Contaminated street drugs: new data, myths, and realities.

Yes, researchers have found fentanyl in some other street drugs. But nobody is dying from unwittingly smoking fentanyl-laced weed.

There are two drug-related myths that particularly bother me.

• Myth #1: It’s possible to experience clinical effects (and even overdose) from touching or by passive exposure to fentanyl (a strong opioid) or its analogues.

• Myth #2: People have died from consuming marijuana/THC that was secretly laced with fentanyl or its analogues.

Photo by Michał Parzuchowski on Unsplash

Both of these are false, and basically are modern incarnations of “Reefer madness.” That is, they are urban legends that have entered the public consciousness because they sound like important cautionary tales that should be shouted from the rooftops in an effort to keep the public safe.

Except they are bullshit, and spreading misinformation is always bad.

Drug misinformation is coming from “inside the building.”

Debunking these drug-related myths has been especially difficult. Why? Primarily because non-experts who look like experts have propagated these stories in the name of scaring people.

Regarding Myth #1, the amount of misinformation from a Department of Justice (DOJ) video and a US Drug Enforcement Administration (DEA) press release about the risks of fentanyl exposure is truly impressive. To its credit, the CDC has done some work to debunk this, but it’s just not a priority for them. (Sidebar: I wrote what I believe is the first mainstream media article debunking this myth for Slate back in 2017. Later in 2017, two expert toxicology bodies finalized a document on the topic that had long been in the works; I spoke extensively with some of the authors on that paper, and those conversations formed the underpinnings of my own work earlier in the year.)

Regarding Myth #2, as far as I know, despite rumors and “reports,” there has never been a confirmed case of fentanyl-laced marijuana causing an overdose. In fact, New York State took some initiative on this, releasing a document that nicely laid out the facts.

Enter new data…

New data: cross contamination in street drugs is common. What does that mean?

A new paper in the Journal of the American Medical Association found that counterfeit prescription pills confiscated by law enforcement often contained substances other than what they were “supposed” to have. This is not exactly shocking.

To understand what this means (and relate it all to you), I read the paper carefully, and then spoke to its lead author, Dr. Rachel Wightman, of Brown University. (I’m not using any quotes from Dr. Wightman, but her views informed some of my opinions below, though not others. So, if there’s something you don’t like or take issue with, blame me first.)

From that, here’s what I came away with:

Cross contamination in counterfeit pills sold illegally—i.e., someone buys one thing, but instead gets something impure with multiple “active” compounds—is increasingly common. But mostly, these street pills contained substances in the same class of drug as what was being marketed. So, if someone thought they were getting “Xanax” (whose generic name is alprazolam, a benzodiazepine), they might have gotten some other benzodiazepine in there as well. This could be problematic because the doses could be different (or highly variable), and recipients might be getting a lot more (or less) than they thought.

What also caught my attention is that in 2022, nearly 5% of street alprazolam in Rhode Island (where the study occurred) had fentanyl. Does this mean that I’m wrong about Myth #2, and that, in reality, there is a scourge of fentanyl reaching people who never intended to use it? Not really. It seems like this was just cross contamination (though we do not have quantifications in the JAMA study). But, if there were clinical effects from this, it certainly hasn’t been borne out in recent mortality data. (I checked, albeit only insofar as “big data” can take you.) In Rhode Island, deaths due to accidental overdoses from benzodiazepines and fentanyl went up from 2018-2021, but went down in 2022. Meanwhile, the rate at which fentanyl was found in counterfeit Xanax (alprazolam) doubled in 2021-2022 in Rhode Island. If tiny amounts of fentanyl making their way into street Xanax were as dangerous as the DOJ and the DEA say, you’d expect to see a spike in benzodiazepine-related overdoses (even overdoses caused by counterfeit benzos). Keep in mind that there are law enforcement officials who literally think you can die just by being in the same room as fentanyl. But here we have some fake Xanax pills being sold with some fentanyl cross contamination being handled by a non-trivial number of Rhode Island residents, and nobody is just dying from that (let alone from ingesting it). If that’s happening in small numbers (that is, cross contamination is causing an increase in accidental overdoses), the culprit is more likely related to the unpredictable doses of active ingredients in street pills, and the unpredictable effects of a bunch of medications being in the system all at once—a very dangerous condition called “polypharmacy”—rather than the appearance of one particular scary drug into these pills.

And what about the possibility of marijuana laced with fentanyl or other “hard drugs”? While that was not reported in the JAMA paper, the same lab that conducted the analysis elsewhere states that there have been so few instances of adulterated THC that they don’t even bother to report it.

Summary:

1. Counterfeit street drugs are not pure. They may contain other ingredients, including other drugs.

2. Most of the time, the other substances found were variants on the “intended” one. This could alter the clinical effects, and could be dangerous. If someone thinks they are taking 0.5 milligrams of Xanax, but they’re getting the equivalent of 50-times more, that could cause major problems.

3. It’s unlikely that cross contamination with dangerous opioids like fentanyl found in street Xanax is causing any dangerous or accidental overdoses.

4. There continues to be no evidence that people who think they are getting marijuana are actually being slipped fentanyl by their dealers.

So, this is an example of a situation where two things are true at the same time. Yes, contamination of counterfeit street drugs (like Xanax) has increased, and the clinical effects of this are probably widely variable. But no, it does not seem like people who bought anti-anxiety pills on the streets of Rhode Island started to drop dead in droves due to some cross contamination with fentanyl. Similarly, people who are smoking or consuming edible marijuana are not turning up dead because—as the urban legend goes—some evildoer has laced it with a strong opioid, unbeknownst to the user.

Not only is there no evidence that this has occurred but it would make no sense. As toxicologists like Dr. Ryan Marino often say, chemists and dealers know that killing their clients is bad for business. And, if nothing else, underground economies (such as selling illegal pills) are businesses. Chemists may be looking to cut corners—and that poses dangers that toxicologists like Dr. Wightman are helping officials and epidemiologists track—but they are not looking to shrink their market.

Questions? Feedback? Chime in down in the Comments section!