Fake Pharmaceuticals Laced with Fentanyl Are a Global Health Crisis
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From KQED Public Radio in San Francisco, I'm Leslie McClurg in for Alexis Madrigal. Counterfeit pills can look so real that even experts can't tell the difference between them and the real medication. But these drugs can be lethal. The DEA estimates that 70% of fake drugs contain a deadly dose of fentanyl. We talk to experts about the problem and hear from a parent whose child tried to buy Percocet.

but unknowingly bought a lethal dose of fentanyl. That's next after this news. Welcome to Forum. I'm Leslie McClurg. I'm in today for Alexis Madrigal.

If you're a college student on deadline or you're a teen who's low on their ADHD medication, you can go to Snapchat to buy Adderall or Percocet or Xanax to take you up or maybe help you relax. But you might not get the real thing. The DEA estimates that 70% of counterfeit pills contain a deadly dose of fentanyl. It's so common that 22 teens are dying weekly from fake pharmaceuticals, according to a UCLA study.

And this market is growing. These imposters are rippling out across the globe. This hour, we're going to talk to experts and hear from a parent who lost a son to a pill purchased online. We're joined by Dr. Dan Ciceroni. He's the Justine Minor Endowed Professorship in Addiction Medicine at UCSF.

Dr. Bonnie Halpern-Felscher, she's a pediatrics professor at Stanford University and also the founder of the REACH Lab. REACH stands for Research and Education to Empower Adolescents and Young Adults to Choose Health.

And Ed Ternan, he's the founder of A Song for Charlie, a nonprofit focused on counterfeit pill education and demand reduction among teens and young people. Welcome to you all. I would love to start with you, Dan. You recently co-authored an article in the medical journal Lancet about the prevalence of counterfeit pills. Why now? This is not a new issue. Why are you sort of raising the attention to this issue right now?

So we have been focused on the problem that is fentanyl for about 10 years now. It's been a disaster, a crisis, an epidemic in the United States and Canada. What we did in this article was review what's going on worldwide. And there's two things to pay attention to here. One is that, based on prior research that we published, that

Fentanyl pills are taking over the fentanyl market so that, you know, it comes in a powder form, comes in a pill form. There's no legitimate pill form. So when I talk about fentanyl pills, they're all fake. And the proportion that a fentanyl that's coming in is that in pill form is now in the majority. Right. There's more in pill form than powder form. And that started happening, I think, around 2022.

It's spreading to all parts of the United States. And in this paper, in The Lancet, we documented that the issue is spreading worldwide. And describe these counterfeit pills. They can look very realistic. I'll tell you a story. I'm a doctor. I worked in an addiction clinic. I had a patient who was being treated for both chronic pain and addiction to opioids. And she found her way to a doctor.

fake pill. And the reason we found out is because she overdosed. And we were like, oh, did she overdose on our medication? So I had her partner bring in some of these pills that she bought. And I tested them with a fentanyl test strip and found out they were positive for fentanyl. And then I alerted the hospital and said, you know, this is a fentanyl exposure. And she survived and was treated well. They are, this pill, I could tell you, looked absolutely perfect.

It looked like a pharmaceutical. And so I think that's the problem. The problem is people think they're getting legitimate, let's say Adderall, like you said, to stay awake or Xanax to relax. And they think they trust their friend or the person that sold it to them. And they cannot do that anymore. It's too widespread. And the DEA is reporting that 70% of these counterfeit pills contain a possible deadly dose of fentanyl.

Why would a drug dealer put fentanyl in Ritalin or Percocet? Well, we don't really know. It's hard to actually get... In their minds? Exactly. It's hard to get into their heads what's going on. They're trying to meet a demand, right? And this is hard to sort of accept. But there's a lot of demand for pain pills still.

We had what I called wave one of the overdose epidemic, 2000 and 2012, lots of deaths due to prescription opioids. And then we pulled those back. So some patients claim to be abandoned by their doctors. Some people are saying, I'm still in pain. And they go seeking alternatives. Right.

And then adolescents and young adults will, you know, do what they do. You know, they're going to take risks and try this and try that. I mean, I understand why someone who's searching for opioids might, you know, that makes sense, someone who's looking for pain pills. But why add it to Percocet or Xanax? Well, Percocet's in opioids. Excuse me, sorry. Sorry, in line. The Xanax. Ritalin, that's what I meant to say, sorry. Can't say, you know.

Can't say. But they're being consumed in large quantities. So there's something we still need to understand about demand on this as well. Do we know for sure that these, you know, the teen overdoses, this number, the 70% from the DEA, is that a direct cause? Do we know for sure that it's these pills that are causing kids to overdose and potentially die? Yeah.

