Counterfeit drugs pose emergent threat

In an emerging national trend, counterfeit prescription medications laced with powerful synthetic opioid drugs are appearing on the black market, leading to multiple deaths across the U.S. since March.

Carroll County is the first jurisdiction in Maryland to have confirmed the presence of these poisonous pills, but health officials believe it is only a matter of time before they become more widely distributed.


Sophisticated copycat versions of medications such as Xanax, Percocet and others have been linked to at least nine deaths in the area around Tampa Bay, Florida, in late March, and 14 deaths in the Sacramento, California, region. Unlike the authentic versions of these medications, the counterfeits have been found to contain the potent synthetic opioid drug fentanyl, which is 100 times more powerful than morphine.

Fentanyl is powerful enough to lead to a fatal overdose, even in opioid drug users with a high tolerance who might have purchased counterfeit narcotics on the black market with the assumption that the strength of the pills was a known quantity. But even more concerning to health officials is the appearance of fentanyl in counterfeit Xanax, the authentic version of which is an antianxiety medication often used to get high, but which does not contain opioids.


"Using drugs purchased from the streets that are sold as benzodiazepines and actually receiving a medication that is a potent opioid is extremely risky. Persons who are considered opioid naive clearly would have an adverse reaction that most likely would be an overdose," said Sue Doyle, director of the Carroll County Health Department's Bureau of Prevention, Wellness and Recovery. Benzodiazepines are the class of drugs including Xanaz and Valium, among others.

Carroll public health officials have confirmed at least one case of fentanyl poisoning as a result of a counterfeit Xanax pill. Although she could not go into greater detail because of patient confidentiality, Health Department Substance Abuse Prevention Supervisor Linda Auerback said that a Carroll resident had experienced a nonfatal overdose and admitted that they had taken Xanax purchased on the street in Westminster.

Although she said she could not give the exact date of the counterfeit overdose incident without possibly revealing confidential patient information, Auerback could confirm that it took place at some point since late February.

It was that close call that prompted the Health Department to issue a public alert on April 18 in an effort to get the word out to anyone who might be using black market pharmaceuticals: This new trend means that you can no longer be certain of what you are getting, even if it looks authentic.


"Do not ingest any pills that you purchased on the street, or even that a friend has given you," Auerback said. "If you did not get a prescription written by your doctor and filled at a pharmacy, don't take them. Your life literally depends on it."

Tracking down counterfeits

One of the ways health officials are able to track emerging trends in illicit drug use is through the National Drug Early Warning System, a network of monitoring sentinel sites across the country that is currently coordinated and operated by the Center for Substance Abuse Research, or CESAR, at the University of Maryland, College Park.

CESAR Deputy Director for Policy Erin Artigiani first learned about counterfeit pill overdoses in other parts of the country through this network and an informal online community of more than 1,500 researchers.

"One of the first reports that I heard of the counterfeit pills in Maryland was this alert that just recently came out from [the Carroll County Health Department]," she said. "I heard reports from about 10 other sites [outside Maryland] about different kinds of synthetic opiates appearing in pills."

One of those reports came from Jim Hall, an epidemiologist at the Center for Applied Research on Substance Use and Health Disparities at Nova Southeastern University in Fort Lauderdale, Florida.

"Our first reports came out in late March, and that was out of Pinellas County, which is in the Tampa Bay area. They had nine deaths associated with counterfeit medications that contained fentanyl," Hall said.

The counterfeit pills found in Florida included copycat 2mg Xanax bars — oblong pills with three score marks allowing them to be broken into four equal doses — as well as generic oxycodone pills — a prescription opioid painkiller — marked with the letter A and the numbers 215, according to Hall. The quality of the counterfeiting, he said, is very good.

"The authentic Xanax pill was slightly thicker than the counterfeit, but a person buying this would not really notice that," he said. "The authentic pill also had a more even, beveled edge — a little harder to replicate."

In California, the Los Angeles Times recently reported on officials with both the U.S. Centers for Disease Control and Prevention, and Sacramento County tallying 14 deaths due to counterfeit versions of an opioid pain pill called Norco, pills that were also found to contain fentanyl, rather than acetaminophen and hydrocodone as in the authentic medications.

Several drug seizures have revealed drug traffickers to be using commercial-quality pill presses shipped from China, according to Hall, likely from one of the many black market Chinese labs that provide domestic traffickers with fentanyl. This marks a new evolution in the use of powerful synthetics in the drug trade, he said.

