Synthetic Opioids—The New Threats of Fentanyl, Carfentanil, Gray Death, and …?
Normally here at Saint Jude Retreats, we stay well out of the hysteria whipped up by the media regarding the “heroin epidemic”. Media coverage of heroin use in the US tends toward the sensational and exaggerated to play upon people’s fears of encountering an uncontrollable, “there but for the grace of God” compulsion type of use that could claim them, their children, or loved ones at any moment. We strongly prefer facts and evidence to anecdotes and hyperbole.
There is, however, a current threat that may not be able to be overstated- Synthetic Opioids. Opioids are naturally derived, semi-synthetic, or synthetic. Natural opioids are derived directly from the opium poppy and include opium, morphine, and codeine. Semi-synthetic opioids and synthetic opioids are more modern forms as they are driven by chemistry, in whole or in part, and are less dependent on a natural source for production, making their production cheaper and less limited by a finite grown resource. Synthetic sources have become a cheaper, purer, more potent form of opioids and can have significantly less risk to transport and distribute. Natural, semi-synthetic and synthetic opioids are important for pain relief with chronic pain, oncology, and palliative and hospice care to name a few. Semi-synthetic and synthetic opioids include heroin, hydrocodone, oxycodone, methadone, oxymorphone, and many others. When these opioids are diverted to illicit use, their use and even their production may be uncontrolled and can be harmful, even producing lethal results. The synthetic opioids that are rising as new threats include fentanyl, carfentanil (marketed as Wildnil® for veterinary use- there is no human form to market), and Gray Death which have been hitting the streets in unknown quantities and guises.
Synthetic opioids are chemically produced opioids. Their manufacture isn’t dependent on someone nurturing opium poppies in Mexico, Columbia, Afghanistan, Myanmar, Laos, Thailand, India, Pakistan, or Iran. It is much easier and cheaper to rely on chemical production entirely for an almost unlimited supply of product, more potent product than natural opiates, and their potency allows a much smaller volume to pack a greater punch. Smaller volume means less product goes further and is easily transported and concealed.
The Drug That Killed Prince- Fentanyl
Fentanyl is a synthetic opioid that you may have heard about in the wake of Prince’s drug overdose death in 2016. After autopsy and an investigation of his home, it is at least plausible he was unaware he was consuming fentanyl. The tablets found in his home were labeled “Watson 385” in an relabeled Aleve bottle. This name is used for hydrocodone and the pills were pressed and marked to look exactly like hydrocodone pills. These pills, however, contained fentanyl, an opioid far more powerful than hydrocodone or morphine. If Prince thought he was getting hydrocodone, he could’ve consumed a dose he was used to easily handling of hydrocodone but getting a drug in fentanyl many times more powerful. He didn’t possess prescriptions for hydrocodone or fentanyl. The more powerful drug fentanyl caused an opioid toxicity or drug overdose in his system that killed him.
Carfentanil- They Drug Elephants with it
Never heard of carfentanil? You’re not alone. It is an animal tranquilizer for large animals-try elephant sized animals in fact- and is extremely powerful. While it’s been around since the mid 1970s, it wasn’t a blip on the screen of drug threats until recently as it had no known safe human use. Carfentanil wasn’t a drug that DEA (Drug Enforcement Agency) or police encountered until recently. In just the last few years, carfentanil has been found to be mixed into heroin, and sometimes cocaine, as a way to increase the high and stretch the drug supply further.
If you were to put together all the carfentanil needed by zoos and vets in the US to drug large animals like elephants, moose, and buffalo for a full year, you would only need 18 grams, or the equivalent of 18 artificial sweetener packets. It is 100 times stronger than its chemical cousin, fentanyl, and 10,000 times stronger than morphine or heroin. It’s such a drastic difference in dose that a single grain of salt sized dose of carfentanil can kill a 250 pound man.
Even if a substance user is seeking a high using heroin, cocaine, or prescription drugs, they could encounter carfentanil or fentanyl instead. Carfentanil is yet again many times more powerful than fentanyl and equally undetectable, whether pressed into pill form or mixed into heroin, cocaine, or other substances.
