The opioid epidemic has hit the United States and Canada with such force that stakeholders invested in the problem find themselves searching for answers.  Among the more than 64,000 drug overdose deaths estimated in 2016 within the US, the sharpest increase occurred among deaths related to fentanyl and fentanyl analogs (synthetic opioids) with over 20,000 overdose deaths. Fentanyl and carfentanil have found their way to the streets of cities and towns across North America, being sold as heroin and cocaine to unsuspecting buyers or often as fentanyl itself, where the lure of the high has proven irresistible and often fatal.  The issue has become so concerning that on October 26, 2017, President Trump declared the opioid crisis a national public health emergency, stating, “As Americans, we cannot allow this to continue. It is time to liberate our communities from this scourge of drug addiction. It’s never been this way. We can be the generation that ends the opioid epidemic. We can do it.”  In recent months, more intense effort has been placed on solving the issues that accompany this crisis with limited success.  Little attention has been focused on an aspect of this crisis that could impact hundreds, if not thousands, of innocent civilians.  Could this drug be used by an individual or group to cause fatalities and injuries as a weapon of mass destruction?

What is Fentanyl and Carfentanil?

As a legal drug, fentanyl is a powerful synthetic opioid analgesic that is similar to morphine but is 50 to 100 times more potent.  It is a schedule II prescription drug and it is typically used to treat patients with severe pain or to manage pain after surgery.  It is also sometimes used to treat patients with chronic pain who are physically tolerant to other opioids.

In recent years, fentanyl has been used in the illegal drug market, being sold initially as an additive to other drugs like heroin or cocaine for an added “kick” to increase potency.  More recently, fentanyl is being blended or cut with more benign substances like lactose or talc and sold as a powder or in pill form taken orally, injected or snorted.  Often, the buyer is unaware that the product being sold is fentanyl, believing it to be heroin, cocaine or other drugs like OxyContin.  Mixing fentanyl is by no means an exact science.  Often, one pill may contain little to no fentanyl when another in the same batch may contain a fatal dose.  The user plays this game of Russian roulette each time he/she uses.

Carfentanil is also a synthetic opioid, up to 100 times stronger than fentanyl.  It is the most potent commercially available opioid in the world.  There is no listed acceptable use in humans and is sold as a large animal (elephants, bison) sedation medication.  Carfentanil has recently been found in several US states as an illicit drug for the purpose of distribution for human use.

Use of Carfentanil as a Potential WMD

As the number of overdose deaths from fentanyl and its derivatives continues to rise in North America, focus remains on eradicating its use as an illicit drug and the treatment of those already addicted to it.  But, there is potentially a more nefarious plan for this drug that could be used to harm or kill scores of innocent people.  Fentanyl, carfentanil and its many derivatives are deadly in very small amounts.  It is estimated that the lethal dose of fentanyl in humans is 2 mg, with the lethal dose of carfentanil unknown.

The use of fentanyl or carfentanil as a weapon of mass destruction by an individual intent on causing death or terror is not only plausible, but probable given the ease in which it could be obtained.

Although carfentanil and three similar drugs were recently added to China’s list of banned substances, several distributers continue to advertise the sale of these drugs at a cost that is not considered prohibitive.  As recent as April 2017, the AP identified 12 Chinese businesses that said they would export carfentanil to the United States, Canada the United Kingdom, France, Germany, Belgium and Australia for as little as $2750 a kilogram (2.2 pounds), no questions asked.  In another recent

article, vendors said they lie on customs forms, guaranteeing delivery to countries where carfentanil is banned and volunteer strategic advice on sneaking packages past law enforcement.  Andrew Weber, assistant secretary of defense for nuclear, chemical, and biological defense programs under President Obama from 2009 to 2014 stated, “It’s a weapon.  Companies shouldn’t be just sending it to anybody.” These chemicals are banned from the battlefield under the Chemical Weapons Convention.  Michael Morell, former acting director of the CIA wrote in August of 2017 that the threat the opioid crisis poses extends beyond public health; it is a national security threat.

