Fentanyl has eclipsed heroin in Alaska’s drug supply, decreasing prices and raising risks

In just a few years, the powerful synthetic painkiller fentanyl has almost entirely replaced heroin as the dominant opioid in the Alaska drug supply.

The change has major implications for public health and safety, especially among street drug users.

Though quantifying trends in the illegal drug supply is difficult, data from law enforcement, nonprofit services and drug users themselves all paint a similar picture.

“There’s no heroin anymore,” said Crislyn Carmack, an employee with the Alaska AIDS Assistance Association, which runs the state’s largest syringe exchange program. “I don’t hear anything about it. It’s fentanyl, fentanyl, fentanyl.”

For more than two decades, the opioid epidemic in the United States has been marked by successive waves of substances supplied to millions of dependent users. First came pharmaceutical painkillers like OxyContin, prescribed to patients within the health care system at increasing frequency and volume beginning in the late 1990s and through the 2000s, according to the nonpartisan Congressional Research Service. Rates of lethal overdoses rose dramatically, as did the black-market trade in painkillers and illegal prescribing practices. Next came cheap heroin, much of it — especially within Western states — grown, refined and distributed by criminal networks headquartered in Mexico.

“In 2016, synthetic opioids — led by fentanyl — surpassed heroin and prescription drugs as the leading type of opioids involved in U.S. overdose deaths,” the Congressional Research Service wrote.

As with many national trends, changes in the opioid market were late to arrive to Alaska but are consistent with what’s happened in the rest of the country. According to Lt. Daron Cooper, Deputy commander of statewide Drug Enforcement Unit for the Department of Public Safety, heroin produced in Mexico was the primary opioid across Alaska until about 2019. Before that, fentanyl was known but wasn’t viewed as a significant threat.

“We weren’t seeing it really in any quantity here in the state,” Cooper said.

[2023 was Alaska’s deadliest year for opioid overdoses — and the state saw the highest increase in deaths in the nation]

Just before the COVID-19 pandemic in 2020, Alaska law enforcement began seeing fentanyl overtake heroin in drug seizures around the state.

“And then the last couple years, it’s really increased,” Cooper said. “You start to see (heroin) come down and that fentanyl, essentially, gradually came up.”

Seizure data reported by an anti-drug trafficking program in Alaska backs that up. In 2023, Alaska law enforcement agencies seized a total of 83 kilograms of fentanyl, compared to 9 kilograms of heroin.

The two substances are not perfect equivalents. Fentanyl most commonly comes into Alaska in the form of counterfeit pills, many of them blue and marked “M30″ to resemble pharmaceutical oxycodone products. White powder fentanyl, which in its unadulterated form can be up to 50 times stronger than heroin, is rarer. In both formulations, Cooper said, potency varies widely. Pills and powder come into the state in a variety of ways: Sent in the mail, hidden in shipped freight, carried onto commercial flights, stowed on fishing vessels or inside luggage brought aboard the state ferry. Law enforcement is intercepting such huge volumes of the counterfeit pills that they measure seizures by the overall weight rather than tasking officers with counting hundreds, sometimes thousands, of individual pills.

“We know that a big chunk of the fentanyl coming up into the states, and definitely into Alaska, is sourced from the southern border,” Cooper said.

Alaska is a lucrative market because drugs can be sold for prices dramatically higher than in the Lower 48, particularly in rural communities one or two logistical hops away from urban population centers. In the state’s most recent drug report, which includes pricing data, single fentanyl pills sold for $20 in Sterling, $80 in Dillingham, and $100 in Sand Point. In Anchorage, they can be as little as $10 a pill. An affidavit from a police officer filed as part of a drug case against Trevor Latimer, sentenced this summer in state court, included evidence from his supplier, Andrea Eden, who bought fentanyl pills in Colorado for 70 cents each that were then sold on the Kenai Peninsula for $10 to $15 apiece.

“It really depends on market saturation and what’s available,” Cooper said. “We really see it in the Kodiaks, the Bethels, the Dillinghams, the Western Alaska places where if ... it’s dry and they only have 10 pills on island, those pills are going to command a hefty price.”

In a state close to America’s southern border, the same knock-off pill could sell for less than a dollar, he said.

The drugs that end up in small, rural Alaska communities typically pass first through Anchorage, where fentanyl is abundant.

“The streets are flooded with pills because they’re cheap to make and people are profiting off them,” said Venus Staten, director of HIV Prevention and Education at the Alaska AIDS Assistance Association, or FourA’s.

Through the syringe exchange, Staten and her staff interact with hundreds of clients who come to return used needles and receive new ones, along with other supplies to use drugs more safely. Though not without criticism or controversy, public health experts have long held up such programs as an effective way to prevent the spread of deadly diseases and bring hard-to-reach individuals into contact with health care and social service providers.

