Isabel Rancu: Fighting Fentanyl— From Rural South Carolina to National Efforts
Two years ago, Dr. Doug McGuff was working a shift at an ER in Upstate South Carolina when a group of first-year college students were rushed in, unable to breathe. From the first responders, he gathered that they had been found using marijuana, a mild psychoactive drug capable of inducing hallucinations; however, he knew that the marijuana alone could never be responsible for such an aggressive reaction. As Dr. McGuff worked to save the lives of his patients, he knew he was witnessing an episode of the same public health crisis documented around the country- a crisis that plagued patients from San Francisco to Baltimore. He was racing against a silent killer, one found in mere microgram quantities within the bloodstream of his patients: fentanyl.
Although “synthetic fentanyl” refers to a general category of drugs, it is typically discussed in two specific subcategories: pharmaceutical and illicitly manufactured fentanyl. The former is the type prescribed by doctors, typically to treat severe pain after surgery or for advanced cancer (4). The latter, however, has been exclusively used in recreational settings, particularly when combined with other drugs. Fentanyl itself is one powerhouse of a drug. In equal quantities, it is up to 50 times stronger than heroin and 100 times stronger than morphine. Deceptively, it looks like many other drugs on the market, while also lacking a unique color and odor to make it difficult to detect. However, its effects are instantaneously apparent. When ingested, it induces an extreme high, accompanied by relaxation, euphoria, and pain relief; however, what comes up must inevitably come down. As soon as the peak wears off, users experience side effects such as dizziness, nausea, vomiting, pupillary constriction, and most concerning , respiratory depression, and in extreme cases, death (6).
Despite knowing the horrible crash induced by fentanyl, drugmakers continue to add it to a wide range of synthetic drugs, including heroin, marijuana, and methamphetamine, because of its addictive qualities. The sheer quantity of fentanyl found in synthetic drugs, specifically counterfeit opioids, can make them deadly. Handling safe quantities of fentanyl means measuring out quantities on the scale of micrograms, requiring precise measurements which do not exist in black market production, where drug producers reportedly use McDonald's ice cream cones for such tasks (3). Therefore, it becomes even easier for people to overdose on smaller quantities of pills. As quantified by Senior Deputy Coroner of the Greenville County Coroner's Office, “You’re talking about something, size comparison-wise, as small as three grains of salt, is enough to kill someone” (1).
In 2022, the South Carolina Department of Alcohol and Other Drug Abuse Services conducted an analysis on the circulating black-market opioids found in the upstate. To no one’s surprise, more than half of the fake pills tested contained lethal doses of fentanyl. In 2022 alone, out of 163 reported overdoses in SC, an overwhelming majoring of 112 involved fentanyl. Additionally, according to a recent study carried out from 2019 to 2020, the department also found that,the total number of opioid-involved overdose deaths in South Carolina increased by 59%, indicating an increase in accessibility and circulation of laced drugs (2).
Beyond the increased appearance of fentanyl laced drugs, the agency also noticed a spike in the number of teens or young people involved in the circulation. However, the connection differs from any previously seen trades, since younger people have begun utilizing a different source for obtaining their drugs: social media. Because of the disconnect created between the user and dealer, many young adults, particularly teenagers, ultimately end up with counterfeit or even mislabeled pills. For example, the DAODAS reported incidents of highschoolers attempting to purchase Xanax through dealers they met on Snapchat; however, it was not until the children were in the ER did they realize they had in fact been given Adderall laced with fentanyl (1).
Unfortunately, this issue is not limited by the Blue Ridge Mountains of South Carolina. All over the country, young individuals, whether in high school or college, are getting entangled with buying counterfeit pills over social media accounts on Snapchat, TikTok, and others. Many of the overdose cases reported nationwide follow the same unfortunate trends as those seen in South Carolina: a young victim is found unresponsive, an investigation is commenced to discern the source of the pills, and the police ultimately identify social media as the hub for drug-related communication.
What makes the connection between drug dealers and social media users so concerning is the simplicity of the transaction. Today, roughly 75% of teenagers between the ages of 13-17 have at least one active social media account and 51% of teenagers check social media at least once a day (7). Additionally, social media has become the dominant norm of contact used by Millennials and Generation Z, creating in contrast with the traditional communication most parents grew up seeing. It becomes challenging for parents to continuously monitor their children’s social media accounts given the diversity of the platforms and the existence of multiple accounts associated with a single physical person.
Beyond the effortless communication outlets they use on social media, drug dealers add an extra layer of confusion by creating secret codes that correlate to whatever drug they are selling on the online market. For example, dealers on TikTok or Instagram might use a string of emojis that symbolize Adderall (3). If a child knows the emoji string, a simple search for that particular sequence will lead straight to the account of a dealer.
Even as authorities have begun figuring out how children are able to easily find synthetic drugs through TikTok or Snapchat, dealers seem to be a step ahead. According to the New York Times, drug dealers have recently changed their drug tags from emojis to #s with celebrity names, making it even more embedded with typical media, challenging authorities to track down supply chains (3). Moreover, with this change in communication there is even less information about the contents of what drug seekers are buying. Similar to the trend in South Carolina, cities around the country are experiencing phenomena with teenagers overdosing from synthetic drugs due to the fact that they are unaware of what they are taking. Apart from potential fentanyl overdosing within the synthetic drug, people are overdosing from consuming an entirely different drug than what they think they are buying.