We don't. We call it an ecological correlation. So there's some, as pills have risen, we know that adolescent deaths have doubled, I think even tripled by this point, from a fairly low number. We have to remember that we've had a decade or two, a generation really, of deaths.

drug use among young people. And yet this pill thing is going to reverse that trend. So some of the reasons as to why adolescents and young adults are taking the pills are unknown. And, you know, as we say in research, more research is needed. Fair enough. Bonnie, I'd love to bring you into the conversation. This is Dr. Bonnie Halpern, Felsher at Pediatrics or a pediatrician at Stanford University.

Bonnie, why are kids buying fake pills on social media? Why are they turning to social media to find these pills? Good morning, everybody. So, you know, as we're hearing from Dan, they're not purposely, from what we understand, they're not purposely buying fake pills. What we're seeing is that adolescents and young adults are buying pills to...

Feel better for their ADHD. Maybe they're in pain. Maybe they're stressed out. They're anxious right before an exam in college or in high school or whatever it might be. So they're going online thinking that they're buying a pharmaceutical, thinking that they're buying an actual pill that is real.

What they're seeking and instead because maybe they're buying it on Snapchat or through a non reputable source or they're buying it, they think that they're buying it from a pharmacy and they're not and they're or they're getting it from friends.

And those are not reputable sources. And they're getting a fake pill, a fentanyl pill, whatever you might want to call it. So and as Dan was saying, they look very much like the actual pharmaceuticals. Some differences sometimes, but to to a young person's eyes, if you're not trained, you're not going to be able to tell the difference.

So, again, they're not actively seeking that pill and actively seeking fentanyl for the most part. And it's also important to note that...

Most of the teens and young adults who are dying from fentanyl overdose right now are also not people who are, quote, drug users or seeking an illicit substance or seeking to get that high. Some are, and I certainly won't blame or shame anybody who might be seeking such pills, but many of them, most of them, are drugged.

one time they wanted or for a few times they just wanted that pain pill or that anti-anxiety pill. And then again, what they get is that fake pill. I want to bring Ed Turnan in here. Ed, again, you are the founder of A Song for Charlie and your work is really deeply personal. Tell us about what happened to your son, Charlie.

Thanks, Leslie. Thanks for having me on. My wife, Mary, and I founded Song for Charlie about six months after losing our youngest son to a counterfeit prescription pill, what he thought was a Percocet. And that was in May of 2020. Charlie was a senior in college about to graduate from Santa Clara University.

And it was the first few, a couple of months of COVID. And Charlie had some back pain, had had some surgery, and he was self-medicating, hanging out, preparing to do a job interview on the phone. When he made a decision, which is kind of what we're talking about here today, right? Not really unusual for a young person to say, okay,

I have had Percocet before when I had my surgery a year and a half ago. I know what it is. I know what it does to me. I'm going to get some off script without taking the time to go to a doctor. So he and a friend found a dealer using the Snapchat app. And Charlie took one tablet as prescribed of a medication he was very familiar with. But it killed him because, as Bonnie said, it was not what he wanted.

he was seeking. It was not what he thought it was. It was presented to him and it confirmed to be a Percocet. The dealer said, "This is a Percocet." So the deception and the marking of these pills, which young people are familiar with, they think they're safe in the world of drug prevention. We've learned this phrase, perception of risk, perception of harm. There's a very low perception among youth that a pill

will harm you compared to say powders and Daniel and Joseph Friedman point that out in their study. The perception of harm for powders is much higher than it is for pills. So kids are very comfortable reaching for these pills. The drug dealing complex understands that they're meeting that demand. At Songford Charlie, we focus on trying to reduce that demand by educating young people about that new risk.

Ed, we've got about a minute before we go to a break, but were you even familiar that this was an issue? Did you even know about this problem? Mary and I think about this, and we had probably heard the term fentanyl in a medical context. We did not know that this was a thing, but we were lucky that we, unlike some parents who wait long,

And unfortunately, months to get a toxicology result, we had someone on scene, law enforcement, kind of whispered to us, hey, this is going to be fentanyl the very day that we learned about Charlie's death. And we started researching it, quickly found that it was happening to other families. And that's what set up us on our mission to say, what little can we do as just regular people? Well, people are dying because they don't know. Let's find a way to go out and tell them.

We're talking about the crisis of counterfeit prescription pills that are laced with fentanyl and as you just heard can be deadly to teens today. We're joined by Dr. Dan Ciccarone. He's an addiction medication specialist at UCSF.

