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The Threat of Fentanyl‐Based Counterfeits in Mexican Pharmacies: Addressing a Growing Public Health Crisis

April 2025
37(4):978-988

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Pharmacists are perceived as protectors of public health, advancing trust in pharmacies and the drugs provided. However, this trust is often misplaced in Mexico, where pharmacists frequently dispense dangerous fentanyl‐based counterfeits without prescription orders and on‐demand. The convergence of four trends occurring in Mexico—the influx of international tourists seeking pharmaceuticals without prescription orders, increased domestic consumption of illicit fentanyl, expanded domestic production of illicit fentanyl, and the rise of fentanyl‐based counterfeits in Mexican pharmacies—has created a substantial risk to regional public health. Mexican cartels manufacture and distribute these counterfeit drugs, facilitated by corrupt officials engaged in limited drug enforcement. To address this emerging public health crisis, an independent fentanyl enforcement division should be established in Mexico to oversee expanded drug enforcement operations targeting cartels and their intermediaries. This division should conduct rigorous and surprise inspections of pharmacies accompanied by international observers and provide anonymous whistleblower channels for pharmacists and the public. Pharmacy owners found knowingly selling fentanyl‐based counterfeits should face severe penalties, including forfeiture of pharmacy licences, lifetime bans from owning and operating pharmacies, significant fines, and incarceration. By enacting these enforcement and public health reforms, Mexico can more effectively minimize the dispensation of fentanyl‐based counterfeits and safeguard regional public health.

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Journal of International Development, 2025; 37:978–988

https://doi.org/10.1002/jid.3998

978

Journal of International Development

REVIEW ARTICLE

The Threat of Fentanyl- Based Counterfeits in Mexican

Pharmacies: Addressing a Growing Public Health Crisis

NicholasLassi1 | SuJiang2

1School of Law, Southwest University of Political Science and Law, Chongqing, China | 2Law School, Peking University, Beijing,China

Correspondence: Su Jiang (sujiang@pku.edu.cn)

Received: 27 June 2024 | Revised: 10 December 202 4 | Accepted: 29 Januar y 2025

Funding: The authors received no specif ic funding for this work.

Keywords: drug cartels| fentanyl| global public health| medical tourism| Mexican pharmacies

ABSTRACT

Pharmacists are perceived as protectors of public health, advancing trust in pharmacies and the drugs provided. However,

this trust is often misplaced in Mexico, where pharmacists frequently dispense dangerous fentanyl- based counterfeits without

prescription orders and on- demand. The convergence of four trends occurring in Mexico—the influx of international tourists

seeking pharmaceuticals w ithout prescription orders, increased domestic consumption of illicit fentanyl, expanded domestic pro-

duction of illicit fentanyl, and the rise of fentanyl- based counterfeits in Mexican pharmacies—has created a substantial risk to re-

gional public health. Mexican cartels manufacture and distribute these counterfeit drugs, facilitated by corrupt officials engaged

in limited drug enforcement. To address this emerging public health crisis, an independent fentanyl enforcement division should

be established in Mexico to oversee expanded drug enforcement operations targeting cartels and their intermediaries. This di-

vision should conduct rigorous and surprise inspections of pharmacies accompanied by international observers and provide

anonymous whistleblower channels for pharmacists and the public. Pharmacy owners found knowingly selling fentanyl- based

counterfeits should face severe penalties, including forfeiture of pharmacy licences, lifetime bans from owning and operating

pharmacies, significant fines, and incarceration. By enacting these enforcement and public health reforms, Mexico can more

effectively minimize the dispensation of fentanyl- based counterfeits and safeguard regional public health.

1 | Introduction

Mexico is a leading destination for American medical tourists

seeking outbound medical care (Stoney etal.2022). Due to the

rising costs of medical care in the United States and Mexico's

geographical proximity (Brenan2023; Maniam2015), the num-

ber of Americans travelling to Mexico for medical and pharma-

ceutical purposes is increasing (Grunebaum 2022). American

tourists also have a long history of buying prescription- only

pharmaceuticals for medical and non- medical purposes

without prescription orders at Mexican pharmacies (Wirtz

etal.2009). The widespread sale of prescription- only medicines

without prescriptions is dangerous, and this risk has recently

escalated. Consumers now face a significant risk of encounter-

ing fentanyl- based counterfeit pharmaceuticals at pharmacies

(Bonello2023a).

