What to Know About Illicit Fentanyl and Fake Pills

Fentanyl is a powerful synthetic opioid. According to provisional data from the CDC, the majority of drug overdoses in 2025 included synthetic opioids, including fentanyl. While medical professionals prescribe pharmaceutical fentanyl for severe pain, most fentanyl-related overdose deaths are linked to illicitly manufactured fentanyl circulating in the illegal drug supply. Fentanyl overdoses pose a serious risk to people across ages, backgrounds, and communities who share overlapping vulnerabilities – including stress, trauma, mental health challenges, substance use, social isolation, unstable housing, mismanagement of prescription medication, and limited access to information or services.

The good news is that fentanyl overdose deaths are preventable. Learning about illicit fentanyl, understanding the risk of fake pills, carrying naloxone, and knowing how to respond to an overdose can help save lives.

What Is Fentanyl?

Prescribed by doctors, fentanyl is a synthetic opioid that has been around since the 1960s and used for legitimate medical purposes as a pain reliever and anesthetic. Pharmaceutical fentanyl can be used to treat severe pain, such as in cases of advanced cancer or surgery, in emergency departments, or for individuals experiencing chronic pain that does not respond to other treatments. Typically, patients are given a fentanyl patch, lozenges, or shots and are monitored by a physician.

What Is Illicit Fentanyl?

Illegally made fentanyl, however, is produced and distributed through the illicit drug market and is up to 50 times stronger than heroin and 100 times stronger than morphine. It is commonly found as a powder, mixed with other drugs such as cocaine or methamphetamine, or pressed into counterfeit or fake pills made to resemble authentic prescription medication. Fentanyl is incredibly strong without a distinct smell or taste, making detection difficult. According to the Drug Enforcement Agency (DEA), just 2mg, similar to the amount of just a few grains of table salt, can be potentially lethal. Illicit fentanyl has substantially increased the risk of fatal overdose because of its potency, unpredictable presence/concentration, and widespread mixing with other drugs.

Fake Pills Can Look Real

Counterfeit, or “fake,” pills are manufactured to look like legitimate prescription medications. According to the DEA, about 29% of counterfeit pills tested at DEA laboratories contain a deadly dose of fentanyl. They may resemble oxycodone, hydrocodone, Xanax, Adderall, or other medications. But instead of containing the expected medication and dose, they often contain illegally made fentanyl in potentially lethal doses. Fake prescription pills are often bought online, through social media, from friends or acquaintances, or from other unregulated sources rather than a licensed pharmacy.

The DEA warns that medications obtained outside a licensed pharmacy can be dangerous and potentially deadly. Color, shape, markings, or appearance cannot reliably identify counterfeit pills.

This risk is especially important when talking with teens and young adults. The CDC reports that counterfeit pills are a leading source of unintentional fentanyl exposure among youth. From 2020 through 2024, 75% of overdose deaths among young people ages 10–19 involved fentanyl.

Families can help by having open, nonjudgmental conversations about fake pills. A useful message is simple: Never take a pill that was not prescribed to you and obtained from a licensed pharmacy.

Overdose Deaths Can Be Prevented

Knowing the signs of an opioid overdose can make the difference between life and death. Naloxone is a medication that can rapidly reverse an opioid overdose, including an overdose involving fentanyl. It is safe and easy for bystanders to administer. Warning signs of an overdose can include:

Breathing – slow, shallow, irregular, or stopped breathing
Lips – blue, gray, or purple lips or fingernails
Unresponsive – unable to wake up, limp body
Eyes – very small, “pinpoint” pupils

Other warning signs may include:

• Choking, snoring, or gurgling sounds
• Pale, cold, or clammy skin

If you think someone may be experiencing an opioid overdose, treat it as an emergency and follow these steps, according to the California Department of Public Health:

→ Give naloxone, and call 911.
→ If needed, provide a second dose of naloxone (using a new naloxone container) after 2-3 minutes.
→ Keep the person awake and breathing.
→ If the person is not breathing, you can perform rescue breathing or CPR.
→ Lay the person on their side to prevent choking.
→ Stay with the person until 911 responders arrive.

Be Prepared. Share What You Know.

You do not need to know someone who uses opioids to carry naloxone. Having it available means you may be prepared to help a friend, relative, coworker, neighbor, or stranger experiencing an overdose.

San Mateo County is expanding access to free naloxone through vending machines and Naloxone Stand Boxes located throughout the county. Naloxone is also available at local pharmacies and major retailers without a prescription.

Overdose is preventable, and each of us can be prepared to help save a life. Visit the overdose prevention page to find free naloxone near you, watch training videos, and learn how to get involved with the San Mateo County Overdose Prevention Coalition.