Dr. Bonnie Halpern-Felscher. She's a pediatrics professor at Stanford University. And Ed Ternan. He's founder of A Song for Charlie, a nonprofit focused on counterfeit pill education. We would love to hear from you. Has this problem affected you, a family member, a friend? Do you know if your kids have ever purchased a fake drug online? Give us a call now at 866-733-6786. Again, that's

866-733-6786 or you can email your comments and questions to forum at kqed.org. We'll be right back. Hi, I'm Bianca Taylor. I'm the host of KQED's daily news podcast, The Latest.

Welcome back to Forum.

This is Leslie McClurg. I'm in today for Alexis Madrigal. And we're talking about the crisis of counterfeit prescription pills that are laced with fentanyl.

often in, as we just heard, deadly quantities. We're joined by Dr. Dan Ciccarone. He's an addiction medication specialist at UCSF. Dr. Bonnie Halpern-Felscher, she's a pediatrics professor at Stanford University. And Ed Ternan, he's a founder for the nonprofit A Song for Charlie, which is focused on counterfeit pill education. And we want to hear from you. Has this problem affected someone in your family? Hopefully not your child.

What questions do you have about counterfeit pharmaceuticals? Give us a call now at 866-733-6786, 866-733-6786. You can email your comments, your questions to forum at kqed.org. You can find us on all the social media channels, Blue Sky, Instagram. We're at KQED Forum. Or join our Discord community. We'd love to hear from you.

Dan, there has been some good news, I think, in the last year as I'm a health reporter when I'm not sitting in this chair that drug overdoses are declining. Does that also include overdoses from fake pills? It's not entirely clear. So we applaud the good news. It's not entirely known why overdoses are going down. It's a good scientific mystery at this point. Yeah.

Pill deaths, we believe, are still going up. There's certain segments of the population, like young people, African-Americans, unfortunately, where the death rate is still going up. And we have to remember that even if overdose deaths have gone down, let me say, 10%, 15% over the last year, they're still at an unbelievably high level, an unacceptably high level.

Fair enough. Let's go to a caller, Sydney in Santa Rosa. You're on the air.

Hi, thanks so much for taking my call. And just to observe that over the last decade or so, generally speaking, our young children are being medicated and that's or receiving medications, prescribed medications. It's so normalized in families now. And that seems to be kind of something that's just underlying what I'm hearing. And I'm just, you know, I move. I'm sad. Thank you.

Thank you for taking my call. Yeah. Bonnie, do you think we're overprescribing drugs to kids? And that's part of the problem here.

Well, it depends on what kind of drug we're talking about as well. The young people who are getting these fake pills and dying from the pills are not necessarily dying from the or seeking the same kinds of pills that we're over-medicating. In other words, yes, we do have a lot of ADHD medication out there, certainly a lot of antibiotics that we don't necessarily need to be prescribing. But this idea that

somebody can reach out. And a lot of my research is on risk perceptions and decision making, and particularly around drug use. And this idea that we could just take a pill to feel better or chemically fix ourselves is certainly out there. It's certainly pervasive.

So it's hard to say if we're literally overprescribing in terms of that there's opioids and it's important to make the distinction between people who are having an addiction to opioids who then overdose because they are continuing to use and yes fentanyl is a form a synthetic form of opioid but

People who are in the crisis that we're seeing, and Dan was talking about that we've had for quite a number of years, often was somebody being prescribed Oxycontin or some other pain medication from surgery. We see that. There was an article published by my colleagues at Stanford that we saw young people who had wisdom teeth removal were certainly prescribed a lot of opioids and other pain medication, and then we were concerned that they were going on to be addicted and that could cause overdose.

The fentanyl crisis that we're talking about is a little bit different. It's not necessarily, again, people are seeking the medication that they've been prescribed over and over again and then dying. So it's not a straightforward answer. I'm not disagreeing with the caller. I think it's a very good observation. We definitely have people who think that the pill culture is there. But I think that the fentanyl overdose that we're seeing is a little bit nuanced.

Tamar writes, is fentanyl less expensive than Percocet, Adderall, or all the other pills it's added to? I don't understand why the makers of these fake pills would lease them with a substance that kills their customers. Dan? Yes, unfortunately, they are cheaper. Fentanyl is cheaper. The fentanyl-laced pill is cheaper. So if people were able to get a legitimate, let's say, Adderall on the street, it's going to cost you, right? But a fake one? No.