Mexican cartels are manufacturing large quantities of fentanyl-

based counterfeit pharmaceuticals and supplying them to

pharmacies throughout Mexico (Blakinger, Brittny, and Sheets

2023; Sheets and Blakinger2023a). Fentanyl is mixed with filler

substances and pressed into tablets to resemble legitimate pre-

scription drugs. Counterfeit oxycodone, hydrocodone, Vicodin,

Percocet, and other prescription medicines laced with fentanyl

are dispensed without prescriptions at pharmacies from Tijuana

and northern border areas to the southern tip of Mexico, with a

ResearchGate has not been able to resolve any citations for this publication.

Strengthening pill press control to combat fentanyl: Legislative and law enforcement imperatives

Article

Full-text available

Aug 2023

Nicholas Lassi

Background: Fentanyl has garnered significant focus from governments, academics, and the media due to the unparalleled increase in overdose fatalities it has triggered in North America. However, the pill presses, dies, and molds used to tablet counterfeit fentanyl-laced pills in Mexico and the United States (U.S.) have gone largely unstudied despite their substantial influence on fentanyl production. The Biden-Harris administration's recent initiative to intensify the prosecution of illicit fentanyl supply chains and the U.S. Treasury Department's decision to impose sanctions on numerous Chinese entities for illicit pill press production and distribution highlights the need to increase controls on pill-press proliferation. Objective: Review the existing legislative frameworks and enforcement in the U.S., China, and Mexico that pertain to pill press control and provide recommendations for improvement. Methods: A literature review was conducted to gather information on counterfeit fentanyl-laced pill production, pill press control, and related legislative frameworks and enforcement in the U.S., China, and Mexico. Federal and state laws, policies, and enforcement mechanisms were reviewed to identify gaps, limitations, and potential for improvement. A comparative study was then performed to determine the strengths and weaknesses of these states' prevailing legislative structures and enforcement mechanisms. Results: In the U.S., pill press laws at the federal level are limited, and state laws are generally weak or nonexistent. The U.S. Controlled Substances Act should be amended to include harsher penalties for the unregistered possession of pill presses with or without the intent to tablet illicit substances. China, the primary source of illicitly distributed pill presses, does not have laws regulating pill presses and should enact strong pill press legislation and engage in rigorous enforcement. Conclusions: As pill presses are integral to the final and crucial step in counterfeit fentanyl-laced pill production, pill press control should receive more legislative and law enforcement attention in the U.S., China, and Mexico.

Fentanyl, Heroin, and Methamphetamine-Based Counterfeit Pills Sold at Tourist-Oriented Pharmacies in Mexico: An Ethnographic and Drug Checking Study

