By Dr. Leeds, osteopathic physician and deprescribing specialist.
Are these oxycodone pills real, or are they fake pills?
If you have pills in front of you that came from somewhere other than a pharmacy, and you are wondering whether they are real, the honest answer is that you cannot tell by looking, and neither can I. The blue oxycodone 30s, the Percocets, the Xanax bars, and even Suboxone films are being counterfeited, and the fakes are made to pass inspection.
For years, people who used opioids believed that prescription pills were the safe choice, because a tablet from a pharmaceutical company contained exactly what the imprint promised. That belief was reasonable once. Unfortunately, it is now false.
A pressed pill that looks like a 30 mg oxycodone tablet may contain no oxycodone at all. These are fentanyl pills, whatever the imprint says, and the dose was measured by nobody and varies from one pill to the next.
Are the blues in your hand real? Would you know if they were not? And, if they are fentanyl, what happens on the day the dose in the pill is a little higher than the last one?
The blue oxycodone 30s are the most faked pill in America.
Oxycodone 30 mg tablets, known on the street as roxies, blues, or M30s, are the small blue pills with an M on one side and a 30 on the other. They were the most sought-after pill because they were pharmaceutical grade, and for the same reason they became the most counterfeited, fentanyl and filler pressed into the shape of the real thing.
While the M30 came first, it was only the beginning. Percocet is faked. Xanax, or alprazolam, is faked, and a fake bar may contain fentanyl, because that is what the press had on hand. Adderall, the stimulant for attention deficit disorder, is faked.
In fact, there are fake films sold as Suboxone, the buprenorphine medication used to treat opioid dependence, and fake tablets sold as Subutex, the old buprenorphine-only brand. When you are sick with withdrawal, a fake Subutex made of fentanyl will take the sickness away, along with doing everything else that fentanyl does.
And, crushing and snorting any opioid pill, real or fake, sold as an oxycodone 30 or as Nucynta, rushes the drug into the blood and brings an overdose closer.
Why fentanyl, in so many of these? Follow the money. A small amount of fentanyl makes a very large number of pills, and each one sells for the price of real oxycodone.
Fake Xanax, and every other street drug, carries the same risk.
The counterfeit pill problem is not an opioid problem. The Drug Enforcement Administration has warned for years about pressed pills sold as Xanax, Adderall, and Percocet that contain fentanyl, and a person who buys “Xanax” on the street because a prescriber cut them off, or because a taper felt too slow, is taking exactly the chance an oxycodone buyer takes. For someone whose body has never met an opioid, that chance is worse, not better.
Powders carry it too. Cocaine, crack, and methamphetamine have turned up with fentanyl in them in overdose deaths across the country, in people who never meant to take an opioid and had no tolerance for one. And, while reports of fentanyl in cannabis are rare and mostly unconfirmed, the rule does not change: nothing bought outside a pharmacy can be assumed clean, and a test strip or a lab is the only way to know.
So, this article says pills, and it means pills, but read it as every drug bought on the street. The danger is the supply, not the label on the bag.
Why can’t you tell a fake pill by looking at it?
Articles online offer checklists for spotting fake pills: the imprint, the color, the score line, the edges. I believe these checklists do more harm than good, because they teach you that a pill which passes is safe.
An analogy that might help is the rubber stamp. A stamp that says PAID prints PAID on whatever paper is under it, whether the bill was paid or not, and a die that says M30 presses M30 into whatever powder is in the hopper.
While this is not a perfect analogy, it makes the point. The imprint tells you which stamp was used, not what happened to the bill, and not what is in the pill.
Then there is the dealer’s story, that the pills came from a relative’s prescription or a sick uncle with a bad back. Every dealer in Florida seems to have an uncle with a bad back and a very generous prescription, and the dealer may believe it, because the supplier above them switched to pressed pills without saying so.
So, treat the imprint as the stamp, never as the receipt. If the pill did not come from a pharmacy, assume that it contains fentanyl or something like it, not because every pill does, but because the ones that do look exactly like the ones that do not.
What have I seen in my own office?
I do not have to rely on news stories for this. Patients come to me for buprenorphine treatment after using what they were sure were oxycodone tablets, bought from one trusted source and nothing else. A pattern I have seen more than once is that the drug screen shows fentanyl and no oxycodone at all.
Did these patients know? They did not. They would have told you, with complete confidence, that they had never touched fentanyl, and in weeks or months of taking it the pill had never once looked or felt wrong to them.