So one clue we can use to educate our young people is that if the pill seems like it's too cheap, do not trust it. Fascinating. Patrick writes, "The 22 deaths a week is a staggering number." I agree, Patrick. We had to double check that several times. My daughter is at CU Boulder and she said that six people living in the same house overdosed and were hospitalized, but she did not die. Thank God.

She said the students know the dangers, but they still want to do cocaine or molly. So they continue to use the illicit drugs. How would you say, how do you compare, you know, say, coke or molly or heroin compared to these counterfeit pills? Is that the same category now? Oh, that's unfortunately too complicated a question to give an answer to. Fair enough.

We could, through education, be guiding our kids towards, you know, we have legal drugs, right? We have alcohol. We have nicotine and various products, right? They're regulated, right?

I think one of the possibilities here is to teach young people that there's some green light recreational drugs and then there's some yellow and red light recreational drugs. And Europe's been doing this for a long time now. And so instead of having an absolutist approach, don't ever, we have a relative safety approach. And this is what we call harm reduction. And you would put the counterfeit pills in the red, like don't buy this stuff online. You know...

I have to say yes. I would put them in the red category. Let's go back to the phones. Tamar from Los Altos, you're on the air.

Hi, thank you very much for taking my call. So I think my initial question about why they would lace fake drugs with a substance that kills off their customers has been answered. But I just wanted to make a comment that I have two children in college. I beg them, literally beg them not to buy any drugs.

pills online, I tell them I'll get them a prescription for anything they need. I also have gotten Narcan for all of their cars and backpacks, as well as fentanyl test strips. They do laugh at me and say no one's going to test their fake drugs or the drugs they bought online for fentanyl, but I keep urging them that if they are in the presence of anyone using a drug, a pill they bought online, to test it and to have

to have dark hands nearby. I think we can't be naive about it and think our kids aren't doing it or their friends aren't doing it. We have to face this straight on and give them the tools to deal with anything that can happen. Tamara, you got a big thumbs up from Dan here in the studio on your advice there.

Ed, I would love to hear your thoughts in terms of how do we equip parents? What kind of advice are you offering them to do exactly what this caller says and more? What else are you advising them to do? We have done some research and we have talked to parents, surveyed parents. And one of the things we learned is that

Parents' reluctance to talk to their kids about drugs comes in large part because they feel ill-equipped, uninformed. And the drug landscape has changed so radically, so quickly that they don't feel like they have enough information, not confident enough to bring the subject up. So one of the things that we're doing is we're educating not just youth, but also families, parents.

And we encourage parents to think of this not as a one-time talk, the drug talk. We actually call our program the new drug talk, but it's a dialogue. It's an ongoing dialogue and kind of a pro tip that we tell parents is think of this as a new issue and invite your child into the discovery process, so to speak. You can say things like, hey, I've heard about this new thing that's going on with these pills.

and they look like real medications. That seems really scary. What do you know about that? What do your friends think about that? And let's agree that we're going to learn about this together and kind of make it a family project to stay informed about this. So there are communications tips and tactics that we're developing for young people, for parents, for students, for classroom materials.

that really kind of re-imagined the drug education and the drug conversation in light of this new trend of really potent chemicals being passed off as other substances.

Bonnie, we heard there from the caller. Go ahead. It looks like you're going to jump in. Go for it. Oh, if I may. First of all, fantastic questions from your callers and very thoughtful. And Ed, your work is fantastic. And just to piggyback on some of the things that we've heard, what Ed's saying is very much so. I found it in direct our REACH lab and we have a number of curriculums on drug prevention and intervention and cessation.

What Ed's saying is exactly how we talk to young people and parents as well, that idea of discovering together. I heard parents who are listening right now to Forum go home and say to your children, I just heard a conversation about fentanyl. What do you know about it? Let's learn together. You can go on Song for Charlie. Our Reach Lab website has information, and many others do as well. We also have an entire curriculum, school-based curriculum on fentanyl. But I want to just...

Also talk about that, you know, this idea of the red light, green light that Dan was talking about. It's interesting. I'm also a parent of two adult children, and I very much believe in harm reduction. And I've often said, you know, if you're going to drink, don't drive. Make sure you have a sober sitter, things like that. It is the first time that I've ever.

ever looked at one of them recently and said, just don't buy this pill online. Just don't. Don't do it. And it is not a conversation that I've ever had with them in their 24 and 28 years of life. And yet at the same time, I don't believe in the just say NO idea. I do want us to have the conversation. So the idea that the caller said about harm reduction of having Narcan, having fentanyl test strips,

is super important. So we do need to talk to our young people and our parents and say, I go all the time. Do you have Narcan with you? I carry it all the time.

