The autopsy suite at the coroner’s office in Cincinnati has all the necessary equipment for disassembling a corpse, from an array of scalpels and blades to a pair of pruning shears. Determining a person’s cause of death is a grisly but essential business, especially when the bodies start piling up like they did this past summer.
Surrounded by the tools of her trade, Dr. Lakshmi Sammarco recalls the stretch in August when Cincinnati and surrounding Hamilton County experienced an unprecedented 174 drug overdoses in a six-day span. At least three of the cases were fatal, and Sammarco was mystified — and alarmed — when autopsies revealed that something other than heroin was the culprit.
“There was a lot of scratching of the head going on,” she said. “It was like, now what? What are we going to do? We need to find this stuff.”
Sammarco eventually linked at least 21 of the deaths in the area to carfentanil, a synthetic opioid that zookeepers use to tranquilize elephants, rhinos, and other large animals. As a physician trained on humans, she’d never heard of carfentanil, but she was already very familiar with its chemical cousin fentanyl, the ultra-powerful opioid that caused 238 of Cincinnati’s 414 fatal overdoses in 2015. Carfentanil is roughly 100 times stronger than fentanyl, which is about 50 times more potent than heroin.
“I was looking at my staff and going, ‘Are you kidding me?’” she said. “Like, fentanyl wasn’t bad enough? They have to go out and get something that’s 100 times as potent as fentanyl? Why would anyone even put that poison in their bodies?”
Carfentanil fits with an unsettling trend in the country’s opioid crisis. As more and more Americans have switched to heroin from prescription painkillers, drug dealers have turned to synthetic opioids to meet the skyrocketing demand.
Watch the segment on carfentanil in the Monday, October 18, edition of VICE News Tonight on HBO.
Federal authorities are still trying to piece together exactly how and why Ohio became America’s carfentanil epicenter. In late September, a Cincinnati couple was arrested and charged with selling the drug in the area, and on October 15 a federal grand jury indicted two young men from nearby Rowan County, Kentucky, who are allegedly linked to at least seven fatal carfentanil overdoses. But Tim Regan, the resident agent in charge of the Drug Enforcement Administration’s Cincinnati office, told VICE News there’s still no explanation beyond the local level.
“It’s so new for us that we’re just playing catch-up, at least in Cincinnati,” Regan said. “We know the street-level dealers and we’re trying to work our way up from there. The carfentanil thing totally caught us off guard.”
The rate of fatal overdoses in the U.S. involving synthetic opioids nearly doubled from 2013 to 2014, the most recent year that complete data is available, climbing from 3,105 deaths to 5,544. The Centers for Disease Control says heroin laced with fentanyl drove the increase. CDC researchers have said unpublished data from 2015 shows an even sharper spike.
Researchers at the DEA’s Special Research and Testing lab have been tracking the rise of carfentanil and other potent synthetic opioids as they spread across the U.S. At a nondescript office park in a Virginia suburb a few miles west of Washington, D.C., Jill Head, the facility’s supervisory chemist, showed VICE News an assortment of vials filled with various forms of fentanyl seized during investigations across the country. Pure fentanyl and carfentanil are white powder, but the samples she produced included a purplish substance, and green plant material doused with synthetic marijuana and opioids.
Head said that since carfentanil turned up in Cincinnati, it’s also been found in Florida, Michigan, Rhode Island, Illinois, and Kentucky, with suspected but still unconfirmed incidents in Georgia, New York, West Virginia, and Pennsylvania. “It’s really moved beyond Ohio,” Head said. “We’re seeing it in communities across the United States.”
She explained that while fentanyl is still the most common illicit synthetic opioid in the U.S., more obscure variations — such as acetylfentanyl, valerylfentanyl, and furanylfentanyl — have also started turning up on a regular basis. Many of fentanyl’s relatives are already regulated in the U.S., but some are still technically legal.
Most synthetic opioids are manufactured in China. Under pressure to crack down on the trade, the Chinese government recently added 116 synthetic drugs to its controlled-substances list, but carfentanil is still unregulated and readily available for purchase online. A kilo — enough to cause around 50 million fatal overdoses — sells for as little as $2,750.