With the ever evolving social media ties and the increased presence of deadly fentanyl quantities, first responders, doctors, and legal authorities have been forced to alter their tactics. Instead of fighting the problem from the outside (i.e. cutting off dealers), they are now trying to fix the problem from the inside.
At a municipal level, lawmakers and first responders alike have begun working together to treat fentanyl overdoses as a public health crisis. For example, in upstate South Carolina, schools have made a strong push for including educational information to help break ignorance on fentanyl. By South Carolina law, public schools are required to have an alcohol/drug prevention week with activities designed to spread awareness on the risks of drug consumption (1). During the school year, teachers and officers have begun volunteering in high school health classes, discussing overdose prevention and what to do in case of a drug-related emergency. Specifically, South Carolina educational programs put a big emphasis on teaching students not to accept pills from strangers and friends alike to limit potential exposure to unknown substances. In other words, abstinence is still the most encouraged practice when teaching teenagers in public high schools.
Outside of education, local ER departments have started making big changes to their overdose protocols. In upstate South Carolina, ERs have moved to distribute more Narcan, a medication designed to reverse the effects of an opioid induced overdose in minutes. Doctors have become trained in using Narcan within the ER, and they have also begun educating overdosed patients in using nasal Narcan in case of a future crisis. First responders have now been trained to handle IV, nasal, and tracheal Narcan to handle on sight overdose emergencies in the field. Additionally, South Carolina has opened more “safe centers” where people can access Narcan for fentanyl test strips to reveal any potential fentanyl contamination/
On a national level, many have taken more steps to create programs designed to educate kids on not only the drugs themselves, but the serious risks that are accompanied with street drugs. Rather than take the same approach as the “Just Say No” campaigns of the late 20th century, new programs, such as Bay Area’s Safety First, are designed to educate teenagers on the critical dangers surrounding counterfeit pills (8). However, a critical component of this new wave of drug education is that abstinence is not the only thing emphasized. In fact, many of the education techniques used all over the country have begun teaching reduced risk rather than abstinence, creating realistic guidelines for avoiding life threatening situations.
Despite these efforts in prevention of overdose, it has been impossible for lawmakers to deny the immediate need for overdose treatment. In late March 2023, the FDA approved the first ever over-the-counter Narcan, or O.T.C. naloxone, set to be sold in pharmacies and drug stores in the United States (10). This two-dose package of prescription Narcan can be used in emergent, overdose situations by someone without any medical training. Although the role of such an emergent drug faces potential conflicts with insurance companies, like price gouging in big cities or failure to cover under insurance, rolling out readily available anti-overdose medicine hopes to be the immediate solution to saving lives. Now, however, public health officials are faced with properly rolling out the drug, ensuring that it reaches both rural and urban areas that need it most. Places like rural South Carolina are often not the first priority, but lawmakers and medical professionals alike are pushing for OTC naloxone distribution to prevent another night like the one Dr. McGuff faced two years ago.
Isabel Rancu is a first year at Yale University in Pauli Murray College
Citations
Houck, T. (2022). Officials: More than half of South Carolina fake pills contained fentanyl. WYFF News 4. Retrieved from https://www.wyff4.com/article/south-carolina-fake-pills-contained-fentanyl/41396182#.
Overdose Death Prevention (2022). Department of Alcohol and Other Drug Abuse Services. Retrieved from https://www.daodas.sc.gov/services/prevention/overdose-death-prevention/.
Hoffman, J. (2022). Fentaynyl tainted pills bought on social media cause youth drug deaths to soar. The New York Times. Retrieved from https://www.nytimes.com/2022/05/19/health/pills-fentanyl-social-media.html.
Fentanyl (2023). United States Drug Enforcement Administration. Retrieved from https://www.dea.gov/factsheets/fentanyl#:~:text=How%20does%20it%20affect%20the,pupillary%20constriction%2C%20and%20respiratory%20depression.
Maslin Nir, S. (2022). Inside Fentanyl’s Mounting Death Toll: “This is Poison.” The New York Times. Retrieved from https://www.nytimes.com/2021/11/20/nyregion/fentanyl-opioid-deaths.html.
Fentanyl Facts (2022). Centers for Disease and Prevention. Retrieved from https://www.cdc.gov/stopoverdose/fentanyl/index.html.
Social Media and Teens. (2018). American Academy of Child and Adolescent Psychiatry. Retreived from https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/.
Szalavitz, M. (2022). How to Talk to Kids About Drugs in the Age of Fentanyl. The New York Times. Retrieved from https://www.nytimes.com/2022/11/08/opinion/fentanyl-teens.html.
Rockett, A. (2022). Summerville police warn of fentanyl-laced marijuana after two overdoses. The Post and Courier. Retrieved from https://www.postandcourier.com/news/summerville-police-warn-of-fentanyl-laced-marijuana-after-two-overdoses/article_22220f54-516d-11ed-b85b-77a73257b2a9.html.
Hoffman, J. (2023). F.D.A. Approves Narcan for Over-the-Counter Sales. The New York Times. Retrieved from https://www.nytimes.com/2023/03/29/health/narcan-over-the-counter.html.
Interview with Dr. McGuff, 2022.