Talk about, if you want, talk more about the pros and cons of fentanyl test strips because they're not perfect by any stretch. But we need to do that. We need to talk about if you are going to take a pill that you've not, don't know what it is, where it came from, don't do so alone. Make sure that you've got somebody with you who's not using because you cannot administer the Narcan to yourself. You need somebody who's around.

and talk about 9-1-1. A lot of young people are afraid to call 9-1-1 because they think that they're going to get in trouble because they're using alcohol, tobacco, other drugs. Fentanyl may or may not be mixed into it, but they're afraid to call 9-1-1. And it's incredibly important that we talk to young people about good Samaritan laws.

California and most states have really good Samaritan laws that if you call 911 and because somebody is sick, because somebody is not breathing and learn the signs, the police will not arrest you. You will not be busted. They may take the drugs away from you, but that is the extent of it. We need to save lives and have that straight conversation with people.

Dan, break down the fentanyl test strips for us. Where can parents get them? And should kids be using them on everything from their weed to these pills? And do they work on these pills? So let me just start with the larger picture of drug checking. So I've never seen a harm reduction test.

technology skill set take off like I've seen drug checking take off. So the kids will have heard about it. It's available in places that typically have harm reduction services that distribute Narcan that provides sterile syringes for those who inject, for example. But you can get the test strips

online easily. I'm also a big proponent of naloxone. I applaud the caller who said that they have their kids carry naloxone. My 17-year-old carries naloxone in her backpack. Also known as Narcan. Also known as Narcan, brand name Narcan. So the test strips will only tell you yes or no that fentanyl is in your drug.

If we think about sort of a hierarchy of drugs that are more likely, I would put pills at the top as being, like you said, 70% are going to have fentanyl in it. So those should be tested. We go all the way to the opposite end of the spectrum is cannabis products where nobody is actually detected.

Now, there's been rumors and reports and stuff like that. But if they actually get the drug and test it, no one finds fentanyl. So cocaine is sort of in the middle. I would argue that most people who want to use powdered cocaine should test it.

Crack is lower. It's a solid, so the fentanyl can't go into it very easily. And methamphetamine in crystal form is also on the low end. So cocaine pills are on my high end for drug testing, for drug checking. Let's go back to the phones. Dan in San Rafael, you're on the air.

I've got two questions, actually. One is, what's the legitimate purpose of fentanyl? It sounds like it's just a poison, but it must be created some legitimate purpose. And two, does

Dan?

So, remember the first question, sorry. What is fentanyl used for? Yeah, so thank you for that question. Fentanyl has 50 years of experience, no more than 50 years, 70 years, I believe, in surgery. We use it in anesthesia. We use it in childbirth. It is a very light opiate in the medical and surgical settings because it's

quick. It's short-acting. So if there's any adverse consequence that's happening to the patient, they can quickly reverse it. It's very titratable in terms of dosing. So it is a favorite drug. I had major surgery two years ago. I received fentanyl as part of that surgery in the right hands.

And so, you know, we're not talking in any way, shape or form about legitimate fentanyl making it to the streets. We're talking most of the fentanyl, whether it's in powder form or pill form that's being used on the streets is from illegitimate sources. We've got a listener here with a media suggestion. A user on Blue Sky writes, the excellent new Max medical drama, The Pit, just aired an episode about a young woman who took a counterfeit pill and nearly died. And

and the actual death of the young man who gave it to her. Very sensitively written and very informative about the situation. Our producer also watched this and says it was great. So there you go. Dan, given the high cost of prescription medication, many people are going to go online to try to get generic pills, maybe even travel overseas. So talk about how that could be a dangerous place to get your pills.

Yes. We document in the paper that there is a kind of pharmaceutical tourism that's happening in Mexico. It's been known for a while now. But again, the fact that fentanyl is being sold in these what look like legitimate pharmacies is the problem. What else?

I guess what I was reading about is that it's dangerous, what I'm saying, is what I was reading in your article, to go to Mexico and to potentially buy something. Yeah. And the same thing is happening online. You know, the dark web is still up and running and there's various versions of variants of Silk Road that have come back.

So people can buy these things online. They'll pay a little bit more for them online. They can't be trusted anymore than trusting them on the street. And getting back to that caller's question about trust, we got a hint of that in one of the previous statements about the rising pharmaceutical culture of our society and young people. And so there are...

And I'm not saying that's necessarily wrong, but there may be some confusion there where your friend is on Adderall and is willing to share. And so trust is built, but that doesn't mean that it's going to be there all the time.

