Counterfeit Fentanyl – The Drug Cartel’s Answer to CDC Opioid Guidelines?

Counterfeit Fentanyl – The Drug Cartel’s Answer to CDC Opioid Guidelines?

By Kurt W.G. Matthies

Recent reports of fentanyl appearing on North American streets are in the news. Counterfeit “Norco” (hydrocodone/APAP) tablets are appearing on California streets, but chemical analysis shows them to contain fentanyl. A large supply of counterfeit fentanyl pills have been seized by Canadian authorities.~~

This powerful opioid is not being diverted from controlled medical stores but is being manufactured in Asia and believed to be smuggled into America via Mexico. Powerless to stop the flow of counterfeit drugs with its multi-billion dollar budget the DEA has released a warning against these new entrants into American drug markets.

These pills bear a certain verisimilitude with heroin pills.

Fentanyl has long been a part of American street heroin culture. Called China White, this high-potency combination of Heroin, morphine, and fentanyl, began to appear on NYC streets during the Vietnam War, and is preferred by many Heroin connoisseurs over other forms of street dope. China White was made famous by the 1960’s French Connection case as told by the popular 1971 American movie starring Gene Hackman.

Because of medical abandonment related to CDC opioid guidelines/restrictions, many suffering Americans who live with chronic pain are turning to the street drug markets to self-medicate their under-treated pain and suffering. As predicted by pain advocates, the drug cartels are inventing new products to fill America’s needs for effective analgesia.

While I would never recommend self-medication with street drugs, I believe it’s important for those who are desperate for effective pain relief and considering this departure from conventional medical care to understand the risks involved with this choice. Remember that all medical treatment, whether or not that treatment is ordered by a licensed physician, is best managed under the principle of informed consent.

All people in pain considering the use of counterfeit fentanyl or street heroin should understand that the unknown dosing and purity of street drugs add an incalculable element of risk to the use of analgesics, even when those drugs are taken orally and not intravenously. You need also to realize that while fentanyl is a highly effective opioid against pain, it is poorly suited pharmacologically for chronic pain treatment. There can be no denial that there is a low probability for success when choosing self-medication with street drugs, especially fentanyl which can kill with the slip of a decimal point.

People who self-medicate with fentanyl can unintentionally “wake up dead.”^^

Fentanyl Use in American Medicine

The transdermal fentanyl patch (Duragesic, Mylan) is used to treat baseline chronic pain. These patches are worn on the skin and are constructed so that medication is slowly and regularly absorbed through the skin, delivering a steady-state dose of fentanyl to the system. This dose is measured in micrograms per hour, i.e., by absorption through the skin.

A microgram is 1/1000 of a milligram or in other words, 1000 micrograms equals one milligram.

A typical starting dose for transdermal fentanyl ranges from 25 to 50 micrograms/hour. Transdermal fentanyl patches come in fixed sizes delivering 12.5, 25, 50, 75, or 100 micrograms per hour. The fentanyl rate of absorption is controlled by the surface area of the patch, thus the 100 microgram patch has twice the surface area of the 50 microgram patch.

FDA warnings clearly state that the transdermal fentanyl patch should only be prescribed for the pain patient who is deemed opioid tolerant, meaning that he or she has used chronic opioid therapy (COT) for 6 months or more, and is requiring regular dose increases due to the effects of opioid tolerance.

When first prescribed the Duragesic transdermal fentanyl patch in 1997, I was using 40mg of oral oxycodone a day and needed yet another dose adjustment to control my pain. My starting dose was titrated to 50 micrograms / hour, but within 18 months, I required 150 micrograms / hour for an equal level of analgesia. Within two years the rapid tolerance caused by fentanyl boosted my opioid dose to unmanageable heights and I was rotated to an appropriate opioid medication.

Use of “the patch” was common during the Decade of Pain, as medical experts believed it to be an abuse-proof drug delivery system. However, resourceful Americans hell-bent on opioid misuse soon discovered that oral absorption of the gel contained within the Duragesic patch, or chewing portions of the Mylan patch quickly maximized a controlled dose of fentanyl to the brain, causing the euphoric rush that accelerates addictive craving.

