Luca decided to try fentanyl when heroin stopped giving him the effect it once had. A 50-year old from Rome, Luca has been doing drugs, mainly heroin, for 30 years. But after a recent drop in global production, he says there has also been a drop in its quality. Today, heroin has little of its active ingredient, because it is cut with much more.
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“As a long-time heroin user, I started looking around,” Luca says. “That’s how I got to fentanyl.” He obtained the pills and the nasal spray through a friend, who in turn had stolen them from a relative and cancer patient. But Luca was disappointed by fentanyl. “A person like me who has developed a high tolerance to opiates doesn’t get very high from prescription fentanyl,” he says. “The problem arises when it is used to cut heroin. That’s when it gets dangerous.”
An American emergency
Fentanyl is an analgesic opioid that was first synthesized in 1959. Lollipops, nasal sprays and pills containing the opioid are considered as a valid alternative to morphine injections and pain therapy, which has favored its spread among cancer patients, especially during the 1990s. That is also when its use for non-medical purposes became a problem.
Fentanyl creates addiction within a few days. A study by the Massachusetts General Hospital shows that its use stops breathing before patients lose consciousness, and that 2 to 3 milligrams of fentanyl is enough to kill a person.
Many started doing fentanyl without knowing it, which made things worse.
The fentanyl epidemic has hit the U.S. the hardest: Almost 1 million people lost their lives between the late 1990s and 2022 due to fentanyl overdoses. At the beginning, one of the main problems was the pressure exerted by pharmaceutical companies on doctors to prescribe fentanyl as much as possible. It was easy to access and cheap, which boosted its use.
Then the Mexican drug cartels arrived and started using fentanyl imported from China to cut heroin and other drugs supplied to the American market. Many started doing fentanyl without knowing it, which made things worse. In the U.S., 75,000 people died of a fentanyl overdose in 2023 alone.
The fentanyl epidemic has been defined as the worst national health emergency in the U.S. since the postwar period. But in Europe things are different. In 2021, 137 Europeans died from fentanyl overdoses, especially in Germany and the Baltic states. Italy is almost invisible in the statistics, but this doesn’t mean that the opioid is not spreading in the country.
Fentanyl arrives in Italy
“In the province of Venice we’ve known about it for almost 10 years,” says Mauro, 42. He first used it in the city of Mestre, near Venice, in 2016, which is when heroin cut with fentanyl started circulating. It was expensive — 80 euros per gram, compared to around 20 euros for heroin — but it was so strong that a small dosage would be enough to get high. You could even save money in the long run.
“I used it for a couple of years and it was horrible,” Mauro says. “Fentanyl, besides the physical pain, cuts your breath; it feels like you’re not breathing. Withdrawal was also a problem: It would come quickly and with stronger symptoms. It’s unmanageable.”
Mauro was arrested in 2018, and he says that he was lucky because prison forced him to stop. “I don’t know where I would have ended up,” he says. “I have friends who overdosed, others who died. The reports said that they were killed by heroin, but surely, in some cases, the heroin was cut with fentanyl and there were simply not the means to detect it.”
Counting the deaths
The first first fentanyl-related death in Italy was recorded in 2017. A man found dead in his house in Milan was initially found to have died of a heroin overdose, but 18 months later, the Italian National Institute of Health (ISS) identified the cause to ocfentanil, a fentanyl derivative.
A similar event took place in 2018, when traces of another fentanyl derivative, known as furanylfentanyl, were found in a dead body in Varese, north of Milan. Once again, heroin overdose was first thought to be the cause.
The two deaths show that fentanyl was used in Italy to cut heroin even before the pandemic. But the alert system did not work, and the laboratories lacked the instruments to detect the substance.
“Today, we don’t have the slightest idea of how many people have died due to fentanyl,” Ernesto De Bernardis, a doctor specialized in addictions, said in 2018.
In recent years, fentanyl in Italy seems to have become more widespread. The police have seized dozens of loads between 2020 and 2023, and in the same period various investigations led to the arrest of doctors and pharmacists accused of trafficking fentanyl-based drugs with fake prescriptions and store thefts.
