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The illicit market for pain pills never went away. Now fake ones are flooding the street and causing even higher rates of overdose deaths.

Fake “rainbow fentanyl” pain pills point to the explosive growth of counterfeit tablets taking over illicit drug markets nationwide — spurring record overdose deaths, say experts. It’s a new turn in the overdose crisis as the pills overtake the illegal market for heroin.

In late August, the Drug Enforcement Administration warned that brightly colored powders and pills containing fentanyl had been seized by police in 18 states that month in illegal drug arrests. DEA Administrator Anne Milgram called this sudden appearance of candy-colored fentanyl “a deliberate effort by drug traffickers to drive addiction among kids and young adults,” setting off news reports and politician’s tweets.

But the DEA’s threat to kids contention is doubtful, experts told Grid, and raises risks of undercutting fake fentanyl pill awareness campaigns aimed at adult casual drug users — the ones most at risk from counterfeit pain tablets. “I think DEA is jumping the gun, just automatically assuming that these are colored pills meant for children,” said Jon Zibbell, a senior public health scientist at RTI International, a nonprofit institute headquartered in Research Triangle Park, North Carolina. “The last thing we want in this epidemic is more moral panics. We need real, empirical, public health science about where the threats are.”

More than 80 million fentanyl-laced fake pills were sold in the illicit drug market last year, according to estimates based on seizure data, with the tablets moving from Mexico into the U.S. Many are stamped with “M” and “30″ to resemble oxycodone pills or other medications, and are the blue-green color of the actual medication. Counterfeit pain pills laced with illicit fentanyl have been blamed in the deaths of celebrities such as Prince and Los Angeles Angels pitcher Tyler Skaggs, and play an increasing part in overdose deaths nationwide. (At the start of 2015, illicit fentanyl killed fewer than 6,000 people a year, and it now kills more than 70,000 a year, roughly two-thirds of all U.S. overdose deaths.) Approximately 2 to 3 milligrams of fentanyl, a pinhead-sized amount, can be lethal, particularly for those not habituated by past use to higher doses.

“To put it simply, the pills that look like real pills are the ones that scare me more,” said Zibbell. In North Carolina and West Virginia, where he does fieldwork among people who use drugs, he has not seen rainbow-colored tablets, but plenty of the counterfeit ones that look real. The real danger in the fake pills is among casual drug users unwittingly taking them thinking they’re getting oxycodone, he said. “I would much rather have a bright red rainbow fentanyl pill than one that looks like an oxycodone 30 [milligrams]. Right? Because at least people are going to know they’re fake.”

The DEA has not yet responded to Grid’s requests for comment on its news release, which did not list the 18 states where rainbow fentanyl seizures were made. However, Department of Justice news reports have noted the seizure of 15,000 colored fentanyl tablets in Nogales, Arizona, as well as others in California, Oregon, West Virginia and Washington, D.C. For perspective, the DEA’s Los Angeles branch announced the seizure of 1 million counterfeit fentanyl pills in one record bust alone in July.

“These fake pills are designed to look like real prescription pills right down to the size, shape, color and stamping,” said the DEA news release.

The DEA has a history of past drug scares that spurred the excessive policing and over-incarceration in the “war on drugs.” A 2016 video campaign led by DEA told police officers that mere skin contact with fentanyl could cause a deadly overdose, misinformation that has sent people to prison and still triggers dubious events in some cops. Likewise, federal officials have pushed dubious reports of fentanyl contaminating the illicit marijuana market, anecdotes usually tied to drug tests revealing trace contamination. All of that makes experts a bit dubious about rainbow fentanyl truly being aimed at kids.

Instead, the appearance of the brightly colored tablets shows that the underlying black market for illicit pain pills never disappeared, said medical anthropologist Dan Ciccarone of the University of California, San Francisco. That’s despite efforts to fight the overdose crisis that emphasized limiting prescriptions for opioid pain pills. Those painkillers are now prescribed in nearly half the numbers they were a decade ago. That past overprescribing, the subject of wide-ranging lawsuits against pharmaceutical firms and suppliers, is blamed for the “first wave” of opioid-drug-related U.S. overdose deaths, which seeded subsequent, bigger, waves of heroin and then fentanyl deaths as the illicit drug market turned to those drugs.

