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Fentanyl, a synthetic opioid, has become more dangerous than ever because it is being used in “pressed pills,” and it is being consumed by people who are unaware of its presence. In our local area, fentanyl was responsible for approximately 75% of all drug overdose fatalities in 2021. In light of this sobering statistic, it is frightening to think that an even more potent opioid is in the U.S. and may soon make its way into the Shenandoah Valley: isotonitazene, or “ISO” for short.  

Background of ISO

ISO is a synthetic version of etonitazene, which is an opioid discovered in 1957. Etonitazene is so powerful, and so addictive, that it was never made commercially available for human use.3 Isotonitazene, though not as strong as etonitazene, is perceived to be no less dangerous, and therefore it “is not an approved pharmaceutical product and is not approved for medical use anywhere in the world.”1  

To put this in perspective, consider this: Fentanyl is 100x more powerful than morphine and ISO is even more potent than fentanyl. Though studies are still being conducted to determine its potency, the DEA cited a study in mice that found ISO to be 500x more potent than morphine,2 and the Florida Attorney General stated, “ISO is approximately 20 to 100 times stronger than fentanyl.”7 

ISO’s Advancement in the U.S.

Its deadly infiltration into the U.S. started slow but has been gaining momentum at an alarming rate. ISO was found in California as early as April 2019, and was responsible for at least 18 deaths between August 2019 and January 2020. Over the next six-month period, there were 31 additional deaths, bringing the number of confirmed deaths from iso to a total of 49 by August 2020. Estimates indicate that by the summer of 2020, the number of deaths attributable to ISO increased to approximately 40 to 50 deaths per month.4

A man sleeping on the couch with his dog watching him--if he has taken ISO, he could be overdosing.
ISO’s incredible potency makes it a dangerous opioid. Because it is 20 to 100 times more potent than fentanyl, it takes even less of it to cause an overdose.

The increase could be even more dramatic than is known. “It’s also difficult to know if ISO is on par with fentanyl because most toxicology reports don’t test for its presence in overdose cases. It’s possible that some overdose deaths linked to heroin or fentanyl may have actually resulted from ISO’s presence within those drugs,” reports New Horizon Drug Rehab.3 In fact, from January 1, 2020 to July 31, 2020, there were at least 40 fatal overdoses involving ISO just in Cook County, IL, and Milwaukee County, WI.  

In March 2020, ISO was discovered in counterfeit Dilaudid pills, which is an opioid intended for those with severe pain, postoperative acute pain, or severe chronic pain. Dilaudid itself is listed as possibly habit-forming—in other words, a person taking Dilaudid could develop a dependence or even a substance use disorder. It also lists as a precaution that taking a larger-than-prescribed dose can cause breathing problems. Taking a counterfeit pill laced with iso would increase the risk of “breathing problems,” which actually means that your breathing would slow, causing you to fall asleep, pass out, and/or even die.  

This, among other factors such as the high possibility of addiction and its high potency, led to the DEA issuing a temporary order placing ISO into Schedule 1 of the Controlled Substances Act (announced in June of 2020, effective August of 2020-August 2022). 1 

Protecting Yourself from ISO

Whether ISO overtakes fentanyl as the top overdose killer in the U.S. remains to be seen. The best way to protect yourself from either of these deadly substances is to stay away from illicit pills. Counterfeit pills most likely contain fentanyl or iso, and as DEA tests have shown, four out of ten pills will contain potentially lethal doses of the illegal drugs.  

If you currently have an opioid use disorder, remember that recovery is possible. We are here to help. Check our resources page, or visit our partners at the Warren Coalition to request help. And always keep naloxone on hand. You and your loved ones can sign up for our free Revive! Training and receive two free doses of Narcan.


Sources/For More Information

1. https://www.deadiversion.usdoj.gov/drug_chem_info/isotonitazene.pdf 

2. https://www.deadiversion.usdoj.gov/fed_regs/rules/2020/fr0618.htm 

3. https://newhorizondrugrehab.com/isotonitazene-the-deadly-synthetic-opioid-you-dont-know-about/ 

4. https://www.usnews.com/news/health-news/articles/2020-06-09/iso-a-deadly-new-synthetic-opioid-has-hit-american-streets 

5. https://www.healthline.com/health-news/iso-the-new-synthetic-opioid-that-is-causing-overdose-deaths 

6. https://www.scribd.com/document/555143308/Emerging-Characteristics-of-Isotonitazene-Involved-14 

7. http://www.myfloridalegal.com/newsrel.nsf/newsreleases/A19BD1D4E0D39DFD852588070057E62D 

The preliminary overdose deaths for 2021 are now available on the Virginia Department of Health website, and they reveal a sobering fact: fentanyl is becoming an increasing problem in the northern Shenandoah Valley. 

