Topic: High levels of adulterants in drugs 

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“In the typical street sample today, we’re seeing multiple lethal and toxic compounds that cause both overdose– fatal and non-fatal– and chronic long term health problems”(1).

-Thom Browne, MA – CEO, Colombo Plan Secretariat; President and CEO, Rubicon Global Enterprises

The problem

Many opioids, including synthetics, are more potent than heroin and have increased in usage for the past decade. Synthetic opioids often contain unknown quantities of additives, or adulterants.

In past years, the amount of adulterants in the drug supply has increased, leading to increased overdoses across the United States. In 2020, 1,878 Missourians died from overdose deaths (not including alcohol). Of the total overdose deaths, 1,204 deaths included the use of synthetic opioids such as fentanyl (3). This rise in the amount of more potent adulterants being added to street drugs has coincided with an increase in overdose death rates.

Amounts and types of adulterants in street samples vary by region and type of drug sample, but a recent analysis showed 32% of opioids and cocaine found on the street are adulterated 9 times or more and 30% are combined 5-8 times with other agents (1). With additives like fentanyl being prevalent (potency 80-100 times stronger than morphine and 50 times more potent than heroin), and in unknown amounts, even casual users are at risk for overdose. Someone wanting to use cocaine once, could end up with cocaine laced with several types of adulterants, including multiple types of fentanyl unknowingly (1).

Adulterant Ramifications

 When this article was written in September 2022, we were aware of the following complications. With the addition of other components to street drugs– sometimes up to 20 per sample– the downstream health effects are relatively unknown. As more compounds get added to local supplies, variability regionally is high, and health effects cannot be predicted as easily. Our techniques for measuring these compounds are relatively inefficient, as well, so many of these adulterants likely go unmonitored, especially if compositions of drug products change frequently (1).

Added adulterants can cause long-term effects in addition to the higher immediate risk of overdose. Long-term effects can include a myriad of health complications still being studied. One known effect of some common additives like levamisole is reduction in white blood cell count, leading to a decreased immune response and increased risk of infections and chronic health conditions. This caused a lot of problems during COVID-19, putting current drug users at risk of infection and serious complications with COVID-19 cases. 

These particular adulterants boost the levels of the drugs, making them much more potent, and more likely to cause overdose.

Prevention, Education

To prevent overdose and death, some precautions can be taken. Policies and access prove challenging. Information is subject to change, as this is a very complicated issue.

Test strips are a tool that can be utilized to test for fentanyl and fentanyl analogs in drug samples, but are limited, as they cannot tell the amount of fentanyl, just the presence or absence. Anyone can purchase these strips, but they’re illegal and are considered drug paraphernalia in many states, including Missouri. There are efforts to decriminalize the possession and distribution of these test strips in Missouri, though. (4).

Naloxone/Narcan is a drug used to counteract the effects of opioid overdose. With rising amounts of adulterants, more Narcan is needed to prevent overdose death. Proper training and access to Narcan is imperative in these instances. If opioid overdose is suspected but not certain, there are no harmful effects to administering Narcan. Even if the individual did not have opioids in their system, Narcan will not harm them.

See our Narcan training video here (5)!

Some adulterants, like synthetic cannabinoids that are in increasing presence in street samples as well, do not respond to Narcan. These substances also can lead to overdose and death, and are not currently easily measured in real time.


The amount and types of adulterants added to street drugs needs to continue to be monitored. This can provide updated information about Naloxone/Narcan administration as well as additional adulterants that can cause other issues. 

Using the information, updated recommendations can be given to the general public and healthcare providers. 

The Take Home:

There is a need for test strips to prevent overdose, and a need for Narcan boxes/access in public places. 

Access to test strips could be a helpful tool.

Continuing to monitor drug compounds and composition in this dynamic environment can help inform future actions.

This is a complex and ever-changing issue, and continuing to monitor and keep informed is crucial, for adapting practices and policy in this dynamic landscape.

See more information about Opioid Overdose by Missouri Counties here (6).


  1. 2022. Beyond Fentanyl:  How Drug Adulterants/ Cutting Agents are Contributing to Overdose, Chronic Health Problems, and Affecting Naloxone Administration [Webinar]. [Online]. JCOIN Coordination and Translation Center. 11July2022.<>
  2. Centers for Disease Control and Prevention. (2022). Understanding Drug Overdoses and Death. 13Oct2022. Retrieved from
  3. Missouri Department of Health and Senior Services (2022). Drug Overdose Dashboard- Fatal Overdoses. Retrieved from
  4. Gutierrez, Lisa. The Kansas City Star. (April 2022). Here’s how some states prevent fentanyl overdoses. It’s illegal in Kansas and Missouri. Retrieved from
  5. Galloway, Myra. How to Save a Life with Naloxone. Retrieved from
  6. Missouri Department of Health and Senior Services. (2022). Our Communities– State and County Opioids Fact Sheets. Retrieved from