Preprint

Full-text available

Jan 2023

Background Our ethnographic team has conducted longitudinal research focused on illicit drug markets in Northern Mexico since 2018. In 2021-2022, study participants described the arrival of new, unusually potent tablets sold as ostensibly controlled substances, without a prescription, directly from pharmacies that cater to US tourists. Concurrently, fentanyl- and methamphetamine-based counterfeit prescription drugs have driven escalating overdose death rates in the US, however their presence in Mexico has not been assessed. Aims To characterize the availability of counterfeit and authentic controlled substances at pharmacies in Northern Mexico available to English-speaking tourists without a prescription. Methods We employed an iterative, exploratory, mixed methods design. Longitudinal ethnographic data were used to characterize tourist-oriented micro-neighborhoods and guide the selection of n=40 pharmacies in n=4 cities in Northern Mexico. In each pharmacy, samples of 'oxycodone', 'Xanax', and 'Adderall' were sought as single pills, during English-language encounters, after which detailed ethnographic accounts were recorded. We employed immunoassay-based testing strips to check each pill for the presence of fentanyls, benzodiazepines, amphetamines, and methamphetamines. We used Fourier-Transform Infrared Spectroscopy to further characterize drug contents. Results Of 40 pharmacies, these controlled substances could be obtained in any form with no prescription at 68.3% and as single pills at 46.3%. Counterfeit pills were obtained at n=11 (26.8%) of pharmacies. Of n=45 samples sold as one-off controlled substances, n=20 were counterfeit including 9 of 11 (81.8%) of samples sold as 'Adderall' that contained methamphetamine, and 8 of 27 (29.6%) of samples sold as 'Oxycodone' that contained fentanyl, and n=3 'Oxycodone' samples containing heroin. Pharmacies providing counterfeit drugs were uniformly located in tourist-serving micro-neighborhoods, and generally featured English-language advertisements for erectile dysfunction medications and 'painkillers'. Pharmacy employees occasionally expressed concern about overdose risk and provided harm reduction guidance. Discussion The availability of fentanyl-, heroin-, and methamphetamine-based counterfeit medications in Northern Mexico represents a public health risk, and occurs in the context of 1) the normalization of medical tourism as a response to rising unaffordability of healthcare in the US, 2) plummeting rates of opioid prescription in the US, affecting both chronic pain patients and the availability of legitimate pharmaceuticals on the unregulated market, 3) the rise of fentanyl-based counterfeit opioids as a key driver of the fourth, and deadliest-to-date, wave of the opioid crisis. It is not possible to distinguish counterfeit medications based on appearance, because identically-appearing authentic and counterfeit versions are often sold in close geographic proximity. Nevertheless, US tourist drug consumers may be more trusting of controlled substances purchased directly from pharmacies. Due to Mexico's limited opioid overdose surveillance infrastructure, the current death rate from these substances remains unknown.

Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Philadelphia, Pennsylvania, USA

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Xylazine, an alpha-2 adrenergic receptor agonist typically used as a sedative and analgesic in veterinary medicine, is being illicitly supplied to persons who inject drugs (PWID), especially in Puerto Rico and Philadelphia, Pennsylvania in the USA. There is a high prevalence (up to 78%) of xylazine in fentanyl in these areas and also a steep increase in fatalities from its overdose. In this case report, we discuss a case of xylazine-induced skin ulcers in a PWID in the city of Philadelphia. The patient is a 37-year-old female who was injecting about eight to ten "bags" of "dope" (fentanyl, which is typically mixed with xylazine in Philadelphia) every day. She typically injected into her veins on the hands and sometimes into the legs. She presented with ulcers on her lower extremities extending from the knees to ankles, associated with copious purulent drainage and a foul smell. There was extensive necrosis of the subcutaneous tissues, abscesses, and tibial osteomyelitis. This led to multiple hospitalizations with bacteremia from Strep pyogenes, methicillin-resistant Staphylococcus aureus, methicillin-sensitive S. aureus, Enterococcus faecalis, Escherichia coli, and Proteus requiring intravenous antibiotics. She required debridement of the wounds and topical care to treat them. In the areas with a high prevalence of the use of xylazine mixed with fentanyl or heroin, abscesses, and painful skin ulcers are very often reported. The mechanism is thought to be due to its direct vasoconstricting effect on local blood vessels and the resultant decreased skin perfusion. Prolonged use can lead to decreased perfusion and impaired wound healing, leading to higher chances of infection of these ulcers. In addition to the topical effect of vasoconstriction, xylazine also leads to hypotension, bradycardia, and respiratory depression. A skin ulcer in a PWID, similar to the ones reported in our case, should raise clinical suspicion for the presence of xylazine in opiates and other substances.