An earlier article of mine said that if you are used to oxycodone, you will know the difference when a pill is fentanyl. I was wrong to write that, and it is gone. People do not know the difference. Very often, the first sign that the pill was fentanyl is the overdose.
Should you test your pills for fentanyl?
Fentanyl test strips are cheap, and if you are going to take a pill from the street anyway, testing it is better than not. A positive strip means fentanyl is present, and the pill and every pill bought with it should be thrown away.
Yet, a negative strip is not a safe pill, because fentanyl strips detect fentanyl and some of its close relatives and miss others. Nitazenes, a family of synthetic opioids that can be stronger than fentanyl, do not show up on a fentanyl strip. And, xylazine, the veterinary sedative now in much of the supply, is not an opioid at all, and naloxone is not expected to reverse it, which is one more reason to give the spray and call 911 anyway.
This is why I suggest testing for two things, the fentanyl and the drug the pill is supposed to be. Why test for the oxycodone too? Because a pill that is negative for both is made of something the strip cannot see, and if it is positive for both, the oxycodone was not the point.
Testing is harm reduction, and harm reduction means protecting a person until they can get out of harm’s way. It is not a guarantee.
The heroin supply is no longer heroin.
Fake pills are half of the story. The other half is that what is sold as heroin is, in much of the country, a synthetic opioid and no heroin at all, and the same lottery applies to every bag.
The mixtures have had names. Gray death, seized in Georgia and Alabama in 2017, was a gray, concrete-looking mix of heroin, fentanyl, and other synthetic opioids, and Pink, or U-47700, was a research chemical pressed into fake oxycodone tablets.
Carfentanil, a tranquilizer made for large animals, made the headlines that same year, went quiet for several years, and has been turning up in overdose deaths again since 2024. Benzodiazepines are sometimes in the mix as well, and naloxone does nothing for the benzodiazepine.
Is any of this new? Not really. While the story we hear is that doctors overprescribed pain pills and then fentanyl arrived from overseas, synthetic fentanyl analogs have been cycling into the American heroin supply since the late 1970s.
The name China White originally meant heroin from Southeast Asia, and more than forty years ago a home-made fentanyl analog was already being sold under that name in California to people who thought they were buying heroin. The deaths come from that illicit supply, not from hospital fentanyl and not, for the most part, from prescriptions, which have been falling for more than a decade while the deaths rose for years afterward.
So, alongside interdiction, the answer is sterile syringes, test strips, naloxone in every pocket, and buprenorphine treatment a person can start this week. Keeping people alive comes first.
Overdoses from these mixtures may need more than one dose of naloxone.
There is a rumor that some of these drugs are Narcan-resistant. No opioid is resistant to naloxone, the drug in Narcan. What is true is that a very potent or long-lasting opioid may need a second dose, or a third, and that a person may slip back under when the first dose wears off.
Does that mean the spray failed? No. It means the opioid outlasted the first dose, so give the spray, call 911, and if there is no response after two or three minutes, give another dose in the other nostril.
Never let the word “resistant” talk you out of using it. Naloxone nasal spray has been sold without a prescription since 2023, and every household where opioids are used should have it. And, touching fentanyl does not cause an overdose, so nobody should hesitate to check on a person who has collapsed and give the spray.
Tests mislead the same way. A standard urine panel misses most novel synthetic opioids, so a person with pinpoint pupils who is barely breathing and cannot be woken has an opioid overdose until proven otherwise, whatever a test says.
In the early 1980s in California, a home-made meperidine analog contaminated with a chemical called MPTP left the young people who injected it with permanent parkinsonism, the same disability as Parkinson’s disease, within days. Nobody predicted it, and a new synthetic opioid can carry a harm that nobody knows about until the first patients arrive.
Never use alone, and never let someone else use alone. If you are with a person who has taken a pill or a powder from the street, call 911 or get them to an emergency room if:
- They cannot be woken by shouting or by rubbing hard on their breastbone.
- Their breathing is slow, shallow, gurgling, or has stopped.
- Their lips, fingertips, or face are turning blue or gray.
- They came around after naloxone and are starting to fade again.
While you wait, give naloxone if you have it, stay with them, and turn them on their side if they are breathing but cannot stay awake. Do not wait to see whether they come around on their own.
