A young woman lies unconscious, propped against the wall of a drug detox center in Kensington, Philadelphia.

“She’s wasn’t breathing,” says Danielle, a 26-year-old woman wearing a baseball hat and jeans. “I found her half under a car. Somebody robbed her. They could have robbed her and called 911 …”

Paramedics arrive and administer Narcan, the nasal form of naloxone used to counter opioid overdoses. The woman comes round and refuses further treatment.

Minutes later, a man staggers and collapses. His breathing is shallow: the line between intoxication and overdose neared but not crossed. Paramedics get him back on his feet. It’s a grim dance, one that continues night and day in this rundown section of the city.



Laura, 28, another long-term addict who has made a home on Emerald Street, shoots six bags every few hours. Photograph: Edward Helmore/The Guardian

“It’s busiest at six in the morning when people are out trying to get a fix so they don’t get sick,” said Patrick Trainor, a special agent with the Philadelphia division of the Drug Enforcement Administration (DEA) who has monitored this neighborhood for two decades.

Kensington’s street users know Trainor – at least they know his unmarked car – and eye him warily. But it’s not DEA business to bust them, only to keep an eye on the narcotics reaching the streets. A surge in fatal overdoses, blamed on the powerful synthetic opioid fentanyl and its analogs, is shifting the decade-long opioid crisis from rural areas to cities.

Last week, the US Centers for Disease Control and Prevention (CDC) released figures indicating that a sharp rise in drug overdose deaths, which many attribute in part to fentanyl, is causing a drop in American life expectancy. Opioids killed almost 64,000 people in 2016. The figure for 2017 is likely to be higher again. In October, Donald Trump declared a public health emergency.

When fentanyl came on people didn’t know about it. They didn’t know what they were messing with. They OD-ing all over Danny

On the streets of Kensington, a crisis is taking shape that an anti-drug advertising campaign proposed by Trump may do little to ease.

“Fentanyl has drastically changed the landscape,” Trainor said. “Sixty-four percent of fatals in Philadelphia County are fentanyl-related. There’s no dope out here now, it’s all fentanyl. Even the old timers are scared of it.”

In Kensington, many addicts congregate in a small park. It has become busier since authorities fenced off and filled in “the Tracks”, an aptly named encampment near train lines where residents once set up tables and mirrors to aid fixing in the neck. Others moved to an underpass on Emerald Street, known as Emerald City.

In either area, even addicts now carry Narcan. It’s an optimistic gesture, but barely.

Nationally, over the past three years, fentanyl-related deaths have increased by 540%. For the first time, the majority of fatal overdoses are fentanyl-related, accounting for “nearly all the increases in drug overdose deaths from 2015 to 2016”, according to the Journal of the American Medical Association. In Philadelphia, a city previously known for pure and relatively inexpensive heroin, there have been nearly 800 fentanyl overdoses this year.

Used needles litter the ground in the Kensington section of Philadelphia on 2 February 2017. Photograph: Michael Bryant/AP

‘Dropping like flies’

The drug behind this surge in fatalities has been used by anesthesiologists for decades. Several years ago, the DEA noticed illicitly produced fentanyl appearing as a cut for low-quality Mexican heroin. Then the agency began seeing fentanyl itself, originating from labs in China and Mexico.

What started as a trickle is now a flood. Up and down the eastern seaboard, fentanyl seizures are soaring. Unlike heroin, which has a raw opium base that must be harvested in remote mountain valleys, fentanyl is made in clandestine labs using relatively inexpensive chemicals.

About 80% of fentanyl seized in the New York area appears to be linked to Mexico’s Sinaloa cartel. In Philadelphia, the drug is more likely to have come from labs in China, some of it shipped through Mexico.

Fentanyl in a hospital. Photograph: Joe Amon/Denver Post via Getty Images

In November, Trump warned Chinese leaders over the production of fentanyl. The attorney general, Jeff Sessions, traveled to New York’s JFK airport, to meet customs agents.

“With synthetic drugs flooding our streets, drugs are now more powerful, more addictive and more dangerous than ever,” Sessions said. “Fentanyl is the number one killer drug in America. And as deadly as it is, you can go online and order it through the mail.”

Over four days last month, DEA seized 40kg of fentanyl from Dominican traffickers, all of it destined for the Philadelphia market, in Trainor’s words “an insane amount if you calculate each kilo yields 330,000 doses”. Local press reported that a single kilo was enough to kill half the residents in the county.

The economics of fentanyl trafficking are straightforward. The chemicals needed to produce a kilo cost no more than $5,000 and there is no need to wait for the poppy harvest. At $55,000-$60,000 per kilo delivered, fentanyl is the about the same price as heroin but yields far more once it is cut and packaged for the street.