The Newest Deadly High on the Block – Gray Death
The newest concern in synthetic opioids is an amalgam of drugs called Gray Death. Gray Death combines heroin, fentanyl, carfentanil, and U-47700 (also known as “Pink”) into a gray concrete looking substance that can be a powder or a solid. Gray death has been confirmed in California, Florida, Georgia, Indiana, Illinois, Kentucky, New Hampshire, New York, North Carolina, Ohio, Pennsylvania, Texas, and Wisconsin, thus far. Although it is believed the ingredients for Gray Death are obtained by being mailed from China or smuggled from Mexico, it is likely Gray Death is “manufactured” in the US. The exact ingredients and ratios for this concoction can vary so no one buying Gray Death has any idea what they are really getting. When the least potent substance in the mixture is heroin, it is very strong, strong enough to kill with a single dose. Like carfentanil and fentanyl, it can be accidentally absorbed through the skin or inhaled if in powder form. Exposure can cause death in minutes to seconds depending on strength of the ingredients used.
Will Users Really Get the “Ultimate High” They’re Seeking from Synthetic Opioids?
Users who are seeking the “ultimate high” from the most potent opioids known to man thus far may find they never experience it except as potent sedative effects. Any of these drugs—fentanyl, carfentanil, grey death- are such strong sedatives, alone or in combination, that people nod off and often die in their sleep due to the depression of their central nervous system’s regulation of breathing and heartbeat. Users become sedated, experience respiratory depression, and never wake up again. We suspect that sleep and death are not exactly the effects they were searching for.
Substance users do habituate to drug effects as they continue to use them which sends some on a quest for greater and greater highs. The euphoric effect of opioid use may never be experienced in these synthetic drugs and drug concoctions as they are so potent and overpower the human system so quickly. There are always people who will seek out the most powerful drug available in the hopes of finding that perfect ultimate high-even if it kills them.
There’s No Way to Ensure Safety—Even if You’re Not Seeking Synthetic Opioids
Synthetic opioids are infiltrating the drug supply and no one really knows to what extent. Heroin and cocaine supplies are being cut with synthetic opioids to increase their effect and stretch the supply for sale. Synthetic opioids are being mixed with other drugs or substances and then pressed into pill shapes with the colors and markings of prescription drugs. We’ll likely never know if Prince thought he was taking hydrocodone or intended to take Fentanyl as he might have believed he was swallowing hydrocodone as the pill form, color, and markings identified it to be. Counterfeit prescription drugs containing synthetic opioids are a growing concern. These synthetic opioids can’t be detected by sight or smell. The incredibly small amounts required for lethality through opioid toxicity and drug overdose– as small as a grain of salt for carfentanil for example- can be transported, mixed, and disguised easily.
Fentanyl and Fentanyl Analogs Are Following the White Heroin Powder Market
The DEA (Drug Enforcement Agency) and CDC (Centers for Disease Control) reported that fentanyl submissions for testing increased 426% in 2013-14 and synthetic opioid deaths increased 79% nationally. The problem with even these numbers is they are likely underrated. Heroin metabolizes into morphine quickly in the human body so it is often underreported as a cause of death unless enough heroin remains in the system to confirm by toxicology testing. Add to this challenge that fentanyl may be mixed into heroin supply and it too is often not tested for, detected, or reported consistently.
Death certificate reporting is not consistent and standardized from state to state. The result being that fentanyl, fentanyl analogs, and other synthetic opioids are not always separated out in the data. If someone dies of a suspected heroin overdose, the chances of further investigation to verify it was in fact fentanyl or a fentanyl analog that caused the death vary greatly state to state. Only those on the forefront of this synthetic opioid drug supply infiltration are beginning to look beyond the obvious drug overdose to the deeper investigation of the exact cause by determining the substance(s) in question.
When the CDC tried to look into the growing issues with synthetic opioids, they were met with challenges from inconsistent data recording and a lack of conclusive testing and substance identification. For the 2013-2014 report, they were only able to use data from 27 states, just over half of the country. They were able to identify eight “high burden” states- Florida, Kentucky, Maine, Maryland, Massachusetts, New Hampshire, North Carolina, and Ohio where synthetic opioid deaths increased significantly within the year span of 2013-14. Researchers could identify that the increased occurance of fentanyl products for testing were not rising from medications legitimately prescribed as medication prescription rates containing fentanyl remained steady or dipped slightly. Instead, these fentanyl increases correlated with the rise in synthetic opioid deaths and suggested that there were linked to illicitly manufactured fentanyl (IMF). The 27 states rates studied in 2013-14 accounted for 75% of the synthetic opioid deaths reported in the US. Fentanyl prescription rates were stable in these states so it was dismissed as a factor in the increase of deaths and testing samples.