Notional Scenario

0745, Tuesday in October: Boston, MA- Massachusetts Bay Transportation Authority (MBTA) Red Line, South Station to Downtown Crossing

An inbound Red Line train is stopped at South Station, one of the busiest terminals on the line.  At this time of the morning, each passenger car is somewhere between “policy and crush” capacity, with approximately 230 passengers, seated and standing.  Many passengers are carrying briefcases or pocketbooks and some have backpacks, as many are students.

As the doors close and the train begins moving, a passenger dons an N95 mask, pulls out several bags of powder and throws them into the crowded train.  Several passengers fall ill, the closest to the perpetrator quickly losing consciousness.  Several passengers attempt to subdue the perpetrator and are shot before the individual takes his own life with a firearm.  Others are attempting to escape the train with no success.  Transit time between South Station and Downtown Crossing is approximately one and a half minutes.

Several passengers in the car exhibit symptoms including respiratory depression or arrest, drowsiness, profound exhaustion, disorientation, sedation, pinpoint pupils and clammy skin when arriving at Downtown Crossing.  As the doors open, passengers clamor to exit the car, stepping over and on other passengers who are barely conscious and unable to move.  Many passengers are unable to get by the incapacitated victims and fall ill themselves.  As bystanders attempt to help the victims, some exhibit similar symptoms.

Within minutes, EMS and other first responders arrive and begin treating the victims.  Initial responders exhibit similar symptoms.  Narcan is given to many of the victims but initial supply is short.  Those that do receive Narcan and are not immediately transported begin to re-display signs and symptoms and lose consciousness.






MBTA Policy Capacity vs. Crush Capacity, MIT RED LINE @ KENDALL TRANSIT STUDY


This scenario may sound implausible to some.  To the contrary, carfentanil is the perfect terrorist weapon.  One only needs to look to the past.  On October 23, 2002, Russian special police units resorted to using what is believed to be carfentanil and another potent fentanyl derivative, remifentanil as an incapacitating agent in a hostage scenario.  In the aftermath, 127 of the 800 hostages were killed along with all of the hostage takers.  Several others were incapacitated.

Carfentanil is easily obtained (one is easily able to obtain step-by-step instruction on how to access the “dark web” within minutes) and available in large quantities.  A kilo (2.2 pounds) could be carried in a back pack without alarming the public.  There is little to no bag security on the rail system.  There is no need to manufacture or process the product as it arrives on the doorstep of the perpetrator as pure or close to pure.  Very little carfentanil inhaled can be deadly within minutes.  Narcan, although carried by local EMS, is not carried in quantities that would be sufficient in such a scenario.  According to JEMS (Journal of Emergency Medical Services, Feb. 2016), patients may require unusually large or repeated doses of naloxone (Narcan). Even with reversal of acute symptoms with naloxone, recurrence of symptoms may occur and warrants prolonged observation in a hospital setting. Failure to treat in a timely manner can result in respiratory arrest, hypoxia or death.

“Could it be weaponized? Yeah, it could be weaponized,” said Peter Ostrovsky, Assistant Special Agent in Charge at Homeland Security Investigations in the U.S. “Because so little can affect so many, there’s just a greater concern.”

“It is a concern not just for the willful illicit drug user, but it’s a public safety concern for uninvolved third parties.”

Lastly, Andrew Weber, referred to earlier, described ways carfentanil could be used as a weapon, such as knocking troops out and taking them hostage or killing civilians in closed spaces like train stations.

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David DiGregorio currently serves as the Director for the Massachusetts Department of Fire Services Hazardous Materials Emergency Response Division. He retired from the US Army and Massachusetts Army National Guard after 32 years of service in 2014, and served as the Deputy Director of the division from September 2014 through January 2107. He has earned a MS degree in Emergency Management from the Massachusetts Maritime Academy as well as a BS degree and MS degree in Physician Assistant Studies from the University of Nebraska Medical Center. He currently serves on the faculty of the Massachusetts Maritime Academy as a capstone advisor for the graduate level Emergency Management course. David is married with 3 children and resides in Hopkinton, MA.