Inmates in the women’s cellblock at the Fayette County Jail in Washington Court House, Ohio, a state hit hard by the country’s fentanyl crisis. FIGHTING FENTANYL Trump called the opioid epidemic a priority, but fentanyl deaths soar as resources fail to keep pace scroll down Warning: This graphic requires JavaScript. Please enable JavaScript for the best experience.

— In a dungeon-like jail in the center of this depressed farming town, 18 women in orange-and-white-striped prison uniforms are crammed into a two-story cellblock. Many of them are withdrawing from fentanyl.

The jail, built in 1884 to hold 24, now houses 55 men and women, a number that can swell to as many as 90. The inmates are sprawled on metal bunk beds and mattresses that line the floors as they wait for court appearances or serve time on low-level drug offenses.

The medical exam room, used to treat minor ailments, is tucked into a broom closet beneath a concrete stairwell. With few drug treatment options, prisoners strung out on fentanyl go through days of withdrawal with little help, shivering and curled up on the beds and floors of the jail.

“It’s definitely our detox center right now. They just sit there, and they withdraw there,” Fayette County Deputy Health Commissioner Leigh N. Cannon said. “Treatment is where we need help. We keep hearing that money is coming, but we haven’t really seen it.”

The inmates here are at least alive — unlike so many drug users in this part of central Ohio, 40 miles southwest of Columbus. Fayette County has the seventh-highest number of fentanyl overdose deaths per capita in the nation, according to internal data from the Centers for Disease Control and Prevention obtained and analyzed by The Washington Post.

While the Trump administration has made the opioid epidemic a priority, people in communities across the country continue to die in record numbers from fentanyl, and health officials are struggling to provide treatment for tens of thousands more, like the men and women warehoused inside this jail.

President Trump has taken a number of steps to confront the crisis, stem the flow of fentanyl into the country from China and Mexico, and step up prosecutions of traffickers. Congress also has increased spending on drug treatment.

“Everyone here today is united by the same vital goal — to liberate our fellow Americans from the grip of drug addiction and to end the opioid crisis once and for all,” Trump said at a drug abuse summit in Atlanta on April 24. “It’s happening. It’s happening.”

But health policy experts say drug treatment funding is not nearly enough, and the administration’s response was hobbled by the failure to appoint a drug czar in its chaotic first year and confusion over who was in charge of drug policy. The depth of the problem continues to overwhelm the government’s response, and the administration has yet to produce a comprehensive strategy that is legally required by Congress.

John P. Walters, director of the White House Office of National Drug Control Policy during the George W. Bush administration, said that after two years and a presidential commission to study the problem, the Trump administration is still struggling to confront the deadliest drug crisis in U.S. history and is not dedicating nearly enough federal resources.

“What other threat that is preventable is going to kill tens of thousands of Americans?” Walters said. “We’re spending much more money on terrorism, as we should, but we’re not spending a similar amount on the source of death to many more Americans right now.”

[Have you lost a family member or loved one to a fentanyl-related overdose? Tell us about them.]

In 2017, the first year of the Trump presidency, a record 28,869 people died from synthetic-opioid-related overdoses, a 46.4 percent increase from the year before. Most were from fentanyl, which is 50 times more powerful than heroin. Estimates for the first eight months of 2018, the most recent available, show that an additional 20,537 Americans died — a toll on pace to exceed the previous year’s.

“The scale of death here is really unprecedented, and so you have to judge the response against the scale of the problem,” said Joshua M. Sharfstein, vice dean at the Johns Hopkins Bloomberg School of Public Health. “You can have some progress, but it’s really insufficient if you are not up to the scale of the problem.”

Sharfstein and other public health experts also note that the administration is seeking to repeal the Affordable Care Act and cut $1.5 trillion over 10 years from Medicaid. More than 500,000 people addicted to opioids could lose their drug treatment coverage if the ACA is repealed, according to the Kaiser Family Foundation. The proposed Medicaid cuts could further reduce coverage.

Trump officials said they are making progress against the epidemic on a range of fronts, including interdiction, prosecution and treatment, but they acknowledge that it remains a huge challenge.

“We didn’t get into this crisis overnight. We’re not going to get out overnight,” Kellyanne Conway, counselor to the president and the administration’s leading voice on the epidemic, said in an interview.

Conway said Trump views his handling of the crisis as a “legacy issue” and continually asks her for updates about what is taking place in the states.