In the 8 high burden states, all demographic groups showed an increase in synthetic opioid deaths. Certain characteristics stood out as having very high rates of increase in synthetic opioid deaths: males showed an increase of 229%; people aged 15-24 had an increase of 347%, people aged 25-34 years increased 248%, and those 35-44 increased 230%; non-Hispanic whites increased 290%, and people in what was classified as large fringe metro areas increased 230%. The increases follow a pattern of the demographics of those likely to use heroin, especially in what are termed “white powder heroin markets”. The distribution of heroin has had a pattern of Mexican black tar heroin and brown powder heroin sold in the western portions of the country and white powder heroin more commonly sold in the eastern states.
Fentanyl and carfentanil have been found in all 50 states to varying extents according to the DEA. The drug market will likely continue to be increasingly tainted with synthetic opioids as drug suppliers find the small quantities needed of synthetic opioids, easy portability, and relative return on investment (ROI) appealing. There is a market for those seeking a stronger, quicker high and, even those unknowingly exposed, will attest to the greater potency of the drugs received, if they are alive to do so.
The DEA released a 2016 National Heroin Threat Assessment Summary in June of 2016 stating that deaths involving heroin tripled between 2010 and 2014 and the rate of heroin use tripled between 2007 and 2014. The synthetic opioid market seems to be following the heroin market. The facts from the 2016 Summary on heroin make for a likely increasing market for synthetic opioids, whether sought on their own, or as users receive synthetic opioids cut into their heroin or cocaine, as a part of counterfeit prescription drugs, or in other opioid combinations.
Heroin availability and related deaths are increasing nationwide, but particularly in the Northeast and Midwest. Since these white powder heroin market patterns seem to link to growing fentanyl and other synthetic opioid use, it is a concern as even careful, experienced heroin users may encounter fentanyl and fentanyl analogs in their supply. It is no guarantee to check with the seller as he or she may be unaware of the exact composition of their supply. Even within a “batch”, the content of synthetic opioids could vary significantly, especially when a lethal dose is a mere grain for some opioids. The greater effect of synthetic opioids can mean a dose of a drug like heroin, for example, that an experienced user has managed safely in the past, could be several times what they are used to and even prove fatal if they unknowingly receive synthetic opioids.
Counterfeit prescription medications are turning up nationally in the form of oxycodone, hydrocodone (Norco®) , Xanax®, and other prescription pills. America’s growing interest in prescription drugs for recreational use and pain relief are being met with increasing quantities of counterfeit drugs flooding the market. Unless a drug is dispensed from a pharmacy or other health care provider directly, it’s nearly impossible without laboratory testing to determine whether it’s a counterfeit or not. Using a counterfeit drug may prove to be ineffective at best, or, at worst, it contains fentanyl or some other drug that you didn’t expect and can’t predict your physical reactions to.
Who’s At Risk for Accidental Exposure to Synthetic Opioids?
The threat of accidental exposure isn’t limited to those seeking illicit drugs for use. An increasing number of people -first responders, police and federal agents, emergency room personnel, police canines, and even the general public- could encounter synthetic opioids and not be aware of the danger or even know what they’ve been exposed to.
Synthetic Opioids Challenge How Police Can Do Their Job and Remain Safe
Fentanyl and other synthetic opioids are already changing the way police do their jobs. Gone are the days of the roadside stop with a drug testing kit or even drug testing on the premises during a search warrant. With synthetic opioids able to kill a grown man with a sample the size of a grain of salt, it is no longer ok to touch any powder anywhere. Fentany, fentanyl analogs, and many synthetic opioids in combination can be absorbed through the skin or inhaled.
It was standard police procedure to field test suspicious substances and remove excess air from bags containing drugs or suspected illegal substances prior to taking them in as evidence. Now such behavior could kill you. Police are being advised to wear protective gear-gloves, respirators, even level A Haz-mat suiting if fentanyl or other fentanyl analogs are involved or suspected in a seizure. Double gloving with nitrile gloves, wearing a respirator, and goggles are precautions recommended to be minimally safe if a sample must be taken at an arrest scene. Wherever possible, police and agents are being urged to not field test or take samples for fear of exposing themselves or others in the area to these substances. Fentanyl, in powder form, resembles heroin or cocaine and is often mixed in at varying consistences to conceal its presence. It can even falsely test positive as heroin or cocaine rendering field testing ineffectual and could lead to deadly exposure. Police can’t be assured that a substance is what they are told it is. For their safety, they must assume it is fentanyl or an analog and treat it as such. Laboratory testing at a facility that can safely handle and test synthetic opioids is always the best solution for all involved.
