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Overdose deaths in North America have soared, primarily because of the spread of illegally manufactured fentanyl. This paper uses detailed qualitative and transaction-level data to analyse an early and prominent dark web fentanyl-selling operation. The data record the date, drug, quantity, and selling price for 5,589 transactions comprising 872,659 items sold for a little over $2.8 million through AlphaBay. Findings include that the organisation sustained an impressive sales growth rate of approximately 15% per week, compounded. Increasing order sizes by a factor of ten reduced the price per pill by approximately 25% for Oxycodone and 50% for Xanax. Those steep quantity discounts imply large price markups when selling further down the distribution chain. Such high growth rates and price markups suggest that it might be difficult to constrain supply by shutting down individual organisations, since any remaining organisations may be able to quickly grow to fill unmet demand. [ABSTRACT FROM AUTHOR]

Objectives: The United States faces an ongoing drug overdose crisis, but accurate information on the prevalence of opioid use disorder (OUD) remains limited. A recent analysis by Keyes et al used a multiplier approach with drug poisoning mortality data to estimate OUD prevalence. Although insightful, this approach made stringent and partly inconsistent assumptions in interpreting mortality data, particularly synthetic opioid (SO)-involved and non-opioid-involved mortality. We revise that approach and resulting estimates to resolve inconsistencies and examine several alternative assumptions., Methods: We examine 4 adjustments to Keyes and colleagues' estimation approach: (A) revising how the equations account for SO effects on mortality, (B) incorporating fentanyl prevalence data to inform estimates of SO lethality, (C) using opioid-involved drug poisoning data to estimate a plausible range for OUD prevalence, and (D) adjusting mortality data to account for underreporting of opioid involvement., Results: Revising the estimation equation and SO lethality effect (adj. A and B) while using Keyes and colleagues' original assumption that people with OUD account for all fatal drug poisonings yields slightly higher estimates, with OUD population reaching 9.3 million in 2016 before declining to 7.6 million by 2019. Using only opioid-involved drug poisoning data (adj. C and D) provides a lower range, peaking at 6.4 million in 2014-2015 and declining to 3.8 million in 2019., Conclusions: The revised estimation equation presented is feasible and addresses limitations of the earlier method and hence should be used in future estimations. Alternative assumptions around drug poisoning data can also provide a plausible range of estimates for OUD population., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 American Society of Addiction Medicine.)