“It can’t all be gloom and doom. You can’t just have the negative, harrowing, so-sad statistics of grief and loss and devastation. We have to start talking about solutions,” she said. “The battleship is starting to turn in the other direction.”

Highest annual rate of synthetic opioid deaths Cabell County, W.Va. 62.9 Baltimore City, Md. 40.8 Montgomery County, Ohio 36.3 Berkeley County, W.Va. 31.1 Harrison County, Ky. 30.0 Clark County, Ohio 28.6 Fayette County, Ohio 28.5 St. Louis City, Mo. 26.2 Butler County, Ohio 25.7 Hamilton County, Ohio 24.8 Note: Death rates are a per-year average, per 100,000 people from 2013-2017 • Source: Washington Post analysis of CDC data

The CDC data obtained by The Post documents for the first time the 10 places with the highest per capita fentanyl-related overdose death rates: five counties in Ohio, two in West Virginia and one in Kentucky and the cities of Baltimore and St. Louis. Local health officials told The Post they are still not receiving enough federal money to fund drug treatment programs to wean people off highly addictive opioids or launch prevention programs to warn people of the dangers of fentanyl.

In Cabell County, W.Va., the county with the highest fentanyl overdose death rate in the nation, there are long waiting lists for treatment.

“When somebody is saying, ‘I’m ready for treatment’ and they want help, they shouldn’t have to wait six months, six weeks or six days,” said Steve Williams, mayor of Huntington, the county seat of Cabell. “They should be able to get in a treatment program within six hours.”

In Ohio, deaths from fentanyl have ravaged vast sections of the state. In 2015, there were 1,255 synthetic-opioid-related deaths, most from fentanyl. By the end of 2017, that number had nearly tripled to 3,572.

In rural counties of Ohio, federal money recently appropriated by Congress has started to arrive, but health officials there say it is not enough.

“The situation four years ago was looking desperate. Today, it’s looking dire,” said Scott Gehring, president of the Community Health Alliance, a drug treatment facility in Butler County, Ohio, which has the ninth-highest fentanyl overdose death rate in the nation. “People are sicker. More people are dying.”

Between January and April 2017, 9,442 people died from fentanyl and other synthetic opioids. Elizabeth Loranzo, 25, a mother and beautician from Middletown, Pa., was one of them.

‘Let’s do it’

Between January and April 2017, 9,442 people died from fentanyl and other synthetic opioids. Elizabeth Loranzo, 25, a mother and beautician from Middletown, Pa., was one of them.

In the run-up to the 2016 presidential election, Trump promised to halt the flow of heroin into the United States. He mentioned that drug, not fentanyl, at least 57 times during his speeches and appearances, and he tied the crisis to the need to build a wall along the border with Mexico. On the campaign trail, Trump was moved by the people he met who had lost family members to the epidemic, Conway said. As he left one stop, someone called out: “Please follow through on the drugs and opioids. You promised.”

Trump also said addiction was a deeply personal issue for him. His older brother, Fred Jr., who suffered from alcoholism, died in 1981 at age 43.

On March 29, 2017, two months after his inauguration, Trump invited then-New Jersey Gov. Chris Christie to the White House.

Christie had told Trump that his administration was inheriting an out-of-control opioid epidemic that blew up with the arrival of fentanyl during the Obama administration — between 2013 and 2017, more than 67,000 people died from the synthetic drug.

The opioid epidemic had begun in the late 1990s when a generation of Americans became addicted to prescription pain pills. After the government started to crack down on doctors, pain clinics, and drug manufacturers and distributors in the mid-2000s, addicts turned to heroin and then fentanyl.

[What you need to know about fentanyl]

In just a few years, the synthetic painkiller became the deadliest drug ever to hit U.S. streets. Manufactured in Chinese and Mexican labs, illicit fentanyl has played a significant role in reducing the overall life expectancy of Americans. It is so powerful, just a few flecks the size of grains of salt can cause acute respiratory failure and rapid death.

Obama administration officials were slow to address the fentanyl epidemic. The administration saw fentanyl as an add-on to the overall opioid crisis, rather than a singular danger that required a strategy of its own because it was so deadly and was coming into the country largely unimpeded through the mail. Senior White House and Justice Department officials, motivated by a desire to rectify racial inequality in sentencing, emphasized drug treatment over incarceration, and drug prosecutions fell off as fentanyl coursed through sections of the country.

