Mac Miller‘s Sept. 7 death has been officially ruled an accidental overdose due to multiple drug toxicity including fentanyl, the same opiate that was the cause of Tom Petty‘s death on Oct. 2, 2017 and Prince‘s death on April 21, 2016.
While fentanyl may not be as immediately familiar to many people as more commonly cited drugs like Percocet or Oxycontin, addiction expert and founder of Origins Behavioral Healthcare, Ben Levenson, told PEOPLE the extremely powerful, synthetic opiate isn’t uncommon.
Explaining what exactly the drug is, Levenson – who also founded The Levenson Foundation and frequently works on Dr. Phil as an addiction advisor – compared the potency of the drug to other regular abused drugs.
“It’s very, very powerful. 50 to 100 times more potent than morphine and 25 to 50 times more potent than heroin,” he said. “Depending on the grade, about 40 times more potent than heroin.”
The CDC estimates that fentanyl is 80 times as potent as morphine and hundreds of times more potent than heroin. Classified as a Schedule II drug by the federal government, its medical uses are typically pain management following surgery or for chronic pain.
However, Levenson said using the drug to regularly treat pain management isn’t the best option, as fentanyl – which is so potent it’s prescribed in micrograms as opposed to milligrams – hits patients quickly, in about five minutes, but wears off quickly as well, lasting only about an hour.
“Fentanyl was utilized initially to make the death experience painless,” Levenson, a recovered addict himself, explained. “It was never intended to be used during the course of someone’s life to manage pain. It is extremely over-prescribed and highly sought after by addicts.
“It hits you fast and it wears off fast, so it’s not a good drug for someone who is, for instance, recovering from knee surgery, although it’s widely prescribed. It was never designed for that.”
Now marketed under the brand names Actiq, Duragesic and Sublimaze, fentanyl was originally synthesized by Paul Janssen in 1959 and introduced in 1960 as a structurally related analog for pethidine (more commonly known as Demerol), which had been created a few years prior. Levenson said the original means for the drug was palliative care.
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Fentanyl was being abused recreationally by the 1970s. Apparently, it’s appeared on the streets under names like: Apache, China Girl, China White, Dance Fever, Goodfella, Jackpot, Murder 8, TNT and bizarrely, Tango and Cash. While initially, it was simply stolen from pharmacies, it has also been synthesized by drug dealers and is frequently “cut” or mixed with heroin or cocaine, going by ominous names like Bomb, Drop Dead, Flatline and Lethal Injection. One gram of pure fentanyl can be cut into approximately 7,000 doses for street sale, and manufacture of the drug requires relatively little technical knowledge.
Now, the drug is medically administered in a variety of ways, including a spray form taken orally and a lollipop, which Levenson said is highly sought after. It can also be taken intravenously or made into a powder and snorted, similar to cocaine.
Despite its potency and the fact that it is in the category of drugs – along with morphine and oxycontin – with the highest potential of abuse and fatalities, Levenson said doctor’s continue to give it to patients because, over time, they’ve been trained to prescribe for pain. Additionally, patients taking opiates develop a tolerance that push them towards higher strength prescriptions.
“You can’t challenge patients’ pain reports. If a patient reports, ‘My pain is an 8,’ you have to treat them at an 8,” Levenson added. “The reason people get to the level of needing fentanyl, and doctors going ahead and prescribing them is because they’ve worked their way through lower strength opiates.”
Although the DEA occasionally discovered illicit fentanyl labs throughout the eighties and nineties, it wasn’t until the 2000s that the drug’s appearance on the street increased markedly. The CDC reports that from 2005-2007, there were a total of 1,013 deaths related to fentanyl in the U.S., most of which were concentrated in Illinois and Michigan. In the early ’00s, the drug also flooded Eastern Europe, where, in a dark foreshadowing of its place in the U.S., it overtook heroin as the hard drug of choice. Estonia was hit particularly hard; at one point, the drug was killing more people than traffic accidents.
More recently, in 2013, a previously unseen fentanyl analog was blamed for 14 overdose deaths among drug users in Rhode Island. In most of the cases, the drug was, as usual, mixed with cocaine, heroin or other drugs. In August 2015, a spate of overdoses in Western Canada were linked to the drug, which was being trafficked along a common drug route that flowed from British Columbia to Alberta and Vancouver. Canadian authorities have linked 500 deaths to the drug since 2013.
In the U.S., fentanyl has quietly usurped heroin in many regions. In New Hampshire, for example, the drug killed 158 people in 2015, while heroin killed 32.
“It started out as an opioid epidemic, then heroin, but now it’s a fentanyl epidemic,” Maura Healey, the attorney general of Massachusetts, told the New York Times in March.
“Massachusetts is the epicenter for the heroin/fentanyl trade,” Healey added. “From Lawrence, it’s being trafficked and sold all over the New England states.”
In March of 2015, the DEA issued a nationwide alert about the drug. “Drug incidents and overdoses related to fentanyl are occurring at an alarming rate throughout the United States and represent a significant threat to public health and safety,” DEA Administrator Michele M. Leonhart wrote. The report specified New Hampshire, New Jersey, Rhode Island, Pennsylvania and the St. Louis area as being hit particularly hard, with California one West Coast outlier, owing to its common use as a traffic route for drug cartels in Mexico.
The alert did not come without solid cause, as Levenson told PEOPLE that America is facing a “national opioid epidemic, with overdose being the number one cause of accidental deaths in the country.
“Ultimately, you end up with overdoses and fatalities because of tolerance. They’re not getting the effect so they take more and more and more, but there’s a point when more is deadly,” he said. “Long-term fentanyl use leads to death.”