Fentanyl: what it is and why it matters

Because fentanyl is so strong, a very small amount is a full dose. NIDA notes that as little as 2 milligrams, about the size of a few grains of salt, can be fatal.

It is also cheap to make. NIDA explains that it gets mixed into heroin, cocaine and methamphetamine, and that in many cases people do not know their drugs contain it.

A person can no longer judge a dose by experience. The same bag or the same batch of pills can hold very different amounts from one piece to the next.

The effect on deaths has been large. The CDC reports that about 69 percent of all drug overdose deaths in 2023 involved synthetic opioids other than methadone, a category that is mostly fentanyl.

A newer problem sits on top of this. Xylazine, an animal sedative that is not an opioid, is increasingly found mixed with fentanyl. The CDC warns that the combination is especially dangerous. Naloxone does not reverse xylazine, but it should still be given, because the fentanyl is usually what stops breathing.

Illegally made fentanyl is often pressed into counterfeit pills. The CDC says they commonly resemble oxycodone tablets, such as the blue pills stamped M30, or alprazolam, sold as Xanax.

They are made to look identical to pharmacy pills. You cannot tell by color, stamp or feel.

Someone buying what they believe is an anxiety pill or a painkiller from a friend, a dealer or a social media contact may be taking fentanyl.

The safe rule is simple. A pill is only what the label says if a pharmacy dispensed it to you. Treat any other pill as if it contains fentanyl.

Fentanyl test strips are small paper strips that detect fentanyl in a drug sample. The CDC describes them as inexpensive, with results in about 5 minutes.

They are a useful tool with real limits:

• A strip tells you whether fentanyl is present. It does not tell you how much.
• Fentanyl is not spread evenly through a pill or powder. The part you test can be negative while another part is not.
• The CDC cautions that strips may not detect some stronger fentanyl-like drugs, such as carfentanil.

So a negative result lowers the odds. It is not an all clear. Keep naloxone nearby and avoid using alone even after a negative test.

Whether test strips are legal where you live

This depends on your state. Some states still count drug checking equipment as drug paraphernalia. Others have changed their laws in recent years to allow test strips.

Your state or local health department can tell you the current position and may supply strips for free. Our state resources page links to each state’s agency.

Fentanyl overdoses can come on fast. The signs are the same as for any opioid: the person cannot be woken, breathing is slow or has stopped, and lips or nails turn blue or gray.

Naloxone works on fentanyl. NIDA says standard strength naloxone still reverses the effects in most people, though some need additional doses. Give it, call 911, and stay with the person. The naloxone guide explains where to get it and how to use it, and risk and overdose covers the full steps.

Call 911 if someone is not breathing or cannot be woken. Call or text 988 for a crisis or thoughts of suicide. For a free referral at any hour, the SAMHSA National Helpline is 1-800-662-4357.

Fentanyl use is treatable with the same FDA approved medications used for other opioids: methadone, buprenorphine and naltrexone.

A few things are worth knowing before you start.

Tell the clinician that fentanyl is involved, or might be. It affects how they time the first dose of buprenorphine, because starting it too soon after a strong opioid can bring on sudden withdrawal. Prescribers plan around this. An NIH funded study found that starting buprenorphine in the emergency department was safe and effective for people who use fentanyl, with very few cases of this problem.

Withdrawal from fentanyl can feel different from withdrawal from heroin or pills. Our page on fentanyl withdrawal covers what to expect.

The higher risk is also the reason to start sooner. Every week on effective medication is a week with less exposure to an unpredictable supply. The treatment directory lists providers that offer medication, state by state.