Fayette County Sheriff Vernon P. Stanforth opens the door to the women’s facility in April at the county jail, where inmates often go through withdrawal from drugs such as fentanyl. The county has the seventh-highest number of fentanyl-related overdose deaths per capita in the nation, according to CDC data. Fayette County Sheriff Vernon P. Stanforth opens the door to the women’s facility in April at the county jail, where inmates often go through withdrawal from drugs such as fentanyl. The county has the seventh-highest number of fentanyl-related overdose deaths per capita in the nation, according to CDC data.

By the time Trump came into office, the dangers of fentanyl were well known. The Drug Enforcement Administration and the CDC had issued numerous warnings. The fatal overdose rate was staggering.

“I said to [Trump] that I thought there was a lack of urgency to the way President Obama’s administration had dealt with this issue, and that as a result, the problem had gotten worse,” Christie recalled in an interview. “We needed to go after this in a really aggressive way.”

Trump signed an executive order establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis.

He put the New Jersey governor in charge.

“Let’s do it,” the president told Christie that day.

Between May and August 2017, an additional 9,487 people died from fentanyl and other synthetic opioids. Matthew Sutton, 39, a barber from Pasadena, Md., was one of them.

A dramatic moment

Between May and August 2017, an additional 9,487 people died from fentanyl and other synthetic opioids. Matthew Sutton, 39, a barber from Pasadena, Md., was one of them.

At the Justice Department, Trump’s first attorney general, Jeff Sessions, launched his own assault on fentanyl.

For Sessions, fentanyl could be met only by the kind of tough law-and-order tactics he deployed as a federal prosecutor in Alabama during the “War on Drugs” of the 1980s and 1990s. While a member of the U.S. Senate for 20 years, Sessions was one of the few lawmakers to rail against bipartisan efforts to roll back the harsh drug sentencing policies of that era.

Sessions promised to make fentanyl a signature issue after his first trip to New Hampshire, a state that had experienced one of the highest fentanyl-related death rates in the country. He attended a “youth summit” on opioids at Manchester’s downtown arena with Gov. Chris Sununu (R) on March 7, 2017.

“One of the most dramatic moments for me was the first trip to New Hampshire where Governor Sununu had 8,000 high school students gathered and 50 mothers stood before them holding large pictures of their children who died from drug overdoses,” Sessions said in an interview.

On May 12 that year, in one of his first actions, Sessions reversed what had become known as the “Holder Memo.” The 2013 document written by then-Attorney General Eric H. Holder Jr. directed federal prosecutors to stop pursuing low-level, nonviolent drug charges that would trigger mandatory minimum prison sentences. Over decades, U.S. drug policy had resulted in long prison terms and increased incarceration for first-time offenders, most of them young black men, and Holder wanted to reverse what he saw as a historic injustice.

A deputy sheriff removes an inmate’s belt at the Fayette County Jail in April. The Ohio facility, built for 24 people, now houses 55 men and women but sometimes holds as many as 90.

Sessions directed his prosecutors to give high priority to drug cases, particularly aiming at fentanyl. Those found guilty would face the most severe penalties possible, according to a memo he sent to each U.S. attorney.

In July 2017, the Justice Department shut down the largest dark-web distributor of illicit drugs. Called AlphaBay, the site allowed users to sell and buy drugs, including fentanyl. At the time of the takedown, there were 250,000 listings for illegal drugs and toxic chemicals on the site, according to the Justice Department.

That fall, the department brought its first criminal charges against Chinese nationals accused of selling fentanyl to Americans over the Internet in cases that were filed in federal courts in North Dakota and Mississippi.

Sessions used an emergency declaration to make all chemical variants of fentanyl, known as analogues, illegal on a temporary basis; Congress must pass legislation to make the ban permanent. Chinese and Mexican chemists and drug traffickers in the United States had been evading the law by tweaking the chemical compounds that make up fentanyl and producing products that don’t fit the precise chemical formula for a banned substance.

Sessions also ramped up federal prosecutions of all fentanyl offenses and sent additional prosecutors to 10 areas in the country with the highest number of overdoses.

Christie, however, was growing frustrated with Sessions’s exclusive focus on law enforcement actions. He said he called the attorney general several times, inviting him to speak at the commission’s public hearings. Instead, Sessions sent his deputy attorney general.

Sessions said he has long believed in prevention and treatment programs, but as the attorney general, he was responsible for focusing on drug trafficking cases.