Oral fentanyl is dosed, not like pills – that are swallowed and metabolized by the GI system — but to quickly dissolve in the mouth and absorbed by the oral mucosa – similar to the trick addicts discovered with that Duragesic goo (but probably more palatable.) Trans-mucosal delivery systems cause dumping of medication into the blood stream, not a new idea. The sublingual tablets used by my grandfather for his heart trouble 60 years ago are a simple transmucosal delivery system for nitroglycerin, which causes rapid vasodilation, relieving the pain of angina pectoris common with cardiac artery insufficiency.

Likewise, transmucosal fentanyl provides quick and effective pain relief for the breakthrough pain experienced by many with chronic pain syndromes maintained on COT. The Actiq fentanyl “lollipop” was an effective medication for the control of severe breakthrough pain in chronic pain patients during the Decade of Pain, but recent fears of misuse and unintentional death have limited transmucosal fentanyl to the realm of palliative care in recent years.

For me, this conservative pullback is a source of pain tantamount to the loss of methadone treatment for baseline chronic pain. My weekend would have benefited from a dose of Actiq after being overcome by an intense pain flare during dinner Friday night. Had I been prescribed Actiq for breakthrough pain, a standard of care for the quick and aggressive treatment of breakthrough pain, my flare would have ended in 10 minutes. Instead, 72 hours later I struggle to get this pain flare under control, and my family plans were again victimized due to the demands of my chronic pain condition.

Intravenous fentanyl (Sublimaze) is very strong medicine, indeed. 100 micrograms (0.1 mg) of Sublimaze is considered to be equivalent to 10 mg of intravenous morphine.

Intravenous fentanyl is considered to be 100 times stronger than morphine.

IV fentanyl is given in the medical procedure room or dentist’s chair in combination with an intravenous benzodiazepene, typically midazolam (Versed), to produce a state known as conscious sedation (or waking anesthesia.) These medications are given at levels to produce moderate anesthesia so that the patient can respond to verbal commands. A typical starting dose might be 35 micrograms fentanyl with 1 mg midazolam, but because of the relatively short half-life of fentanyl, the drug must be repeated every 15 minutes for extended medical procedures.

Fentanyl, like all opioids, depresses respiration, and its medical use against pain must be tapered to minimize this deadly side-effect. But here’s the rub — fentanyl’s half-life for respiratory depression is longer than its analgesic effect, increasing the risk of overdose with extended use against pain. IV fentanyl should never be used without proper medical supervision, and personally I’ve refused IV fentanyl unless administered by a trained anesthesiologist. In my thinking, dentists and surgeons don’t have the training or experience to deal with this powerful drug, especially in an opioid tolerant patient.

The Tragedy of Medical Abandonment

Medical abandonment of people who suffer from daily pain treated with COT is a cruel and dangerous practice in American medicine today. Tragically, many thousands of Americans on COT will be abandoned by their primary care physician this year. Unfortunately, this leaves too many American’s with little choice to stop the pain and suffering. So, they turn to street drugs which are ubiquitous, less expensive, and often easier to acquire than physician prescribed medications in today’s America.

This turn is indeed an act of desperation for the multitudes of abandoned and under treated pain patients caused by opiophobic pain treatment, has the potential to create a public health crisis of unprecedented proportions. An article in last year’s NEJM documents this trend.** The irony is that this crisis will be blamed on those physicians who continue the compassionate and medically sound treatment of chronic pain with opioids.

The hand of the nanny-state driven by the anti-opioid cartel is at the center of this pending public health crisis. Hopefully, strong leadership from the pain management community will help us navigate the National Pain Initiative toward sensible, safer, and compassionate shores. Until they do, all who suffer from chronic pain would benefit from a vigilant awareness of the situation, and I encourage every pain professional to speak out, without fear, regarding the fallacies in today’s current pain treatment paradigm that minimizes the effectiveness of COT. The facts, in unbiased medical research, are evident.

In the meantime, anyone using street drugs to self-medicate pain after medical abandonment needs to be aware of the terrible risk of unintentional overdose and death. If you are considering this route or have already set off down this road, denying the risk involved in using these counterfeit opioids will harm you. By all means, obtain an injectable or intranasal opioid antagonist like Narcan (naloxone) that can quickly reverse overdose, and train a family member to use it. (They must learn to recognize the signs of respiratory depression – you do not want them to inject you if you are only sleeping!)

