Fentanyl now kills more people in the US than any other drug. It seems to have started with 14 overdoses in Rhode Island in 2013.

DEA Fentanyl in powder form.

In retrospect, the 2013 arrests of 20-year-old Rhode Island heroin dealer Victor “Fat Boy” Burgos and his 19-year-old accomplice were the earliest warning signs that a wave of deadly synthetic opioids had hit the US black market. Between March and May 2013, the duo sold heroin laced with an unknown second drug. The tainted product led to the lethal overdoses of 14 people. “I am going to spend the rest of my life in jail because of all those overdose deaths,” Burgos told the mother of one witness to him selling the adulterated heroin, as the Providence Journal reported. After an investigation, Rhode Island health officials figured out the chemical identity of the mystery drug: a man-made, never-before-seen opioid called acetyl fentanyl. “Probably it was already in lots of places besides Rhode Island,” medical anthropologist Jennifer Carroll of Brown University told BuzzFeed News. “But that’s where we noticed it first.” Now five years later, fentanyl and its chemical cousins kill more people in the US than any other drug — accounting for around 20,000 deaths in 2016 and an estimated 25,000 in 2017. These synthetic drugs, used for decades in cancer and hospice care, are 30 to 50 times more potent than the plant-based heroin. In the last few years, fentanyl has been found lurking not only in heroin, but meth and cocaine, and drug users often have no idea how much, or whether, any fentanyl is in their illegal purchase. The story of how, exactly, fentanyl infiltrated the US illicit drug market remains murky, with blame bouncing from Mexico to China to Canada, depending on who’s asked. Regardless of where it started, the story of fentanyl’s spread helps explain the historic epidemic of overdoses that followed those Fat Boy cases five years ago. Soon after those deaths in Rhode Island, two more fatal overdoses turned up in Camden, New Jersey. Then one in Philadelphia, and another in Buffalo. By the end of June 2013, about 50 such deaths were tallied in Pennsylvania, all tied to acetyl fentanyl. By the end of the year, the Drug Enforcement Administration began noting fentanyl seizures in its reports. And nationwide crime lab reports of fentanyl jumped from about 677 cases in 2012 to 978 in 2013, an increase of 44%. Still, of the 26,000 fatal opioid overdoses in 2013, the vast majority came from heroin and prescription painkillers. The 3,105 deaths tied to fentanyl and other synthetic opioids was only slightly higher than previous years and didn’t raise any major red flags. Addiction experts had no idea of the fentanyl tsunami that was about to wash over the country.

US Overdose Deaths By Drug Type CDC / Via cdc.gov The numbers for 2017 are preliminary. The "Rx opioids" category does not include prescription drugs tainted with fentanyl or other synthetic opioids. Researchers say the recent rise in cocaine deaths is probably due to mixing or adulteration with fentanyl and other opioids.

2014 Ominous signs began cropping up all along the East Coast as 2014 began. In North Carolina, at least three deaths were caused by acetyl fentanyl in February. In Rhode Island, 52 deaths were blamed on fentanyl-laced heroin by March. And law enforcement officers in Ohio and Virginia reported that they'd encountered fentanyl more than 100 times in the previous year.

But at that point, public health experts were far more focused on a dramatic wave of heroin deaths. Because it takes a year or more for the CDC to compile death records from coroners across the country, in 2014 health officials were only just finalizing the heroin death numbers from 2012 — up 50% from 2010 in 28 states. Deadly opioid overdoses have come in three waves since the 1990s, according to medical epidemiologist Jay Unick of the University of Maryland, Baltimore County. In the first, from 1999 to 2010, overdoses quadrupled because of prescription pain pills. In the second, from 2011 to 2015, they doubled because of heroin. And in the last three years, they’ve skyrocketed further because of fentanyl and other synthetics. Although some suspect that fentanyl was also behind the increase in heroin deaths in that second wave, Unick said it’s more likely that illicit prescription pill users had switched over to heroin and then fentanyl, and fatally overdosed as a result. “Ultimately this is unknowable since we did not have good data on fentanyl before everyone started testing for it as they do now,” Unick told BuzzFeed News. By 2014, Unick speculates, the increased demand for heroin made it harder to get, leading drug dealers to stretch their supply by adding fentanyl. This idea is supported by the DEA’s 2014 data on drug seizures, showing that fentanyl was in the top-10 seized drugs in Boston, Baltimore, and Cincinnati. “So I am still hypothesizing that we have seen a perfect storm with the number of users increasing, and then what they are using becoming more dangerous,” Unick said. 2015

News articles mentioning "fentanyl" from 2014–2015 National Drug Early Warning System (NDEWS) / Via pub.lucidpress.com Articles per week, based on searches of the LexisNexis ALLNEWS database for "fentanyl."