Geographic distribution of risk ("Hotspots") for HIV, HCV, and drug overdose among persons who use drugs in New York City: The importance of local history

Article

Full-text available

Sep 2019

Aims: To identify geographic "hotspots" for potential transmission of HIV and HCV and for drug overdose among persons who use heroin and cocaine in New York City and to examine historical continuities in problem drug use hotspots in the city. Methods: A total of 2714 study participants were recruited among persons entering Beth Israel substance use treatment programs. A structured questionnaire was administered and blood samples for HIV and HCV testing were collected. Hotspots for potential virus transmission were defined as ZIP codes with 10+ participants, 2+ persons infected with the virus and engaging in transmission behavior, and 2+ persons not infected and engaging in acquisition behavior. ZIP codes with 3+ persons with previous overdoses were considered potential hotspots for future overdoses. Results: Participants resided in 166/178 (93%) of the ZIP codes in New York City. Injecting drug use was reported in 150/178 (84%) of the ZIP codes. No zip codes were identified for injecting-related HIV transmission, 5 zip codes were identified for sexual HIV transmission, 3 for HCV transmission, and 8 for drug overdose. Many of the ZIP code potential hotspots were in neighborhoods long associated with drug use: Lower Eastside and Harlem in Manhattan, the South Bronx, and Central Brooklyn. Discussion: Heroin and cocaine use requiring treatment were reported from almost all ZIP codes in New York City, indicating needs for widely dispersed harm reduction services. Identified hotspots should be targeted for reducing sexual transmission of HIV, transmission of HCV, and drug overdoses. Some of the hotspots have persisted as problem drug use areas for 40 to over 100 years. Monitoring of drug use patterns in historical hotspot neighborhoods may permit early identification of and response to emerging drug use-related health problems. Persistent historical hotspots for problem drug use present a complex problem for implementing harm reduction services that deserve additional research.

Preference for drugs containing fentanyl from a cross-sectional survey of people who use illicit opioids in three United States cities

Article

Full-text available

Aug 2019
DRUG ALCOHOL DEPEN

Background: Death from fentanyl-related overdose is now a leading cause of mortality among US adults. We sought to characterize fentanyl preference among street-based people who use drugs (PWUD). Methods: Cross-sectional surveys were administered to PWUD (N = 308) who illicitly used heroin or prescription opioids in the prior six months. Recruitment occurred in 2017 in three US east coast cities with high overdose mortality: Baltimore, Boston, and Providence. Our main outcome was preference for fentanyl (yes/no); exposures included sociodemographics, drug use, and overdose history. Pearson's χ2, Shapiro-Wilk-Mann rank-sum tests, and tiered log-binomial regression determined sociodemographic and exposure-related factors associated with fentanyl preference. Results: Preference for nonmedical use of fentanyl was reported by 27% (n = 83) of the sample. Fentanyl preference was associated with non-Hispanic white race (adjusted risk ratio (ARR) = 1.68, 95% confidence interval (CI):1.18-2.40), daily illicit drug use (aRR = 2.2, CI:1.71-2.87), and overdose ≥1 year ago (aRR = 1.33, CI:1.18-1.50). Age (in decades; aRR = 0.77, CI:0.61-0.98) and overdose <1 year ago (aRR = 0.92, CI:0.87-0.97) were associated with a decreased likelihood of preference. In our model excluding sociodemographics, initiating opioid use with non-prescribed opioids was associated with fentanyl preference (aRR = 1.48, CI:1.26-1.73). Conclusion: In three cities with high levels of opioid use and overdose, a quarter of street based PWUD reported preferring fentanyl. An opioid use age cohort effect and disproportionate access to prescription opioids by race could be contributing to preference. Frequency of opioid use, not route of administration, was associated with preference. Our data demonstrate the need to consider preferences for fentanyl when targeting services and interventions for PWUD.

Opium Poppy Detection Using Deep Learning

Article

Full-text available

Nov 2018

Opium poppies are a major source of traditional drugs, which are not only harmful to physical and mental health, but also threaten the economy and society. Monitoring poppy cultivation in key regions through remote sensing is therefore a crucial task; the location coordinates of poppy parcels represent particularly important information for their eradication by local governments. We propose a new methodology based on deep learning target detection to identify the location of poppy parcels and map their spatial distribution. We first make six training datasets with different band combinations and slide window sizes using two ZiYuan3 (ZY3) remote sensing images and separately train the single shot multibox detector (SSD) model. Then, we choose the best model and test its performance using 225 km2 verification images from Lao People’s Democratic Republic (Lao PDR), which exhibits a precision of 95% for a recall of 85%. The speed of our method is 4.5 km2/s on 1080TI Graphics Processing Unit (GPU). This study is the first attempt to monitor opium poppies with the deep learning method and achieve a high recognition rate. Our method does not require manual feature extraction and provides an alternative way to rapidly obtain the exact location coordinates of opium poppy cultivation patches.