International factors
Italy has not been immune to fentanyl due to combination of factors at the international level. After returning to power in Afghanistan in 2021, the Taliban outlawed the cultivation of opium, which is used to produce heroin. Opium production in the country fell by 95% in 2023, with massive consequences both on the national economy and the international supply of synthetic drugs. Afghanistan was the top opium producer worldwide until 2022, before being overtaken by Myanmar.
“For years international organizations have been telling us that we needed to repurpose those crops to deal a blow to the international drug market. Now that it’s been done, we find that the situation could be even worse, because with less heroin in circulation the spread of counterfeit heroin becomes more likely, or it paves the way for the spread of opiates such as fentanyl,” says Riccardo Gatti, a physician specializing in addiction.
Fentanyl is circulating, but we still don’t know to what extent.
“Today in Italy, we are at a stalemate, like in a waiting room: Fentanyl is circulating, but we still don’t know to what extent. Moreover, the country’s drug intervention system already has weaknesses, especially in areas such as in the south. If another drug comes along, you risk not having the tools to deal with it.”
As heroin quality keeps worsening, some have been looking for new substances. “In our surveys, fentanyl is sometimes mentioned among the substances used,” says Elisa Fornero, who coordinates Neutravel, a project engaged in the fight against drug addiction in Turin. “But the numbers are really small. Fentanyl is for those who want to try new things. Those consuming heroin for a long time are not really interested,” she adds.
Some use fentanyl because it is the only drug they can get. “I’ve tried it with some others in the community,” says Lorenzo, 29. “The doctor would prescribe pills for a guy with neurological problems. He would put the pill in his mouth, but then he would spit it out and give it to us. Then we would snort it.”
Identifying the problem
“The consumption of fentanyl-based drugs for non-medical purposes is marginal and should not be exaggerated just because of some microdoses used to cut other drugs,” says Alessio Guidotti, who advocates along with itaNPUD for the protection of drug consumers’ rights. “The danger instead is seeing here what happened in the U.S. and Canada, where fentanyl produced in laboratories is used to cut other substances.”
Guidotti says that Italy is mistaking the problem: fentanyl circulation is on the rise because of what is happening in Afghanistan, but there’s a lot more. “People take all kinds of shit, cocktails of paracetamol, opioids and other substances,” he says. “Perhaps people don’t die in the streets like in other countries, but the problem is already here.”
In May 2021 in Vancouver, 160 people died of overdoses, mainly fentanyl-related. Faced with such a number, the Drug User Liberation Front (DULF), a group of local activists, set up a radical but innovative system to deal with the issue: It purchased heroin on the dark web, tested it to make sure that it was fentanyl-free, and then packed it and distributed it to consumers to make sure that they would take a controlled substance. No overdose was recorded.
ItaNPUD and other associations are trying to do something similar with the Eroina (Heroin) project: a mapping that takes into account the quality of the substance to understand what it is cut with, including fentanyl.
Unintended consequences
Recently Italy’s institutions have started paying attention to the problem as well. On March 12, the government presented a national plan for the prevention and contrast of fentanyl, making it among the first to do so in Europe. For Italian Prime Minister Giorgia Meloni, “the fight against drugs and all pathological addictions is one of the absolute priorities of this government.”
But it is nothing more than a media campaign, which so far has not been supported by concrete measures. The government has also outlawed some fentanyl derivatives, a measure that could limit the imports of some drugs and create problems for some patients. Giacomo, for example, has been using fentanyl for years to treat a neurological disease. But because supplies are limited, the 21-year-old is now forced to use less than prescribed.
The prohibitionist and stigmatizing approach has never been beneficial in history.
“There is a kind of demonization of opioids for medical use in Italy, we are among the countries in Europe where they are administered the least,” he says. Giacomo and some of his acquaintances who need fentanyl for medical use are rationing the substance. Sometimes they are even forced to take half of what has been prescribed to them. The way we discuss fentanyl in Italy, with no distinction between its medical and recreational use, could make things worse.
“The prohibitionist and stigmatizing approach has never been beneficial in history,” Giacomo says. “This is not how the problem of fentanyl use outside of medical treatment will be solved. If anything, more problems will be created.”