“I didn’t find him helpful at all on the issue,” Christie said. “He only had one tune, which was enforcement. He didn’t want to talk about the other parts of the issue. I wanted him to engage on treatment, on drug courts, and he had no interest in engaging in that. So, after a while, I just stopped calling because, what was the use?

“He was a one-trick pony.”

Between September and December 2017, an additional 9,940 people died from fentanyl and other synthetic opioids. Samantha Huntley, 20, a tanning salon employee from Springfield, Mo., was one of them.

‘Reinventing the wheel’

Between September and December 2017, an additional 9,940 people died from fentanyl and other synthetic opioids. Samantha Huntley, 20, a tanning salon employee from Springfield, Mo., was one of them.

During Trump’s first months in office, the administration shunted aside its White House Office of National Drug Control Policy. The office, whose director is known as the “drug czar,” is responsible for coordinating anti-drug efforts across 16 federal agencies and producing the National Drug Control Strategy, an annual drug policy plan mandated by Congress.

Former Trump administration officials said the White House did not trust the career staffers at the office. One former official, who spoke on the condition of anonymity to discuss internal deliberations, said the president and his aides wanted to “transcend the drug czar” and “raise the issue to a higher level.”

White House officials treated the drug czar’s office as a backwater. They staffed it with political operatives who had little or no drug policy experience and installed a 24-year-old campaign worker as the deputy chief of staff. Senior staffers with years of experience were sidelined. In May 2017, the administration proposed cutting the office’s budget by 95 percent.

Ohio’s Butler County has the ninth-highest number of fentanyl-related overdose deaths per capita in the United States, according to CDC data. Four other Ohio counties are in the top 10.

No one was immediately nominated to become the drug czar. As the Trump presidency entered its seventh month, there was no permanent official in charge of coordinating drug policy across myriad federal agencies — the CDC, the National Institute on Drug Abuse, the Justice Department and the Department of Homeland Security.

Lawmakers on Capitol Hill were growing impatient with the administration’s lack of plans to confront the opioid epidemic. On July 26, the House Oversight and Reform Committee summoned then-acting drug czar Richard Baum, who had been in his job for four months, to explain why he had not submitted a comprehensive plan to operate and fund the office.

“Any idea when it might be submitted?” Rep. Gerald E. Connolly (D-Va.) asked Baum.

“I don’t want to give you a timeline,” Baum replied. “But I can tell you this. I’ve studied the issue very closely.”

“Likewise, we need a strategy,” Connolly said. “Any idea when a strategy will be submitted to the Congress?”

“We’re developing a strategy now,” Baum said.

The opioid overdose death rate, by then almost entirely fueled by illicit fentanyl, continued to climb. In 2017, fentanyl for the first time became the leading cause of overdose deaths in America.

On Sept. 1, Trump nominated Rep. Tom Marino (R-Pa.) to be his first permanent White House drug czar. Marino, a former prosecutor, had been one of Trump’s earliest and most ardent supporters in Congress.

But Marino’s nomination quickly fell apart. A joint investigation by The Post and “60 Minutes” disclosed that Marino had close ties to the opioid industry. The investigation found that the congressman had sponsored legislation that made it harder for the DEA to penalize drug distributors and manufacturers when they failed to report suspicious orders and shipments of narcotics.

On Oct. 17, a little more than a month after his nomination, Marino withdrew, creating even more uncertainty within the drug czar’s office.

Amanda Busa, 27, jokes with her fiance, Jason Mitchell, at her daughter’s softball game in Frankfort, Ohio, in April. She is in recovery after years of addiction, which began with pain pills and fentanyl patches. “This disease is real,” she says. “People are dying.”

A week later, Trump mentioned fentanyl publicly for the first time as president; he had been in office for nine months. Trump also took Christie’s advice by declaring the opioid crisis to be a public health emergency — a step Obama officials had decided not to take in May 2016, when health policy experts asked for the declaration for fentanyl.

“As Americans, we cannot allow this to continue,” Trump said in an Oct. 26, 2017, White House speech. “It is time to liberate our communities from this scourge of drug addiction. Never been this way. We can be the generation that ends the opioid epidemic.”

But two things were missing: money and a detailed plan.

“When you say this is an emergency, you would expect to hear what they plan to do about the emergency,” said Andrew Kolodny, co-director of opioid policy research at Brandeis University. “When President Trump designated the opioid crisis a public health emergency, at the very same time, he should have said, ‘Here’s what we’re going to do about it,’ and put out a detailed plan outlining what every federal agency was going to do.”

A top Trump official would later testify before Congress that the public health declaration was intended “to bring awareness.”

