Fentanyl on the Streets vs. in the Hospital: Know the Difference

Stephanie Ray, RN, BSN

Understanding Fentanyl: A Powerful Opioid with Serious Risks

Fentanyl is a synthetic opioid that is 50 to 100 times more potent than morphine. While it has legitimate medical uses and benefits, its illicit production and distribution have contributed significantly to the opioid overdose crisis in the United States.

What Is Fentanyl?

Fentanyl is a synthetic opioid used medically to treat severe pain, particularly in cancer patients or those recovering from surgery. It is available in various forms, including patches, lozenges, and injectable solutions. However, the majority of fentanyl-related harms and overdoses are linked to illegally made fentanyl (IMF), which is often mixed with other substances like heroin, cocaine, or counterfeit prescription pills without the user's knowledge.

It's important to note that Medical Fentanyl is measured in Micrograms (mcg)

In a clinical or hospital setting, fentanyl is administered in microgram (mcg) doses because it is extremely potent.

• 1 microgram (mcg) = 0.001 milligrams (mg)

  
  

To give a sense of scale:100 mcg of fentanyl given intravenously is enough to produce strong pain relief and sedation in an adult.

So:

• 100 mcg of fentanyl is roughly equivalent to 10 mg of morphine — but it's faster-acting and has a shorter duration.

• That means fentanyl is effective at doses that are 100x smaller than morphine.

The Dangers of Illegally Made Fentanyl

Illegally made fentanyl is typically found in powder form or pressed into counterfeit pills resembling prescription medications such as oxycodone or alprazolam (Xanax). These counterfeit pills are often sold as "M30" or "Xanax" and can be easily mistaken for legitimate prescription medications. The presence of fentanyl in these substances significantly increases the risk of overdose, as users may be unaware of its inclusion .

Because fentanyl is so potent:

• A tiny miscalculation — just a few extra micrograms — can cause respiratory depression or death.

• Illicit fentanyl is often not measured accurately, and users may think they're taking heroin or oxycodone. But just 2 mg (2000 mcg) of fentanyl — about the size of a few grains of salt — can be fatal, depending on body weight, opioid tolerance, and other factors (DEA, 2021).

Overdose Risks and Signs

Overdose symptoms from fentanyl include:

• Unresponsiveness

• Slow or irregular breathing

• Constricted (pinpoint) pupils

• Cyanosis (bluish or grayish skin, especially around the lips or fingertips)

If you suspect someone has overdosed on fentanyl, it is crucial to seek emergency medical help immediately. Naloxone, a medication that can reverse opioid overdoses, may be effective but could require multiple doses due to fentanyl's potency.

The Impact on Public Health

Fentanyl has been a significant driver of the opioid overdose crisis. In 2024, synthetic opioids, primarily illegally made fentanyl, were involved in approximately 68% of overdose deaths in the U.S. The widespread availability and potency of fentanyl have made it a central focus in efforts to combat the opioid epidemic.

Harm Reduction and Prevention

To mitigate the risks associated with fentanyl:

• Use fentanyl test strips: These inexpensive tools can detect the presence of fentanyl in drugs, allowing users to make more informed decisions however, they are not always effective.

• Carry naloxone: Having naloxone on hand can save lives in the event of an overdose.

• Seek treatment for substance use disorders: Accessing professional help can provide support and resources for those struggling with addiction.

  
  

Conclusion

Fentanyl is a potent opioid with effective medical uses in the hospital setting but poses significant risks when misused or encountered unknowingly. Public awareness, harm reduction strategies, and access to treatment are essential in addressing the challenges posed by fentanyl.

• In hospitals, fentanyl is safely administered in mcg (microgram) doses by trained professionals.

• It is 50–100 times more potent than morphine, so only very small doses are needed.

• Illicit fentanyl is often unpredictable in concentration, which greatly increases overdose risk.

References

Centers for Disease Control and Prevention (CDC). Fentanyl | Overdose Prevention. https://www.cdc.gov/overdose-prevention/about/fentanyl.html

National Institute on Drug Abuse (NIDA). What is Fentanyl? https://nida.nih.gov/research-topics/trends-statistics/infographics/what-fentanyl

National Institute on Drug Abuse (NIDA). Fentanyl-induced reward seeking is sex and dose dependent and is prevented by D-cysteine ethylester.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10546209/

Centers for Disease Control and Prevention (CDC). Fentanyl and Work. https://www.cdc.gov/niosh/substance-use/fentanyl/index.html

Centers for Disease Control and Prevention (CDC). US drug overdose deaths dropped to 5-year low in 2024, CDC data shows. https://www.reuters.com/business/healthcare-pharmaceuticals/us-drug-overdose-deaths-dropped-5-year-low-2024-cdc-data-shows-2025-05-14/

Assessed and Endorsed by the MedReport Medical Review Board