Last week in the Cincinnati area, 174 people overdosed on opioids in six days. The prior week in Huntington, West Virginia, 26 people overdosed in a four-hour span. Even for a country numb to grim reports about the heroin crisis, the numbers were shocking.
But the mass overdoses came as little surprise to police and public health experts who have been tracking the emergence of fentanyl, a synthetic opioid 50 to 100 times more powerful than morphine, and its chemical cousins, including one used to tranquilize elephants. Fentanyl has been linked to widespread overdoses since at least 2005, but drug enforcement and public health officials warn that its use is exploding.
"We're urging you, please don't do heroin right now," said Tom Synan, chief of police in Newtown, Ohio, and the head of a Cincinnati-area drug task force. "If for no other reason, because we don't know what's in the stuff on the street."
The DEA issued a nationwide alert about fentanyl in March 2015 after more than 700 overdose deaths were linked to the drug in late 2013 and 2014. Just this year, fentanyl and related synthetic opioids were linked to 53 overdoses — a dozen of them fatal — in Sacramento, 17 deadly overdoses in one week in New Haven, Connecticut, 11 overdoses that killed two people in a single night in Columbus, Ohio, and nine drug-induced deaths in three months in Tampa, Florida.
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Local labs aren't equipped to test for fentanyl and other obscure opioid compounds, so police are still waiting to confirm whether the drug was behind the overdoses in Cincinnati and Huntington, but the latest data from the Drug Enforcement Administration (DEA) and Centers for Disease Control and Prevention (CDC) indicates that fentanyl and similar drugs could be the culprit.
A report last week from the CDC observed a 426 percent increase in cases where fentanyl or other synthetic opioids turned up in drugs seized by police in 2013 and 2014, the most recent years that data is available. At the same time, they noted a corresponding 79 percent rise in fatal overdoses in 27 states — including Ohio and West Virginia. Many coroners and state crime labs don't routinely test for fentanyl, so the drug could be even more prevalent.
"When we went to the data, it really indicated fentanyl," the report's lead author, R. Matthew Gladden, said of the deadly drug poisonings. "It was the primary driver of this."
Adding to the alarm, Gladden and his co-authors suggested people were likely dying because they were taking fentanyl unknowingly, in the form of cut heroin or counterfeit pills made to look like OxyContin and other sought-after painkiller brands. The findings square with law enforcement intelligence about how synthetic opioids have flooded the illicit drug supply in North America.
The spread of fentanyl is partly due to basic economics: Unlike heroin, which requires careful cultivation of poppy fields, synthetic opioids can be cheaply manufactured on an industrial scale with basic chemical knowhow. It costs $3,000 to $4,000 to produce a kilo of fentanyl — the same cost as to produce a kilo of heroin, according to Russ Baer, a DEA spokesman. That kilo of heroin sells in the US for $60,000 or more, with a street value of several hundred thousand dollars when diluted and sold by the gram. But fentanyl's extreme potency means it can be cut and split into many more kilos, increasing a dealer's profits.
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"That one kilo of fentanyl can produce between 16 and 24 kilos [of drug product], ultimately yielding profits of $1.3 million after it's sold on the streets," Baer said. "It's more lucrative than heroin."
Sensing a business opportunity, Mexican gangsters — Baer singled out the Sinaloa and Jalisco New Generation cartels — have ramped up fentanyl production, either importing the finished product directly from China, where it is manufactured both illicitly and by legitimate pharmaceutical companies, or buying the requisite precursor chemicals from the Chinese and making it themselves.
Beyond selling fentanyl in its powder form or using it to cut heroin, Mexican cartels and dealers in the US and Canada are also pressing it into pills. In addition to boosting the retail value of the drug — a dose of fentanyl is less than two milligrams, meaning a kilo can produce more than 650,000 pills that sell for $20-$30 each — pills broaden the customer base to include people wary of smoking or injecting heroin. Baer noted that as the pills move down the supply chain, buyers and sellers are often unaware they contain fentanyl.
'The drug dealers don't know what they're selling, the consumers don't know what they're buying and putting in their body.'
"The drug dealers don't know what they're selling, the consumers don't know what they're buying and putting in their body," Baer said. "Now with the counterfeit opioid labeling, it's an expansion of what is a frankly ingenious marketing technique by these Mexican cartels."
A DEA intelligence brief published in July noted that Mexican cartels aren't the only ones making and cashing in on fentanyl pills. In January, DEA agents seized 6,000 fentanyl pills made to look like oxycodone from a dealer who was manufacturing them in his New York residence. A similar pill pressing operation was discovered in Los Angeles in March.
While fentanyl is tightly regulated in the US, Baer said Chinese labs have begun tweaking the molecular formula to create similar drugs that aren't yet illegal in either country, some even more potent than fentanyl. One variation, which is already regulated in the US, is Carfentanil, a tranquilizer that veterinarians use to sedate elephants and other large animals. Itturned up recently in heroin seized in Cincinnati, and it has also been linked to overdoses in Kentucky, Florida, and Akron, Ohio, which saw 230 drug poisonings — 20 of them fatal — in July.
"We're trying to get a better handle on how widespread it is and where it is," said Gladden, the CDC researcher.
Related: How doctors and big pharma helped create North America's fentanyl crisis
Baer described an "unprecedented" level of cooperation between US and Chinese authorities to reduce the supply of fentanyl, but public health and drug policy experts are warning that the only way to address the problem is to reduce demand, which means getting more people into drug treatment programs.
Leo Beletsky, an associate professor of law and health sciences at Northeastern University, said the current opioid crisis is partly the result of authorities cracking down on prescription pill prescribers while failing to get addicted patients into rehab.
"That's one of the paradoxes of doing supply-side strategy," Beletsky said. "You could be fueling the problem you're trying to address. "
Even the DEA acknowledges that it's virtually impossible to completely cut off the flow of fentanyl from China and Mexico.
"At the end of the day, it's an addiction problem," Baer said. "The drugs are going to flow where the demand is, and right now the demand for opioids — whether it's heroin, fentanyl, or fentanyl-related compounds — is in our country."
Follow Keegan Hamilton on Twitter: @keegan_hamilton
CORRECTION (August 31, 2:10pm): An earlier version of this story incorrectly said that the drug carfentanil is legal in the US. The US regulates it as a Schedule II drug.
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