Despite the crackdown, prescription pain pills still kill about the same number of people now — around 12,000 annually, according to the Centers for Disease Control and Prevention — as they did in 2015, noted Ciccarone. “The first wave never ended. Tablets are still part of the illicit drug market.”

The people taking the fake fentanyl pills are largely in their late 20s and early 30s, not children, he added. “There is good messaging, ‘One Pill Can Kill,’ in high schools, although there are still problems there, of course,” said Ciccarone. “Tablet culture is very much a concern with people in their 20s who are more casual drug users [and] who haven’t gotten the message.”

“The most important thing is getting that word out about how dangerous and widespread these counterfeits are to those people,” he said.

Illicit fentanyl has replaced heroin in the U.S. black market for simple economic reasons, said Bryce Pardo, associate director of the Drug Policy Research Center at the Rand Corporation. It is a cheap, fast, synthetic drug made from base chemicals that doesn’t require growing a poppy crop. It is more potent, meaning it can be smuggled more easily. And while a kilogram of heroin might have a street value of $35,000, a kilogram of fentanyl might be valued at $110,000. Fake fentanyl pills are now replacing the black tar heroin sold in the Western half of the U.S., just as fentanyl powder replaced the heroin powder sold on the East Coast starting a decade ago.

Why brightly colored counterfeit pills are making an appearance in the illicit drug market now is unclear, said Pardo. “It’s probably more a signal of dosing,” he said. “There is some precedent for that.” For instance, a Bay Area distribution chain in the past sold colored fentanyl powder, with different colors supposedly denoting a lesser or greater potency. However, the DEA release stated the various colors of powder and pill seized in August were all the same potency. (“It would be helpful if DEA were to do their job and analyze the seizures and produce reports showing the purity levels of tablets across different colors, so then we can kind of get a sense as to what is the purity,” said Pardo.)

Another possibility is that cartels in Mexico are looking to distinguish their fentanyl from competitors in a bid to draw customers in an illicit drug market that everyone now recognizes is completely saturated with fake pills. “After a few years of this happening, everyone kind of realizes, ‘Well, the market is basically booked so maybe I gotta switch up and sell yellow tablets instead of blue tablets,’ to deal with the same product,” said Pardo.

Alternately, for casual users with a higher overdose risk, the colors could signal that the pills contain potentially lethal fentanyl — a safety measure — while telling habitual users, who might want the drug for its heavier dose, what the tablet contains. “Tablets actually present some benefits for users because you can’t tamper with tablets. You know that baggie of heroin that you’re using is stepped on probably you know, six, seven times,” said Pardo.

Zibbell suggested the different colors are the product of chance and the amateur, clandestine laboratory work that produces the pills in Mexico. A recent Wall Street Journal report visited fentanyl labs in disused garages there, with batches of fentanyl cooked up in a few days in metal drums. “It’s the impurities in the production process. Sometimes they will turn the color. It’s not like [the TV series] “Breaking Bad,” where you’re trying to use a blue powder to advertise,” he said. Experienced drug users have for decades tried to use colors to navigate the drug market and discern just what they are buying, Zibbell added.

Rather than solely seeing cartels looking to hook kids on fentanyl with rainbow fentanyl, said Pardo, the DEA would be better served by seeing the black market as a genuine market, with the colored pills sending some kind of signal to customers.

“I don’t think the DEA is really considering how much of a game changer tablets are,” said Pardo. “People who have never used drugs before, those individuals may come to realize that it’s just too risky, because everything contains fentanyl, everything is fake, so I’m not going to get involved.”

Thanks to Alicia Benjamin for copy editing this article.

Dan Vergano is a science reporter for Grid.

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