BOWLING GREEN, Ohio -- Michael K. Williams achieved stardom with his brilliant portrayal of a fictional character in a hit television program about the illicit drug trade. His death in real life from a drug overdose should be a lesson for us all. On Sept. 24, the New York City medical examiner released the findings of Williams’ autopsy results: The star of “The Wire” died from an accidental overdose of fentanyl, p-fluorofentanyl (also known as parafluorofentanyl), heroin, and cocaine.
Many articles about this tragic event highlighted that Williams died of a fentanyl overdose without explaining more precisely the combination of specific drugs found in his blood. Of those drugs, p-fluorofentanyl is the most potent of the opioids Williams ingested.
p-Fluorofentanyl is a clandestinely produced and chemically modified version of fentanyl that has not been evaluated in humans. It is often referred to as “China White” or “fentanyl.” To refer to p-fluorofentanyl simply as “fentanyl” without further explanation is misleading. Opioids produce their effects by binding to the opioid target protein in the brain known as the mu receptor. When opioids interact with the mu receptors, they induce both desired effects (pharmacology) and undesired effects (toxicology). Scientific studies have shown that, compared to fentanyl, p-fluorofentanyl is more potent in activating the mu receptor.
Consider this: Between June and August of this year, the Ohio Bureau of Criminal Investigation (BCI) has documented 298 p-fluorofentanyl cases, in contrast to only four cases from October 2020 to January 2021. Importantly, the p-fluorofentanyl that Williams ingested is not unique. In fact, BCI has found nearly 20 different forms of fentanyl. These synthetic fentanyls are not easy to detect and have not been tested in humans.
Unfortunately, Williams’ overdose is not uncommon. In the 12 months ending in May 2020, the federal Centers for Disease Control and Prevention (CDC) reported more than 81,000 overdose deaths in the United States, and illicitly manufactured fentanyl was the primary cause of those deaths. The danger is compounded by the proliferation of clandestine laboratories producing synthetic forms of fentanyl.
Many of these synthetic fentanyls come from China. In May 2019, under pressure primarily from the United States, China banned the sale of fentanyl and many of its variants. But the precursors required for synthesis of fentanyl and fentanyl-related drugs were not banned. To circumvent the fentanyl ban, clandestine labs again played the chemistry game that was originally created to develop the novel psychoactive substances. This time, the game was played not just with the final product but also with the precursors used to synthesize fentanyl. Disturbingly, the nonprofit Center for Advanced Defense Studies has found that some of the synthetic drugs are so new that they bypass the 2019 ban and are sold mainly on the clear web in a deceptive fashion in social media sites.
In the case of the p-fluorofentanyl variant that contributed to Williams’ death, that variant is considered by the U.S. Drug Enforcement Administration as a “Schedule I” drug.
The chemical modifications made to fentanyl result in compounds whose precise potency is often unknown. These synthetic forms of fentanyl are often blended with another opioid, such as heroin or other drugs like cocaine. Therefore, persons who think they are purchasing only heroin (or cocaine) may have no idea that one or more variants of synthetic fentanyl are also present in what they buy. This may have been what happened to cause Williams’ death.
Williams’ tragic death should be a wakeup call for the need for increased public awareness of multiple and dangerous forms of fentanyl.
Bluntly put, because synthetic forms of fentanyl can have enhanced and unpredictable potency, “caveat emptor” seems a weak warning to persons such as Williams who use clandestinely produced drugs.
Jon E. Sprague is the Ohio Bureau of Criminal Investigation’s Eminent Scholar at Bowling Green State University and the director of science and research for the Ohio Attorney General’s Office.
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