Fentanyl, Heroin, and Methamphetamine-Based Counterfeit Pills Sold at Tourist-Oriented Pharmacies in Mexico: An Ethnographic and Drug Checking Study

Article

Jun 2023
DRUG ALCOHOL DEPEN

Background: Fentanyl- and methamphetamine-based counterfeit prescription drugs have driven escalating overdose death rates in the US, however their presence in Mexico has not been assessed. Our ethnographic team has conducted longitudinal research focused on illicit drug markets in Northern Mexico since 2018. In 2021-2022, study participants described the arrival of new, unusually potent tablets sold as ostensibly controlled substances, without a prescription, directly from pharmacies that cater to US tourists. Aims: To characterize the availability of counterfeit and authentic controlled substances at pharmacies in Northern Mexico available to English-speaking tourists without a prescription. Methods: We employed an iterative, exploratory, mixed methods design. Longitudinal ethnographic data was used to characterize tourist-oriented micro-neighborhoods and guide the selection of n=40 pharmacies in n=4 cities in Northern Mexico. In each pharmacy, samples of "oxycodone", "Xanax", and "Adderall" were sought as single pills, during English-language encounters, after which detailed ethnographic accounts were recorded. We employed immunoassay-based testing strips to check each pill for the presence of fentanyls, benzodiazepines, amphetamines, and methamphetamines. We used Fourier-Transform Infrared Spectroscopy to further characterize drug contents. Results: Of n=40 pharmacies, one or more of the requested controlled substances could be obtained with no prescription (as single pills or in bottles) at 28 (70.0%) and as single pills at 19 (47.5%). Counterfeit pills were obtained at 11 pharmacies (27.5%). Of n=45 samples sold as one-off controlled substances, 18 were counterfeit. 7 of 11 (63.6%) samples sold as "Adderall" contained methamphetamine, 8 of 27 (29.6%) samples sold as "Oxycodone" contained fentanyl, and 3 "Oxycodone" samples contained heroin. Pharmacies providing counterfeit drugs were uniformly located in tourist-serving micro-neighborhoods, and generally featured English-language advertisements for erectile dysfunction medications and "painkillers". Pharmacy employees occasionally expressed concern about overdose risk and provided harm reduction guidance. Discussion: The availability of fentanyl-, heroin-, and methamphetamine-based counterfeit medications in tourist-oriented independent pharmacies in Northern Mexico represents a public health risk, and occurs in the context of 1) the normalization of medical tourism as a response to rising unaffordability of healthcare in the US, 2) plummeting rates of opioid prescription in the US, affecting both chronic pain patients and the availability of legitimate pharmaceuticals on the unregulated market, 3) the rise of fentanyl-based counterfeit opioids as a key driver of the fourth, and deadliest-to-date, wave of the opioid crisis. It was not possible to distinguish counterfeit medications based on appearance of pills or geography of pharmacies, because identically-appearing authentic and counterfeit versions were often sold in close geographic proximity. Nevertheless, people who consume drugs may be more trusting of controlled substances purchased directly from pharmacies. Due to Mexico's limited opioid overdose surveillance infrastructure, the current death rate from these substances remains unknown.

