A drug 50 times deadlier than heroin finds its way to California

 

Aris Turner was 34 years old. A father of four, the Chico resident died from acute fentanyl, methamphetamine and cocaine poisoning on Jan. 12, the Chico Enterprise-Record reported. He likely didn’t know that fentanyl was in his system.

Fourteen people were hospitalized from the same home in Chico that day in one of the worst mass overdose events in Northern California since the opioid epidemic began. Police officers were called to a home in Chico where multiple overdoses occurred, where they found cocaine, alcohol and other paraphernalia.

“We were waiting and have been waiting unfortunately for this to happen in the sense that we knew fentanyl had been moving west,” Chico Police Chief Mike O’Brien told reporters at a press brief in January.

The rate of drug overdoses per year more than tripled from 1999 to 2016, according to a report by the U.S. Centers for Disease Control and National Center for Health Statistics. In 2016, there were 63,632 deaths due to drug overdoses.

California is one of the 29 funded states through the CDC’s Prevention for States initiative: an effort to combat the opioid epidemic. Still, California has not seen the worst of the issue, especially since fentanyl has not had as much of a presence on the West Coast as on the East Coast.

Fentanyl is a drug used for severe pain control in hospitals, mostly in end-of-life situations. The synthetic opioid is 100 times more potent than morphine and 50 times more potent than heroin. Due to its strength, it is offered by the microgram — a thousandth of a milligram — in hospital settings. Now, it is the most commonly used drug in overdoses: about 30 percent of overdoses in 2016 involved fentanyl. In 2016, the rate of overdoses involving fentanyl was 12 times larger than it was in 2013.

Patil Armenian, M.D., an emergency physician and medical toxicologist at University of California, San Francisco – Fresno, responded to a string of overdoses involving fentanyl in Fresno County in January. She practices at the Community Regional Medical Center in Fresno where she’s been dealing with overdoses for years. But, starting in the 1990s the trend was very much the opposite, she said, with more emphasis put on pain control in medical care coupled with a push from pharmaceutical companies, resulting in an increase in opioid prescriptions.

“Well, we created an opioid epidemic,” she said.

Doctors started prescribing less in the last few years, Armenian said, but it was too late. The drugs hit the street in more dangerous forms, so when people look for painkillers, the doctor’s office might not be the first stop. For those addicted to drugs, that means they don’t always know what they’re getting: they might not know the potency of what they’re buying or how to use it.

The crisis started around 2009 with pills — oxycodone and percocet — before addicts turned to methadone and heroin. Armenian said a lot of people think primarily of heroin, but prior to the epidemic, deaths attributed to heroin had been relatively stable at 2,000-3,000 per year. Fentanyl mirrored that rise starting in 2014 when it began trading in illicit drug markets. Trafficking organizations and cartels started lacing counterfeit pills with fentanyl and fentanyl analogues, or look-a-likes, Armenian said.

Every state in the U.S. has reported at least one batch of heroin with fentanyl in it, she added.

The heroin supply in the states is divided by the Mississippi River, said Sarah Mars, M.D., Ph.D., a researcher at University of California, San Francisco. Heroin on the east coast tends to come as a powder, which can be mixed with water easily, she said, while the West Coast’s heroin is predominantly black tar — a weaker, sticky solid, which needs to be heated to dissolve in water. Fentanyl is easier to mix into the East Coast version while the black tar tends to be less powerful.

Mars, along with principal investigator Daniel Ciccarone, M.D., M.P.H, have been traveling across the U.S. to places where the opioid epidemic has had the most casualties, like Baltimore, M.D., and researching the impact of fentanyl and analogues on the heroin supply. The project, “Heroin in Transition,” funded by the National Institutes of Health, analyzes drug users reactions to changes in the drug supply and what they believe is in their drugs. Their findings show that most drug users don’t know whether fentanyl is present at all.

“Fentanyl itself is more potent than heroin and if you don’t know it’s in there, you’re at a high risk of overdose,” Mars said.

Fentanyl primarily comes from China, where pharmaceutical and chemical manufacturing practices are not well-regulated, Mars said. From there, the potent painkiller travels via freight shipping companies and the U.S. postal service through the U.S., Canada and Mexico, Armenian explained. Most of the fentanyl in California will go through illicit factories in Mexico for processing, where it will be mixed with heroin and oxycodone replicas.

What’s scary is that the illicit producers of the drug don’t really know the doses, meaning that some of the manufactured pills are strong enough to kill in small amounts, Armenian said. The powerful drug can also cross contaminate recreational drugs while shipping, like cocaine.

Cartels use fentanyl because it is cheap: Armenian estimated that one kilo of wholesale fentanyl from China costs $2 to $3 thousand. She said the money that traffickers can turn on that is anywhere between $5 million and $20 million.

“Why wouldn’t they do it? It’s lucrative,” she said.

Fentanyl’s presence is not detected on a standard drug test. Adding a fentanyl test in overdose cases became necessary, but the test can’t catch all analogues, which are often more dangerous. Carfentanil, one variation of fentanyl analogue, is 100 times more potent than fentanyl, meaning it is 100,000 times more potent than morphine and 50,000 times more potent than heroin, according to the Drug Enforcement Administration. The Federal Analogue Act rules that analogues of drugs are the same schedule drug as their original, but it’s hard to catch a new analogue every time one pops up. Mars said she’s unsure of how often it is to survive a carfentanil overdose.

The intervention time for reviving people with naloxone, a narcotic which can treat an overdose in an emergency situation, is much shorter with fentanyl than it is with heroin. Additionally, the amount of naloxone needed varies greatly. For heroin, one- or two-tenths of a milligram should improve breathing and a regular opioid overdose can be reversed with three to four milligrams. Carfentanil requires 15 to 20 milligrams.

First responders in Chico were carrying naloxone on Jan. 12, when they administered 24 milligrams of the common brand Narcan, Chico Police Sergeant Curtis Prosise told the San Francisco Chronicle. Most emergency responders now carry naloxone and recent legislation in California made it possible for people to buy naloxone behind the counter without a prescription. Both Mars and Armenian recommended that addicts and friends learn how to use naloxone, and that addicts don’t do drugs alone.

“Honestly, most of these buyers are just trying to party,” Armenian said. “You have no idea what’s in there, you buy what you think is in there. The problem is that you probably don’t have any idea what you’re getting. And that’s terrifying to me.”