid exposure can sensitize and change the brain making abuse, dependence and behavioral disorders more likely. Thus environmental exposure and sensitization may be an important risk factor in physician addiction.”
Some of the commercial names for fentanyl include: Sublimaze, Durogesic, Duragesic, Fentanyl citrate, Lazanda, Nasalfent, Subsys and Actiq. On the street, however, it can sometimes be sold as: drop dead, serial killer, Apache, China girl, dance fever, goodfella, jackpot, murder 8, TNT and others.
While fentanyl addiction rates remained relatively low for several decades, however, the federal and state crackdowns on opioid prescriptions caused a seismic shift in the drug trafficking market: As prescription opioids became harder to acquire, more addicts began seeking illegal street drugs like heroin. Drug traffickers, in turn, began to see fentanyl as a cutting agent — a cheap narcotic, easy to manufacture in clandestine labs, that can potentiate heroin, stretch the amount of heroin and saturate the market so that the returns on investment are astronomical.
According to the CDC , “Beginning in 2013, the distribution of (illegally manufactured fentanyl) increased to unprecedented levels … curing 2013–2014, the number of drug products obtained by law enforcement that tested positive for fentanyl (fentanyl submissions) increased by 426%.” In December 2018, The Associated Press reported  “much of the illicit fentanyl consumed in the U.S. originates in China, but is often smuggled through Mexico. Mexican cartels have also been known to produce the drug from precursor chemicals mainly imported from China.”
Despite law enforcement efforts, black market fentanyl remains a problem — mostly because so little is required to kill so many. Case in point: U.S. Customs and Border Protection agents arrested an individual this month in Escondido, California, with 5.3 pounds of fentanyl and more than 41 pounds of cocaine hidden in his vehicle. How deadly is the fentanyl by itself? “1.2 million lethal doses,” according to news reports. 
Signs Someone Is Addicted to Fentanyl: How Does It Affect the Brain?
According to the National Institute on Drug Abuse, “Like heroin, morphine, and other opioid drugs, fentanyl works by binding to the body's opioid receptors, which are found in areas of the brain that control pain and emotions.” The way opioids like fentanyl work is this:
- Normal receptors, according to a PBS primer , “catch chemical messengers — called neurotransmitters — to activate your nerve cells, triggering electric pulses that carry the signal forward.”
- Opioid receptors, however, work differently: “They stop electric pulses from traveling through your nerve cells in the first place. To do this, opioids bind to three major receptors, called Mu, Kappa and Delta.”
- The Mu receptor is the gatekeeper responsible for the effects of opiates, whether it’s fentanyl, heroin or codeine cough syrup.
- The opioids consumed by an addict — whether orally, nasally, intravenously or even rectally — trigger different effects in different areas of the brain as they pass through the Mu receptor. In the brain stem, they “slow respiration, cause constipation, lower blood pressure and decrease alertness.” In the midbrain, they turn off neurons that act as a “traffic cop” for the brain’s euphoria and pleasure networks.
- As a result, the brain is flooded with dopamine, unchecked by those “cop” neurons. In the nucleus accumbens, dopamine unleashes euphoria, and in the amygdala, “the brain’s fear center, it relieves anxiety and stress. Both of these events reinforce the idea that opioids are rewarding. These areas of the brain are constantly communicating with decision-making hubs in the prefrontal cortex, which make value judgments about good and bad. When it hears ‘This pill feels good. Let’s do more,’ the mind begins to develop habits and cravings.”
- Over time and through repetition, these subconscious conversations become a habit, and as tolerance grows, those conversations become louder and angrier, leading to drug-seeking behavior as a priority over other normal activities, according to the National Institute on Drug Abuse (NIDA) : “After taking opioids many times, the brain adapts to the drug, diminishing its sensitivity, making it hard to feel pleasure from anything besides the drug. When people become addicted, drug seeking and drug use take over their lives.”
Keep in mind: Fentanyl is a synthetic opioid that affects the brain and the body is the same way as other opioids, whether they’re prescription pills like hydrocodone or black tar heroin. While the biological effects on the brain are the same, so are the side effects of fentanyl use, according to the NIDA: “extreme happiness, drowsiness, nausea, confusion, constipation, sedation, problems breathing (and) unconsciousness.”
