Fentanyl-laced street drugs "kill hundreds"
By David Boddiger
With street names such as Drop Dead, Flatline, and Lethal Injection, fentanyl-laced heroin and cocaine are marketed by drug dealers as the ultimate high. But these drugs are so dangerous that hundreds have died. From Chicago, one of the hardest hit US cities, David Boddiger reports.
Mike Wickster, a bald and tattooed 34-year-old, has been brought back from death's door ten times after overdosing on heroin, most recently on heroin he believes was laced with the powerful synthetic opiate fentanyl. He survived and eventually wound up in jail where he had to go "clean". With help, he has stayed off drugs for 7 months and now works in a harm-reduction programme trying to help drug users. But friends from his drug-using past still call when they have found a source for heroin with fentanyl.
"Just yesterday someone said, 'I know where to get fentanyl.' People want it because it's powerful and extreme. Deaths are like an advertisement-for every 10 people that die, 100 more will go looking for it", he says.
Fentanyl is not new to veteran abusers, but in the past it had been obtained by diverting prescriptions. According to Timothy Ogden, Chicago's top Drug Enforcement Administration (DEA) official, clandestine fentanyl labs were occasionally discovered in the 1980s and 1990s. But those operations were nowhere near the size and scope of today's fentanyl networks controlled by international drug traffickers.
"In 30 years of law enforcement experience, I haven't seen this much of a threat before", Ogden says. "It's like a game of Russian roulette, only you're putting five bullets in the chamber."
Health workers began to notice a spike in opiate overdoses and overdose deaths late last year. When sophisticated toxicology tests of autopsy material revealed the presence of fentanyl, police started testing the heroin from street dealers finding the synthetic opiate.
By May this year, fentanyl overdoses had spread to cities in eight states, including Chicago, Detroit, St Louis, Philadelphia, Pittsburgh, and Camden, New Jersey. Fentanyl has been linked to 130 deaths in Detroit and 100 in Chicago in only a few months. In New Jersey, the drug cocktail killed three and hospitalised 42 in one weekend alone.
"The May numbers are the highest we've seen yet, and we expect that trend to continue", says Edmund Donoghue, medical examiner for Chicago's Cook County. "This is something we haven't seen in Chicago before. We're really stunned by it. We have had problems where ambulances were called for multiple overdoses, entire groups of people in the same place."
Compounding the problem, the demographics of heroin abuse in the USA are starting to shift. While overall demand for heroin has remained stable in recent years, what once used to be considered an urban drug is now showing up in suburban areas and attracting younger users.
In June, a recent high school graduate and son of a suburban Chicago police officer was found dead in his car from a fatal overdose of fentanyl-laced heroin. In a suburb of Detroit, police arrested a dealer and charged him with the fatal overdose of a 17-year-old female student.
"[Heroin] is no longer considered just an inner city drug. It's out in the suburbs, and that's why it's becoming such a big issue", says Wickster.
A 2005 report by the US Justice Department's National Drug Intelligence Center noted an increase in heroin abuse in Chicago suburbs, "resulting in a rise in the consequences of heroin abuse in Chicago, a primary market area". This increase is attributed particularly to an increase in the number of users under the age of 25 years.
Many health-care workers who help treat substance abusers believe the USA's traditional focus on "supply-side" law enforcement, which emphasises the prosecution over treatment, is futile. The supply-side approach, critics charge, fails to address the root of the problem: demand. Money is poured into enforcement, they say, while effective outreach and addiction treatment programmes go under-funded.
Access to methadone programmes is one of the most pressing problems for heroin users who want help, says Sarz Maxwell, medical director for the Chicago Recovery Alliance (CRA), which runs a mobile methadone clinic and needle-exchange programme. The clinic is operated out of a large van that travels around the city distributing methadone for 2 hours a day, 7 days a week.
"Methadone is one of the best researched tools we have. It's incredibly safe and effective, and without it, the relapse rate is 95. Yet it continues to be unbelievably regulated", she says.
US Congressman Danny Davis, whose Illinois district has been one of the hardest hit by the fentanyl crisis, agrees that regulation of public methadone programmes is far too restrictive. 600 people are on a waiting list for methadone treatment in Chicago's Cook County alone, he says.
According to Jennifer Smith of the John H Stroger Hospital, Chicago's largest public hospital system, between April, 2004, and June, 2006, 906 patients in three Chicago hospitals were forced to wait an average of 17 days for entry into methadone maintenance programmes. Only 18 actually entered the scheme. When methadone treatment was made available the day after hospital discharge, 67 of patients entered treatment.
In 2003, some 10000 people seeking publicly funded substance-abuse treatment in Illinois were turned away, says Melody Heaps, president of Treatment Alternatives for Safe Communities, an Illinois non-profit group that provides behavioural health services to people with substance abuse and mental-health disorders.
Wickster was one of the statistics. "I'm calling around to get on methadone and they said they were full. I said, 'I'm gonna die' and they told me, 'You're not the only one'," he recalls.
Westley Clark, director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the federal government's Department of Health and Human Services, noted that during the past 3 years, Illinois received 22 million in federal funding for addiction recovery programmes.
"We are trying to enhance the availability of treatment and prevention strategies. We hope by the end of the fiscal year to have 40 states with more money", Clark says.
Clark adds that SAMHSA also encourages doctors to use methadone and provide behavioural treatment, as well as educating them about buprenorphine, which helps decrease heroin craving.
But many heroin users who lack health insurance coverage have had difficulty affording buprenorphine, says the CRA's Maxwell.
The epidemic also points to the need to pursue a much more aggressive harm-reduction strategy, including providing drug users with the opiate-antagonist naloxone so they can administer the drug to their friends on the spot, says Maxwell. Since the recent spike in overdose deaths, most emergency responders now carry naloxone. But distributing it freely to users has met some resistance.
Maxwell believes her organisation's naloxone distribution programme has saved 450 lives through "peer revival" since the initiative was started in 2000. Wickster, whose life was saved more than once by naloxone injections, including once when his wife injected the drug, now helps distribute it along with clean needles and information on the same street corners where he once bought and sold drugs.
"People need to be educated about naloxone, especially now with fentanyl everywhere", Wickster says. "Saving someone's life just may motivate them to say, 'that's enough'. That's what happened to me."
Federal drug authorities, however, currently do not support naloxone distribution to drug users. "I'm not sure that's a rational strategy in and of itself. Local jurisdictions should be permitted to use whatever strategies they believe are important...but it is not a federal position", SAMHSA's Clark says.
According to the European Centre for Drugs and Drug Addiction, trafficking of illegally produced fentanyl is on the rise, noting that seizures of the drug has been reported in a number of countries bordering the Baltic Sea and the Russian Federation. In Estonia, for example, fentanyl appeared on the drug market as a heroin substitute in 2001.
US officials warn that where there is heroin abuse and fentanyl, overdose epidemics like those being seen in US cities are likely to follow. "Other countries should know this can happen and they need to have the resources to address it. If it's not recognised, it's costly", says SAMHSA's Clark.
Donoghue, the Chicago medical examiner, agrees. "We need to warn other countries that if you have a market for heroin and cocaine, you may begin to see this happen."
- Medical / Clinical