On Nov. 1, Christie’s commission released its final report, with 56 recommendations on the opioid crisis. Some drug policy experts criticized the commission for taking too long and repackaging old ideas instead of crafting a new strategy.

“They spent a year reinventing the wheel on opioid policy with things we already knew,” said Andrew Kessler, a policy consultant who specializes in behavioral health. “It’s all been recommended before.”

Some health policy experts said the report, while not groundbreaking, did provide a blueprint for the Trump administration to follow.

It called for launching an anti-opioid public relations campaign, providing more funding for drug treatment and continuing to target traffickers. The report also called for access to medicine designed to wean people off opioids and to naloxone, an expensive medication that reverses overdoses.

Whitney Millay, second from right, heads into a residential recovery facility in Washington Court House, the only one for women in Fayette County, in April. She says she overdosed 10 times on fentanyl. “It was a fine line between oblivion and death,” Millay says.

Christie said the commission’s work was an important start.

“I think we have to understand the fact that even the steps that we take today, as aggressive as they are compared to where we were, it’s still going to take time to catch up with the problem,” Christie said. “Fentanyl deaths going higher are completely predictable because fentanyl is so much stronger and more lethal than street heroin.”

One of the six members of the commission, former congressman Patrick J. Kennedy (D-R.I.), a recovering addict, said he was disappointed that Trump did not do more to promote the report.

“We just never got the president to really give it the firepower and to elevate it,” Kennedy said in an interview.

He also hoped that Trump would use the report to press Congress for significant funding to fight the opioid epidemic, comparable to the $28 billion the federal government spends each year to fight the HIV/AIDS epidemic in the United States.

Another member, Bertha Madras, said she was proud of the work. While she understood the importance of getting buy-in from the federal agencies, she was frustrated by the amount of time it took. The commission had to wait several months for officials to respond to the recommendations before the report could be issued, she said.

“In the meanwhile, people are dying, and that’s haunted me,” said Madras, a Harvard Medical School professor who served in the drug czar’s office during the George W. Bush administration.

Between January and April 2018, an additional 10,017 people died from fentanyl and other synthetic opioids. Amanda Gray, 24, a psychology student from Manhasset, N.Y., was one of them.

‘Keep the damn drugs out’

Between January and April 2018, an additional 10,017 people died from fentanyl and other synthetic opioids. Amanda Gray, 24, a psychology student from Manhasset, N.Y., was one of them.

The White House drug czar’s office was still leaderless when Christie’s commission issued its report in November 2017. A few weeks later, Trump named Conway, a former Republican Party pollster, to be his point person on the opioid epidemic. A highly skilled political operative with no drug policy experience, Conway was now in charge of coordinating the government’s response to the epidemic.

She was particularly drawn to the issue after seeing devastated families on the 2016 presidential campaign trail and the toll the epidemic had taken in places like Ohio, Pennsylvania and New Hampshire. She also had attended the public hearings held by Christie’s commission.

“There was such a sense of urgency to literally stop the bleeding and try to stem the losses that people were feeling, that we worked as hard as we could work, as assiduously and as quickly as we could to get our arms around, ‘Why now, why this?’ ” Conway said.

The epidemic was a key issue in important swing states. The Journal of the American Medical Association found a correlation between chronic use of prescription painkillers and regions that supported Trump. Medicare reimbursements for opioid prescriptions also documented the epidemic’s disproportionate impact on areas where Trump polled well.

“Counties and states with the highest opioid use were often areas carried by the Republican candidate,” the researchers found. “In many areas with high rates of drug overdose, voter turnout in 2016 exceeded that in 2012, with Donald Trump overwhelmingly favored.”

As Conway took control of the opioid issue, confusion spread within the drug czar’s office and across the government, according to former staffers who spoke on the condition of anonymity because they feared reprisals from the administration. Staffers in the office said they would frequently field calls from other agencies and congressional offices, requesting direction on how to increase funding for treatment or how to launch anti-opioid public education campaigns. They said they had no authority to make decisions on their own, and the queries languished.

Conway said their criticism was unfounded.

“Some of the career people there, respectfully, should be really excited to finally have an administration who cares enough to try to break the back of the worst drug crisis in our nation’s history,” Conway said.

On March 19, 2018, Trump and Sessions traveled to Manchester, N.H., to highlight the fight against opioids. The president told the crowd gathered at Manchester Community College that Congress was working on legislation that would set aside billions to fight the epidemic. He said he planned to increase funding to develop nonaddictive painkillers. He also said he was working to shut down illegal online marketplaces to block fentanyl coming in from China.

