Photo: AI-generated image (Dall-E) representing fentanyl on a map of South Africa. Image edited using Photoshop by GroundUp staff.
Recent drug tests have found people at South African clinics testing positive for fentanyl. This is a highly potent opioid drug which has caused tens of thousands of deaths in the US.
It is the first direct evidence that South Africa could be headed for a fentanyl crisis of its own, though more data is needed.
Researchers say that to address the problem, naloxone will need to be distributed widely. This is a medication which can reverse opioid overdose.
People in the Eastern Cape and KwaZulu-Natal have tested positive for fentanyl, a lab-made painkiller that has been at the centre of the opioid crisis in the United States (US). In the US, fentanyl has caused tens of thousands of deaths each year, often among people in their 20s and 30s. While the drug can be prescribed as a legal pharmaceutical, the US crisis is primarily driven by illegally-made fentanyl, distributed by drug cartels.
Up until recently, South Africa appeared to be insulated from the illicit fentanyl crisis. But preliminary research suggests the drug has made its way onto our streets. The study is still ongoing, but lead researcher Dr Alanna Bergman provided GroundUp with information about the findings so far.
Bergman is an American nursing scientist who received funding from Johns Hopkins University to import highly precise urine drug tests. In February, she began using them to test people at clinics in East London, Port Elizabeth and Durban.
The patients who were tested were people who had drug-resistant TB, and were being monitored as part of a separate study. Nurses suspected that many people in the group may have been using substances.
There are a few possible reasons that this may have been the case. One is that HIV rates are high among South Africans who inject drugs, due to the sharing of needles. In turn, HIV can compromise the immune system, making active TB more likely.
Bergman was asked to step in to conduct voluntary drug testing at the clinics. In line with the expectations of nurses, Bergman’s tests found that 60 out of 100 patients tested positive for illicit drugs of some kind and 32 tested positive for fentanyl specifically.
Medical records suggest that none of these patients had been prescribed legal fentanyl. Surprised by the findings, Bergman imported more tests, which she has been rolling out since October.
“I believe we now have 320 people that we’ve tested,” says Bergman, “The fentanyl rate remains high. Each day, a few more people are added to the sample. When I check in on it, it’s anywhere between 25 and 33 percent who are positive for fentanyl at any given time”.
Bergman’s research is some of the first direct testing showing fentanyl use in South Africa. But there have already been signs of a brewing problem. One is a largely overlooked 2021 study, which tested wastewater at several treatment plants in Gauteng. It found biological markers for fentanyl in the sewage at each plant.
A second is a recent string of police reports related to fentanyl (which Daily Maverick summarised here).
What is fentanyl?
Fentanyl is an opioid medication (in the same category as codeine and heroin). It was developed as a strong painkiller, and can be taken as a pill, patch, lozenge or via injection.
In South Africa, it is sometimes used for medical procedures, for instance, as an epidural during childbirth. It can also be prescribed for chronic pain that hasn’t been cured by weaker medications. This is similar to how it’s used elsewhere.
People can also use the drug to get high; it produces a feeling of euphoria and relaxation. Like other opioids, people who use it for long enough can become physically dependent. At 30 to 50 times the potency of heroin, it can be deadly. There is a fairly narrow difference between a dose that can get you high, and an amount that could kill you.
In the US, the crisis is primarily driven by illegally made fentanyl, which the US Drug Enforcement Agency alleges is made in China. These include pills (often referred to as Blues) as well as powders, which are snorted or injected. Canada has also faced an illicit fentanyl crisis.
People using fentanyl by mistake?
In North America, people who use drugs sometimes end up taking fentanyl unintentionally. In a study conducted in Canada, roughly three-quarters of people who tested positive for fentanyl were unaware that they had ever taken the drug. This is because fentanyl is often added to other substances, like heroin. One study says that this is presumably to “reduce the amount of heroin needed for each dose” (since fentanyl is so much more potent).
Researchers suspect that something similar may have happened in South Africa, though the extent is unclear.
Shaun Shelly, a South African drug policy researcher, told GroundUp: “I don’t think anyone in South Africa is going out to get fentanyl intentionally; who here knows what that is?” Instead, it is more likely that people who tested positive for fentanyl had been buying what they thought was heroin, says Shelly.
Bergman noted that some people who tested positive for fentanyl also had morphine in their system (heroin turns into morphine in the body). But she says that “most are positive for fentanyl only”. Bergman says that this could mean that in some cases, fentanyl has replaced the heroin supply, rather than being used as an adulterant. She emphasizes that more data will be needed to confirm this.
If fentanyl adulteration or replacement is taking place, it could be difficult to reverse. “Fentanyl is a subjectively different experience to heroin,” says Shelly. “People get used to fentanyl, and then that’s all that can get them to the state they want.”
Shelly says that when fentanyl is cut into heroin it often “clumps”, meaning that it isn’t evenly distributed across a batch. As a result, “somebody can take a dose of one supply and they’re ok with it, but the next dose could potentially kill them, because the fentanyl is much more concentrated in that second dose.”
Government needs to act fast
To prevent widespread overdosing, the government will need to act fast, according to researchers. Bergman says one basic step would be to distribute naloxone more widely. This is a drug which is used to reverse opioid overdose. It has no potential for abuse.
The World Health Organisation recommends distributing naloxone to anyone who is likely to witness an opioid overdose. This includes emergency workers as well as close family members or peers of people who use drugs.
“There’s also going to need to be a lot of public health safety education,” says Bergman. For example: “Don’t use [substances] alone. You need to use with a partner so that someone can reverse an overdose.”
“These are the most basic low hanging fruit,” she says.