Please take the time to educate yourself on the use of both opioid agonists and antagonists from a medical perspective. This knowledge may save your life.



~~ DEA Warns of Fake Fentanyl Pain Pills

~~ Chinese suppliers flood US with fentanyl

^^ Wake up dead – death from an opioid overdose.

** Shifting Patterns of Prescription Opioid and Heroin Abuse in the United States, N Engl J Med 2015;

373:1789-179 DOI: 10.1056/NEJMc1505541

Photo Credit – Calgary Police Service









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Authored by: Kurt W.G. Matthies

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Mary Jane

After reading the CDC’s recommendations, I was quite surprised that applying self restraint and discipline did not cause the regeneration of my spine. 20 mg of hydrocodone was all it took to control my pain, for YEARS, until my pain Doctor placed more importance on placating the CDC than honoring his oath. I’d rather be dependent on illegal drugs than the whim of this agency. I might suggest the CDC remedy their addiction to the notion that they know better than chronic pain patients and the doctors who had properly cared for them.

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NationalPainReport started out of the history and compassion of it’s 3 founders, for the chronic pain community, and is intended solely to lend a voice and offer a place to report pain related news in one place.

We appreciate your readership and recognize that you have plenty of sources for your news, some of which may or may not be wholly sponsored by large pharma companies.

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Sorry, the national pain report is doing just that, reporting on the fake or altered pills! They will not help us in any way. Btw, where does their money come from? Im sure they believe if we vent and rant here, so what? Do you think they will be on our side? Not if they want to keep their money. Which is all you have to do, follow the money to find all the answers to the burning questions , who benefits? Certainly not the pain patient! Hmm, lets see, the fda, now having a “former” employee of big pharma, also in charge of who gets what, and if they dont play ball, well?………plus then theres the cdc, whos also members of prop, have financial interests in rehab, government funded btw, which means tons of income! And again big pharma, produces suboxone nalaxone etc, buprephine (sp) ( apologies ) which of course during and after treatment, is rx’d by the truckload, and patients will have to stay on indefinately, otherwise the dreaded wd’s, which are longer due to the half life of them. Oh and of course you just had bill put forth to increase drs amout of patients they can treat with said drugs, so, then you have the lowly pain patient who now has little choice if the pain is bad enoug& but to buy them on the streets, use heroin, or use drugs to die, because they can no longer “take” their pain without some kind of relief before they lose their minds. Then you have our police etc, to take i` these people, take everything they own, and guess what? Give it to the goverrnment! And around n round she goes. So still hope things will change for the better for the person who lives with painm24/7 365? Lol? What do you think? Anyone?

Holly Rose

Marian, thank you for the mention….we need to band together and stop the maddness! Before ppl we love die!

dave rosen

this is americas way of thinning out the population. the drugs in the streets are in higher volume and stronger then ever. if they take away our pain medication they know many will turn to the streets. instead of putting their money and power in eliminating street drugs yhey are taking away the legal one for the people that need it most.

Michael Wagner

One good thing about the internet is if you need information about a street drug, you can find it, your post here has everything on this Fentanyl except for the
milligram’s, Which if a street person had them they might be more careful on how much they should take, I am sure most of them that are overdosing would be more careful. as there intention is not killing them selves, but getting a good high.
Which I am not into. does anyone know what the price of street fentanyl is?
I would bet some of you would think this is a strange comment, but this is what is in the real world.


As Holly Rose and many others here have said, this plan to remove opiates from everyone across the board is bound to send many to the streets or other alternative ways to gain some relief. How can the DEA, CDC, whoever is responsible for this, be so stupid. Did they really think we were all going to go okay, no more meds, oh, well. As far as threats of death for using these drugs go, what makes them think that that would be a negative outcome for many of us. Most of my life has already been taken away from me. I am an older woman. I have nothing to look forward to but more limitation and pain. They need to rethink this and quickly. Unintended outcomes are occurring and will certainly continue to do so.