What really opened public health experts’ eyes to fentanyl, CDC epidemiologist John Halpin told BuzzFeed News, was an investigation in Ohio in October 2015. As usual a year behind, the state reported 502 deaths in 2014 tied to fentanyl, a 500% increase from the year before. CDC investigators were dispatched to Columbus try and figure out what was going on. Most of these deaths were happening to younger men, unlike prescription painkiller deaths, which happen to middle-aged people. And the Ohio men who overdosed on fentanyl were significantly more likely to have been released from jail, a hospital, or a detox center, painting a picture of drug users who had accidentally ingested fentanyl while taking heroin. “It was sold as heroin, but it was fentanyl-laced heroin,” Halpin said.

Law Enforcement Reports Of Fentanyl: 2013 vs. 2015 CDC / Via cdc.gov Law enforcement encounters with fentanyl, based on reports from laboratories participating in the National Forensic Laboratory Information System. CDC / Via cdc.gov Law enforcement encounters with fentanyl, based on reports from laboratories participating in the National Forensic Laboratory Information System. ← Slide → Left : 2013 | Right : 2015 CDC / Via cdc.gov Law enforcement encounters with fentanyl, based on reports from laboratories participating in the National Forensic Laboratory Information System.

Two-thirds of the people who had overdosed had been prescribed opioid painkillers at some time in the past. That supported Unick’s picture of drug users turning from painkiller pills to heroin to fentanyl.

Asked where he suspects fentanyl came from, Halpin doesn’t know, but speculates that it was Canada. Starting in 2009, a widespread fentanyl problem started north of the border ahead of the US outbreak. From 2009 to 2014, Canada saw at least 1,019 fatal overdoses involving fentanyl, most in the last two of those years, according to the Canadian Community Epidemiology Network on Drug Use (CCENDU). The agency sent its first alert about fentanyl in 2013. Most of the deaths were in Ontario, a province bordering New England and Midwestern states that have seen the biggest influx of fentanyl.

If you ask Canadian experts, they don’t think their country triggered the US outbreak.

But if you ask Canadian experts, they don’t think their country triggered the US outbreak. The CCENDU’s Matthew Young points out that the Canadian overdoses were largely tied to counterfeit pain pills laced with fentanyl, rather than the tainted brown powder heroin seen in the US. (Most of the US heroin sold east of the Mississippi River is brown powder heroin from Colombia, easily adulterated with fentanyl, unlike sticky black tar heroin sold in Western states.) “It was really an unintended consequence of decreasing the supply of prescription painkillers,” Young told BuzzFeed News. The Canadian government began monitoring opioid prescriptions in 2010, and started medical education to urge doctors to prescribe less in the first place. Two years later, it halted sales of Oxycodone, a prescription painkiller prone to abuse. “People sought out a replacement and organized crime stepped in when they saw the opportunity with fentanyl,” Young said. “People were confident they were buying Oxycodone, and they weren’t, and the overdoses started spiking.” Young speculated that the same thing probably happened in the US with heroin. In 2015, the DEA started tallying up what kinds of synthetic opioids it was seizing. The CDC started asking more labs to test for fentanyl in overdose victims, and recommended public health agencies and paramedics distribute more naloxone, a drug that reverses opioid overdoses. Overall, more than 33,000 people died of opioid overdoses in the US in 2015, and 9,580 of them were caused by fentanyl and other synthetic opioids — a 72% increase from the year before. 2016

Bruce Taylor, New Hampshire State Police Forensic Lab A lethal dose of different kinds of opioids.

From 2015 to 2016, National Institute on Drug Abuse–funded researchers in Baltimore interviewed drug users about what they were taking, including "scramble," a white mixture of raw heroin mixed with quinine and milk sugar that’s only about 10% pure.