Police Officers Are At Increasing Daily Risk for Synthetic Opioid Exposure Just Doing Their Job
In August of 2015, Detectives Dan Kallen and Eric Price of the Atlantic County NJ police department were investigating a home and found a bag with suspicious powder. Upon closing it, a bit of the substance was pushed out of the bag into the air. Almost immediately, detectives felt ill and were rushed to the hospital where they were treated for opioid overdose and made full recoveries. They had been exposed to cocaine and heroin tainted with fentanyl. The detectives described finding it hard to breathe, feeling nauseous and wanting to pass out.
In May of 2017, Officer Chris Green of the East Liverpool, Ohio Police Department was engaged in a traffic stop. The occupants fled the vehicle and dumped their drugs in the car. Officer Green led the search of the car and had some dust on his uniform. At the station, an officer asked him about a speck on his uniform and he tried to wipe the powder from his shirt. He passed out and was given a dose of Narcan before being taken to the hospital where he required 3 additional doses of Narcan to overcome the effects of the fentanyl he had either breathed in and/or absorbed through his fingertips. Captain Patrick Wright declared they would end field testing as a practice as it was simply too dangerous for officers to safely continue.
East Liverpool Police Chief John Lane commented in an Inside Edition interview,”Think about this, nobody sees that on his shirt. He leaves and goes home, takes off his shirt, throws it in the wash. His mom, his wife, his girlfriend goes in the laundry, touches his shirt-boom. They drop. He goes home to his kid. ‘Daddy! Daddy’ They hug him-boom. They drop. His dog sniffs his shirt, it kills his dog. This could never end.”
Suspending field testing has its own legal consequences as often courts require the results of field testing to issue arrest warrants and move forward with prosecution. Officers are reluctant to use safety equipment like gas masks or respirators in raids as they can impact vision and communication which can endanger officers safety. It becomes a matter of choosing one safety over another—much like a rock and a hard place.
Police Canines Are More At Risk For Sudden Death Than Handlers Exposed to Synthetic Opioids
Even more at risk are police canine officers as the amount that can kill them is even smaller. They can be exposed to synthetic opioids either airborne or absorbed through their foot pads and be dead in minutes. Additionally, there is less time to treat them and not all animal hospitals or veterinary offices are equipped to handle a canine overdose with opioid reversal medications on hand.
Even when precautions are taken, there can be accidental exposures as was the case for three canine officers in Broward County, Florida on October 27, 2016. The canine officers and their handlers were going through a house looking for evidence. The drug supplier who lived there had been arrested weeks ago. No drugs were suspected of still being on the premises but the handlers visually checked anyway prior to working the dogs in the house. Primus, a currency sniffing German short haired pointer, and his fellow canine officers, Packer and Finn, swept the house. No drugs were found but Primus, Packer, and Finn started to behave strangely. They stared off into space and became unresponsive. Their breathing became shallow. Their officer handlers drove them quickly to Coral Springs Animal Hospital where they were all treated for opioid overdoses and recovered fully. Their officer handlers now carry Narcan, the primary opioid reversal drug, at all times to provide an initial rescue dose to keep their dogs alive until they can get to an animal hospital equipped for opioid overdose treatment.
Synthetic Opioids Can Overpower Narcan
Narcan is used to revive a person (or animal) from a heroin or other opioid overdose but substances like fentanyl, carfentanil, U-47700, and Gray Death are many times stronger than heroin. They can produce quick onset, deep respiratory depression effects that Narcan sometimes can’t reverse. If Narcan is immediately available, administered, and is able to reverse some of the overdose effect, it will still take many doses to support a patient. If multiple doses of Narcan aren’t available, the patient will overdose again, as the effects of the drug overwhelm the effect of the Narcan. they still may overdose and die.
When administering Narcan for heroin overdoses, EMTs typically have adopted a watch and wait protocol to see how a patient responds. Narcan works for a short time and, if the drug is still in the patient’s system, it may be required to be administered again. A heroin overdose typically will take 1-2 doses of Narcan to reverse.
Often EMTs and ER/ED personnel don’t know and can’t be sure what a person has taken and in what quantities. Even the patient or those around him may believe he or she has taken heroin or a prescription drug, they may be unaware it is tainted with fentanyl or other synthetic opioid, complicating matters still further.