Jean Price

Carrie…I agree that other countries seem to have better care practices, both in treating pain and allowing those who have viable medical related reasons to end their lives. It’s hard to understand why! When we live here though, we are either going to follow our laws or chose to operate outside of them. Unless we can effectively change them, and the “we” in that sentence includes those who cannot work on this for themselves! Unfortunately they have to depend on others and a system that works slowly if at all! I believe high profile legal action against the CDC would give us some hope, but our advocacy groups would be in the best position to initiate this and I don’t see any pursuing this. I think you are right about some of the opiate deaths being suicides to escape pain, or rather life with pain…and I’m certain we will have more, sadly. Yet that feeds into the statistical craziness besides putting our doctors in jeopardy and I’m hoping and praying this doesn’t happen. Both because each life is special and because the ripple effects on loved ones (and the pain community) will be devastating.

Holly Rose

Amen Mary!

Kimberly Miller

Kurt, I shudder to think of the many thousands of chronic pain patients who are about to get the shock of their lives. I cannot believe this situation has come to this, all the while the anti-opioid lobby is attacking the wrong people for the wrong issue and achieving the opposite results. Instead of rethinking the whole mess, they just make harsher, stricter and more unrealistic demands upon the chronic pain community.

The definition of insanity in this case becomes the definition of greed. PROP and Phoenix House are deliberately sabotaging the rights of chronic pain patients to reap the rewards of government subsidized rehabilitation for addiction centers currently suffering financially. By seeking the guidance of PROP and Kolodny, the CDC guidelines are a roadmap for entrance into rehab.

The biggest issue, besides a government agency being used for the self serving needs of the greedy, is the fact that their is no rehab for chronic pain. Just because someone is no longer physically dependant on a medication that provided them some semblance of quality of life, does not mean they no longer have their chronic pain issues.

Having been through many, too many, modalities, before being prescribed opioids for my numerous chronic pain conditions, I can tell you that taking away the only thing that helps me be able to have any life at all, is not an improvement. Furthermore, taking my pain medication away, or many thousands of other pain patients’ medications away, will NEVER have any hope of stopping drug addiction.

We are pain patients, not drug addicts, and both groups of people need help, but not court mandated help. Medically supervised and individualized help.

Kim Miller

Mary s

Agree, we need to stop this cycle of madness! Everything is out of control. The government doesn’t belong in between a patient and their medication. Let the doctors for their job, treat the patient(s)!

Doesn’t the CDC and others realize chronic pain patients will be seeking any pain relief, in anyway? So why not give them pain medication?

Also, You the government have no problem sending us “boots on the ground” off to war, but if we make it home, you will not let us be treated for our pain. WTH*ll is going on in this country?


Jean Price,
I would like to have the same option for my quality of life as do the people of Switzerland. Dignatas, after careful screening, alows the patient in intractable pain legal physician prescribed suicide access. Which at least keeps the statistics clear on whose died for what REASON. Opiate overdose is the listed cause of death of many intended deaths to escape from the constant pain.
If we are not allowed access to the medications that works for quality of life, at least let me have SOME legal action left open.

Holly Rose

It really gets my host when people say chronic pain patients aren’t being monitored enough…I personally must visit pm at least monthly, most of the time I’m seen approximately every 14 days, for both prescriptions and other treatments like steroid injections, radio frequency ablation or random drug tests or pull counts… As someone in pain management for 5 years, I have never failed a urine screen or pill count and I have never refused to try alternate treatment options (other than opioid meds) for hopes they could take away or decrease the pain (as a way to reduce or even eventually discontinue pain meds)…
The government is taking steps to crucify people in chronic pain. I see more action being taken to dismantle our quality of life, than to strengthen monitoring of our meds…not that the government should have any part of my medical treatments. I prefer to have a trained physician do that, as he/she was licensed to do.
There’s so much wrong with what the CDC guidelines are “suggesting” and more terribly wrong with the DEA targeting ethical, moral & caring physicians for not following “suggested guidelines”…did I miss something? Is this the law now? Yeah, I didn’t think so…but reputable doctors are being raided and when found to be innocent of all claims by the DEA, his/her practice has no way of recovering fully…some succumb totally…So of course people are scared. Physicians are scared to lose everything they’ve worked for, same goes for pharmacists…making patients who depend on pain meds left to chose other options…
Speaking of other options…we have the all mighty, suffer and deal with it…the, search and scramble to find another doctor who’s not afraid to help with scripts (the same one(s) we’ve been on for years that allow us to feel mostly human)…there’s also the, find a drug dealer route which I discourage wholly and with a passion…or we could announce ourselves as drug addicts (rather than patients with a drpendancy) so to get maintenance dosing of opioid “type” drugs like methadone & suboxone (to name a couple)….And last but not least, no definitely not least at all….we could chose suicide…unfortunately many will chose to finally end the agony for good, and the government will include them in a statistical analysis that will probably label them as unstasble mental health patients or drug addicts…either way is false because with proper pain management those same now deceased humans were actively partaking in their lives…right up until the CDC guidelines created a personal Hell for millions!!
We are humans who, not at our own choosing or fault became sick with pain that developed into agony, that already killed parts of the lives we loved…Take away the things that make it tolerable, and yes, many humans will choose to kill the rest of what they had left…Thank you to our Free lands government, for not giving 1 cr*p about my life!

