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Case Files – Fentanyl in Illicit Drugs

Rainbow Fentanyl M30 Pills
Rainbow Fentanyl M30 Pills
Toxicology Case Files from the Utah Poison Control Center
Teaching Points
  • Illicit drugs of abuse such as oxycodone, heroin, methamphetamine, and benzodiazepines often contain fentanyl whether it be fentanyl alone or in combination with another illicit drug
  • 60% of fentanyl-laced drugs contain lethal doses of fentanyl to opioid-naïve individuals
  • Fentanyl overdose may require higher doses of naloxone to reverse opioid toxicity
  • Traditional opiate urine drug screens will not detect fentanyl
  • Call the Utah Poison Control Center with abnormal cases of illicit drug use for guidance and to promote real-time surveillance
Case Presentation

A 28 y/o M presented to the ED via EMS unconscious with pinpoint pupils and a respiratory rate of 6-8 breaths per minute. Vitals were otherwise normal. While with EMS, the patient was placed on oxygen and received 0.4 mg naloxone IM with minimal response. The patient was found down at a gas station with colorful pills in a baggie. The pills had M30 imprinted on them. 

The patient was given an additional 3 boluses of 1 mg naloxone IV over 10 minutes to which he had a complete response. Once alert and oriented, the patient reported that this was his first time using illicit oxycodone. The patient was observed for 6 hours following his last naloxone dose with no change in his mental status or vitals. The patient was discharged home in good health.

The patient’s urine drug screen was negative for opiates. A fentanyl-specific urine drug test was positive for fentanyl.

Fentanyl Toxicity and Background

Fentanyl is a synthetic opioid that acts on mu opioid receptors. It is about 50 times more potent than heroin and 100 times more potent than morphine. Fentanyl overdoses present with classic opioid toxicity including pinpoint pupils, unconsciousness, and decreased respiratory drive.

Fentanyl is ubiquitously found in a variety of illicit street drugs. Fake M-30 tablets notably contain fentanyl and no oxycodone. White or colored powder, sometimes mistaken for heroin or cocaine, may also contain fentanyl.  Other illicit drugs such as methamphetamine and fake street benzodiazepines have also reportedly contained fentanyl. In 2022, DEA laboratory testing found that 6 out of 10 fentanyl-laced fake prescription pills, such as the M-30 tablets, contain potentially lethal doses of fentanyl. This can result in significant opioid overdoses of unaware users.

In Utah, deaths involving fentanyl doubled from 2019 (n=53) to 2020 (n=120). Fentanyl pill seized by Utah law enforcement also increased from 6,125 pills in all of 2020 to 70,103 pills in the first three months of 2021 alone. The most common counterfeit pills were blue M-30 tablets; however, M-30 tablets are now found in an array of colors.

Fentanyl Management

Management is similar to other opioid overdoses. Patients should receive frequent boluses of naloxone until respiratory drive stabilizes. Smaller doses (0.04-0.1mg) may be initially used to avoid precipitating withdrawal symptoms. Larger doses (1-2 mg), however, may ultimately be required given fentanyl’s high potency. If a patient does not respond to 10-15 mg of naloxone, it is unlikely additional naloxone will be beneficial.

Fentanyl is not detected by traditional opiate urine drug screens. Those wishing to test for fentanyl must order a fentanyl-specific urine drug screen such as those used in pain clinics. Coordinate with your lab to ensure the correct urine drug screen is selected.

Call the Utah Poison Control Center with concerns of any illicit drug overdose especially if the clinical presentation is more exaggerated or inconsistent with the reported exposure. Doing so will contribute to the Utah Poison Control Center’s ability to detect and involve state and local public health officials to respond to clusters of potentially lethal illicit drug sources across the state in live-time.

Discharge all patients with naloxone and a referral to local substance use disorder treatment resources.

  4. Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367(2):146-155. doi:10.1056/NEJMra1202561
Author: Joseph E. Lambson, PharmD, Clinical Toxicology Fellow, Utah Poison Control Center