There’s no greater endorsement for a trafficker than when his product kills somebody. That’s not mythology Patrick Trainor, DEA

“You’re paying the same for something that’s roughly 100 times more powerful, so why would you buy heroin?’ Trainor said. “The demand is for the most powerful thing they can get. Heroin will never be able to compete with fentanyl. It just can’t.”

Customers, however, are dying. Danny, a long-term Kensington drug user, said high OD rates were initially caused by dealers not knowing how to handle fentanyl. According to police one brand, AK-47, caused nine deaths in 36 hours and was part of a batch that left 35 people dead.

“When fentanyl came on people didn’t know about it,” Danny said. “They didn’t know what they were messing with. They OD-ing all over. Once the dealers saw people dropping like flies, they were going, ‘Wow, we’re doing something wrong.’ Now they getting the cut right.

“Nowadays, if anyone’s dying its mostly visitors who just got out of jail or rehab. They think they can do three bags. They can’t … they’re done.”

Street dealers compete for customers, selling high-purity drugs.

“We’ve seen purity of heroin jump from 63 to 93%, which is insane,” said Trainor. “There’s no greater endorsement for a trafficker than when his product kills somebody. That’s not mythology. We see it all the time. We’ve had wiretaps of drug traffickers bragging how many people their drugs killed.”

Another longtime Kensington resident and addict, also named Danny, countered: “They blame the dealers but it ain’t them. The people are doing to themselves. It’s people coming down here from outta county thinking they can do whatever they want.”

Authorities only started to take notice, he said, when people starting coming to Kensington and dying: people from other neighborhoods, people with money, white, maybe politically connected. “When one of them kids from the other hoods OD, suddenly they make a big deal,” he said. “When it was just Kensington people they didn’t give a fuck …”

Kensington is a harsh place. For many women there, work means sex work. For men it’s pimping or, for the cost of a couple of $5 bags, acting as a guide to customers from elsewhere. Some sell Suboxone pills from legitimate prescriptions, or clean needles for a dollar each.

‘There’s no one person controlling it’

Besides fentanyl’s terrifying strength, two related factors are causing problems for the authorities: a lack of a dominant trafficker and the ease with which variants of the drug can be produced.

In the past, drugs coming into any area would probably be controlled by a single, relatively predictable trafficker or trafficking family. That’s not the case with fentanyl. It’s coming from China, ordered over the dark web, or coming up from Mexico.

“There’s no one person controlling it coming in, and there’s more than we know what to do with,” Trainor said.

You can kick heroin in five or six days but with fentanyl it takes 45 to 60 days … it's just worse Laura

Because it is synthetic, fentanyl is relatively simple to modify. Each subtle change in formulation keeps DEA analysts playing catch-up.

At the top end is carfentanil, used as a painkiller for elephants and other large mammals and estimated to be 10,000 times stronger than morphine. It’s still rare on the street but it has shown up in four ODs at the Philadelphia medical examiner’s office. A carfentanil overdose can take several doses of Narcan to counteract. Police and medics are warned that even touching carfentanil powder can cause intoxication.

“It used to be just fentanyl but now we’ve noticed eight different analogs in this area and around 40 nationally,” Trainor said. “Our chemists estimate there could be 200 additional variants.”



Fentanyl is marketed in stamped bags: White House, Dynamite, Colt 45. “Right now Colt 45 is the strongest thing,” said one Kensington resident struggling with active addiction. “It’s straight-up fentanyl. You can OD on half a bag.”

Whatever romanticism was ever associated with opium, or later morphine and heroin, it is lacking with fentanyl. It is painful to use because it burns the vein. Some choose to put the solution under the skin, despite an elevated risk of absesses, to reduce the risk of overdose and prolong the high.

Compared with heroin, addicts say, a fentanyl rush is intense and immediate. Overdoses come on almost instantaneously, the comedown is abrupt and withdrawal long and uncomfortable. Since tolerance builds up quickly, dependence escalates rapidly. The drug is so strong that a user who has overdosed can slip back under after the short-acting Narcan wears off.

Laura, 28, another long-term addict who has made a home on Emerald Street, shoots six bags every few hours.

“With fentanyl you get a strong rush but it dies away and you get sick,” she said. “The withdrawal is much different. You can kick heroin in five or six days but with fentanyl it takes 45 to 60 days. It’s longer, it’s the chemicals in it, and it’s just worse.”

Some addicts say fentanyl had convinced them to get into a programme. “I didn’t want to die,” said Michael, who recently entered a methadone programme. This could ultimately prove the silver lining to fentanyl’s devastating march – it’s ultimately just too strong and too dangerous to use.

“This is a very dangerous time for someone struggling with substance use disorder with all of the fatal overdoses that are occurring in Philadelphia,” said Trainor. “Law enforcement is increasingly working with public health and treatment agencies to address this crisis and to save lives, and that’s a win.”