Using Timely Overdose Data to Address a Spike in Nonfatal Overdoses and Inform a Coordinated Community-Level Response in Rhode Island, 2019

Article

Nov 2021

The Rhode Island Department of Health (RIDOH) uses emergency department data to monitor nonfatal opioid overdoses in Rhode Island. In April 2019, RIDOH detected an increase in nonfatal opioid overdoses in Woonsocket, Rhode Island, and sent an alert to state and local partners (eg, fire departments, emergency departments, faith leaders) with guidance on how to respond. To guide community-level, strategic response efforts, RIDOH analyzed surveillance data to identify overdose patterns, populations, and geographic areas most affected. During April–June 2019, nonfatal opioid overdoses in Woonsocket increased 463% (from 13 to 73) when compared with the previous 3 months. Because of the sustained increase in nonfatal opioid overdoses, RIDOH brought together community partners at a meeting in June 2019 to discuss RIDOH opioid overdose data and coordinate next steps. Data analyses were essential to framing the discussion and allowed community partners at the event to identify an unexpected increase in cocaine-involved nonfatal opioid overdoses in Woonsocket. Many patients with cocaine-involved nonfatal overdoses also had fentanyl in their system, and input from community partners suggested that many patients were unaware of using fentanyl. Community response actions included targeting harm reduction services (eg, distribution of naloxone, mobile needle exchange); deploying peer recovery support specialists to overdose hotspots to connect people to treatment and recovery resources; placing harm reduction messaging in high-traffic areas; and targeted social media messaging. After the meeting, nonfatal opioid overdoses returned to pre-outbreak levels. This case study provides an example of how timely opioid overdose data can be effectively used to detect a spike in nonfatal opioid overdoses and inform a strategic, community-level response.

Population-based surveillance of medical tourism among US residents from 11 states and territories: Findings from the Behavioral Risk Factor Surveillance System

Article

Jul 2021

Objective To describe medical tourism among a subset of US residents; identify possible indicators for medical tourism. Methods The US Centers for Disease Control and Prevention collaborated with 11 states and territories to ask 6 questions about medical tourism, using the Behavioral Risk Factor Surveillance System. Data collected from January 1, 2016, through December 31, 2016, included whether respondents traveled internationally for preplanned care, travel reasons and destinations, procedures received, and occurrence and treatment of complications. A descriptive analysis of demographics, socioeconomic status and health access variables was performed, and a regression model with a log-link function and Poisson distribution was used to estimate prevalence ratios (PR) for medical tourism. Results Of 93,492 respondents, 517 (0.55%) traveled internationally during the previous year for care. Mexico was the most common destination (41% of trips). Dentistry accounted for 55% of treatments. Complications from care received abroad were reported by 5% of medical tourists; 67% sought care upon returning to the United States. The prevalence of medical tourism was 1.32% (95% CI, 1.00–1.64). The prevalence of medical tourism was higher in Hispanics and non-whites (PR, 3.97; 95% CI, 2.48–6.32) and higher among those without current health insurance (PR, 2.70; 95% CI, 1.69–4.34). Conclusions This is the largest collection of population-based surveillance data describing medical tourism among US residents from multiple states and territories. Understanding the demographic and socioeconomic factors associated with medical tourism can inform evidence-based recommendations for travelers and clinicians who may advise or care for these individuals before, during, or after travel.

Increasing presence of xylazine in heroin and/or fentanyl deaths, Philadelphia, Pennsylvania, 2010–2019

Article

Feb 2021

Reports from active drug users state that xylazine, the veterinary tranquilliser, has been increasing in the illicit drug supply in Philadelphia. To describe trends and characteristics of unintentional deaths from heroin and/or fentanyl overdose with xylazine detections occurring in Philadelphia, Pennsylvania, the Philadelphia Department of Public Health analysed data on deaths from unintentional heroin and/or fentanyl overdose from the Philadelphia Medical Examiner’s Office over a 10-year period (2010–2019). Xylazine went from being detected in less than 2% cases of fatal heroin and/or fentanyl overdose between 2010 and 2015 to 262 (31%) of the 858 fatal heroin and/or fentanyl overdose cases in 2019. Currently, information is limited on the presence of xylazine in continental United States. Xylazine’s association with adverse outcomes in other locations indicates that potential health consequences should also be monitored in the USA. Whenever possible, jurisdictions should consistently test for xylazine.

The Threat of Fentanyl‐Based Counterfeits in Mexican Pharmacies: Addressing a Growing Public Health Crisis

Abstract

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