One heroin user told the team: “Scramble a lot of times the chemical that it’s cut with would be, you might have heard of it, it’s called fentanyl.” “And fentanyl is probably the number one cause of overdoses, right?” the user continued. “Now fentanyl, I would tell a person if you don’t have experience with this stay far away. Stay far away. Right? Now, see because you’re gonna enjoy your experience with it if you survive it ... but there’s no guarantee you’ll survive.” When talking to drug users about fentanyl, the researchers found some common themes: One was that the drug increased their opioid tolerance so that heroin no longer gave them the same high it once had. To avoid the pain of withdrawal, they said, they kept taking fentanyl. “Some of those who liked it had become tolerant to the euphoric effects of heroin after long-term use and fentanyl gave them that,” Sarah Mars of the University of California, San Francisco, told BuzzFeed News. “Others hated the experience or feared overdosing and tried to avoid it.” Heroin users in other places have also noticed the change in the heroin supply. In a study carried out by the same “Heroin in Transition” team in Massachusetts in 2016, a man who was using heroin for 18 years complained that his heroin was spiked with “bullshit.” “What do you mean by 'bullshit'?” a researcher asked. “Like, cut. Well, the fake cut or fentanyl or whatever.” Drug users told the researchers that fentanyl drugs were hugely variable, with some only slightly stronger than heroin and others, such as carfentanil, far stronger. (Carfentanil, which is hundreds of times more potent than heroin, figured in a remarkable 53 hours in Huntington, West Virginia, that killed two people and saw 26 others overdose in August of 2016.) “These substances are added inconsistently and unpredictably to the drug supply, so that what a user learns one day cannot necessarily be applied the next,” Mars said. Counterfeit pain pills tainted with fentanyl also made a US appearance in 2016, most notably with Prince’s fatal overdose. By the end of 2016, about 20,000 people had died of overdoses of fentanyl and its variants, according to the CDC, surpassing both heroin and prescription painkillers as leading causes of death nationwide. The overall number of overdose deaths was so high that US life expectancy declined for a second year in a row.

2017–2018

DEA

Today, the fentanyl crisis has mushroomed into a crisis of related chemicals such as acetyl fentanyl. The DEA reported seizures of 76 different fentanyl analogs in the Northeastern states alone in 2017, according to DEA chemist Jill Head. It’s pretty easy for chemists to alter fentanyl and create new synthetic opioids that are totally legal, Head noted. That’s led to a cat-and-mouse game between the DEA and drug dealers, with new analogs appearing as soon as the old ones are outlawed. “It’s whack-a-mole but we have to do it,” ambassador William Brownfield of the US State Department’s International Narcotics and Law Enforcement Affairs office told BuzzFeed News last year. The State Department has worked with China and the DEA to outlaw new opioid varieties as they crop up. And in November, the DEA temporarily changed all fentanyl analogs into Schedule I narcotics — dangerous drugs without any medical use, equivalent to heroin. (Fentanyl itself, widely used to treat pain in cancer patients, is a Schedule II drug with medical uses.) Until then, prosecutors had to overcome legal hurdles to convicting people selling analogs not listed under the Controlled Substance Act, sometimes ordering them straight from the lab in China. “By scheduling all fentanyls, we empower our law enforcement officers and prosecutors to take swift and necessary action against those spreading these deadly poisons,” Attorney General Jeff Sessions said in a November statement. But the Pandora’s box of fentanyl has already been opened in places hard hit by the overdose crisis, particularly the East Coast and Appalachian states where heroin is sold as a powder easily adulterated with fentanyl. The various analogs have led to heroin products that come in colors ranging from green to yellow to “grey death.” “A lot of people don’t know what’s in what they are buying, but it’s the new normal,” filmmaker Mark Floyd told BuzzFeed News. In recovery from a heroin use disorder, he made a short YouTube video with a colleague in February in which they compared the time it takes to buy heroin in Hanford, Connecticut, against the time to order a hamburger at a McDonald’s drive-thru.

“A lot of people don’t know what’s in what they are buying, but it’s the new normal.”

It was basically a tie: 8 minutes for a hamburger vs. 10 minutes for heroin, which Floyd hurriedly flushed down a toilet. “It’s very dangerous for people in recovery to be around heroin,” he said. “But we wanted to do something to show how easy it is to get.” The true geographic origin of fentanyl may not matter as much as the circumstances that demanded its appearance — huge numbers of people physically dependent on opioids who turned to an illicit market. Roughly 11.5 million people misuse prescription painkillers and 948,000 people use heroin, according to federal survey data. Confronted by those huge numbers, “there might be no answer,” to exactly where the US fentanyl crisis started, said Carroll the medical epidemiologist. Burgos, the Rhode Island drug dealer charged in the 2013 acetyl fentanyl cases, faced two charges, each carrying prison terms of 20 years. He pleaded guilty, and was sentenced to three years in prison.