However: Because of the potency of fentanyl, the risk of overdose is much greater, as the Drug Policy Alliance points out : “Fentanyl overdoses occur in seconds to minutes, often with the needle still inserted.” And while there are individuals who seek to use fentanyl exclusively, many addicts, the organization points out, are completely unaware of the fate that awaits them: “Most users do not appear to be seeking fentanyl and are not aware that their illicit drugs may contain fentanyl. The heroin (particularly white powder heroin), methamphetamine, and cocaine supply is all at risk for fentanyl adulteration. There have also been cases of counterfeit Xanax and Oxycodone tablets that contain fentanyl.”
So What ARE the Signs Someone Is Addicted to Fentanyl?
Again, fentanyl is an opioid — synthetic, but an opioid nonetheless, and therefore the signs someone is addicted to fentanyl will mimic those who are addicted to opioids. In addition to the general side effects that are a package deal with any addiction to opioids, however, there are some specific signs that may indicate someone is using one of the most powerful drugs ever manufactured:
- Behavioral and psychological changes. Because of its potency, fentanyl addiction can cause a much more rapid and severe decline than addiction to other opioids. Extreme and out-of-character mood swings, engagement in risky or dangerous behavior, sudden withdrawal from social circles and family activities, obvious cognitive impairment and a general decline in health and well-being could all be signs someone is addicted to fentanyl.
- Withdrawal symptoms. Even if someone is taking fentanyl as prescribed by a doctor, the drug’s potency can cause dependence. While there’s a difference between dependence and addiction, the former can lead to the latter, but withdrawal symptoms if an individual stops taking fentanyl should be a cause for concern. Some of those symptoms can include, according to the NIDA , “muscle and bone pain, sleep problems, diarrhea and vomiting, cold flashes with goose bumps, uncontrollable leg movements (and) severe cravings. These symptoms can be extremely uncomfortable and are the reason many people find it so difficult to stop taking fentanyl.”
- Drug-seeking behavior. Opioids are under much tighter restrictions than they once were, but even when providers were writing prescriptions for narcotics before the opioid epidemic made headlines, fentanyl wasn’t the first opioid they would prescribe. Because its strength has been well-known for decades, it’s use is limited to patients who deal with extreme chronic pain or have undergone seriously invasive medical procedures. However, those who seek fentanyl may go out of their way to find pain patients who use transdermal fentanyl patches so they can help themselves.
- Serious legal, vocational or educational consequences: Obviously, getting arrested, being fired or getting kick out of school are all signs someone is addicted to fentanyl. Granted, the drug of choice may not be readily apparent, but facing serious life ramifications because of drug use is a clear sign that someone has a problem.
- Overdose: This is a big one, because getting the individual help depends on whether they survive the overdose. Because of fentanyl’s potency, it’s much more likely to cause an overdose than other opioids, whether it’s taken directly as the intended drug of abuse or because it’s been combined with other substances without the individual’s knowledge. Either way, overdosing on the drug is one of the obvious signs someone is addicted to fentanyl, and it’s extremely important to keep in mind: The difference between a dose that will get a user high and a dose that will kill the user is extremely small.
Granted these are just a few of the signs someone is addicted to fentanyl, and some users of fentanyl may not exhibit any of them. Coverage of the drug’s effects on the American addiction landscape are broad and, at times, likely histrionic, but it’s important to remember: “In all likelihood, fentanyl is here to stay,” according to a 2019 article in the journal Substance Use and Misuse . “The Drug Enforcement Administration estimates that raw heroin costs nearly twenty times that of a similar quantity of fentanyl, which makes it highly attractive to traffickers and distributors. Moreover, the current study, among others, demonstrates the existence of some demand for fentanyl specifically, even in a climate characterized by widespread fear and avoidance of fentanyl.”
In other words, fentanyl may very well be a permanent part of the American drug culture, either as an additive to make other substances more potent or as a drug of choice all on its own. Beneath the claxons sounding alarms over it, there needs to be a better understanding of what it is, where it comes from and the drug and alcohol treatment options available for those who struggle with it.