Preparing for the coming Fourth Wave of the Opioid Crisis. The following article has been written by John Johnson. It includes editorial content which is the opinion and story of the writer.
There is a fourth wave of the opioid crisis on the way, we are just not certain how bad it will be or even when it will start. The first wave of the opioid epidemic began in the late 1990s when prescribing opioids for pain management became increasingly common. The second wave began around 2010 when people now addicted to pain killers, turned to diverted pills and heroin. By 2013 the third and present wave of overdoses began to rise from an already all-time high of 5.4 deaths per 100,000 people to a trend busting 28 deaths per 100,000 people. This volume of deaths cannot be attributed to heroin and diverted pill users alone. From 1999 to 2020 more than a million Americans have died from opioid related overdoses. It is now the leading cause of death in the 18–45-year-old age group. More than COVID (21,335), cancer (17,114), car accidents (22,442), and suicide (21,678).
While 13% of adults surveyed by the CDC started or increased their drug use during the early stages of the pandemic, youth (18-25 years old) drug use significantly decreased (NIH Study) over the same time period. Yet this age group represents the fastest growing rate of deaths by fentanyl overdose, and is more likely to use illicit prescription medications than any other age group (Newport). In fact, 40% of young adults have taken medication not prescribed to them. In the 12-month period ending in April 2021, the CDC reported that nearly two-thirds (64%) of all drug overdose deaths, which was up 49% from the year before, were fentanyl-related. Because of its potency, the amount of fentanyl is 25-30x smaller in mass to meet the same demand as heroin.
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Synthesized fentanyl is increasingly replacing heroin, but the potent and inexpensive opioid is not only impacting heavy drug users – it is in our communities, affecting individuals and families. What may look like Oxycodone, Adderall, Percocet, Xanax or even kids vitamins may in fact be a counterfeit pill that contains fentanyl, or other synthetic opioids. These fake pills can be indistinguishable from actual prescription drugs. Social media has supercharged the drug trade in ways we do not yet fully understand. Combined with the targeted efforts of a $700 billion illicit drug trade capitalizing on our tolerance for taking pills, we have a virtually unstoppable conflagration driving an increasing number of overdoses. The ease at which teens can order prescriptions or even the fact that they are advertised on social media makes it far too simple. And with delivery services common in the food industry the circle of ordering and getting drugs delivered quickly right to the door is complete.
Shift to Counterfeit Pharmaceuticals – The “Scripts”
According to the DEA, criminal drug networks are flooding the U.S and creating an oversupply of fentanyl, in effect driving down prices. Counterfeit pharmaceuticals pose a unique and significant threat to public health due to their ubiquity and as prices drop quanity demanded increases. The DEA has determined that 60% of pills containing fentanyl contain a dose that is lethally toxic to those who do not have a tolerance to opioids, which includes recreational and first-time users. In the 2022 calendar year the DEA recorded seizing 50.6 million fentanyl pills this exceeds the combined total of the previous three years. With an expectation that 6 out of every 10 pills contain a fatally toxic dose, over 30 million of these pills will be lethal to anyone who has not built up a tolerance to opiods. Namely high school kids and young adults. It only takes one pill, one mistake.
 Tools and Technologies Needed for First Responders
 Supply side reduction and interdiction depends entirely on using technology to make a field confirmatory assessment to know if a pill is in fact counterfeit. The difficulty is not in the chemistry but in the concentration of the active component, the fentanyl compounds, relative to the non-active ingredients found in the pill.
There are dozens of commercially available technologies on the market all with the intent to detect or identify synthetic opioids. Often overlooked is the fact that there is a significant difference between detection and identification. Detection is an indicator, while identification gives you the exact chemical name. These results can be so specific that it will often tell the difference between closely related compounds based solely on their molecular structure. The Scientific Working Group for the Analysis of Seized Drugs (SWGDURG) defines three categories of techniques for analyzing drug samples by discriminating power. These categories are labeled as A, B, and C with A having the highest level of molecular discrimination. But not all category A techniques are best in all situations and as we focus on the use of field technologies some important distinctions must be considered including but not limited to purpose, benefit, and limitation.
Given the extreme potency of compounds like carfentanyl, technologies that can rapidly identify the miniscule amounts found in counterfeit pills must have the ability to perform a trace level analysis. It’s not only vital to be able to identify fentanyl in bulk form, but also at trace levels to apprehend and safeguard against these substances from directly infiltrating our communities. It is here at the community level where identifying counterfeit pills to protect our communities matters.
While there are several technologies in use with Law Enforcement to identify counterfeit fentanyl pills there is a capabilities gap that is growing every day. The optical based systems, such as Raman and FTIR, operate to identify compounds that are 10% or more of the mixture. Most conterfeit fentanyl pills have mixtures of 0.25% to 3%, well below the 10% level of detection for Raman and FTIR based technology, this is the gap. Mass spectroscopy (mass spec) plays a critical role in filling this gap with its ability to detect down to 0.5% of a mixture. While not perfect we are able to use this technology to narrow the gap.
Mass spec is not a new science or even a new technology. It is a technology that has been operating as the mainstay of forensic labs for the better part of 50 years. What is relatively new is the introduction of High-Pressure Mass Spectrometry in a small handheld configuration. What would historically have taken weeks to identify at a laboratory only takes minutes with a handheld mass spec device in the field. Handheld mass spectrometry devices have been increasing in popularity, adopted by leading government agencies, such as the Department of Homeland Security, the DEA and local law enforcement organizations. The rapid and accurate analyses performed with these devices are protecting law enforcement officials and other rescue personnel, including EMTs, and firefighters, from fentanyl exposure which can be very hazardous to their individual health, and prevent their ability to complete their job safely.
Combating the 4th Fentanyl Wave
 While difficult to imagine, new and more dangerous drugs are on the way, drugs like xylazine and isonitazine are already being found mixed with fentanyl pills. Some of these new substances are resistant to current medical countermeasures, such as naloxone, making them much more dangerous to both first-time, recreational, and substance abuse disorder victims. Handheld, sensitive devices in the field offer the ability to detect and identify materials with greater speed and accuracy in time-sensitive situations than previously was able by legacy technologies. As the fentanyl crisis continues to escalate, testing will become an increasingly important factor when considering public health, criminal investigations, and supply reduction. Governments will need to prioritize maintaining a high level of safety and preparedness to keep our communities safe.
About the Author
As Sr. Director of Business Development, John Johnson oversees the strategic direction and market adoption of the 908 Devices handheld mass spectrometer device, an industry-leading trace identification solution. John has served many roles over the course of his 30 years in public safety, launching 17 different products in over 61 countries and working with more than 312 public safety organizations. Since 2001, John has focused his efforts on changing mindsets and driving acceptance of novel technological approaches to identifying explosives, chemical weapons, and narcotics by bringing technology used in forensic laboratories to the field, including Mass spectrometry, FTIR, Raman and Rapid DNA. John’s influence in these areas has led to standard industry practices and broad technology adoption, all aimed at improving public safety outcomes.
