Abstract
Synthetic illicit drugs, such as nitazenes and fentanyls, are becoming commonplace in countries around the world, including in Europe, Australia, and Latin America, which raises concern for overdose crises like those seen in North America. An important dimension of the risk represented by synthetic drugs is the fact that they are increasingly packaged in counterfeit pill form. These pills-often indistinguishable from authentic pharmaceuticals-have substantially widened the scope of populations susceptible to synthetic drug overdose in North America (eg, among adolescents experimenting with pills or tourists from the USA seeking psychoactive medications from pharmacies in Mexico). The non-medical use of diverted prescription medications is relatively more common, and less stigmatised, than the use of powder drugs. Many consumers of counterfeit pills are unaware that they contain synthetic illicit drugs, believe them to be authentic pharmaceuticals, and would be unlikely to consume those drugs knowingly or if in powder form. Given these issues, we recommend the expansion of educational and awareness campaigns, pill testing programmes to help consumers shift demand to safer products, increased monitoring in routine clinical scenarios and overdose death toxicology, and expanding medically managed safer alternatives to counterfeit pill use.