Fentanyl is a highly potent synthetic opioid that is increasingly commonly found in the drug supply across the United States and the rest of the world. Fentanyl is between 50 and 100 times stronger than morphine and 30 to 50 times stronger than heroin. [1]
These numbers are incredibly high and rising quickly. In 2022, there were over 108,000 overdose deaths in the US. [2] This is equivalent to 295 overdoses per day, and most of these incidents involved opioids. Because of how potent fentanyl is, people who use it are at especially high risk of overdose.
While taking fentanyl can never be made completely safe, there are ways to reduce the risks. These harm reduction strategies allow people who use drugs to decide for themselves what level of risk they are willing to tolerate.
- Fentanyl is an extremely powerful opioid that is both used intentionally and commonly found contaminating other drugs. It is associated with a dramatic increase in the number of overdose deaths across the United States
- Fentanyl overdose leads to decreased breathing (respiratory depression), coma, and death
- Harm reduction practices, particularly carrying naloxone, can help reduce the risk of fatal fentanyl overdose
Understanding the risks of fentanyl use
To make an informed decision about fentanyl use, it’s important to understand the risks involved.
Fentanyl is commonly found in a wide variety of different drugs. One study found fentanyl in 75% of heroin tested, as well as in other drugs, including cocaine and methamphetamine.[3] This means that you might be taking fentanyl without being aware of it. Taking fentanyl unknowingly makes it difficult to take steps to keep yourself safer.
Even when taken deliberately, only a small amount of fentanyl is required to potentially overdose. A fentanyl overdose leads to very slow, shallow breathing, which can be fatal.
The risk of fentanyl overdose is higher if you have not taken opioids for a period of time, because your tolerance will have decreased, if you are taking it with other drugs, or if you have previously overdosed on fentanyl. You might want to take extra care if any of those apply to you.
Fentanyl use comes with other risks as well, that are unrelated to overdose. These include the risk of infection, especially if you share needles and equipment.
Harm reduction strategies for fentanyl use
Overdose prevention and harm reduction include things that you can do before, during, and after taking drugs.[1]
Dr. Brooke Keels, Chief Clinical Officer of Lighthouse Recovery, Dallas, highlights the importance of harm reduction strategies for fentanyl users.
Medical advisor
PhD, LPC-MHSP, LPC
Using fentanyl test strips
Fentanyl test strips were originally designed to demonstrate fentanyl use by detecting the drug in urine. As a harm reduction tool, they tell you whether fentanyl is present in the drugs you are about to take.
These strips make it easier for you to avoid fentanyl if you want to, as you can reject, discard, or resell drugs, or reduce quantities and take additional harm reduction methods when fentanyl is present. Most importantly, it allows you to make an informed decision about your drug use.
Carrying and using naloxone (Narcan)
Naloxone is in a class of drugs known as opioid overdose reversal medications (OORMs) and has been available since 1971.[4] These drugs help to reverse the immediate effects of an opioid overdose and help someone start breathing again.[1]
There is significant evidence that increased availability of naloxone reduces overdose deaths. When naloxone access laws were introduced, they reduced opioid overdose deaths by 14%.[4] It is less effective in cases of polysubstance overdose (where someone has taken multiple different drugs) because it only reverses the effects of opioid overdose.
Naloxone is available in different forms. The most common are intramuscular injection or via a nasal spray. Because it is taken during an overdose, it is designed to be administered to someone else, rather than by yourself.
Dr. Keels adds:
Someone carrying naloxone moves from helplessness to preparedness, which benefits their psychological well-being even if they never need to use it, regardless of whether you are the one struggling with substance use or someone who is caring for one. [15]
Medical advisor
PhD, LPC-MHSP, LPC
Naloxone should be given to anyone who might be experiencing an opioid overdose. It is highly unlikely to cause any harm if it is given when it wasn’t needed (because the person wasn’t overdosing). It can cause withdrawal effects, so avoid giving two doses close together. After administering naloxone, wait 2-3 minutes, while administering rescue breaths or carrying out chest compressions, to see whether it has been effective.[1]
Safe drug use practices
Using around other people
This can be both a benefit and a risk. There’s someone around to help you if you get into trouble, but you might be in a chaotic environment, and safer practices can be more difficult; for example, it can be hard to keep track of which equipment belongs to whom.[5]
You may also find a “never use alone” hotline, such as Safe Spot, if you do not have people you feel safe using drugs around
Using a ‘tester’ shot
One strategy used to minimize the risks of fentanyl in your drugs is to use a small ‘tester’ shot from any new batch or supply of drugs.[3][6] This allows you to adjust your usage based on the effect you receive.