scott michaels

Truer words have never been spoken. we are the victims of a society that places the welfare of junkies above the welfare of productive citizens that live with severe chronic pain, wounded military veterans and elderly. The new America.


Very interesting - thanks. Since the Feds goal of “saving lives” is horsewallop, this is just another example of the harm these rules have caused to save addicts who probably just switched to heroin & died anyway…..

Scary. All of it. I’ve realized that if opioids are less available I might have to get medical Marijuana card. But fentanyl? Isn’t the CDC worried about fentanyl abuse, misuse and death? And funding the illegal drug trade? My RA pain has been unusually strong this week due to a fall I took Sunday. I did just take 1/2 of a vicodin and it panics me to see my supply dwindle. What happens when I can’t get more? I use between 6-10 vicodins per month. Is that abuse? It’s disconcerting about my future and ability to maintain employment.

Toni P

So chronic pain sufferers are being hurt and told to live with their pain or put on neurological meds with huge side effects, when it is not going to make much difference in our drug culture? Super! Another win by the federal government! (SARCASM)

Brooke K.

Great article Kurt! I wanted to write about this topic but haven’t had the time so I am glad you did it and did it so well. In the last month I know of four people (daughter of best friend, guy I went to high school with, and two kids my son went to high school with) who died of a heroin overdose. They are NOT dying from heroin. They are all dying from fentanyl. Our local papers and tv news aren’t report it and when they do they mention nothing about fentanyl. It infruriates me. What I don’t understand is why they are making fentanyl pills when they could just as easily make the real hydrocodone or oxycodone in a lab. Makes you wonder. Other countries are committing acts of terrorism and no one is picking up on it. More have died from this than 9/11 or any terrorism plot. Drug dealers should be charged with murder. After all, if someone was going around selling cyanide-laced pills they’d be in jail so why is fentanyl any different? Because the DEA SUCK at their jobs! That is why they go after doctors. Pathetic and sad. The CDC confirmed in an emailed FOIL request to me that all fentanyl overdoses are recorded in their statistics as “prescription drug overoses”. So, hello! Our idiot DEA and politicians are rounding up doctors though most of these people actually died from street drugs NOT prescribed medicine. I feel like I am living that movie, “Idiocracy”.

K. Levine

I’m wondering WHY the *fake* drugs are a surprise to anyone???? No surprise to me! Those who produce drugs for street sale are in it for the money so why WOULDN’T they make *fake* drugs to sell???? No surprise there.

I actually had an appointment with my doctor today and he says PHARMACIES have contacted him, encouraging him to write LESS prescriptions, less quantity for pain patients, as they’re going to stock less.

Yes, the CDC at work. He’s being forced into doing this or endanger his medical license. He’s being forced to decrease dosage for his patients, no matter what their medical issues are, how great their pain is, no matter if what he’s had them on is successfully controlling their pain.

During our conversation he asked me what *I* thought would happen. So I gave him my honest opinion-that people in major pain will turn to the streets for drugs, that this new proposal by the government, who should NOT be involved in doctor/patient care in the first place, will NOT stop abusers, and there would probably be an increase in suicide and accidental death by going to dealers on the stteet. He agreed on all points, yet his hands are tied.