Counterintuitively, as fentanyl has overtaken heroin as the most common opioid on the street, the number of syringes FourA’s gives out for intravenous injection has actually declined over the last few years. Some users say they will not “poke,” given that the amount of actual fentanyl in a blue M30 or small dose of white “fetty” powder can be all over the map. Smoking opioids won’t bring on as intense of a high, they say, but is far less likely to trigger a lethal overdose.

“We’re not ordering a million syringes a year anymore,” Staten said. “Literally a million. In 2019 we hit over a million.”

The organization’s employees still give out hundreds of syringes a day at their office and from a van that regularly drives into areas close to large homeless encampments. But plenty of people who come up to the van window for supplies don’t want “rigs,” as needles are often called. Many ask only for “bubbles” and “stems,” small glass pipes for inhaling the smoke from vaporized pills or “clear,” a nickname for meth. In the east-side park where Carmack takes the van once a week to hand out supplies, it’s not hard to find squares of tinfoil on the ground with tar-black splotches left from a melted pill, the DIY way to smoke a dose if there’s no bubble on hand.

Needles and pipes are not mutually exclusive. Plenty of people are using both. What state health experts call “polysubstance use” is increasingly common in Alaska: people regularly using two or more substances from different drug categories in combination, most often opioids and methamphetamine. A 2023 report from the Department of Health to the Legislature labeled polysubstance use an “emerging concern,” noting that of “the 886 total drug overdose deaths that occurred in Alaska between 2018-2022, 58% involved” multiple drugs.

The rise of fentanyl is accompanied by the growth of the anti-overdose medication naloxone, distributed in the form of a nasal spray branded as Narcan.

“Oh my gosh,” Staten said with a sigh, “we go through Narcan so fast here.”

That’s true beyond just her organization or Anchorage. Since 2017, the state of Alaska has given out Narcan kits for free to groups of nonprofits and first-responders through the Department of Health. Originally, health officials aimed to distribute 5,000 kits a year in Alaska. But since then, with the growth of fentanyl — and fentanyl overdoses — distribution has increased by an order of magnitude. Between May 2023 and April of this year, the state recorded giving away 44,985 Narcan kits.

Some users keep a tally of how many people they’ve “brought back” and can rattle off instances where it took two, three or even more units to revive someone. As nonprofits, health care facilities and pharmacies have moved to routinely distribute Narcan kits, they’ve become a staple among drug users, picked up regularly and carried alongside other supplies like tourniquets, disinfectant wipes and cookers.

Over the last decade, the annual number of fatal overdoses in Alaska has more than doubled. Opioids account for most of those deaths, and in the last few years the overwhelming majority were linked to fentanyl. According to vital records statistics analyzed by the Health Department, in 2018 just nine overdose deaths were attributed to fentanyl. In 2022, fentanyl killed 151 people in Alaska, frequently turning up alongside other drugs used in combination.

“In Alaska, fentanyl was involved in four out of five opioid overdose deaths, and many of these fentanyl-involved overdose deaths involved an additional substance, such as methamphetamine or heroin. The high potency of fentanyl combined with the tendency for mixing or co-use with other substances complicates intervention and treatment efforts,” notes a report prepared by the Health Analytics and Vital Records Section and Office of Substance Misuse and Addiction Prevention within the state Health Department.

Because it’s potent and cheap, fentanyl frequently shows up in other drugs, added either by accident or to lace other substances with a mild analgesic boost that can make them more pleasurable and more addictive, according to the state Department of Health.

As she hands out supplies to clients, Carmack, with the syringe exchange program, hears stories about fentanyl added into uppers like meth and cocaine, but even occasionally to cannabis bought outside the legal dispensary system.

“It’s like Russian roulette when you start messing around with that fentanyl, ‘cause you just never know,” she said.

Fentanyl also has a shorter lifespan than heroin, so users, particularly those with a serious dependency, have to use it more frequently to stave off the effects of withdrawal. Carmack hears that constantly having to cook down, tie off and inject fentanyl is less convenient than smoking, swallowing or snorting, even if the high isn’t as intense.

“Everybody’s smoking instead of shooting. It’s easier,” she said.

Though the syringe exchange program is anonymous, employees do ask clients for basic information like their date of birth. Carmack said she sees young people who have never used heroin but came into hard drugs through products containing fentanyl. The harmful effects of the drug, she said, appear to be more rapid and acute, with people who have been using for only a short time appearing to struggle mightily.

“What has happened to someone that’s been using heroin for like 20 years, it looks like someone that’s been using fentanyl for a week,” Carmack said. “It just deteriorates you.”