We're talking about counterfeit prescription pills, and we will be right back after this break. We're joined by Dr. Dan Ciccarone from UCSF, Dr. Bonnie Halpern-Felsher from Stanford, and Ed Ternan, who unfortunately lost his son to this issue. We'll be right back after this break. Stay with us.

Coming up in the next hour of Forum with Mina Kim, Imani Perry says the color blue tells the story of her people. It represents both oppression and resilience, sorrow and hope. In her new book called Black and Blues, Perry explores the significance of the color in Black American history and culture, from the indigo trade to the blues music tradition. And she stitches together histories that connect the color to spirituality, community, resistance, and the complexities of identity.

Perry joins us. To listen to past Forum shows, go to Spotify or Apple Podcasts or wherever you get your podcasts. Just search KQED Forum.

You're listening to Forum. I'm Leslie McClurg. I'm in today for Alexis Madrigal, and we are talking about counterfeit prescription pills that are unfortunately laced with fentanyl and therefore sometimes deadly. We're joined by Dr. Dan Ciccarone. He's an addiction medication specialist at UCSF. Dr. Bonnie Halpern-Felscher, again, a pediatrics professor at Stanford University, and Ed Ternan-Ross.

who is the founder of A Song for Charlie, a nonprofit that's focused on counterfeit pill education. We have a listener who writes, I understand that you can't really test these fake pills for fentanyl using test strips, that the strip isn't necessarily effective. Can you please explain that? Ed? Yeah, it's a good question, and it's something that we explain the nuance of this in our messaging to youth.

There's something, a characteristic nicknamed the chocolate chip cookie effect, which is the idea that fentanyl can be unevenly distributed within a single tablet or certainly within a batch of pills.

You know, sloppy mixing, a lack of quality control is really at the root of this entire problem. So you can't, with any confidence, scrape off or break off a part of a tablet and test that part, get a negative result, and then be confident that the rest of the tablet is free of fentanyl. It just doesn't work that way. You have to destroy the entire pill and dissolve it in water and test the solution to be 100% sure that that pill is free of fentanyl.

and you can't tell test like let's say one pill from a baggie of 10 and then you know be confident that the other nine contain no fentanyl so as bonnie alluded to um there's some uh serious risks with fentanyl test strips i agree with dan what we say to people we believe messaging is very different for young adults in college than it is for maybe middle school and high school kids

If you're going to consume a powder, a street powder, you need to test it for fentanyl. If you mix that powder up pretty well and you dissolve a small portion, it's a pretty good chance that you will find out if there's fentanyl in it or not. But a pill, you have to destroy the whole thing and you can't test just one pill in a baggie. It's just not safe. And Bonnie, what would you say if you do it one time and should you assume as the consumer that going forward, that dealer, that place online is safe?

Yeah, it's a great question. And no, simply put, you should not assume such. And this gets to the idea, and I was talking about this, I was earlier about risk perceptions. And unfortunately, young people, and to be honest, in this case, because it is so new and heightened, that

heightened awareness now, thankfully, is that people just overall don't understand. And we do need education. We need communication about this. So we need to explain to everybody that just because you test one pill from a dealer or

from a pharmacy that you may have gotten online from Snapchat or so on. It does not mean that you can trust the whole thing. And that's a hard message to get out there to people. It's, you know, when we say, well, don't do this. And they say, yeah, but I did and it was great and I enjoyed it. So there must be okay. No, that's not necessarily the case.

And so we often talk about it in messaging, as I was saying, you know, if to a young person to get very concrete, if somebody hands you a pill, any pill, or you buy any individual pill and says it's tested, it's safe.

That is not the case. The only way to know that it is tested is if it is in that solution and negative and only referring to that specific pill, nothing beyond that. And that's a hard message to get out, but we need to. Dan, every morning I'm kind of confronted with this crisis when I get off the BART. It's 16th.

It's colorful. And the mayor here in San Francisco has declared fentanyl an emergency. And you can see that all over our streets, what havoc this drug is doing to our residents. What does that mean to have a fentanyl emergency? And do you think the city is doing enough? Well, let's just be clear. The visibility problem of street-based powdered fentanyl use is different than what we're generally talking about this hour.

It's what we in social science call miasma, where there's a confluence of homelessness, social marginalization, and medical problems such as mental illness and substance use. So miasmas are hard to treat. Now, I like the idea of declaring an emergency. I think it's appropriate.

