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Fifty times more powerful than heroin, Fentanyl is driving a surge in overdose deaths and ratcheting up the stakes in the opioid crisis. Where does the synthetic drug come from, and how can it be managed? William Brangham reports from Massachusetts as part of our series, “America Addicted.”
But first: The drug crisis in America today is killing more people each year than AIDS, gun deaths or car crashes did at their peaks.
Tonight, we look at the role of fentanyl, a powerful synthetic opioid increasingly driving that high mortality rate, pushing law enforcement, health professionals and lawmakers to search for new solutions.
William Brangham visited Massachusetts, a state that's seen a dramatic rise in opioid deaths, more than 2,000 people just last year.
It's the focus of our weekly segment on The Leading Edge, and part of our series America Addicted.
Knowing that that next bag is going to kill you, it doesn't matter, because you — you're addicted, you know? And it certainly didn't stop me.
Kelsey, who asked that we not use her last name, began shooting heroin 12 years ago. She was just 15.
Earlier this year, she overdosed here in the bathroom inside Boston's Health Care for the Homeless, which sits on the city's South End, an area known as Methadone Mile for its cluster of treatment centers.
One afternoon, I was walking along, and I looked on the ground, and I found a bag. And it had six bags of dope bagged out. And I was like, oh, cool. I did it, and the next thing I know, I'm waking up in the ambulance.
Her story isn't unusual. Just a few miles away, a man is found unresponsive. He's revived using naloxone, the drug that reverses opioid overdoses, until paramedics arrive.
In the past few years, this has become a daily scene here for Boston's emergency services, says deputy superintendent Leonard Shubitowski.
LEONARD SHUBITOWSKI, Deputy Superintendent, Boston emergency Medical Services: There were about 100 narcotic-related deaths last year. We're on a pace to certainly exceed that by a fair number this year, although the actual number of cases is only up by about 125. So, incidence hasn't really increased, but mortality has.
What's driving that higher mortality rate is a drug called fentanyl. It's a synthetic opioid that's roughly 50 to 100 times more potent than morphine. It was found in about 80 percent of autopsies the state did on overdose victims earlier this year.
MICHAEL FERGUSON, Special Agent in Charge, New England DEA: We're talking about a substance that is poison. It is manufactured death.
Michael Ferguson is the top official in New England for the U.S. Drug Enforcement Agency.
Just here in the Commonwealth of Massachusetts, six individuals a day are dying from an opioid death. It's alarming, and it's happening, and it's not unique to Massachusetts. It's happening all over New England. It's happening all over the country.
For decades, fentanyl has been used in hospital settings as an anesthetic and to treat severe pain.
But starting around 2013, the DEA began to find illicitly manufactured forms of the drug much more often in drug seizures. It seems dealers were using it as an additive to heroin, a cheap way to boost the drug's potency.
So, the deadly combination is high-purity heroin. And I'm talking about heroin that is 50, 60, 80, up to 94 percent pure. That in itself will kill you.
Now you add in fentanyl, a synthetic opioid. If anything can be likened to a weapon of mass destruction and what it does to a community, it's fentanyl.
According to the Centers for Disease Control and Prevention, last year, more than 64,000 people died from drug overdoses across the nation. That's a higher rate than deaths from AIDS at the peak of that epidemic.
Fentanyl was involved in more than 20,000 of those fatalities, more than heroin or prescription pills. And, in fact, fentanyl-related deaths have risen 540 percent since 2013.
Many current and former users told us they only found out they had taken fentanyl after they overdosed.
You don't know what you're getting when you buy something. You don't know how strong it is. You don't even know what drug you're buying half the time when you're getting something. So you're really playing Russian roulette with your life.
yes, we're all afraid of it. We have watched — me and my husband have watched a lot of our friends pass away. A lot.
That tiny bit of dust of powder in there is what's considered possibly a lethal dose?
JILL HEAD, Supervisory Chemist, DEA: Right. Right. So, it's a very small quantity.
Jill Head runs the DEA's special testing lab in Northern Virginia, where samples of seized drugs from around the country are sent for analysis.
Here's a fatal dose of fentanyl, two milligrams, shown next to a penny for comparison.
These tablets, which are made to look like a pharmaceutical preparation or a pharmaceutical drug that's supposed to contain oxycodone actually contains about 1.7 milligrams of fentanyl per tablet.
In addition to finding fentanyl in knock-off prescription pills like these, sold on the streets to users, as well as in cocaine and methamphetamines, in the past year, her team has identified 20 new synthetic opioids developed not just for their potency, but to stay ahead of law enforcement.
