What Is Fentanyl and How Does It Kill You?

By Neville Elder 06/04/16

How does fentanyl kill you? As details emerge that Prince's death was caused by an overdose of fentanyl—the same medicine that caused a wave of OD deaths across the US—The Fix takes a closer look at one of the strongest opioid painkillers available.

How Does Fentanyl Kill You?
Photo via the DEA

This week we learned that Prince died from an accidental overdose of the pain medication fentanyl. His death comes on the heels of an alarming increase in the number of overdose deaths thought to be caused by the drug.

During a terrifying Easter week in Sacramento County, California, 28 people overdosed with, what experts now believe, are black market pills mixed with the powerful synthetic opioid, fentanyl. 

As reported in the LA Times, at least six people died in the space of a week from taking pills that appeared to be Norco, a prescription drug used for medium pain management. The Sacramento County Division of Public Health declared a public health emergency; so many cases were reported in the space of 48 hours.

On the other side of the country, fentanyl, aka fake heroin, has been identified as the deadly hidden ingredient in a series of overdoses and deaths in New England. As the NY Times reports, last year fentanyl killed 158 in New Hampshire, and played a part in another 120 deaths. In the same period, heroin killed 32. 

Many heroin addicts are consuming drug cocktails of heroin and fentanyl without their knowledge, though heroin laced with fentanyl has been around for a while. The recent ODs in Sacramento County that killed six appear to be people taking what they believed was a completely different drug. And it’s not the first time drugs have shown up marked as a well-known brand for authorities to find they contained fentanyl. A man in Ohio was recently busted with hundreds of pills marked as oxycodone, but when tested, the pills were revealed as fentanyl. 

It’s a potentially fatal mistake. Fentanyl is up to 100 times stronger than heroin, and much more dangerous on its own than popular prescription opioids like oxycodone. 


The versatility of fentanyl made the drug the number one choice for doctors for pain management in recent decades. The synthetic opioid first appeared in the 1960s under the name Sublimaze, and its use in cancer treatment and palliative care became widespread when it appeared as a gel-filled patch that could be absorbed through the skin. The drug acts quickly and pharmacists often use it in combination with other opioids that take longer to take effect.

As well as applied intravenously and as a patch, it can also be prescribed as a pill, nasal spray, lollipop or lozenge.

Fentanyl first showed up on the streets in the 1970s and the variety of products were immediately made popular in a culture beginning to abuse prescription medication on a massive scale, and by those turned off by more obviously illegal drugs, like heroin. As a consequence, it’s also been responsible for the accidental deaths of many non-addicts, including children.

These days, it is known by its street names "fake heroin," "apache," "china white" (often when mixed with heroin), and "the bomb." But its unknown presence in prescription pills (pills that can kill you) sold on the black market and its appearance as a deadly cocktail with heroin is the cause of this new wave of ODs.

Symptoms and Treatment

The symptoms of a fentanyl OD are much like those of a heroin overdose:

  • Clammy skin
  • Seizures
  • Severe drowsiness
  • Low blood pressure
  • Pinpoint pupils
  • Slowed heartbeat
  • Respiratory reduction

Just like with any opioid, Narcan (the brand name for the anti-overdose drug naloxone) can be used to deactivate the effects of the drug. Naloxone is now supplied to police and EMTs in many major U.S. cities and, though effective, may not be applied in time to avoid death. The opioid's immediate effect (it slows breathing) means a fentanyl OD and sudden death are more likely. Naloxone may also have to be given repeatedly in fentanyl-suspected overdoses because of the drug's potency compared to other opioids.

Supply and Demand


Mexican drug cartels have switched over to fentanyl production in the last few years. A type of fentanyl called acetyl fentanyl has a slightly higher street price and the drug lords have found it cheaper to produce than heroin. It can be manufactured without heroin’s key ingredient, opium, which though grown in industrial quantities in Mexico, relies on finite seasonal crops. Fentanyl is made in larger batches to higher concentrations. One gram of pure fentanyl will make 100 grams of "heroin."


In an ironic twist, China, the original source of opium in the 1900s, is becoming a key source of the synthetic heroin.

The Miami Herald reports on a remarkable operation by the U.S. Drug Enforcement Administration. It started with an investigation into a single OD death in Grand Forks, North Dakota in January, and led to the apprehension of a drug kingpin operating from his cell in a Canadian prison, and the bust of a drug ring importing fentanyl pills from China via the Internet to Florida.

Despite the apprehension of the administrators of Silk Road (the Amazon-like illegal drugs website), all manner of illegal trading continues in the hidden part of the Internet called the "dark web," where transactions are conducted using the currency Bitcoin. Chinese fly-by-night labs offering "research chemicals" are easy to find on Alibaba.com, the Chinese version of Amazon, and will ship made-to-order drugs including fentanyl, in any variant the buyer wishes, be it pills or powder or lollipops.

Fentanyl is a reliable high and is sought out by users, but the supercharged drug’s covert introduction into batches of heroin may not make sense until you realize that a tiny amount of fentanyl will improve the potency of poor quality heroin. It comes down to pure economics. In the marketplace of illegal drugs, a dealer’s reputation, and therefore their sales, hinge on the quality of their product. As heroin is passed down the supply chain, it gets diluted or "cut." Baby powder or laxatives or other harmless powders are introduced into the batch to increase inventory, and at the bottom of the ladder, street dealers are then re-cutting their stock with fentanyl to make it stronger and more popular. It only takes 2 mg of fentanyl to make an otherwise run-of-the-mill bag of heroin, deadly. 

There’s another dark side to the OD plague witnessed in New England. If a dealer is identified as selling fentanyl-laced heroin, often by reports of OD deaths, some addicts will flock to the source to score the stronger mix, exposing a second wave of users to possible overdose and death. On the other hand, user groups focused on harm reduction have stepped up to identify areas with suspected fentanyl-tainted opioids in order to warn and protect potential buyers.

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British born Neville Elder is a writer,photographer and filmmaker. He's been sober since 2006, lived in New York since 2001 and is in no hurry to move back to a Brexited Britain. He writes the odd murder ballad with his band Thee Shambels and teaches photography at the New York Institute of photography. Find him on Linkedin and Twitter.