In the United States, synthetic opioid deaths increased 79% from 2013 to 2014 and the number of drug products seized which tested positive for fentanyl increased by 426% during the same period.(1) Recent years have seen fentanyl, a synthetic opioid, contribute significantly to rising mortality rates due to opioid overdose and fentanyl-contaminated heroin use.(2) Due to its potency (50 to 100 times that of morphine),(3) and low production cost, fentanyl or fentanyl derivatives are often used as a component of illicit drugs (e.g. heroin) and counterfeit prescription drugs (e.g. OxyContin), unbeknownst to the buyers of these drugs.(4) Misuse of fentanyl has also been reported in patients receiving opioid maintenance treatment, with one study finding that 18.4% of patients receiving methadone were concomitantly misusing fentanyl.(5)

Many fentanyl users are unaware that they have consumed the drug; the growing mortality associated with fentanyl and its derivatives requires a response that takes this fact into account. One approach that has been suggested is pill-testing technology that is capable of determining whether fentanyl is present in pills.(2) Similarly to what has been done in some European countries for other illicit drugs, pill testing technologies could be provided at safe injection sites, clubs and festivals in order to protect those most at risk of unregulated fentanyl exposure.(2) Additionally, the ready availability of these technologies may incentivise drug-makers to avoid including fentanyl as a component of their products.

Timely administration of naloxone, an opioid receptor antagonist, in a dose sufficient to counteract a fentanyl overdose is important for mortality reduction. A 2013 study found that communities in which “bystanders” received opioid overdose education and community naloxone distribution had reduced opioid death rates,(6) indicating that there may be a benefit achievable by large-scale community “bystander” training. The “bystanders” trained in this study included opioid users at risk for overdose, their friends and families, and social service workers.

In this successful example, the training focused on identifying and responding to overdoses, using in the company of others, accounting for loss of tolerance after abstinence, and avoiding polysubstance misuse. Two of the great challenges in dealing with this frightening public health problem are:

  1. Identifying and engaging those most at risk (and those around them) in training that they stand to benefit from, and
  2. aiding them effectively while staying within the bounds of the law

Incentivising drug-users to participate in the training programs must be done carefully so as to successfully incentivize those at risk without treading on questionable moral ground. A prior study of naloxone training in injecting drug users used food coupons as compensation for participation,(7) and found that appropriate response technique use increased significantly from baseline to follow-up. Studies of this type have recruited participants using street-based outreach, advertisements and one-on-one recruitment.(7, 8) While these studies have successfully identified a portion of drug users within a community, further study is recommended to investigate how to best access the entire drug using community (including those who may not have a significant history of drug use) and how to optimally encourage participation in an ethically sound manner.


  1. Gladden RM MP, Seth P. Fentanyl Law Enforcement Submissions and Increases in Synthetic Opioid–Involved Overdose Deaths — 27 States, 2013–2014. MMWR Morb Mortal Wkly Rep. 2016(65):837–43.
  2. Frank RG, Pollack HA. Addressing the Fentanyl Threat to Public Health. New England Journal of Medicine. 2017;376(7):605-7.
  3. Prevention CfDCa. Increases in Fentanyl Drug Confiscations and Fentanyl-related Overdose Fatalities 2015 [Available from: Date accessed: 2017.
  4. Macmadu A, Carroll JJ, Hadland SE, et al. Prevalence and correlates of fentanyl-contaminated heroin exposure among young adults who use prescription opioids non-medically. Addictive behaviors. 2017;68:35-8.
  5. Krause D, Plorer D, Koller G, et al. High Concomitant Misuse of Fentanyl in Subjects on Opioid Maintenance Treatment. Substance use & misuse. 2017:1-7.
  6. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ : British Medical Journal. 2013;346.
  7. Wagner KD, Valente TW, Casanova M, et al. Evaluation of an Overdose Prevention and Response Training Programme for Injection Drug Users in the Skid Row Area of Los Angeles, California. The International journal on drug policy. 2010;21(3):186-93.
  8. Tobin KE, Sherman SG, Beilenson P, et al. Evaluation of the Staying Alive programme: training injection drug users to properly administer naloxone and save lives. Int J Drug Policy. 2009;20(2):131-6.