If any of this has left you, or the person you love, feeling that there is no way out, call or text 988, the Suicide and Crisis Lifeline, at any hour. Using alone because you have stopped caring what happens is a crisis too.
Why does street fentanyl make starting buprenorphine harder?
In the operating room, fentanyl is a short-acting drug, and a single dose wears off within an hour. Street fentanyl, taken many times a day for months, behaves differently, and patients describe being sick for longer than they ever were with oxycodone, which is why fentanyl withdrawal is so bad.
I do not know the whole reason. One theory is that fentanyl stores in fat tissue with heavy daily use and leaks back out for days after the last dose, so the drug is still on the receptors long after a person feels that they are in full withdrawal.
Buprenorphine holds the opioid receptor tightly and activates it only partway. If it arrives while fentanyl is still on the receptors, it pushes the fentanyl off and drops the person into precipitated withdrawal, which is withdrawal all at once. While waiting until withdrawal had clearly started was enough with oxycodone or heroin, a person coming off of street fentanyl can wait the usual time, feel terrible, and still go into precipitated withdrawal.
Fortunately, there is a way around it. Starting with very small doses of buprenorphine, repeated over several days while the fentanyl fades, lets the medication take over gradually. This is low-dose initiation, also known as the Bernese method, and it is an argument for a doctor who has done it many times, not against starting.
What can a family do when someone is not ready to stop?
Most people who use opioids are, at any given moment, not ready to quit. That is where they are, not a character flaw, and the family’s job in that moment is to keep the person alive until they are ready.
While tough love, meaning throwing someone out with nothing, feels like doing something, it is not treatment, and it puts the person you love in more danger. Harm reduction is what you can do instead.
Keep naloxone in the house and make sure everyone knows where it is. Buy fentanyl test strips and hand them over without a lecture. If injection is involved, sterile syringes prevent the infections that kill people slowly. None of this is helping someone to use drugs. It is helping them to survive.
Surprisingly, an overdose death can make a batch more attractive on the street, because word gets around that it is strong. That is why education matters more than warnings.
And, there is a reason to hang on. In my experience, people very often grow out of addiction, if they are kept alive long enough to do it. Nobody grows out of anything after an overdose.
There are no safe solutions on the street.
Every few months, a patient asks me about something they found outside of medicine. Kratom, which acts on opioid receptors and which I recommend avoiding. Ibogaine, and a list of plant remedies that have never been standardized or approved for this purpose. Diverted Suboxone from a dealer, real or fake.
I understand the impulse. Yet, a product that has never been standardized cannot be dosed, and a pill that came from a dealer cannot be trusted. The treatments that work today come from a pharmacy.
Buying Suboxone on the street deserves its own paragraph, because I know why people do it. A strip from a dealer may be a fentanyl fake, and even a real one comes with no doctor, no plan, and no way off of it. Buprenorphine is an excellent medication, and it is not a street solution.
Fake pills contain fentanyl, and fentanyl dependence is treatable.
If you have been taking fake pills, then you have been taking fentanyl, and stopping suddenly will bring on fentanyl withdrawal. Physical dependence is not addiction. It is a medical condition, and the treatment for a medical condition is medical, not a lesson and not a punishment.
The two opioid medications with a long record for opioid dependence are buprenorphine and methadone. While methadone is dispensed daily at a clinic, at least at first, buprenorphine can be started at home under a doctor’s guidance, which is why it is the medication I use for fentanyl dependence and addiction in my own practice.
Is that trading one addiction for another? It is not. Each treats opioid dependence, and neither causes it. What patients notice first, usually within days, is that the obsession lets go.
Of course, once the medication comes from a pharmacy, the question of whether a pill is real stops mattering, because there are no more pills. The best time to get out of this supply was before fentanyl got into it. The next best time is right now, and you can ask for help today.
Dr. Leeds treats fentanyl dependence with buprenorphine by telemedicine.
Dr. Leeds provides buprenorphine treatment with Suboxone and its film and tablet generics to new patients throughout Florida by telemedicine, with in-office visits available in Fort Lauderdale. Induction is done at home with phone support, and when fentanyl is involved, treatment usually begins with a low-dose initiation.
Care is one-on-one and patient directed, never on a deadline, and Dr. Leeds can discuss methadone and the long-acting buprenorphine injections in a consultation.
If you or someone you love has been taking pills from the street, contact Dr. Leeds through the contact form to ask about opioid dependence treatment.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
