Editorial
Fentanyl in the US heroin supply: A rapidly changing risk environment

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A crisis of historic scale

Deaths due to illicit drug overdose in the United States have reached historic proportions with annual numbers exceeding those due to motor vehicle accidents, gun violence or HIV/AIDS — at the height of the US HIV crisis in the early 1990s (Katz, 2017a, Katz, 2017b). This is driving up the US mortality rate (2015) for the first time since 1999 (Xu, Murphy, Kochanek, & Arias, 2016). The most common cause of drug overdose deaths is opioids with 33,000 opioid deaths in 2015 (Centers for Disease

Contributions to this special section

Taken together the above market factors represent a positive supply shock to the US heroin market as well as a significant shift in the structural risk environment for those who use heroin. The US Centers for Disease Control and Prevention (CDC) identified eight high-burden states in which the crude death rate due to synthetic opioids increased 174% from 2013 to 2014. These eight states were located in the US regions of the Northeast, Midwest and South. The research papers in the Special

Conclusion

Heroin source and form are part of the structural risk environment for users (Ciccarone, 2005, Ciccarone, 2009), which has been worrisomely transformed by the phenomenon of fentanyl-adulterated and -substituted heroin (FASH) (Ciccarone et al., 2017). An understanding of the heroin supply, and how it is changing, supports the geographic correlation between rising heroin overdose and availability of fentanyls. A ready explanation is that illicit fentanyls come in powder form and thus more easily

Acknowledgements

I am indebted to Sarah Mars for contributions to and fact checking and editing of this manuscript. I thank the entire Heroin in Transition research team for their dedicated work: Georgiy Bobashev, Philippe Bourgois, Mary Howe, Sarah Mars, Fernando Montero, Jeff Ondocsin, Dan Rosenblum, George Jay Unick and Eliza Wheeler. A special thanks to Jon E. Zibbell for early and crucial guidance in the development of this Special Section. And thanks to Tim Rhodes at IJDP for planting the seed for this

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