By Taylor Knopf
These days, if you buy a pill off the streets, it’s most likely a counterfeit.
Even if a pill says “Xanax” on it — unless acquired directly from a pharmacy — it’s likely something else. Drug analysts who examine counterfeit pills and toxicology screenings of overdose victims often find fentanyl or other dangerous additives instead of what’s printed on the pill.
Fentanyl is an extremely potent opioid, driving up overdose deaths across the country. In North Carolina, fentanyl-involved overdose deaths more than doubled over the course of the pandemic, increasing by 112 percent from 2019 to 2021. The North Carolina Office of the Chief Medical Examiner found cocaine involved in roughly 30 to 40 percent of fentanyl deaths last year. Fentanyl is not as expensive as some other street drugs and a little goes a long way, which is why it’s been used to up the potency of other drugs, like cocaine. It’s also been pressed into pills and sold to users as something that wouldn’t be nearly as powerful.
“It’s way easier to have a pill press and to press a pill than it is to divert a pharmaceutical pill,” said Loftin Wilson with the North Carolina Harm Reduction Coalition. Harm reduction workers provide people who use drugs with sterile supplies, such as syringes, to prevent injury and disease. They also dispense overdose prevention supplies, such as the overdose reversal drug naloxone or fentanyl test strips which detect the presence of the additive.
Over the last several years, there’s been an uptick in the production and consumption of counterfeit pills. Harm reduction workers are seeing it in communities and chemists who analyze drugs and overdose deaths are seeing it in their labs.
Increase in counterfeit pills
Between the pandemic and the surge in overdose deaths, staff at the NC Office of the Chief Medical Examiner have been extremely busy.
The office recently put out a unique report in which the lone toxicologist in their office examined 23 cases over the past two years with strong evidence of the presence of a counterfeit pill.
The report makes for some grim reading. “Gave friend a Xanax and warned him to only take ¼ bar, then put 4 Xanax bars in soda bottle,” reads the report, which was presented in May at the state’s Public Health Leaders Conference. “Friend felt unwell and went to ED for overdose, returned to find decedent deceased with half consumed soda bottle.”
The dead man was a 27-year-old from Mecklenburg County. His toxicology results showed a mixture of fentanyl, methamphetamine, amphetamine and benzoylecgonine, a substance formed in the liver after someone takes cocaine.
Of the report’s 23 examples, in 17 cases the victim expected the pill to be Xanax. In six cases, the victims thought they were getting oxycodone. Interviews with family and friends, details from police reports or, in some cases, the victim’s text messages assisted the researchers in their determinations.
In most cases, medical examiners discovered the presence of fentanyl or novel psychoactive substances, all of which were first seen in their lab in the last five years. The victims in these cases ranged in age from 17 to 57, of which 65 percent of the deceased were white, 22 percent were Black and the rest multiracial.
Harder to spot
While the majority of counterfeit pills are manufactured outside of the United States, according to the U.S. Drug Enforcement Agency, an “increasing number of pills laced with fentanyl are being produced in the U.S.,” the department said in a 2021 fact sheet. Meanwhile, the counterfeits are getting more difficult to distinguish from the real thing.
Erin Tracy, now a research chemist with the University of North Carolina at Chapel Hill Injury Prevention Research Center, said she started seeing an increase in counterfeit pills around 2017 while working as a substance analyst for the crime lab at the Raleigh/Wake City-County Bureau of Identification.
She said it used to be really easy to spot the fake pills.
“Then they just got really, really good and you could line them up next to each other and not have any idea which was the real one,” she said. “It’s even difficult for me to tell sometimes.”
The DEA also noted that online sales and social media are major sources for buying counterfeit pills.
“A significant number of high school and college students purchase Adderall and Xanax from dark web drug markets and/or through social media referrals, which market deadly versions of these drugs tainted with fentanyl and/or methamphetamine,” the DEA report explained.
“Some students begin using prescription stimulants, often referred to as ‘study drugs,’ in the belief it will benefit their academic performance, but the nonmedical use of prescription stimulants has not been proven to improve academic performance,” the report reads.
Another troubling issue with counterfeit pills is that they open up a wider path for lethal substances, such as fentanyl, to reach new consumers.
Broader pool of victims
Wilson said that selling pills can open up a different, possibly broader, market of people than selling drugs in powder form. That’s also what makes the pills so dangerous. Someone without an opioid tolerance who intended to buy a different drug could unknowingly take a very strong opioid and easily overdose.
Another complicating factor is that people who buy pills aren’t always part of an existing drug using community.
“So they lose the protective factor that you have when you’re part of the group of people who use drugs,” Wilson explained. “You lose the sort of community knowledge and you lose access to harm reduction messaging.”
For example, many people who regularly use heroin, an opioid, know to have the opioid-reversal drug naloxone on hand and not to use alone. If they’re in a community of people who also use drugs, word spreads when there’s a particularly strong batch circultating.
Counterfeit pills are also particularly dangerous for young people, who are often less familiar with the drug market. They may also be more susceptible to falling for the counterfeits of commonly prescribed psychiatric medications, such as Ritalin or Xanax. Wilson said that while there are harm reduction messaging campaigns taking place across some college campuses, he wasn’t aware of the same prevention efforts in high schools and grade schools.