And this is a *free* society??,

Alcoholics abuse alcohol and either die or become extremely sick. But we know that making alcohol illegal doesn’t work. However alcoholic is not a medication that helps lessen pain. No one really needs it. On the other hand, there are literally millions who are in severe pain every day and need pain medication to make their lives less miserable. Look at the chronic pain message boards on Facebook. People are miserable! The topic of opiods is certainly not black and white. People who really need this medication should have access and monitoring.

Jean Price

This article leaves out a very important aspect of the decision to turn to illegal drugs for pain care…and that is….it’s a CHOICE! The regulations don’t MAKE people do things…they may contribute to the decision but it’s still the individual who chooses to go against, most likely, THEIR OWN MORAL CODE, to obtain the care they believe they are being denied. This is a sticky wicket…and I believe one to avoid at all costs, perhaps even the cost of uncontrolled pain. I know this seems harsh, but we have so little control, and to be willing to sacrifice your only real control of being true to yourself and being a person who chooses to live within the law seems like such a huge part of ourselves to hang on to. Illegal drug use helps justify all that the opponents to our need for appropriate care have been saying, as does overdosing to commit suicide! We play right into their game when we do this, don’t we??! I know what being denied pain medication feels like, and what it can do physically to our bodies. Yet I’d rather be that statistic than one that adds ANY fuel to their campaign…giving them real data to support THEIR CASE, NOT OURS. If you are considering this, or if you’ve already chosen to follow this path and take illegal drugs…you may not just be hurting yourself! You may be hurting every person with chronic pain who is trying to fight the unjust, unwarranted “rules” that deny us appropriate pain care. And worse, you are sacrificing your own moral beliefs to do this! Please consider this if you are tempted to go that route or if you already are on that path. Physical pain is awful, but so is the pain of the soul when we make decisions that are against every thing we believe in, and we cannot blame them for “making” us do this! No more than Eve could blame the snake for “making” her take that bite of the apple…she chose to bite it, and it bit her back big time! And impacted others! I use this biblical reference purely as an analogy of the truth of our actions and our decisions in life. We often feel we are “made” to do things we wouldn’t ordinarily do, yet the responsibility lies firmly with us. The consequences of either choice regarding our pain will be harsh, yet as I said…I chose to hold on to myself…regardless of how much a street drug might help my pain! The associated fallout just isn’t worth it, and the dangers are apparent. Please don’t let yourself give in to this monster! Pain is also a monster, BUT NOT OF OUR OWN MAKING! But choosing to use street drugs would be that kind of monster, a monster WE make by our choice to use them! And it can destroy you and many others!


Instead of telling chronic pain patients that opiates are not acceptable, why not just stop punishing them for having pain?! I wonder why so man of them want to keep using the opiates? Maybe it is because they, actually, work for many people!? I am tired of the condescending attitude expressed by this website!

scott michaels

as i said in june of last year. the drug cartells should be thanking the cdc for their meteoric rise in business. Hungry people will fine food and people in terrible pain will find a source to relieve their pain. Now all the snakeoil sales people are out there along with the drug dealers. I heard thru a friend at the VA THAT SUICIDE RATES AARE WAY UP ALSO SINVE THE GUIDELINES HAVE GONE INTO PLACE. THIS IS ON PROP AND THE CDC. KOLODNEY SHOULD BE ARRESTED FOR CAUSING A DRUG EPIDEMIC FOR FINANCIAL GAINS ALSO.

Teresa haney

Fentanyl laced herion is killing people in Ohio every day. I don’t understand why that’s not in the news. I know of 2 young ladies who died last week. They were twins. My heart breaks for their family. This is not unusual its happening daily in Cincinnati. Last year a young man who my children grew up with died from fake percocet someone sold him in a neighborhood bar. Its not new and its not being reported on local news channels. Yet all you hear is pain patients addicted to and overusing opiods. Our use of pain meds has nothing to do with addicts dying from fake drugs. These are not isolated instances. It is happening daily. Thanks for sharing this important information.


It is a sad day indeed when Americans with legitimate pain must be warned of street drugs potency because the medical establishment has all but abandoned them.

National Pain Report, it is within your reach to start organizing a protest of these conditions. What are you waiting for?