What he said next overshadowed his other remarks.

“Drug traffickers kill so many thousands of our citizens every year,” Trump said. “And that’s why my Department of Justice will be seeking so many much tougher penalties than we’ve ever had, and we will be focusing on the penalty that I talked about previously for the big pushers, the ones that are really killing so many people. And that penalty is going to be the death penalty.”

As he did on the campaign trail, Trump then tied the epidemic — and his drug strategy — to immigration at the southern border.

Sheriff Richard K. Jones of Butler County, Ohio, says too much money is being spent on drug treatment programs and not enough on drug prevention and education. “Any politician who says we’re winning this battle with drugs is telling you a lie,” he says.

“Ninety percent of the heroin in America comes from our southern border, where, eventually, the Democrats will agree with us, and we’ll build the wall to keep the damn drugs out,” he said.

“Build that wall! Build that wall! Build that wall!” the audience chanted.

DEA officials have said that most of the fentanyl pouring into the United States is coming from China through the U.S. Postal Service and overnight express services. The majority of Mexican heroin and fentanyl is concealed in cars and tractor-trailers that come into the United States through legal ports of entry along the southern border, according to a 2018 DEA National Drug Threat Assessment. Federal agents say they are also seizing increasing amounts of fentanyl that is coming across the border between the legal ports of entry.

The day after the Manchester speech, Sessions directed his prosecutors to pursue the death penalty against major drug traffickers.

As Trump was calling for the death penalty, one of the cities that had a high fentanyl overdose death rate was running out of money to purchase naloxone, an overdose reversal drug. In Baltimore, fentanyl deaths had risen by nearly 5,000 percent between 2013 and 2017, and the death toll was continuing to climb.

Leana Wen, the health commissioner in Baltimore at the time, had to choose who could receive the lifesaving medicine.

“We are rationing the medication that would save people’s lives at the moment that they’re overdosing,” Wen recalled in a recent interview. “How is that possible?”

In a May 3, 2018, letter to Conway, Wen pleaded with the Trump administration to use its influence to lower the price of naloxone. The brand name of the drug, Narcan, cost $75 for two doses. In the previous three years, naloxone had reversed more than 10,000 overdoses in Baltimore, Wen said.

“We request that the Trump Administration establish a national program to procure naloxone treatments and supply them to state and local health and law enforcement programs,” the letter said.

“Nothing happened,” Wen said. “We never heard back.”

Conway said she never saw the letter.

Between May and August 2018, an additional 10,520 people died from fentanyl and other synthetic opioids, the most recent time period for which CDC data is available. Colton Gutknecht, 20, a fashion design student from Peoria, Ariz., was one of them.

‘It’s all fentanyl now’

Between May and August 2018, an additional 10,520 people died from fentanyl and other synthetic opioids, the most recent time period for which CDC data is available. Colton Gutknecht, 20, a fashion design student from Peoria, Ariz., was one of them.

Several nights a week, Christine Birhanzl drives the streets of Hamilton, a former paper and steel mill town in southwestern Ohio, handing out blankets, food and clothes to addicts.

Birhanzl is a recovering addict herself. She is now a director at Sojourner Recovery Services, a treatment facility in Butler County. One man she tried to help was James Proffit, 40, who had lived on the streets for years. His path to fentanyl was typical. He started by taking large doses of OxyContin and then turned to heroin, not knowing it had been laced with fentanyl.

James Proffit smokes a cigarette at a Sojourner Recovery Services treatment facility in Hamilton, Ohio, in April. Proffit had overdosed four times before seeking treatment and has been in recovery since February.

“It’s all fentanyl now,” Proffit said in an interview. “The county is flooded with fentanyl.”

He overdosed four times but kept using.

“It takes all the pain away,” Proffit said. “You get numb, and you don’t feel nothing. That lasts about five hours, and then it starts to wear down, you get cold chills, start cramping up and get sore. And then you have to do it again.”

Birhanzl finally succeeded in getting Proffit help, but only because he was arrested and faced the prospect of six months in jail. He remembered meeting Birhanzl on the street and how she tried to convince him to seek treatment. He asked the judge whether he could get into her program.

“Christine was my guardian angel,” said Proffit, who has been clean since February. “She never gave up on me. They turned me around 180 degrees.”

