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Fentanyl Changed the Opioid Epidemic. Now It’s Getting Worse

The super-potent opioid is getting cut in at every level, and is spreading west. Now, experts say, it could replace heroin entirely

NEW YORK, NY - MAY 04:  Men sit passed out in a park where heroin users gather to shoot up in the Bronx on May 4, 2018 in New York City. In an attempt to reverse the number of overdose deaths, New York City could become the first city in the United States to adopt supervised injection facilities also known as safe injection sites. New York City Mayor Bill de Blasio has moved to open four safe injection sites which he has called Overdose Prevention Centers as part of a one-year pilot program. The Bronx was the borough with the highest number of overdose deaths in 2016 with 308 residents dying.  (Photo by Spencer Platt/Getty Images)

Men in a park where heroin users gather to shoot up in the Bronx. In the past few years, reports of fentanyl in heroin has skyrocketed.

Spencer Platt/Getty Images

If you talk to Tony Parilla, he’ll be the first to tell you that his New York City junkie credentials are impressive. He started shooting dope as a teenager, back when the North Brooklyn neighborhood where he grew up was more Serpico than Girls, and the Lower East Side was a drug-addled hardcore Xanadu.

“You’d walk into an apartment through a hole in the wall, you’d cop in another apartment, and [then] walk out of a completely different building,” says Parilla, 51, who’s been shooting heroin for the past 35 years.

“[Since] I was 15,” he says. “You know, [heroin’s] a beautiful feeling. But it’s not a feeling I would recommend anybody [else] chase.”

He lived in Tompkins Square Park — the needle park of needle parks — during the 1980s. He was there during the 1988 police riots, when the squatters were forcibly evicted in an onslaught of police violence.

“I started running saying ‘They’re coming They’re coming,’ I turned the corner and clip clop clip clop,” he says, mimicking a horse’s hooves, “Smack! Back of the head.”

He’s contracted hepatitis — twice. He’s seen bodies thrown out windows. Just last year, someone threw him onto the subway tracks and split his head open. He grew in the hardcore scene as a punk and a skinhead — plainly, Parilla is robust, and doesn’t easily flinch.

But even a guy like Parilla has been caught off guard by the influx of fentanyl.

“Dope is cut so many different ways now that you don’t know what the fuck is in it,” says Parilla. “And with fentanyl, you can’t really tell until you shoot it.” While an occasional overdose is par the course, Parilla says, this fentanyl thing is totally different. “It’s killing a lot more people in the last two years,” Parilla says. “Actually I tried to figure it out last night and I lost count at 27.”

Perhaps because of this steep death rate, Parilla takes as much precaution as a needle user can.

He carries naloxone — the overdose reversal drug, also commonly known by the brand name Narcan — and he’s had to use it on a number of fellow users. The responsibility falls on him because often he’s the only one who carries it. And he’s usually the most experienced in the room.

“If I’m in a room with 25 people, all junkies, I’m gonna feel responsible. I’m gonna be looking around and it fucks with my head. Who wants to see somebody maybe die?”

For a while, he was carrying around Fentanyl testing strips, which let you test your drugs for any trace of Fentanyl. His old needle exchange provided them for free. But the new exchange he goes to doesn’t give them out.

Those strips are one of the very few ways for a drug user has to know if he’s got a potentially deadly mix. It’s one of the few ways they can keep from becoming another statistic.

“Down in Philly I’m finding bags that are [diluted] fentanyl,” says one expert. “No heroin at all!

The Center for Disease Control’s preliminary data estimates that nearly 72 thousand people died of accidental drug overdose in 2017. That’s more than a 10 percent increase from 2016. Most of those deaths involved opioids. And despite extensive media attention and the best efforts from public health officials and law enforcement, fentanyl — a synthetic opioid 50 to 100 times more potent than heroin — continues to creep into the illicit drug supply and drive drug overdose.

Such a potent opioid is quite useful in a medical setting. It is routinely used as a painkiller and as a general anesthetic, usually given as a patch or a lollipop so the dosage can be closely monitored.

But when it’s introduced into an unregulated, illicit drug supply, where more and more of the country has become opioid dependent, it wreaks havoc. Its potency means it’s nearly impossible to uniformly mix and just a few too many grains can cause even the most heroin-tolerant drug user to overdose.

 

The first time Padilla’s girlfriend, Kayla, heard about Fentanyl, it was in an Emergency Room in Allentown, Pennsylvania. “I went out with the needle still in my arm,” she says. “I’m like fuck, what happened? I had no idea there was fentanyl in it. It was first time I ever heard of it.”

A usual heroin overdose creeps up on you. It can take several hours to overwhelm the respiratory system — most people who OD on heroin are not found dead with needles in their arm — giving them a longer window to be revived. But fentanyl is engineered to be potent and ridiculously fast acting. People are dying with needles in their arms.

That has upped the stakes wildly, leading governments to aim public health campaigns directly at drug users, not telling them to stop, but suggesting best practices.