Some of the drugs available from Chinese labs are so obscure they don’t even have a common name, just a series of letters and numbers to identify them. In September, the DEA moved to put an emergency ban on the synthetic opioid U47700 after it was linked to at least 15 fatal overdoses, including 10 in North Carolina. The DEA said it was being sold on the internet in packages labeled “not for human consumption” or “for research purposes only.”
It’s like what the agency has seen with “bath salts,” the street name for stimulants made from synthetic cathinones, and K2 or Spice, which are common brands of synthetic marijuana. In those cases, manufacturers, mostly in China, have constantly tweaked the chemical formulas of the drugs in an effort to skirt U.S. law.
“We’re seeing that with opioids as well,” Head said, noting that the stakes are much higher with fentanyl-like compounds. “Small changes in the molecule can make it either not effective or tremendously potent.”
To put carfentanil’s extreme potency in perspective, Head picked up a packet of Sweet’N Low. She tore open the package and poured it on a lab bench, separating out a few granules, about two milligrams worth, with a razor blade. This amount, she said, would be enough carfentanil to kill 100 people. The entire gram-sized packet would contain about 50,000 lethal doses. When DEA researchers handle the real thing, they’re required to wear protective gear and have a “guardian angel” waiting nearby to quickly administer the overdose antidote naloxone in case something goes wrong.
“What we’re seeing on the street is not usually pure fentanyl or pure carfentanil,” Head explained. “It’s a couple of specks cut with something.”
The problem, as the DEA expert explained, is that it’s difficult for dealers to make sure the carfentanil is evenly mixed with heroin or drugs. Haphazard mixing can lead to “hot spots” — concentrated doses that are instantly fatal. In Cincinnati, Sammarco said the county her lab is in has found carfentanil and other synthetic opioids in a variety of “powdery substances, some of it white, some of it pink, some of it tan.”
To get a sense of the on-the-street dynamics of the illicit opioid trade in Cincinnati, VICE News went on a routine patrol with Police Specialist Jerry Turner in the city’s Price Hill neighborhood, a rough area where overdoses have soared. “Just about every building on this block, there’s somebody selling heroin,” he said, gesturing toward a strip of low-rise apartments. “Everybody knows it, but there’s really not much we can do about it. You stop five people, they’ll tell you five [different] places they bought it — and that’s just in this one neighborhood.”
Turner said the low-level heroin dealers likely have no idea what’s in their product. He explained the supply chain like this: Wholesalers sell to middlemen, who “step on” the heroin, diluting it with all manner of cutting agents, to increase their profits when they sell to end-of-the-line distributors. “I heard one guy say he used Nestlé Quik,” Turner said, explaining that small-time dealers are everywhere and typically carry only a few grams, a pebble-sized amount that can be easily concealed.
The working theory in Cincinnati, according to the DEA’s Regan, is that Mexican drug cartels are either buying carfentanil from China or making it themselves with precursor chemicals, then sending it north mixed in with shipments of heroin. It has also been found in Canada, where police seized a one-kilogram shipment bound for Calgary in early August and arrested the 24-year-old alleged importer.
Sammarco has a theory that Cincinnati was used as a test market for carfentanil, and that it could spread to other American cities. Detroit’s medical examiner recently confirmed 19 overdose deaths associated with the elephant tranquilizer, saying that “in all cases where it was present, it was combined with other opioids, including heroin, U47700, or other designer opioids.” Many local crime labs aren’t equipped to test for carfentanil, so it’s difficult to say how widespread it has become.
As a doctor, her concern is that the human effects of carfentanil and other obscure synthetic opioids are virtually unknown. At this early stage, she said, users are basically guinea pigs.
“People are seeking the most extreme high possible,” Sammarco said. “We have no idea how this stuff really acts in the human body, how it’s metabolized and sticks around. We can take animal models, but how accurate is that when you’re talking about humans?”
“We don’t have any answers,” she added with exasperation. “Nobody has any answers.”