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Fentanyl has been in the headlines across Texas, grabbing the attention of state leaders worried about the drug crossing over the state’s border with Mexico and overdose deaths among young people.

But often left out of the discussion is that the drug is one part of a broader addiction crisis in the state. The synthetic opioid is rarely taken alone, and health care and law enforcement officials are dealing with multiple deadly drugs at once.

The illicit use of fentanyl began increasing in Texas around 2015, quickly sparking a crisis. Obtained with a doctor’s prescription, the synthetic opioid can be an effective pain reliever. But there’s been a rise both in the illegal use of the drug and now the manufacture of counterfeit prescription drugs that contain fentanyl but are packaged to look like something else, in an effort to cause addiction and generate repeat buyers.

“It’s certainly, at this moment, the drug and the drug supply that is the most dangerous,” said Katharine Neill Harris, a drug policy fellow at Rice University’s Baker Institute for Public Policy.

Opioids, including heroin, prescription pills and fentanyl, have caused the most overdose deaths in Texas, according to a Texas Health and Human Services report that studied death certificate data from 2010 to 2019.

And because opioids are often mixed with other drugs, there’s been a rise in deaths known as polysubstance overdoses. The most recent state data shows those deaths reaching a rate of four per 100,000 people in 2019.

The most prevalent drug combinations were commonly prescribed pills, like hydrocodone and oxycodone, mixed with depressants like benzodiazepines and psychostimulants that include amphetamine and methamphetamine.

“That is the reason I caution very much against focusing on one drug,” Neill Harris said. “Fentanyl is certainly a big problem. But I don’t think it’s necessarily the last drug crime crisis that we are going to face.”

The role of methamphetamine in the illegal drug market has been pushed aside in headlines as images of drug use in the South turned from exploding meth labs to potentially deadly fentanyl pills. But drug experts say meth has made an unwanted comeback as meth manufacturers have begun making a stronger product.

“Meth is eating everybody’s lunch and nobody’s talking about it. Meth is crawling up on everybody,” said Peter Stout, president and chief executive officer of the Houston Forensic Science Center. “Meth fatalities are way up even if you look at the Texas numbers.”

Experts say if Texas wants to solve the overdose problem, officials here must fully realize the state has an overall drug issue that goes beyond fentanyl. Here’s a look at the broader drug situation across Texas.

What are the drug trends? 

When the University of Texas at Austin’s Addiction Research Institute studied calls made to poison control centers, admissions to drug treatment programs and drug seizures in 2021, researchers found the most common drugs flowing across the state’s southern border from Mexico were methamphetamine, heroin, cocaine, marijuana, fentanyl, benzodiazepines like Xanax, and synthetic cannabinoids more commonly known as “spice” or K2.

While marijuana is still popular in Texas, its role in the illegal drug market has diminished greatly as 25 states across the country so far have passed laws to legalize it. When Texas legalized hemp in 2019, the prosecution of low-level pot cases declined due to the costly testing needed to determine if a vape pen liquid or a gummy contains marijuana or hemp because both come from the same plant species.

But hemp contains less than 0.3% of tetrahydrocannabinol, or THC, the ingredient in marijuana that gets you high. Anything with less THC is hemp.

Synthetic narcotics like fentanyl, meanwhile, have shot up the ranks of causes of overdose deaths. In the past five years, deaths from synthetics have surpassed deaths from other opioids, heroin and depressants.

What is fentanyl? 

Illegally manufactured fentanyl is a perilous chemical experiment, a stew of synthetic opioids.

Opium derived from poppies has long been used as a painkiller and recreational drug. Opioids like fentanyl or oxycodone are chemical concoctions that duplicate those effects.

Fentanyl was created in 1960 and approved for use in America in 1968. It’s most commonly used as a sedative and pain reliever for patients. Legally obtained fentanyl is usually administered to patients through pills, intravenous therapy, skin patches or nasal spray.

But it can also be distilled and blended to produce a fine powder that can be easily added to other drugs.

Its potent molecules scurry straight to the brain, where thousands of receptors, similar to tiny satellite dishes, pull in signals from cells in the body. They have different jobs, some gathering information to control organ functions, others emotions or moods.

Fentanyl latches on to the receptors that signal pain and shuts them down. And when those receptors are turned off, the human body reacts in ways that can be fatal, including shutting down lungs and other vital organs.

The drug is considered 100 times more potent than morphine and 50 times more potent than heroin.

Fentanyl isn’t the only drug mixture that has the federal Drug Enforcement Administration concerned as the growing threat of xylazine is starting to make its way into Texas.

Xylazine: A new threat

Xylazine is a tranquilizer, as opposed to a painkiller, doing its work by numbing nerves rather than switching off receptors in the brain. It targets the central nervous system, the nerve highways running in and out of the spinal column that carries messages to the rest of the body.