It’s also led health departments to hire unorthodox experts, like Tino Fuentes, who sold heroin for 30 years. For the last 20 years he’s worked in harm reduction, advocating for clean needles and naloxone. And now he’s contracted with the City of the New York to train public servants in overdose reversal.

Back when Fuentes worked at St. Ann’s Needle Exchange, he and his coworkers were the first place in New York City to offer fentanyl testings strips in the hopes that an informed consumer will play it safe. “Cause nobody’s gonna throw their bag of dope away, right?,” says Fuentes.

“We suspect that [fentanyl is being mixed in] at pretty much all levels,” says one researcher.

Now, he spends a lot of time on the streets, buying drugs, testing them out, trying to figure out what’s going on. “Two thirds of the bags I’m testing in the Bronx are showing up positive,” he says. “Down in Philly I’m finding bags that are [diluted] fentanyl – no heroin at all! And it’s getting worse.”

But drug dealing is a business. And the economics are making fentanyl irresistible.

These days, a dealer makes something like $200,000 on a kilogram of heroin, Tino explains. But a kilogram of Fentanyl costs just a few thousand dollars. Dump that into your bag of heroin and you can cut it with 10 or 20 or 30 kilograms of baby laxative. Bag that up for the streets and you’ve now got millions of dollars worth of dope, for just a little extra investment.

But fentanyl isn’t just being mixed in by the guys who buy and bag it wholesale.

“We suspect that it’s happening at pretty much all levels,” says Bryce Pardo, a researcher at the RAND Corporation who studies drug policy.

That means Pardo spends his days ensconced in media, government and law enforcement reports, trying to wrap his head around exactly what is happening.

Reports find that both of the major Mexican cartels are cutting fentanyl into their dope before sending it along to the United States. It seems that one of the major cartels, Jalisco New Generation, embraced fentanyl back in 2014. It’s main rival, Sinaloa, scrambled to catch up, but now they’ve gone fentanyl, full-breach. Sinaloa is a major supplier of New York City’s heroin. And 2015 was the year when Fentanyl overdose deaths started to skyrocket.

“Really it’s a brilliant move, going to fentanyl,” says Pardo. “They’re very innovative. They know how to [maximize profits].”

So the heroin coming into the city is already being cut with fentanyl before the local distribution network gets to it and works their own chemical magic. “You can get this stuff in the mail,” said Pardo. “It’s available online.”

A screenshot of Fentanyl for sale from an online retailer.

A screenshot of Fentanyl for sale from an online retailer.

However it enters the United States, experts and the DEA all seem to agree that Fentanyl and its constituent parts, or precursors, are coming from China. It’s probable that it’s being diverted from the labs that make fentanyl for legitimate, medical use.

Mail seizure by law enforcement finds that the Fentanyl coming in by post is 90 percent pure. It’s coming by sea — busts in New England have found shipments of fentanyl precursors. And it’s coming by land — seizures at the border are often of watered-down Fentanyl pressed to look like oxycontin and Xanax.

In his on the ground research, Fuentes finds that the guys actually standing out on the corner — street dealers, people “selling to support their habit” — are getting in on the action.

“Somebody can buy two ounces of fentanyl from some knucklehead and drop it in there,” Fuentes says, noting that those dealers have no idea that it may have already been hit a number of times.

Market indicators seem to back Fuentes’ claim. Peter Reuter, a professor of public policy and criminology at the University of Maryland, has made his career studying black markets. Reuter has seen evidence that lowest level players are getting in on the game. Lots of envelopes are coming in with just a few grams of fentanyl. This is enough for someone to cut into a small amount of heroin — what the guy on the street is slinging, but nowhere near enough for a wholesaler or distributor.

“That supports the notion that there are retailers who are bringing in their own fentanyl,” said Reuter.

These guys don’t know what’s in the heroin before they get it. Reuter says these guys think they’re buying stuff that is pure. With all this amateur chemistry going, he says, “I’m surprised more people haven’t died.”

“Innovation will be when somebody figures out how to mix fentanyl with black tar,” says one expert.

 

One reason more people haven’t died is because of the work done by the people down at the needle exchange. It’s only recently that public health officials have began the campaigns for overdose reversal drugs. Harm reduction workers and advocates are to be credited for that, and for getting naloxone out of the hospitals and onto the streets.

Tens of thousands of overdoses have been reversed by naloxone — and most of those saves are done by amateurs. According to one federal health report, less than 20 percent of overdose reversals are administered by first responders. The rest are done by regular people like fellow drug users.

The other main thing that has kept overdose deaths down in the U.S. is that the heroin market here is bifurcated: East of the Mississippi the heroin is powder and stuffed with fentanyl, west of the Mississippi the heroin is a sticky dark brown paste called “black tar.” Powders are much easier to mix — or cut — with an adulterate like fentanyl. Black tar has been served as a sort of firewall against it.

“Innovation will be when somebody figures out how to mix fentanyl with black tar,” Reuter says. “This won’t require a breakthrough in modern science.” And once that happens, all bets are off.

Fuentes agrees. “To say that you can’t put it in tar is ridiculous,” he says. It’s a bit more of a process than just adding powder to powder, but not by much. But it’s not a process Fuentes will not describe in detail. He doesn’t want to give anyone any ideas.