According to both Hall and Artigiani, drug dealers and distributors initially appeared to use fentanyl to cut heroin, stretching their product — and their profits — with indifference to the deaths of users unlucky enough to purchase a bag of poorly mixed heroin with a larger dose of fentanyl. Fentanyl is so much more potent than prescription opioid drugs — and certainly more powerful than benzodiazepines such as Xanax — that the same economics might be driving traffickers to use fentanyl in their clones of all kinds of medication; there is no incentive to illegally obtain real Xanax to sell if an even more potent version can be created without all the hassle.

"The same organizations that have offered the synthetic chemicals are now offering how to make counterfeit medications out of those substances," Hall said. "Our main concern with synthetic opioids had been their substitution or adulteration with street heroin. Now this dramatically expands the potential market."

That market might now include people who use drugs to get high but are not — as yet — users of heroin or opioids, Hall said, thus creating a situation that could expose a whole new group of unsuspecting people to the risks of both opioid addiction and overdose.

"Today, drug use is very much poly-drug activity," he said. "Xanax is nearly the universal mixer for drug-taking activity. For people on a ton of stimulants, alcohol or depressants, there is a reason why they combine then with a benzodiazepine, either to intensify the depression effects or to mitigate the anxiety of coming down."


Even deadlier


One of the aspects of these new counterfeit pills that frightens health and law enforcement officials the most is the possibility that they portend a shift in the illegal drug market toward using newer, more potent drugs that could cause more deaths. The same logic that has led dealers to use fentanyl in their product would also apply to other synthetic opioids, some of which are both more powerful than fentanyl — making them potentially more lucrative — and not yet illegal in the U.S.

Take, for example, the opioid drug known simply as W-18.

Created more than 30 years ago at the University of Alberta in Canada as a possible new pain medication that never made its way to market, W-18 is 100 times as potent as fentanyl and 10,000 times as potent as morphine, according to Hall. And the same Chinese laboratories that are supplying domestic distributors with fentanyl and pill presses have evidently rediscovered and dusted off the synthesis for W-18. In December, a Florida man arrested by the Drug Enforcement Administration and charged with distribution of fentanyl was also found to have 2.5 pounds of W-18 in his possession, as reported by the Tampa Bay Sun Sentinel.

"He was not charged with the W-18 because at the time it was pretty unknown to the authorities, and they felt it would be very difficult to prosecute," Hall said. "Nonetheless, that 2.5 pounds would have potential for causing, with pretty crude mathematics, 184 million overdoses. That would be about half the population of the U.S."

Thus far, no one has detected W-18 or any other of a handful of other worryingly potent synthetic opioids in counterfeit pills in the U.S., but health and law enforcement officials are concerned that no one knows what is already out there, in circulation, just waiting to be taken and discovered through another mortality. Pharmaceutical drugs, often sought after by drug users in the past because of their quality and discrete dosaging, are now anything but a certainty.

Carroll County Sheriff Jim DeWees did not mince words when describing how this emerging threat makes him feel. Local law enforcement has yet to come across or confiscate any of these counterfeit pills, he said, but the recent nonfatal overdose linked to counterfeit Xanax pills purchased in Westminster shows that they are out there — although where and in what number is anyone's guess.

"I think that what scares me is that we know people buy drugs on the street, and this kind of ups the game," DeWees said. "If you are buying counterfeit Xanax and oxy pills and those sorts of things on the street and you are not getting a prescription from a legitimate pharmacy, it's like playing Russian roulette with a gun that's fully loaded — you're going to die."

DeWees said he would like to communicate to people who might use any of these pills illegally to get high that he would rather get the pills off the street than arrest a user for possessing them.

"I will put that out there — if anybody in this community thinks that they have gotten something that is counterfeit, then bring it in to us, no questions asked," he said. "We can work with the DEA and track back where it came from."

The DEA is in harm-reduction mode when it comes to these counterfeit pills, according to Auerback, underscoring the very real danger these counterfeits represent. While amnesty for dealers or distributors is not on the table, she said, her contacts at the DEA provided her with a statement to promulgate within the community, letting people know it is primarily concerned with keeping users alive, and not with putting them in handcuffs.

"We want to encourage people to get the pills out of their hands, out of harm's way," DEA sources said. "They are so dangerous, our first concern is no harm to anyone."



More information

Those who believe they might be in possession of counterfeit medications, or who have information that could lead to the source of these counterfeits, are urged to call the DEA tip line at 530-722-7577, or to bring them to the Carroll County Sheriff's Office at 100 N. Court St. in Westminster. These pills can be relinquished without fear of prosecution for those possessing them.

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