In 2021, in Frederick, Clarke, Warren, Page, and Shenandoah Counties, as well as the city of Winchester, there were a total of 60 overdose fatalities reported. Nearly 87% of those (a total of 52) were a result of fentanyl.  

This is not unique to the local area. According to the CDC, “over 150 people die every day from overdoses related to synthetic opioids like fentanyl.” It has become a leading cause of death in people under 50, surpassing heart disease and cancer. Just last week the University of Ohio issued a warning about fake Adderall pills laced with fentanyl, which were believed to be responsible for the deaths of two students.

The Onslaught of the Pressed Pill  

This surge in overdose deaths is due at least in part to the rapid emergence of these “pressed pills,” or “fentapills,” which are illegally manufactured tablets containing fentanyl. They are created to look like other medications, such as Xanax or Percocet or Adderall. Mixed with fillers and dyes and pressed into a shape resembling their legal counterparts, these fentanyl-based fake pills are often sold online. There is no quality control, no testing that occurs, no oversight to ensure that the amount of fentanyl in each pill is a non-lethal amount.  

In fact, according to the DEA, of the pressed pills containing fentanyl, four out of every ten pills contain a potentially lethal dose of fentanyl. 

Think about that for a moment. In a room of ten people, if each one took a fake Vicodin purchased from a dealer on Snapchat or Instagram, at least four of those people will overdose and potentially die. The danger is so high because fentanyl is so potent. It is 50x more powerful than heroin, and 100x more powerful than morphine. So just a few grains can mean the difference between life and death. In fact, according to fentanylawarenessday.org, “there are documented cases of people dying after ingesting just one half of a fentapill.” 

It’s All About the Money 

For the drug manufacturers and dealers, using fentanyl to imitate real pills is a no-brainer. It is relatively inexpensive to create fentapills and they are highly addictive. That means high profits and a lot of repeat customers. They aren’t trying to kill their customers. They just don’t care if they do.  

Remember the goal of people dealing in these fentapills is not to help you. Their goal is to make money off of you. Fentanyl, like all opioids, is highly addictive. So that “free” sample isn’t provided to help you out of a tough spot. It’s given to you with the hope that you will become addicted and become a regular customer.  

The best way to stay safe is to make sure your prescription pills are coming from a legitimate pharmacy. Don’t believe anyone online who tells you pills are “real,” and don’t try to tell if the pills are real by looking at them, because that is exceptionally difficult and often impossible.  (Take a look at photos of real vs. counterfeit pills on the DEA’s “One Pill Can Kill” website.)

Be smart. Stay safe. Get prescription drugs from your doctor or pharmacy. If cost is a concern, talk with your doctor, local churches, and/or social services office to see what help might be available in your area.  

Tuesday, May 10th is National Fentanyl Awareness Day.  Learn more about the dangers of illegally manufactured fentanyl at https://www.fentanylawarenessday.org/ 

Knowing that opioids are addictive is one thing. Not taking them when you are in pain—that’s more difficult. Fortunately, alternatives to opioids DO exist.

When we brought my tough-as-nails, never-admits-to-pain daughter to the ER with an injured arm, she was in tears. The doctor said she was going to give her a pain-killer—an opioid. Having constantly heard about the dangers of opioids, my (adult) daughter hesitated, then agreed to one dose of codeine that night (though the bill said she received Norco, a different type of opioid).  

They sent her home with a prescription for Norco, which we never picked up. My daughter hated the way she felt on just the one dose. Fortunately for her, the pain was short-term and receded quickly. By alternating acetaminophen (Tylenol) and ibuprofen (Motrin), we were able to manage her pain well.  

Is the pain medication your doctor prescribed an opioid or an opiate? 

An opiate is a natural derivative of the poppy seed plant, while opioid is a broader term—it can be an opiate or a synthetic (i.e., man-made) drug. A wide variety of opioids are available; regardless of the names, they are all highly addictive.  

The list below contains the generic and names of common prescription opioids. (Note that the list is in alphabetical order, not grouped by the same medication. For example, Demerol is the brand name of Merperidine, but the two are not listed together.) Check this list to see if your prescription is an opioid.

Fentanyl has made its way into the Shenandoah Valley, and is believed to be responsible for numerous overdose deaths in recent months. In the drug prevention community and among law enforcement, it is a recognized problem. But for many family members whose loved ones are dealing with a substance use disorder, fentanyl is still unfamiliar. 

What exactly is fentanyl?

Fentanyl is a powerful synthetic prescription opioid that was developed to treat patients with severe pain; usually after surgeries or for people suffering from cancer.