“Having sort of reality-based, current, non-judgmental messaging about safety is really important, especially at that age,” he said. “That’s the time of life when a lot of people start using drugs or encounter drugs, their friends start using drugs or they start thinking about drugs.”
Limitations of test strips
Fentayl test strips have become more widely available in recent years and many harm reduction organizations distribute them alongside sterile supplies and naloxone. These test strips can immediately detect if fentanyl is present in a drug.
Wilson said the test strips are very useful for people taking pills and non-opioid drugs. But they are becoming less useful for people intending to use heroin or other opioids, he said.
“The heroin supply is saturated with fentanyl,” Wilson said. “At this point. Yes, even if it’s heroin, it typically also has some fentanyl in it.”
And fentanyl test strips only indicate if fentanyl is present, not the quantity or potency of it. Most of the people picking up fentanyl test strips from the Durham syringe exchange where Wilson works are using it for pills or other types of drugs.
One new development is that the NC Harm Reduction syringe exchanges are participating in a new program at UNC Street Drug Analysis Lab, a public service program based at the University of North Carolina – Chapel Hill. The lab performs drug checking by mail, and their analyses can give people using drugs more details and insight into what’s actually in a substance.
“It’s obviously limited because there’s a time lapse. You’re not testing something before you use it,” Wilson said. “But it’s helpful for people, especially if they’ve had an odd experience with something. They can mail in a small sample and then there’s like an anonymous way to check your sample number online.”
Drug testing by mail
The UNC Street Drug Analysis Lab sends testing kits out to the participating syringe exchange programs in North Carolina. The owner of the drug puts a small sample into a vial with some solvent and an identification number. The kits look similar to the COVID-19 tests most people are familiar with now, said Tracy, the UNC chemist who used to work at the Raleigh crime lab.
Tracy is the lead chemist at the drug checking lab and analyzes the substances in real time for the program that started earlier this year and is sponsored by the Foundation for Opioid Response Efforts.
Once in the solvent, the drug is no longer in a usable form, which is what allows it to be sent by mail to the lab at UNC for testing, Tracy explained. Participants are also asked to fill out some information to send with their sample, such as what the substance was expected to be, what the texture is like, was it related to an overdose, etc. Tracy then examines the sample on a gas chromatograph mass spectrometer (GCMS) instrument inside the UNC Department of Chemistry.
The lab benefits by being housed within an academic institution, Tracy explained, because these instruments cost several hundreds of thousands of dollars to purchase, a price tag way beyond the thin resources possessed by most harm reduction groups.
“The real kind of simplistic way of thinking about the GCMS is it just separates and identifies components in a mixture,” she said,
Participants who submit samples have a QR code they can use to look up the results within 3 to -5 business days. If they don’t have access to the internet, staff at their local harm reduction organization can look it up for them. The results are online for anyone to see.
The mail-in drug testing has caught the attention of groups even outside of the state. Tracy said they have a sliding scale fee for other harm reduction or public health groups that would like to submit samples to the drug analysis lab.
More testing and alerts
Outside of the lab at UNC, there is one other place that people who use drugs can get samples tested in the state. The same UNC drug analysis team, headed by drug and infectious disease researcher Nabarun Dasgupta, has trained members of the North Carolina Survivors Union in Greensboro to use a smaller drug checking device the group acquired last year.
North Carolina, and the United States in general, is behind on many fronts when it comes to harm reduction efforts and substance use treatment. Other countries, such as France and Switzerland, regularly test street drugs and publish the findings with alerts and advisories broadcast by syringe exchange and safe consumption sites through their countries.
These robust drug checking efforts in European countries allow people who use drugs to know what’s in the supply in their communities at any given time. Their methods have also significantly decreased overdose deaths and drug-related infections.
Advocates within the state would like to see those types of interventions here as well, but say it will take more time.
“We were behind on syringe service programs, we’re still behind on safe consumption sites,” Wilson said. “We just don’t have that infrastructure yet that other countries have to be able to be responsive and adaptive in the same way.”
“I think it would be very life saving to have that kind of constant flow of updated information because right now a lot of times it’s guesswork or it’s sort of after the fact like people start understanding the prevalence of something after it’s already started having lots of harmful effects,” he said.
“It’s always a game of catch up.”
At the UNC lab, Tracy said the program is working on putting together some system with drug alerts when something is becoming more prevalent in the street supply.
It’s a work in progress, she said.
“I would also like to see published drug trends. Those are popular with the Vancouver site and Pennsylvania is putting out regular quarterly reports,” Tracy said. “So that’s definitely a direction I would like to see the lab go so people can easily see a snapshot of what’s going on in North Carolina without having to sort through the website.”
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Sadly, there are no legitimate prescription medications available on the illicit market any longer. In the effort to reduce medication access and production, officials have actually driven the black market, illicit, adulterated counterfeit supply and demand market. What was a safe, known product ( though illicitly sold and purchased) is now poison. Good job.