PROVINCETOWN — Seventy-nine residents of Barnstable County died of opioid overdoses in 2021. That’s three more than in 2020 and marks the second-worst year on record after 2016, when 81 died, according to the state Dept. of Public Health.

The state’s 2021 overdose rate went up 8.8 percent from the year before, grimly marking it as Massachusetts’s worst year ever for overdose deaths.

In the last several years, according to addiction experts, the supply of opioids, other street drugs, and even so-called prescription medications has become completely unpredictable, which has contributed to the nation’s increase in overdose deaths.

This is not only because opiates and other substances more frequently contain fentanyl, a synthetic opioid 50 to 100 times more powerful than morphine, but also because there are varying amounts of fentanyl in each product, said Dr. Ruth Potee, a board-certified family physician and addiction medicine physician who works in Western Massachusetts.

“It’s just a really toxic, unpredictable supply chain,” Potee said. “What an individual might purchase on a Monday from the same source, in the same stamped bag, on a Tuesday is 92 percent different than it was on a Monday. And it might be more toxic.”

Kim Powers, who runs a Cape-wide mobile harm reduction operation to bring needles, fentanyl test strips, and supervision to active drug users, agreed.

“The drug market is horrible, poisonous and contaminated,” she said on June 24. “We need to know what is in the drug supply.” (Powers’s work on harm reduction for drug users was described in a report in the Sept. 2, 2021 issue of the Independent.)

Xylazine, a horse tranquilizer, has been found in dope moving up the East Coast, Powers said. It doesn’t respond to the opioid overdose medication naloxone and “it’s a horror show with infections and abscesses,” Powers said.

Another deadly factor in this new phase of the opioid epidemic is the proliferation of fake pills containing fentanyl that are sold to new and young users. Such sales occur on the “dark web,” Powers said.

“A single use of a single pill will kill you,” Potee said. “And that’s a whole new problem that a harm reduction site can’t fix.”

Potee emphasized the need for public health messaging “everywhere,” including classrooms and on highway billboards.

“It should be taught at every level, starting at the sixth grade or even below that,” Potee said. “Because it’s often kids or young people that are getting exposed. The message that needs to get out to everybody is don’t take a pill from anybody, anywhere,” Potee said.

Staff at the AIDS Support Group of Cape Cod told the Independent that they have changed their messaging and outreach in the last several years to reflect the broader population affected by fentanyl in party drugs such as MDMA and methamphetamine.

“Fentanyl is making its way into all substances,” said Eliza Morrison, a program manager for several of the ASGCC sites. “Our agency’s aim of late is not so much to focus on people who are using opiates — it’s people who are using any substance.”

Potee is advocating two methods to help those who regularly use opioids. The first is expanding access to treatment.

“Treatment really helps people,” Potee said. “And even if it doesn’t make you perfect, even if it doesn’t change your use to zero, it can be very protective against death.”

There are two medications used to treat opioid use disorder: methadone, which under federal regulations can be obtained only from a licensed methadone clinic, and buprenorphine (also known as suboxone), which can be obtained at a pharmacy with a prescription.

According to Potee, methadone is the more effective treatment: “What we know about the fentanyl era is that buprenorphine, or suboxone, isn’t working as well. It just isn’t strong enough to meet the fentanyl need.

“The regulations on methadone need to be examined and deconstructed, not in 10 years, not in 5 years, but it needs to happen in the next three to six months,” Potee continued. “Until methadone is available at the pharmacy, people will continue to not be able to access one of the most effective treatments.”

Users seeking methadone treatment must go to a methadone clinic daily to receive their dose. Currently there are no methadone clinics on the Outer Cape; the nearest one is in Yarmouth.

“When I look at the state, I spend a lot of days worrying about the Cape,” Potee said. “Because that treatment should be available there and it should be made easier to get it there, because people need it.”

The ASGCC has focused on the more reactive strategy of reversing overdoses after they occur. “Our job is to go out in the community and make sure people are prepared in case they do have to address something like an overdose,” said Morrison. “We focus really heavily on getting Narcan into the community and into the hands of businesses and seasonal workers. That’s really important because there have been instances of overdoses in and around businesses.”

The AIDS support group also has a wagon filled with supplies, including Narcan, safe sex materials, and brochures, that volunteers pull down Commercial Street during the summer. The group also offers delivery services through their syringe retrieval program. “Mobile is really the future of harm reduction,” Morrison said.

Both Potee and Powers emphasized the need for fentanyl testing beyond the test strips that already exist.

“What I’m advocating is the next level of testing, which is actually able to tell you the quantitative and not just the qualitative answer of how much fentanyl is in there,” Potee said.

Powers is trying to buy a mass spectrometer — which police use to test drugs — and she argues that all harm reduction sites should offer them to clients. “Drug users are not dumpsters — that is a myth,” Powers said. They have families and jobs, she said, and they do not want to die.

State Sen. Julian Cyr, who represents the Cape and Islands, is the lead sponsor of Bill S1277, which would legalize “harm reduction centers” — places where medication treatment, drug testing, and safe injection could occur.

“When you look at the persistence of this epidemic here in Massachusetts and the fact that we continue to lose people to opioids, I believe we need to do everything we can to save lives,” Cyr said.

These harm reduction centers, if legalized, could be crucial on the Cape, where access to treatment is so limited.

Morrison supports the legalization of harm reduction centers, although the ASGCC doesn’t have specific plans to open its own center if they are legalized.

“Harm reduction is essentially meeting people where they’re at,” Morrison said. “Whether that means physically or emotionally, we accept that there is a very big gray area between complete abstinence and substance use. And so, our goal is to help people who are in that gray area to reduce the harms associated with substance use.”

“There’s no silver bullet here,” Cyr said. “But harm reduction sites have the potential to be one of the tools that we use to help save lives.”

Managing Editor K.C. Myers contributed to this report.