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Quasi-Legal Drug Fifteen Times Stronger Than Heroin Hides in Plain Sight

Emergency docs need to be on the alert

Emergency physicians should expect “an upswing in what on the surface appear to be heroin overdoses,” but are actually overdoses tied to acetyl fentanyl, an opiate that is mixed into street drugs marketed as heroin.

The looming threat of another unregulated quasi-legal drug was detailed August 17 in the online edition of the Annals of Emergency Medicine.

“What’s frightening about this emerging street drug is that users themselves may not be aware that they are ingesting it,” said author John M. Stogner, PhD. “A patient may report heroin use and have symptoms consistent with heroin overdose, but an emergency physician may find that the standard dose of antidote (naloxone) doesn’t work. Larger or additional doses are necessary when acetyl fentanyl is responsible. It’s never good to lose time between overdose and treatment.”

Acetyl fentanyl is an opiate analgesic with no recognized medical use. It is five to 15 times stronger than heroin. Users typically inject it intravenously as a direct substitute for heroin or pharmaceutical-grade opioids, although many are unaware that what they are consuming is not plain heroin. A user who injects pure acetyl fentanyl may suffer severe consequences because of the drug’s extraordinary potency.

Acetyl fentanyl is not specifically regulated, although it qualifies as an analogue of fentanyl (a medical opiate). Therefore, it exists in a legal grey area in that it is considered illicit for human consumption, but if a package is labeled “not for human consumption,” the product is technically legal. A large quantity of acetyl fentanyl would potentially be immune to regulation as long as it was titled, labeled, and stored as a product with industrial or non-human research purposes.

“Clever and well-informed drug distribution networks will likely take advantage of the legal loophole and profit by replacing or cutting a highly regulated drug with this less-regulated one,” Stogner said. “One of the many downsides of illegal drugs is you just can’t trust your drug dealer. The trend of adulterants being worked into street drugs to make them more potent is dangerous. The significant potential for overdose of acetyl fentanyl necessitates more medical research and policy reform.”

Sources: ACEP; August 18, 2014; and Annals of Emergency Medicine; August 17, 2014.

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