The U.S. declared this in the first Trump administration, a national emergency. The question is, what do we do with it as an emergency, right? Emergencies sometimes make us feel scared. It makes us feel anxious. And the reflex then is to go to the police or criminal justice approaches to a problem. And I will say this. It's controversial as it is.

that a monopolar criminal justice solution here will not only not work, it will backfire. And so I've said for 10 years now that fentanyl has been affecting the United States and I've gone to high level DRJ meetings at the national level. And the mantra is it's all hands on deck, right? So it's harm reduction,

and education and treatment and recovery and criminal justice working together. And from what I understand in San Francisco politics, people are not working together. So if the new mayor can get that to happen, I applaud it. A listener asks, I totally understand that this is something to talk about with my kids. What is a conversation to have with a younger child, a tween, not yet in high school? I want to offer the correct information without terrifying them. Ed?

Thank you. And that's a really important question. We think as at Song for Charlie, we talk about reimagining the way we talk about drugs in this country based on the new chemical drug landscape that we need to start the conversation earlier. And we think there are ways to wrap this into other conversations that we already have about health.

Mental wellness, but also physical health. So if you're talking to your fourth grader, you're probably trying to instill in that child healthy eating habits and telling them to get some exercise. And you're also telling them about the medicines they take when they get sick. So you say, well, your sister has a cough, so she gets this cough medicine, but you don't get any because you don't have a cough.

And when your sister's cough is gone, she won't take the medicine anymore. Medicines, that's the way medicines are used, right? And so we teach our kids to be cognizant of what they put in and also the importance of

teaching young people how to control their moods and, and how they feel and their emotions in natural and organic ways that are more sustainable. So someone referred earlier to the, the pill culture that we, we talk about a lot in our messaging. Um,

You know, we don't get into how we fix that. We tell young people and families, you need to learn how to navigate that culture. It happens to be the culture you live in. So fall back to the stuff that your grandmother taught you, right? Eat healthy, only take medications as directed, and only when they come from mom and dad.

and get your fresh air, get away from the screen time, connect with friends, get into art and music and things that stimulate your brain. Find out how to calm yourself down when you're feeling upset. These are all not nice to haves anymore. These are critical life skills that I think we believe at Song for Charlie, we're going to really lean into the mental wellness component of why kids reach for these pills because we think that's really important and it means the conversation should start younger.

Let's go back to the phones. Chris in San Rafael, you're on the air. Hi, I was just listening and wanted to make a comment. As a former drug user who's now in recovery, I'm very familiar with the San Francisco market for breast pills, both on the street and online. And I was just going to make a couple points, just that one of the gentlemen who lost his son to the fentanyl overdose said,

that kids are generally afraid of powders and not of pills, but I wanted to make the point that all of the pills that are being pressed are coming from powders, and it doesn't take anything special to press a pill. I mean, anybody, you or I, can just order the kits on Amazon, whether it be a full packaging, you know, a

a device that will press and imprint the pill with whatever you want on it and package it. Or even in head shops, they have little presses that you can screw together and press one pill at a time. So there should be more education for sure.

describing just that I mean any powder can be pressed into a pill but additionally also wanted to add that I know the San Francisco needle exchange program they offer a resource which is and I might be killing this it's an electrogas spectrometer where you can take any substance to them methamphetamine any drug any pill they

They can look at it and determine what it's made of, the molecular structure, whether there is fentanyl in it or anything like that. And I thought that would just be good for people to know in general. Thank you so much. Very informative call there, Chris. Aaron writes, aside from the risk of death from taking fake pharmaceuticals, in your education and outreach efforts with teens, do you address the potential legal ramifications of getting caught with fake pharmaceuticals off the internet? Ed?

- To be honest, we do not. We are not educating kids about the risk of getting arrested.

We're really trying to get across to young people that the drug landscape has changed very radically. And when I was growing up, it was described to me in terms like it's a journey where you're going to be exposed to some substances and you'll try a little of this and a little of that. And the danger is that along that pathway, you might get off on the wrong track and you might start taking too much of your drug of choice and eventually down the line,

overdose and that was the risk. Today, the drug landscape is more like a minefield than a pathway where your first, second or third venture out there

could be fatal if you don't know the lay of the land, if you don't know what's going on. So our approach is more around a public health warning. Keep yourself safe. We want to empower young people and not scare them. And so we bring them into the conversation to say, you wouldn't want this to happen to anyone you love or any of your friends. So learn what you can about this issue, spread the word and keep yourself safe. No random pills.

A listener asks, I appreciate that parents and families need to be having these conversations. But what are colleges and schools doing in educating kids about this? Sometimes kids will listen to a teacher more than their folks. Bonnie, thoughts on what Stanford is doing?

Yeah, absolutely. And if I may also to piggyback on what Ed was saying about the previous question, we too, with all of our prevention and intervention materials that are directed at young people, elementary, middle, high school and college, totally agree with what Ed was saying. We also don't discuss the legal ramifications properly.

