Recently, CBS NEWS reported the sale of fentanyl pills as less potent oxycodone under a brand name OxyContin. It is a case of counterfeit drug where a fraudulent imitation of fentanyl is done under the cover of oxycodone. Fentanyl, a popular and potent narcotic (Actiq, Duragesic, and Sublimaze), is king of all opiates, being 40 times more powerful than morphine and 100 times more powerful than heroin.

Common street names for the drug (fentanyl) include China white, dance fever, Apache, China girl, jackpot, friend, goodfella, tango and cash, TNT as well as murder 8.

Opioids are a class of drugs that are used as painkillers in different types of pain and are also classified as narcotics. The most common and popular drugs that belong to this class are morphine, the parent drug, and its semi synthetic and synthetic analogues such as heroin, oxycodone, fentanyl, hydrocodone and codeine.

Morphine is most commonly used as a painkiller before and after surgical operations to alleviate severe pain and fentanyl is commonly used in cancer patients for alleviating pain. Oxycodone (OxyContin) is a less potent drug and is used for moderate pain. Since, narcotic drugs are attributed as highly abusive drugs (severe addiction is associated with these drugs), these are only prescription drugs, except codeine which is common ingredient of OTC cough syrups as it is not highly abusive.

In July 2013, an alert update by Canadian Community Epidemiology Network on Drug Abuse (CCENDA) reported that fentanyl pills apparently indistinguishable from oxycodone (brand name OxyContin®) tablets have become increasingly available in several Canadian communities and has increased the risk of overdose among people using oxycodone tablets as they might ingest these fentanyl pills, superficially resembling to the original oxycodone tablets. The counterfeit pills (fentanyl pills) were stamped with the same monogram as that on oxycodone tablets — number 80 on one side and “CDN” on the other and were sold under the street names of “green monsters” or “green beans” in eastern Canada and “green jellies” or “street oxy” in Western Canada. Although these green tablets are more prevalent in Canadian streets, some pills that are white in color and bearing the number 10 in place of the 80, have also surfaced.

Both the American Pharmacist Association (APhA) and Drug Enforcement Authority (DEA), reported the source of these fake oxycodone pills containing fentanyl instead (toting the same markings as oxycodone pills) to be China and Mexico.

The DEA reported more than 700 deaths, nationwide due to fentanyl-related overdoses, between late 2013 and early 2015.

A study published in The New England Journal of Medicine, on January 14, 2016, reported that the nonmedical (illicit) use of prescription opioids is a major public health issue in United States in terms of high prevalence and marked morbidities and mortalities, associated with the illicit use of these drugs. The study proclaimed that a total of 10.3 million persons availed prescription opioids illicitly In 2014 and death rate due to prescription-opioid overdose nearly quadrupled (from 1.5 to 5.9 deaths per 100,000 persons) between 2000 and 2014 (www.nejm.org)

According to National Institute on Drug Abuse(NIDA), incorporation of fentanyl to street-sold heroin or cocaine strikingly augment the strength and the hazards of the later drugs. The cause of fatality in such synergistic combinations is the respiratory depression leading to coma and death.

The CCENDU Bulletin in 2015 reported the death rate statistics due to drugs involving fentanyl in Canada. The bulletin published mortality statistics between 2009 to 2014. About 1,019 deaths were reported due to fentanyl containing drugs and most of these deaths occurred in 2013 and 2014. The report further stated that death rate due to fentanyl containing drugs has increased over 20 times over the years, in Canada’s four largest provinces.

In US, the death toll due to counterfeit drugs containing fentanyl was highest between2005 and 2007 in Philadelphia, Detroit and Chicago, with 1,013 confirmed fatal overdoses. The U.S. Drug Enforcement Agency finally traced the source of these counterfeit drugs, a fake laboratory outside Mexico City, owned by a chemist known by the pet name of “El Cerebro” (the Brain). The offender was found to sell the drug overseas to US in the form of powder where the drug was modified structurally to heroin and distributed and dispensed by a Chicago drug gang known as the Mickey Cobras. The addicts discovered that the composite drug was far more potent and dangerous, which was more exciting for them. The Mexican Lab was later sealed and the “Brain” and his allies Cobras were arrested, putting a halt to the manufacturing and distribution of the drug.

Moreover, Xanax bars were also found to be counterfeit drugs containing fentanyl. It has been known that over a dozen of fentanyl analogues exist. Xanax (generic alprazolam) is an anti-anxiety drug, prescribed for panic disorders and anxiety. Four patients in San Francisco were reported to be in critical condition due to over dosage of the counterfeit Xanax pills containing fentanyl instead. One of the patients actually died and the County health Officials in San Francisco issued a warning to those who would buy Xanax on the street, pronouncing that a deleterious batch of counterfeit pills containing a powerful opioid caused at least three overdoses.

According to San Francisco Department of Health: “Under no circumstances should you accept medication from someone else, or purchase prescription medicine on the street.”

The warning came after a number of East Bay high school students were hospitalized as a result of ingestion of Xanax pills through authorized prescription.

In Ohio there is a movement to make naloxone (anti narcotic or antidote of opioids) an over the counter drug to avoid over dosage fatalities.

Considering the substantial number of fatalities that occurred due to over dosage of these counterfeit pills, it is imperative that US and Canadian governments develop stringent policies along with strict border control to put an end to this mal-trade.