A single patient can use 3-5 times the normal doses of Narcan if they are using fentanyl, carfentanil, or other synthetic opioid, if it works at all. These doses must be quickly administered in rapid succession. The typical wait-and-see protocol can also end in death for the patient as the greater strength of substances like fentanyl or carfentanil quickly overwhelm the ability of Narcan to work and force the patient back into overdose. When these substances are used in combination, such as with Gray Death, there is simply no way to know how many doses of Narcan will help, if it’s even possible to reverse the overdose.
Narcan is depleting faster than some cities, first responders, hospitals, and drug programs can cope or afford. The increased need for multiple doses of Narcan for each patient is overwhelming their resources and budgets. There is also some evidence to suggest that drug manufacturers are taking advantage of the increased access to and need for Narcan by raising prices unjustifiably. Family members, nonprofits, first responders, hospitals, cities, and rural areas are clamoring for Narcan to not only reverse opioid overdoses in substance users but to safeguard police officers and other first responders who go into unknown situations where accidental exposure can occur.
There are only a handful of manufacturers authorized by the FDA to produce Narcan (generic: naloxone). Add to this increasing need for multiple dose administrations with the significant price increases and Narcan is moving out of the price point of concerned family members, nonprofits, and even breaking the budgets of some towns, cities, and states.
Many lay people, including some first responders and family members, may feel uncomfortable injecting a stranger or loved one confidently with Narcan in the emergency situation of an overdose. Enter Evzio, manufactured by Kaleo, as an auto-injector pre-filled with dosed naloxone. In 2014, the cost of 2 dose supply was $690 but, inexplicably, it has risen to $4500 by 2017 or a 552% price increase. Amphastar, which manufactures an off brand use of naloxone for use as a nasal spray, was selling for $20.30 until in October of 2014 it rose within a month to $39.60 or 95% price hike. Hospira, another naloxone manufacturer, has increased its price 129%. Hospira manufactures a vial form of injectable naloxone which sold for $1.10 per vial in 2005 and now costs $19- a price increase of 1627%.
These price increases for Narcan (naloxone) coincided not with an increase in the manufacturing costs of the drug or its components but with an increased need for the overdose reversal medicine. As Narcan access was eased through legislation across the country, concerned family members and lay people could receive training in its use and carry it legally. Narcan is the primary opioid overdose reversal treatment and it appears that these manufacturers are making the most of a crisis by cashing in.
In 2014, 47,000 people died due to drug overdoses -the highest numbers to date in the US. This numbers represent 50% more deaths than people who died in highway accidents that year. 60% of these deaths, or 28,200, were attributed to the use of opioids, whether prescription painkillers or illegal opioids such as heroin. As newer, stronger versions of opioids increase in the drug supply, whether new chemical analogs of opioids or new combinations of existing opioids, the need for Narcan will continue to grow and multi-dose administrations will become increasingly commonplace.
Where Do We Go From Here?
The fact is this growth of synthetic opioids is not going to stop on its own. Now that synthetic opioid use is increasing and overtaking all other drug use it is not about stopping an individual drug. A chemist with access to basic equipment and materials can experiment, and switch a molecule or two, arriving at a completely novel substance with unknown properties and do so cheaply, without worrying about safety concerns or anything other than producing the next big high. No amount of prohibition through legislation, drug wars, or enforcement will stop this. Should we roll over and admit defeat? It may be, instead, a matter of where and how we focus resources. We will need to have police and DEA enforcement and focus on the crimes associated with drug production, distribution, and sales to ensure public safety directly and indirectly. Drugs are currently intimately tied to the criminal state, as it is a marginalized illegal industry. As long as it remains so, there will be a need for law enforcement.
For example, prior to March 2017, online sales from China of fentanyl and fentanyl analogs were as simple as a request and a credit card. Shipments came in the US mail as private carriers asked too many questions. The US Post Office is trying to establish more safeguards but, as with change in any bureaucracy, it is a slow process. Although China was reluctant to acknowledge their part initially, the new prohibition of illicit manufacture and sale will help to stem the traffic of these synthetic opioids and new combinations as the raw elements become more difficult to obtain. What won’t happen is a complete stop. Instead what is termed a “balloon effect” will occur. As the raw elements from China become difficult to get and demand stays the same, prices will increase and new avenues will open as raised demand and prices make it profitable to take the risk and new suppliers fill the void. The idea comes from a balloon when you squeeze air from one section, another swells up to accommodate the change. The drug supply will adjust either its sources, its ingredients, or move on to another concoction that is invented to circumnavigate the problem of diminished supplies. So it is with illicit drug production and sales.
