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Decoding an overdose epidemic

In Rhode Island, 14 deaths have been attributed to acetyl fentanyl, a newly identified synthetic opiate. Here's what we know
By PHILIP EIL  |  June 21, 2013


On the afternoon of Friday, June 14 — around when White House Deputy Director of National Drug Control Policy Michael Botticelli entered a closed-door meeting with health and law enforcement officials in Woonsocket, arranged in light of the region’s recent rash of overdoses — the Rhode Island Department of Health issued a press release.

“The Rhode Island Department of Health (HEALTH) has confirmed two additional deaths linked to Acetanilide, n-1-Phenethyl-4-Piperidyl — also known as acetyl fentanyl,” it read. “These most recent deaths . . . bring the total number of deaths linked to this drug in Rhode Island to 14.”

The dispatch, like one from late May attributing 12 recent deaths to a ”new synthetic drug, known as acetyl fentanyl . . . an illicit synthetic opiate with properties similar to morphine,” was meticulously specific. Most of us need at least a high school chemistry textbook to figure out what “n-1-Phenethyl-4-Piperidyl” means.

But it was also frustratingly vague. The most recent victims were “two individuals who were transported from the same residence in southern Rhode Island.” Back in May, we were told, “Most of these patients were from the northern Rhode Island area, and appear to have been intravenous drug users.”

Taken together, the two announcements delivered a jolt of abstract horror. We know that an astonishing number of Rhode Islanders are dying from a mysterious, never-before-seen, man-made drug. But we know little else. Who? Where? Why?

For the last few weeks, we at the Phoenix have been working to dispel some of the confusion. The results are imperfect; plenty of information remains beyond our reach or locked away.

But after speaking with a variety of officials, doctors, former users, and others about the outbreak — and how it fits into the broader scope of drug use, addiction, and overdose in the Ocean State — the picture does become slightly clearer.

What follows are our best answers to a simple question: What the hell is going on?


The Rhode Island Department of Health hasn’t released names for the 14 people who recently died from acetyl fentanyl and they don’t plan to. This is a matter of medical and legal privacy.

Department spokespeople would say, though, that the victims ranged in age from late teens to upper fifties.

Without knowing the victims specifically, Dr. Robert Swift — a Psychiatry Professor and Associate Director of Brown’s Center for Alcohol and Addiction Studies who treats patients at Providence’s VA hospital — could still speak to the general demographics of IV drug use in Rhode Island.

“They are people we know,” he says. “They are our neighbors. They’re kids of the family down the road, who just happened to get addicted to heroin . . . . They’re veterans who came back with PTSD and are self-medicating their demons from the war.”


While this particular variant of fentanyl might never have been seen before, fentanyl is no mystery drug.

It is a synthetic opiate used for decades as an adjunct to other anesthetics during surgeries, Swift says, when incisions through tissue, muscle, and bone have the potential to wake up a patient or cause a spike in their pulse or blood pressure. The drug also comes in the form of gel-slicked patches that chronic pain sufferers — cancer patients, for example — can apply to their skin for extended relief.

Like other opiates, fentanyl mimics chemicals in the brain — endorphins — that make us feel good and dull or block the sensation of pain, Dr. Swift says. Except fentanyl does this more quickly and more powerfully. (“Fentanyl and analogues of fentanyl are the most potent opioids available for human and veterinary use,” reads a 2010 issue of the Drug Enforcement Administration’s Microgram Bulletin. “Fentanyl is approximately 50 to 100 times more potent than morphine and 30 to 50 times more potent than heroin, depending on the physiological or behavioral measure, the route of administration, and other factors.”)

But the drug, like other opiates, also has a long history of abuse. Decades ago, there was the California outbreak of Parkinson’s-like symptoms among young IV drug that was eventually traced to a tainted batch of fentanyl. Swift recalls a fellow intern in medical school who OD’d on fentanyl, but live to seek treatment for his addiction. He had fallen unconscious in the hospital locker room with the syringe still in his arm.

Even fentanyl analogs — offshoots of fentanyl with slightly altered chemical footprints, like acetyl fentanyl — are nothing new, according to Dr. John Coleman, President of George Mason’s Prescription Drug Research Center and a retired 33-year veteran of the DEA, where he was once in charge of all law enforcement operations. He points to the fentanyl outbreak that caused scores of deaths in American cities in the mid-2000s. (A USA Today headline from July 2008 reads, “U.S. Fentanyl Deaths Top 1,000 Over 2 Years.”)

“We call them ‘labs’ but they’re really not labs in a conventional sense,” Coleman says, describing how amateur chemists constantly tweak the substance’s makeup. “They’re more like backroom bathtub-type operations where. . . instead of sophisticated glassware, they use Pyrex dishware and so forth.”

Such chemists might use automotive tubing to pump chemicals and, for ingredients, the same acetone that a person would use to remove the vinyl tiles from a floor. Potencies and levels of purity vary wildly in these scenarios. Quality control is virtually nonexistent.

“Unfortunately,” Coleman says, “measurement then becomes the number of people who die as a result of the ingestion of those drugs.”

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