Adopting hygiene practices
Simple steps such as washing hands before injecting and using an alcohol wipe to clean the area you are about to inject can help reduce the risk of some bacterial and skin infections (though not from blood-borne diseases).[7]
Using alternative consumption methods
Injecting is considered the most dangerous way to take fentanyl, with those injecting being 40% more likely to experience an overdose than those smoking it.[8] Other methods, including taking it through skin patches, may reduce the risk even further, but are less common outside of medical environments. Taking fentanyl in tablet form may carry fewer risks than injection or smoking, but it can also be harder to control or to take a ‘tester shot’.
Avoiding mixing drugs
Mixing drugs, especially different types of drugs that have similar effects, increases the risk of problems. Learn about fentanyl interactions and be cautious.
Supervised consumption sites
Safer drug use practices often include using drugs in the company of others who can provide support or help in the case of an emergency. Supervised consumption sites go a step further, offering a safe, secure location with trained staff who can spot and respond to signs of overdose.
If you use a supervised consumption site, you will bring your own drugs, but will be offered sterile equipment to allow you to use them more safely.[9] You may also be provided with fentanyl test strips, as well as access to support services if you wish.
People who use substances often expect judgment from healthcare providers based on past experiences and their own cognitive biases. These programs, where compassionate healthcare professionals already understand what substance abusers are going through, can help counter that expectation by offering consistent respect and professional clinical care. [15]
Medical advisor
PhD, LPC-MHSP, LPC
Supervised consumption sites are part of a legal framework in many European countries, but the federal government has not formally sanctioned them in the US. This generally poses a risk for the people providing these sites, rather than for those using them to consume drugs more safely.
Needle exchange programs
Needle and syringe exchange programs offer you sterile needles and syringes to reduce the risk of developing diseases carried in the blood, such as HIV or hepatitis C.[10] These were first developed in the 1980s, and around 90% of needles are returned, suggesting that people using these exchanges find them worthwhile.[9]
Education on overdose
Being able to recognize the signs of overdose, in yourself or others, can help get medical help to those who need it urgently.
Overdose education programs are often connected to naloxone distribution, helping drug users and bystanders feel confident knowing when and how to take action.[9]
What to do if someone overdoses on fentanyl
An overdose of opioids leads to respiratory depression, which eventually leads to a complete stop in breathing. Warning signs to watch for include:
- Breathing that is slow, shallow, or absent
- Unresponsiveness to sound or pain (e.g., calling their name or performing a sternum rub--rub your knuckles on their chest)
- Skin, lips, or fingernails have changed colour, becoming blueish, purple, or gray
- Cold or clammy skin
What to do immediately
If you suspect an overdose:
- Use naloxone right away, if available — don’t wait to call 911.
- Call 911, even if the person wakes up after naloxone. The effects of naloxone wear off in 20–90 minutes, but the opioids may last longer.
- Give rescue breaths or chest compressions if you are trained.
- Repeat naloxone after 2–3 minutes if there’s no response. Continue CPR and additional doses until the person breathes or help arrives.[11]
A fentanyl overdose can take up to 3 hours to be fatal and is reversible until the point of death. If you come across someone who has been overdosing for some time, you should still take action.
Aftercare and emotional support
Experiencing an overdose, whether as a patient or a helper, can be traumatic. If the person who has overdosed doesn’t want to go to the ER, try to stay with them for a few hours after their last dose of naloxone, in case their symptoms return. Offer them empathy and compassion, but also take care of your own well-being. A crisis line, such as 988, may be able to give you support.
This is not intended to replace qualified medical advice. Always seek and follow the advice of 911 operators, EMTs, or qualified medical professionals during a medical emergency such as an overdose.
Where to get help for Fentanyl dependence
Fentanyl dependence is a serious medical condition, and it’s important to seek help if you want to stop. Treatment for fentanyl dependence will usually include both pharmacological treatment, where you move onto other, safer opioids before gradually reducing your intake, and psychological support, where you address the issues that led you to misuse drugs in the first place.
Your doctor or healthcare provider can be a useful first step in finding treatment for fentanyl dependence, and most harm reduction services will be able to help you locate treatment options in your local area. Alternatively, you can find treatment providers and advice about how to afford treatment at the SAMHSA treatment locator.
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