There are steps that will help us now. China was finally persuaded in March of this year to make the manufacture and sale of fentanyl and fentanyl analogs illegal. This ending of legal production and sale will likely curb the illicit traffic in these synthetic opioids, at least temporarily. An ongoing cooperation with countries like China and Mexico that serve as major funnels for drugs and drug making elements to enter the US will aid in curbing supplies. An ongoing cooperation is required as the drug market is constantly changing and adapting in novel and unexpected ways.
If prohibition isn’t the answer, then what is? If there are an endless array of fentanyl analogs and new combinations yet to be dreamed of, what do we do? We know there are no easy, quick, or inexpensive solutions. It is far easier to promote a culture of prohibition and stigma than constructively address the greater issues of substance use. We don’t pretend to have the final answers although we strive to be unafraid in asking the questions as we have in over 28 years of research on why people chose to use and how and why they decide to move beyond substance use as a focus of their lives.
Turning to the more complex issues of why people use is perhaps our only option. People have experimented with altering their consciousness through substance use for religious, spiritual, and recreational reasons since they first discovered they had access to such options. They likely will always do so to some extent as it is biologically hard wired into us to seek novelty and diversion. Dying shouldn’t be part of the equation however, whether it is a purposeful seeking of an ultimate high or an accidental exposure.
We may need to truly explore and focus resources on other avenues of increasing public safety and harms reduction. Our culture continues to move towards a destigmatization of substance use. Moving from the current diseased or genetic basis to the choice based focus supported by decades of addiction research allows for shedding the emotional debris of addiction and blaming to more clearly focusing on constructing solutions. Challenging the myths of substance use, addiction, and the culture of relapse and recovery are essential to stripping the veil off a self-perpetuating system designed to keep people trapped in learned helplessness and focusing on drugs as the enemy, rather than helping people move to evidence based solutions for substance use.
“Fix broken societies and you would fix most of the world’s drug problems” – Dr. Carl Hart
As Dr. Carl Hart writes and speaks of complex, multifactoral solutions involving changes in drug policy, poverty, and unemployment–deep societal changes, he also indicates that focusing on the drugs as the issue is an easy out to avoid effectual change. The scientific evidence is clear that the majority of drug programs and rehabs are using ineffectual methods by clinging to treatment. The War on Drugs has failed as all solely prohibition based measures do. As Dr. Hart puts it, “politicians have essentially used drugs as a scapegoat to dodge their responsibilities to social improvement”.
Promoting truthful discussions on substance use and addiction while debunking the culturally held myths of addiction provides people with the ability to wield their greatest strengths of education and free will. Whether we choose to decriminalize and/or legalize drugs or put more resources into harms reduction efforts or consider another path entirely, it is clear to move forward we can’t continue to hide behind fear, hyperbole, or half-truths that are promulgated in an attempt to scare people into avoiding drugs. We must recognize the body doesn’t discriminate. The opioid given in the hospital after surgery, the opioid prescription written and filled for pain relief at home, and the opioid bought on the street are perceived chemically as the same thing by the body. When you strip the stigma, illegal drugs are dangerous because there is no quality control and people are using them without education, which ensures that they can’t make informed decisions to use or not to use and to what extent.
“We educate people about how to use alcohol, and that’s a drug, so really, we should just be more honest about illegal drugs”. Dr. Carl Hart
Education and free will in decision-making helps us see our way out of the darkness of mythology in traditional addiction treatment. Chemistry influenced by ingenuity and greed will always be a step ahead of the law and even medicine. There are no easy, quick, or inexpensive answers. Those only seem to exist in the laboratory.
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- Date, J. & Sands, G. (2017). “Heroin Overdose Deaths Have Tripled In 5 Years, DEA Says”. ABC News. N.p., 2017. Web. 18 May 2017.
- Dr.Carl Hart. (2017). Dr.Carl Hart. Retrieved 18 May 2017, from http://drcarlhart.com/
- DEA Intelligence Brief: Counterfeit Prescription Pills Containing Fentanyls: A Global Threat. (2017). Drug Enforcement Administration. Retrieved 18 May 2017, from https://content.govdelivery.com/attachments/USDOJDEA/2016/07/22/file_attachments/590360/fentanyl%2Bpil
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- Gupta, R., Shah, N., & Ross, J. (2017). The Rising Price of Naloxone — Risks to Efforts to Stem Overdose Deaths — NEJM. New England Journal of Medicine. Retrieved 18 May 2017, from http://www.nejm.org/doi/full/10.1056/NEJMp1609578#t=article
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