But that knowledge isn’t proprietary. And Reuter’s “breakthrough” is starting to happen.

 

Three thousand miles away from New York City, light pours into the lobby of Homeless Health Care L.A., located in Downtown Los Angeles’ skid row, where a few thousand homeless have made lives for themselves. The whitewashed brick walls of this former warehouse is airy and clean, and behind a plexiglass glass an employee makes made to order safe injection kits.

The sun is shining, the coke is all crack and the heroin is all tar.

Alanah Roy has worked there for about a year. During that time, overdoses have increased — they suspect it’s because of fentanyl. “I can’t speak with us in comparison to the East Coast but I know for us, our numbers are going up,” she says. One particularly visceral indicator is the number of overdose reversals the staff has done. Twenty or 30 so far this year, she says off the top of her head.

“We’re seeing a lot of people reporting that they had positive results,” says a harm-reduction counselor in Los Angeles.

This past year, she says, they started giving out fentanyl testing strips to their clients, encouraging them to test their dope. Two thirds of the time, their clients are reporting, the tar is testing positive for Fentanyl.

“It is mixed into the black tar,” she says.

“We’re seeing a lot of people reporting that they had positive results,” says Roy. When it’s positive, “it just looks like a browner red — [though] it’s hard to generalize, different people will report it looking different ways.”

Their main tool to combat overdose is, of course, Narcan. They give out 250 overdose kits a month and whenever they get used, they encourage their clients to report back to them. So far this year, their clients have successfully reversed more than 200 overdosed. Five have been unsuccessful. Most of those deaths have been younger white men, new to skid row. The older crowd know how to use heroin safely.

“If you’re new to it and you’re young. You’re less likely to use with somebody,” says Roy.

And if you use alone and you’ve got a particularly hot dose of fentanyl, you’re going to drop right out, your overdose reversal kit unopened and useless.

 

Back East, Fuentes has both fentanyl and heroin testing strips in his arsenal. And he’s starting to find more and more bags of dope that test positive for fentanyl and negative for heroin. “I wouldn’t be surprised if synthetic opioids are going to displace heroin markets around the world,” he said.

Neither would the Council of Foreign Relations, which recently published a report detailing what this would look like.

It could possibly disrupt much of the narcotics trade — fentanyl may even be depressing the price of heroin itself. Poppy farmers in Mexico are forced to sell their product 40 to 80 percent below what they’re used to.

When Pardo said you could just buy fentanyl online, he wasn’t talking about the darkweb or cryptocurrency. A kilogram of Fentanyl can easily be purchased by anyone with a search engine and a credit card. For how long can a cartel compete with that? How could the DEA keep up?

“If the U.S. pushed China — could the Chinese government actually do anything?” says Reuter. “Anyway, India would be just as good a producer.”

For now, health authorities are stuck. “We have no idea how to deal with fentanyl,” Reuter says. “Nobody knows.” The NYPD, for example, has made it clear that it will target fentanyl dealers in particular. There have been a number of high profile busts. Yet there’s very little evidence that imprisoning drug dealers will help.

“I’m a fan of heroin-assisted therapy,” says Reuter. In a scattering of European countries, government sanctioned facilities supply users with unadulterated heroin. Prescribed and administered under a doctor’s supervision, they function much like a Methadone clinic. You just pop in a few times a day and get whatever you need to keep going. It’s regulated and no one overdoses.

But that’s Europe — the United States is a different beast. Needle exchanges are still mired in controversy, with beach cities in California suing to keep needle exchanges out. Meanwhile, the Department of Justice just warned cities that any attempt to open sanctioned safe injection facilities will be thwarted. Government prescribed heroin any time soon seems unlikely.

Back at Parrilla’s pad, he and his girlfriend, Kayla, prep their shots. One of the neighborhood dealers, they say, has started touting the purity of his dope. “[It’s] his big advertisement!” Kayla says. “He’s like there’s not a pinch of fentanyl in here — and I’m like yes there is!”

Adds Tony, “It gets in there before you put it in!”

Parilla lives in a pre-war walk up in the North Bronx. It’s not exactly clean, but it’s not a shooting gallery — with the posters on the room you could mistake it for a dorm room, except for the orange needle caps littering a table. Dexter plays in the background. Kayla, 25 years his junior, is a stripper, with a bit of a Fairuz-Balk-circa-1996 vibe and a smile with just a bit of baby fat around the edges. She’s incredibly sensitive, she says, and started using heroin to self-medicate.

“I’m a very emotional person. I’ll cry if you stub your toe. For once I don’t have to feel that,” she says. “I don’t like the feeling. It changes the mood in the room.”

And yet, using heroin, you’re always on your toes, worried someone is going to overdose. “The point of doing a downer is to relax,” she says. “You’d rather just do it alone at that point.”

I ask if they have naloxone in the house. Yes, they say, looking around the room. But neither of them know exactly where they left it.

 

Correction: This story previously stated that bags of pure fentanyl are being found in Philadelphia. The bags are diluted fentanyl, but still do not contain heroin. 

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