Developed in 1962, it’s used by veterinarians to keep elephants and horses calm enough to be examined or have their teeth cleaned. It mostly comes in liquid form and is sold in vials or preloaded syringes.

When tranquilizers are used, the spinal column sends messages to the brain to slow down a bit. This produces a sense of calm and elation, which is why tranquilizers are also used to treat anxiety, panic attacks and sleep disorders.

The Drug Enforcement Administration reported the first instances of this tranquilizer being used in illegal drug activity in the early 2000s by drug dealers in Puerto Rico when they began mixing it with other substances. The practice has now spread across the United States and has been found recently in Texas mixed with fentanyl.

Xylazine has been found in a growing number of overdose deaths across the country and is commonly encountered in combination with fentanyl, cocaine, heroin and a variety of other drugs.

Meth 

Methamphetamine is a white, odorless, crystalline powder that was developed early in the 20th century from its parent, amphetamine, and was originally used in nasal decongestants and inhalers. It can come in liquid form, which is easily made into a crystal form by drug traffickers. The highly addictive stimulant outpaced all others in the 2021 UT study of Texas drug trends.

The drug targets the brain and the spinal cord to create a sense of well-being or euphoria. Symptoms can include talkativeness, decreased appetite and a pleasurable sense of well-being. Meth also speeds up the body’s systems to sometimes lethal levels by increasing blood pressure and heart and respiratory rates.

Texas drug labs have recently started seeing meth being placed in counterfeit Adderall pills, meaning a segment of meth users might be unaware they are even addicted to the drug.

Heroin

Heroin is made from morphine, a natural substance taken from the seed pod of an opium poppy plant typically grown in Asia, Mexico and Colombia. It’s often portrayed in film and television as a needle drug, but the substance can also be snorted or smoked. In the past, heroin was often mixed with crack cocaine, but fentanyl has become the primary substance being added to poppy plant extract. Dealers will often “cut” heroin with other substances to allow them to sell more of it at a higher price.

The 2021 UT study of drug trends showed that Texas has avoided the heroin overdose crisis seen in other states because Mexican black tar heroin is the most common version of the drug found in the state. Black tar heroin tends to have an average purity of 28% and cannot be easily mixed with fentanyl.

“Tar” heroin is usually sold in small balloons from which the user extracts the sticky substance from the balloon by mixing it with water over heat.

Cocaine/crack 

Cocaine, the highly addictive stimulant made from coca leaves, was used more than a century ago to treat a wide variety of illnesses and was often used by early surgeons to block pain before local anesthetics were developed. Frequent use can alter brain structure and function. Users can inject or snort the powdered version of cocaine. “Crack” is the term often given to cocaine after it has been refined into a smokable substance.

What can be done? 

Lawmakers in Texas have recently tried to tackle the state’s overdose problem by aggressively attacking fentanyl distribution and use by means of enforcement and awareness.

Last week, Gov. Greg Abbott signed four bills to combat the growing fentanyl crisis, including House Bill 6, which classifies overdoses from the synthetic opioid as “poisonings,” triggering murder charges for those convicted of giving someone a fatal dose of the synthetic opioid.

“These four laws will forever change Texas through new protections that will help save lives,” he said in a press release. “In 2022, more than 2,000 people died from fentanyl in Texas — more than five a day. It is the No. 1 killer of Americans ages 18-45.”

Other measures signed by Abbott will establish a Fentanyl Poisoning Awareness Month in October and require public schools to provide students with staff to assist with fentanyl abuse prevention and drug poisoning awareness. A fourth law will allow the distribution of Narcan or other opioid antagonists to Texas colleges and universities.

However, bold substance abuse measures like legalizing test strips were once again rejected by lawmakers.

Neill Harris, the drug policy fellow at Rice University’s Baker Institute for Public Policy, said to combat fentanyl and the next impending drug crisis, the state must increase access to medical substance abuse treatments over enforcement measures.

“Until we have policies that address the demand, we’re going to continue to have a problem with drug use,” she said. “Law enforcement has always had problems with reducing the drug supply. We look back over decades and it has never been effective at slowing down the supply. Because there’s always a demand. It’s just simple economics.”

Michele Steeb, a senior fellow at the Texas Public Policy Foundation, a conservative think tank, said their organization views addiction as a complex brain disorder disease.

“Well-supported scientific evidence shows that brain disruptions reduce brain function which inhibits the ability to make decisions and regulate one’s actions, emotions, and impulses,” she said. “… Diseases require treatment.”

If the state can’t control the supply, Neill Harris said, it’s time to focus on reducing the harm of drug use by legalizing testing strips, making substitute drug treatment like methadone more available and giving more substance use options to the uninsured.

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