Could powerful 'fakes' be the new heroin?

The recent overwhelming string of overdoses in Cincinnati and the region during a nationwide heroin epidemic has medical and law enforcement observers betting on sneaky, synthetic opioids as the culprit.

They fear the development is a disturbing harbinger of things to come, with each new heroin knockoff being scarier than the last.

"This might be the new epidemic as heroin is pushed out of the market," said Dr. Adam Bisaga, professor of psychiatry at Columbia University Medical Center. "These substances can be sold as 'heroin' or made into fake prescription painkillers."

“I feel like this is going to be the new business model,” said Van Ingram, executive director of the Kentucky Office of Drug Control Policy.

That’s because, increasingly across the country, communities are reporting more overdoses from fentanyl, a synthetic opiate that can be 50 times stronger than heroin. And now, other similar but even stronger synthetics are seeping into heroin streams.

Take carfentanil, the elephant opioid that’s been dropped into heroin in several Ohio communities, including Cincinnati and Hamilton County, and found elsewhere across the country. In Hamilton County, a derivative called furanylfentanyl also has been identified in heroin. It's another fentanyl analog, made overseas, More worrisome, it isn't even listed as a controlled substance in the United States.

Any of the drugs could be the culprit of the mass of overdoses that totaled nearly 300 in Cincinnati from Aug. 19 through early Friday morning. Three people died. The number of overdoses is far higher than the four-per-day that Cincinnati had previously experienced. The surges are also tormenting Northern Kentucky, Louisville and other communities and states.

The Hamilton County coroner, Dr. Lakshmi Sammarco, is awaiting toxicology reports on the blood of three people who overdosed during the first week that Cincinnati experienced the barrage. She’s tested for fentanyl and carfentanil to try to come up with a match.

What worries the experts: these synthetic drugs are easy to make, they're easy to transport, and they’re easy to market.

“The cost of it is minuscule,” said Dr. Hakique Virani, a specialist in public health, preventative medicine, and addiction medicine at the University of Alberta in Edmonton. Take fentanyl: “Just 30 grams equals 30,000 doses of it.”

The products can be transported in shoe boxes, he said, or even envelopes.

It's not as troublesome to concoct these drugs compared to heroin, says Ingram. Heroin, he noted, requires not only planting poppies but having guards for the crop, making the drug and smuggling into the United States.

“The profits are much, much higher to produce synthetic opioids,” he said.

The U.S. Drug Enforcement Administration says the synthetic drugs are made in labs overseas, primarily in China, and shipped to Mexico or Canada, where Mexican drug organizations intercept them. The Canadian Border Services has found both fentanyl and carfentanil in packages.

Some Canadian researchers are already saying their heroin supplies appear to be down, replaced with fentanyl.

“I don’t think we’re seeing a lot of heroin in Alberta,” Virani said. “Heroin is dwindling.”

And while there's still heroin around, harm reduction health workers are noting a surge in fentanyl that is worrisome.

Eighty-six percent of drugs tested at InSite, a supervised injection site in Vancouver, British Columbia, over a four-week period this summer contained fentanyl, according to a report issued by Vancouver Coastal Health last week.

Drug-checking was offered for the first time this summer as a pilot program.

"The majority of street drugs we have tested in an area in Vancouver where there are a large number of long-term intravenous drug users had fentanyl present," said Anna Marie D'Angelo, spokeswoman for Vancouver Coastal. "I wouldn’t say that there was a change from heroin to fentanyl and can’t speculate what will happen."

Still, Virani said he wouldn't be surprised if heroin fades off. And he hopes people fighting addiction stay focused on the bigger picture of the synthetics:

"Narrowly focused efforts on single drugs fail miserably," Virani said. "The drug trade is notorious for staying steps ahead of drug schedules and law enforcement. It feels much like a game of whack-a-mole, except each novel chemical that comes into the illicit market" is stronger and deadlier.

He agrees with Columbia University's Bisaga, who said the best method of dealing with the scourge is the same as it was with heroin: Treating the addicted, to quell demand for the opioids.

"There's still no telling just how much of these drugs are in the United States," Bisaga said. That's because nobody tests for the synthetics in people, until an overdose occurs.

"It's obviously very troublesome," he said.

"The best strategy to slow it is to decrease demand, and the most efficient way to do it is to offer treatment, preferably medication assisted treatment, so that the barrier to getting it is minimal."