Medicaid paid for his stay at Sojourner Recovery Services. Ohio was one of the states that expanded Medicaid under the ACA — also known as Obamacare — which covers drug treatment for thousands like Proffit.

Last August, four cities sued the administration for undermining the act. The cities — Baltimore, Chicago, Cincinnati and Columbus, Ohio — accused the administration of actively discouraging enrollment, raising rates and limiting health-care services.

In March, the Justice Department sided with 20 Republican-led states seeking to invalidate the entire act as unconstitutional. Trump then said Senate GOP leaders were writing legislation to repeal and replace the ACA. But Republicans quickly signaled that they had little appetite for raising an explosive issue just as the 2020 political season was getting underway.

Proffit waits in line to take his daily medication at the Sojourner treatment facility. He works on an application for the next phase of the drug treatment program. Proffit waits in line to take his daily medication at the Sojourner treatment facility. He works on an application for the next phase of the drug treatment program.

That same month, the White House proposed slashing Medicaid by $1.5 trillion over 10 years, which could further undercut drug treatment coverage nationwide.

Trump’s assistant secretary for health, Adm. Brett P. Giroir, said if Medicaid is cut and the ACA is declared unconstitutional, those programs would have to be replaced so tens of thousands would not be left without coverage.

“If you did something like eliminated coverage for everyone, that would not certainly be positive, unless it’s replaced with something that provided equal or more coverage,” said Giroir, senior opioid adviser to the secretary of the Department of Health and Human Services.

In Ohio, fentanyl is ravaging parts of the state and “overwhelming the system,” Sen. Rob Portman (R-Ohio) said in an interview.

While the overall drug overdose death toll declined by 21 percent in the state between 2017 and 2018, deaths from fentanyl continue to rise. The senator has sponsored legislation to increase federal funding to help the hardest-hit areas of the country. Since 2017, Ohio has received $140 million from the federal government, but he said he knows it’s not enough.

“I’m just trying to fight to keep the funding increasing every year,” Portman said. “I got some pushback from some of my colleagues on the Republican side of the issue, saying, ‘Where’s the money coming from?’ I said, ‘This is a crisis. This is a national emergency.’ ”

In Clark County, outside Dayton, fentanyl overdoses are fueling large cost overruns for government services — foster care, paramedics and police.

“It’s very stressful for my deputies. They’re seeing more death than they’ve ever seen,” said Deborah K. Burchett, the sheriff of Clark County, which had the sixth-highest fentanyl overdose death rate in the nation. “Our biggest problem is, our drug addicts also have mental health problems, and all the hospitals have been closed. They all wind up in the jail.”

Proffit reads a book about drug recovery in his room at the treatment facility.

Health-care officials and drug treatment experts in Clark County say they are starting to see drug treatment money from Washington, but more is needed. Ending the ACA or cutting Medicaid, they said, would be disastrous.

“I can’t even imagine a world like that,” said Greta Mayer, who runs the Mental Health & Recovery Board of Clark, Greene and Madison Counties in Ohio. “All of what we’ve gained would be lost.”

TK TK

‘We’ve got to move quickly’

On Jan. 2, 2019, the Senate confirmed James W. Carroll Jr. to be Trump’s first permanent drug czar. A former Washington-based counsel to the Ford Motor Co., Carroll had served as Trump’s deputy chief of staff. It had been two years since Trump took office.

On Jan. 2, 2019, the Senate confirmed James W. Carroll Jr. to be Trump’s first permanent drug czar. A former Washington-based counsel to the Ford Motor Co., Carroll had served as Trump’s deputy chief of staff. It had been two years since Trump took office.

“You’ve got the worst drug crisis we’ve had ever, and it takes you two years to get somebody in the White House who wakes up every day thinking about the problems?” said Keith Humphreys, who served as a drug policy adviser to the George W. Bush and Obama administrations. “That to me is just an astounding dereliction of duty.”

Carroll, who had been appointed acting drug czar in February 2018, disputed that characterization and said the administration has taken numerous steps to combat the opioid crisis. He noted that the drug czar’s office is only one of several agencies that are trying to battle the epidemic and that he is in close contact with them. Despite the repeated attempts by the Office of Management and Budget to slash his budget, Carroll said he has the full support of the White House. He also said he has proposed spending an additional $1.3 billion on anti-drug efforts.

“This is a priority for the president,” Carroll said in an interview.

He acknowledged that the government needs to spend more money and move faster.