So, if this is fentanyl, I make a change here, this would be acetylfentanyl. If I add some addition carbons in this chain, I make could butyrylfentanyl or pentanoyl fentanyl.
They have also identified carfentanil, a large animal tranquilizer that's used on elephants and rhinos. It's 100 times stronger than fentanyl.
Special Agent Ferguson has been tracking how these synthetic drugs get into the U.S. He says the ingredients used to make them most often come from China in labs like this one. They're bought by cartels and shipped to Mexico, where it's estimated that about 80 percent of the U.S. supply is processed.
And at those locations, they can lace the heroin with the fentanyl, or, increasingly, what we have found over the past year now is kilogram quantities of just fentanyl.
The drugs aren't only coming in through smugglers. They're also coming in via the U.S. mail and private carriers, often purchased directly online from operations in China.
So, as simple as me buying something on Amazon, you could buy some of the drugs to make this on the Internet.
Right. It would be easy for somebody to purchase them from their home computer and have it shipped to their address.
After years of pressure, the DEA says Chinese officials are now cooperating to crack down on these suppliers. But, Ferguson admits, enforcement alone will not stop fentanyl from entering the country.
We can point fingers all we want, but this is America's problem. This is our problem. As long as there's a demand and there's money to be made, this stuff's going to get into the country.
DR. JESSIE GAETA, Chief Medical Officer, Boston Healthcare for the Homeless: Fentanyl really is at the forefront. It defines the epidemic right here, right now.
Back on Methadone Mile, one woman trying to solve this problem is Dr. Jessie Gaeta. Last year, she opened what's known as the SPOT Clinic — it stands for Supportive Place for Observation and Treatment — at Boston's Health Care for the Homeless. She's the chief medical officer there.
DR. JESSIE GAETA:
About three years ago, we started to have between two and five overdoses every single week in the building where we work.
I mean, I thought, first of all, my gosh, we're having so frequent overdoses, that we actually need to build some infrastructure to even manage the response to them.
Today, at SPOT, only after using their drugs, people can come to this small room to ride out their highs in one of these nine chairs, all under the watchful eyes of medical professionals.
Vitals signs like pulse, blood pressure and breathing are monitored for any signs of distress.
So, people walk in, and usually they can still walk and talk when they come in. And, typically, they will say, look, I have used a little bit more today, and I'm worried about what's going to happen. Do you mind if I stay here for a little while?
Dr. Gaeta says it's about giving people in the throes of addiction a place to go before they find themselves in a full-blown overdose and in need of an ambulance.
Kelsey first came to SPOT last year. Today, she says she's alive and in treatment because of this place.
They have been there for me through everything that has ever gone wrong in my life. Like, I could tear up right now talking about it. I have literally picked myself up off the street after some pretty (EXPLETIVE DELETED) things have happened, and walked in there, and they have always been there for me.
Dr. Gaeta, though, knows her work is far from finished. With limited space, and the dangers of fentanyl lurking in possibly every batch and pill, she says people are still overdosing and dying before they can get to SPOT.
Its onset of action is very quick. So, what that means on the street is that I'm seeing overdoses happening literally at the moment of injection. Sometimes, the needle is still in the arm when someone stops breathing.
That fast. So, that's pretty terrifying, if you think about it from a public health point of view, how to prevent that death.
She thinks the country needs to go a big step further, opening what are called supervised injection sites, like this one in Vancouver, Canada.
Here, users can come in and inject their drugs under the care of nurses, using clean needles and with naloxone at the ready. It's a controversial idea, but fentanyl is now forcing the debate.
In June, the American Medical Association endorsed the idea. King County, Washington, which includes Seattle, is moving ahead to open supervised injection sites, as is San Francisco. And there's at least one safe injection site already running underground in the U.S.
At this point in the epidemic, we need to be thinking differently. What we're doing so far is not nearly enough. If we do not create programming for people who are actively using right now and not entering these other systems, I'm afraid that we're not going to really be able to bend this curve down.
While cities and some states press for these reforms, arguing it's a necessary response to the influx of fentanyl, safe injection sites are currently prohibited by federal law, which says you can't allow illegal drug use on any property.
Whether the federal government chooses to fight these efforts remains to be seen.
From Boston, I'm William Brangham for the PBS NewsHour.
Online, you can find much more from our series, including an explainer video that breaks down the science of addiction. Humans have coveted the pain relief provided by opioids for thousands of years. But what actually goes on in the brain?
You can watch that at PBS.org/NewsHour.
Watch the Full Episode
Frank Carlson is a general assignment producer at the PBS NewsHour, where he's been making video since 2010. @frankncarlson
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