That's why I always bring up the Good Samaritan laws, because if anything, what we want to do is encourage young people to be calling 911, getting help and getting help from their parents or other loved ones or teachers or whomever it might be if they are struggling with addiction or struggling with any drug use so that we can help them rather than have it be punitive.

In terms of colleges, yes. So what Stanford's been doing, and I've been involved in this with them, is really trying to get the word out at both Stanford and, to be honest, across the country. We've been going to universities across to discuss making sure that, one, that people are aware of this crisis, that they're aware of fentanyl, fentanyl fake pills,

aware of not buying these pills online and aware of the harm reduction methods. So in a lot of universities, and I know this is true at Stanford, there are boxes. A colleague of mine has this where there's a box that has both Narcan and fentanyl or naloxone and fentanyl test strips available. And it is everywhere throughout the dorms and the education is there too. And in all the health fairs.

We're actually working. We have a curriculum called Safety First curriculum that's a comprehensive drug education curriculum. And we actually created a specific curriculum just on fentanyl and opioid. And we are creating an app for this that will be specifically for college age students during orientation to learn, to know, to understand, to know how to use Narcantide, know how to use fentanyl test strips.

And with the idea also and how to call 911, how to recognize symptoms and then prevention, not using these pills in the first place. So we are doing that. And Stanford and other universities are very much interested in it. What's nice is it's grassroots. It's the Stanford students who are really pushing this forward and pushing the education forward.

I was so impressed in my preparation for today, the number of films and multimedia projects that students are doing to really take care of each other in a response to this crisis. It was quite inspiring.

A listener asked. Oh, sorry. Yeah. Yes, they are. I've talked to too many not only parents like Ed, but too many high school and college students who have lost friends to fentanyl overdose and that they are really sounding the alarm and trying to understand and get out the education and prevention. So I 100 percent agree with you.

And Leslie, if I can just jump in, the statistics that we're seeing in the decline in the growth rates of fentanyl or overdose mortalities is going down faster among ages, say, 20 to 24 than it is with teens. So the young adult college age population

population somehow has figured out some messaging and has started to turn the corner on this. The high school age kids and middle school age kids, mortality there is bending down. That's great news, but not as steeply as the older kids. So at Song for Charlie, we're really doubling down on how can we get that population kind of coached up and get them caught up to their older peers to continue to bend those curves down. We totally agree. And it

And just really quickly, what I'm hearing, and thank you for saying that, we have a very large youth action board of 40 young people who advise us on all of our work, middle high school and college students. And I agree, Ed, the high school is where the students are really struggling to get this information and why we're also working with them to get this information because a lot of the young people in high school and even middle school says, we're

We've heard of this, but we don't have the education and schools are not always, some are not always providing it. So we do need to have this really out there for everybody. We touched on this earlier, but I think this is a good thing to double down on. A listener asks, I know we are talking about counterfeit pills, but is this a problem with weed? Should I be testing cannabis for fentanyl? Can I be assured that cannabis is okay if I buy it from a weed shop?

Yes. There's no concern about fentanyl in cannabis. Excellent. Ed, if you could go back, what do you think Charlie would think of the work that you're having to do today?

Oh, God, you're going to make me choke up. We really chose this path of trying to stay hopeful. We've nicknamed ourselves Team Hope here at Song for Charlie and take the attitude that if we focused on just hope,

keep bringing the good solid information to people like Charlie and his peers and his friends that they can protect themselves. And we really believe that is what Charlie would want us to do. That was his personality. He was a peacemaker. He wasn't like a saber rattler. So his, he influences our work every day and we think about him every day. He inspires us. And, and that's what we think he'd be very proud of us.

I'm very proud of you. Thank you for doing this work. Me too. Thank you all. So sorry for your loss. I agree. We've been talking about the crisis of counterfeit prescription pills that are laced with fentanyl, and as you heard there, can be deadly to kids and adults alike.

We've been joined by Dr. Dan Ciccarone. He's an addiction medication specialist at UCSF. Dr. Bonnie Halpern-Felscher, pediatrics professor at Stanford University. And Ed Ternan, founder of A Song for Charlie, a nonprofit focused on counterfeit pill education. I'm Leslie McClurg in today for Alexis Madrigal. Stay tuned for another hour of Forum Ahead with Mina Kim. Thank you all so much.

Funds for the production of Forum are provided by the John S. and James L. Knight Foundation, the Generosity Foundation, and the Corporation for Public Broadcasting.