El Salvador National Police seized 500 ampoules of medicinal fentanyl citrate along their border with Honduras. Credit: CFSRE
It is certainly not headline news that fentanyl is a threat in the U.S. and other countries. However, a new wrinkle in the ongoing opioid crisis has recently been discovered and labeled an “emerging threat”—injectable liquid fentanyl.
“This threat could have severe implications for the introduction of fentanyl into a country’s illicit drug supply, or make an existing fentanyl epidemic worse,” the Center for Forensic Science Research & Education (CFSRE) said in a public health alert.
Typically, fentanyl misuse or abuse involves the injection or smoking of illicitly manufactured fentanyl (IMF). Illicit fentanyl is most commonly sold on the street as counterfeit tablets or as powders in folded glassine papers. Recently, however, injectable solutions of fentanyl have been reported in countries where IMF has not yet become established, such as Nigeria, Colombia and El Salvador, in addition to Argentina, Brazil and Costa Rica.
Furthermore, there are reports of fentanyl injectable solutions being stolen or diverted from hospitals, clinics and medical supply houses in Panama, the U.S. and Europe. In these cases, the diverted individual ampoules typically contain 50 micrograms of fentanyl citrate—a non-lethal dose. While that sounds like a good thing, injection of 5 to 10 mL of these solutions can cause intoxication, and may lead to death in susceptible individuals or users without opioid tolerance. Worse, the diversion of pharmaceutical-grade fentanyl in non-lethal doses could introduce illicit fentanyl in countries not previously exposed to the substance, without attracting the attention of police or public health authorities.
For example, in May 2023, the National Drug Law Enforcement Agency in Nigeria reported the seizure of diverted pharmaceutical ampoules of fentanyl in an open-air shopping market. Each ampoule contained 50 micrograms of fentanyl in 1 ml of solution. The initial source of the fentanyl was a pharmaceutical firm in the United Kingdom. The same situation occurred in Honduras in November when authorities seized 48,600 ampoules of medicinal-grade fentanyl packed into dozens of sealed cardboard boxes. That shipment also originated in the UK.
Not only can diverted medical fentanyl lead to opioid addiction, but when the source is shut off through law enforcement intervention, local drug distributors and users may turn to the more dangerous, inconsistent powders and pills commonly produced by drug cartels.
In the U.S., researchers and authorities are now seeing IMF in liquid (solution) form. In October 2023, authorities seized 54 gallons of liquid injectable fentanyl solutions in Arizona. Then, in November, they seized another 64 gallons. Bulk quantities are easier to conceal, transport and package for sale.
Fentanyl can be recovered and concentrated in powder form from these diverted injectable solutions by chemical extraction or evaporation. However, evidence showed the intent of these seizures was for intravenous use, to be further broken down into vials for individual sale and consumption.
Uniform individual doses of IMF liquid fentanyl are extremely difficult to safely produce, resulting in similar risks for overdose as with traditional tablet or powder forms. Additionally, drug dealers could mix adulterants like xylazine and other drugs (e.g. cocaine, fentanyl analogs) into liquid fentanyl solutions, creating complex lethal drug mixtures to mimic the effects of similarly adulterated fentanyl powders and pills.