“I am fiscally conservative, but I also believe that it’s going to require more of a financial investment, spent wisely, to get our arms around this,” he said. “We’ve got to move quickly.”

A man at the entrance of Baltimore’s Penn-North Metro station in April snorts fentanyl, according to the man who gave it to him, from a credit card. He was standing a few feet from where members of a nonprofit, Bmore Power, were handing out free doses of Narcan, an opioid reversal medication. The man was asked for his name but did not provide it.

Conway agreed and said the administration is making important strides.

She pointed out that the administration had launched an opioid prevention ad campaign. Dogs are being trained to detect fentanyl at ports of entry. Congress directed the U.S. Postal Service to start electronically tracking packages from foreign countries. The CDC has begun improving overdose collection data to provide a clearer picture of what is happening on the ground. The administration has formed an “opioid cabinet” with representatives from key government agencies, and Conway said they secured an additional $6 billion from Congress to combat the crisis.

Trump also signed a bipartisan legislative package weeks before the 2018 midterm election that creates, expands and renews programs designed to fight the epidemic.

Last month, the president secured a promise from Chinese President Xi Jinping to ban all variants of fentanyl, although government officials said it is too early to tell whether the Chinese government will follow through amid the escalating trade war.

For Rep. Elijah E. Cummings (D-Md.), the fentanyl epidemic has hit home; he has represented Baltimore both in the state capital and in Washington for the past 36 years. He has introduced legislation that calls for spending $100 billion to combat the opioid epidemic.

While the fentanyl epidemic has mostly affected white Americans, the drug is increasingly claiming more African American lives in cities like Washington, Philadelphia, St. Louis and Baltimore. Between 2013 and 2017, 1,261 people died from fentanyl overdoses in Baltimore, which has the second-highest number of fentanyl-related overdose deaths per capita in the country. The Maryland Department of Health found that an additional 566 people died in the first nine months of 2018, the most recently available data for the city. That far exceeds the number of homicides committed during the entire year, when 309 people were murdered in Baltimore.

At a Metro stop in West Baltimore recently, down the block from an open-air drug market, members of the nonprofit Bmore Power handed out free doses of Narcan. Steve Diggs, 47, said he had peddled drugs on the streets of the city for nearly 30 years. Now in recovery and working for the group, he and other former drug dealers and users are trying to prevent more deaths, which he said started to soar with the arrival of fentanyl in 2015.

Baltimore’s Penn-North Metro station sits in a section of the city known for heavy trafficking of heroin and fentanyl. Baltimore has the second-highest number of fentanyl-related overdose deaths per capita in the United States, according to CDC data.

“I’m just trying to help people on the streets,” Diggs said. “They trust me because I lived the life. I know what they’re going through.”

On March 7, Cummings, as the new chairman of the House Oversight and Reform Committee, summoned the White House’s newly confirmed drug czar to testify before his panel. He said he was angry it had taken Carroll so long to appear.

“Last year, I repeatedly asked for Mr. Carroll to testify before us as the acting director of [the drug czar’s office], but he refused,” Cummings said, listing the times Carroll had delayed appearing.

Cummings also was furious that the White House had not produced its National Drug Control Strategy to Congress. It was two years past the congressionally required deadline. Instead of submitting a strategy that normally consisted of more than 100 pages of detailed plans, Carroll had given the committee what Cummings called a 23-page “pamphlet” that did not outline specific goals or measurable objectives. At the hearing, Triana McNeil, a director of the Government Accountability Office, said the document failed to meet congressional requirements.

“The White House office charged with leading our nation’s efforts to combat the drug crisis has been missing in action as deaths continue to mount,” Cummings said. “The White House had no National Drug Control Strategy. None. None. All while tens of thousands of people were dying and the crisis was escalating every day.”

Carroll said he was personally committed to fighting the drug crisis, noting that a member of his own family was struggling with addiction.

“I want every family to have a success story that I really hope and pray that my family is having,” Carroll said.

Carroll also promised to provide the panel with a more complete drug strategy with “quantifiable metrics.” Two months later, on May 9, Carroll and McNeil returned to the committee. Carroll submitted several new documents, which he said met congressional requirements.

McNeil told the panel she had reviewed the documents and asked rhetorically whether the GAO could say that the drug czar’s office has finally produced the congressionally mandated drug strategy.

“Not at this time,” she testified.

A man huddles in an abandoned garage in a drug-riddled section of Baltimore’s Mount Vernon neighborhood in April. The man was asked for his name but did not provide it.