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Fentanyl Deaths Rise As Curbing Supply Proves Difficult06:54

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Anthony Salemi showing a photo of his brother Joe who overdosed on fentanyl earlier this year. (Jesse Costa/WBUR)closemore
Anthony Salemi showing a photo of his brother Joe who overdosed on fentanyl earlier this year. (Jesse Costa/WBUR)

The latest chart of overdose deaths in Massachusetts shows a climbing blue line labeled “fentanyl.” Pick a spot on that line in mid-August and picture a big, affable 40-year-old man from Everett named Joe Salemi. He overdosed at his mom’s home after almost 25 years of heroin use. Salemi had OD'ed before, but this time, his 70-year-old mother couldn’t revive him. Salemi’s brother, Anthony, says he was pretty sure, at the time, that there must have been something besides heroin in the syringe that contained his brother’s last hit.

"I knew, deep in mind, it was going to be the stuff that everyone’s talking about now, fentanyl, because I never thought straight heroin would kill him," said Salemi.

'The Supply Just Keeps Coming In'

Salemi was familiar with fentanyl. He'd been prescribed the powerful painkiller after surgery in 2006. Salemi warned his younger brother about reports that dealers were adding an illicit version of the drug to heroin, sometimes promising a more intense high. Fentanyl is up to 50 times more powerful than heroin.

Buyers rarely know for sure if there is fentanyl in the tiny plastic bags of powder they get or how much. Drug experts say just a few grains is enough to kill most users. In Massachusetts, three quarters of men and women who've overdosed so far this year tested positive for fentanyl.

Late last month, Salemi said the state Medical Examiner’s Office confirmed his suspicion. Joe had overdosed on fentanyl.

"It just seems like the dealers and the drugs are ravaging the whole country. The supply just keeps coming in, no matter how many cops you put at the border, it just keeps coming in," Salemi said. "Please do something, because this is scary."

The Obama administration agrees that fentanyl is a major challenge and says agencies are doing a lot. But reducing the supply is complicated.

How Fentanyl Traffickers Profit, Change Tactics

Fentanyl is a synthetic opioid, made from chemicals, unlike heroin, which is produced from the poppy plant. Drug enforcement agents say clandestine labs across China are the main source of the drug. It’s shipped to Mexico where drug cartels mix it into heroin or press it into blue, pink or white tablets that look like prescription anxiety or pain pills. The powder or pills are delivered to dealers or directly to users via the internet or darknet, an area used for illegal purchases.

"Synthetic drugs are a real winner, right, because they are easy to make, and they’re cheap to produce,"said Kara McDonald, director of policy, planning and coordination at the international narcotics and law enforcement bureau of the State Department. "They’re not dependent on a season or the weather like a plant-based drug. And with the distribution system, through mail order, they can be delivered directly to the door, in some cases, like a pizza."

The profit margin is huge, as high as 50,000 percent. The Drug Enforcement Administration (DEA) says it costs $3,000-$4,000 to produce a kilo of fentanyl, which is a little over two pounds. The fentanyl is cut with cheap fillers to make pills or mixed into bags sold as heroin.

"Drug traffickers involved in the wholesale distribution of those products can yield close to $1.5 million off that one kilogram," said DEA spokesman Russ Baer.

Baer says the DEA has six agents who operate out of Beijing, and work closely with China’s Ministry of Public Security. Chinese officials established controls on 116 new chemicals last year, including 19 types of fentanyl, which Baer says helped reduce the supply of some types of the drug. In September, the DEA moved to declare another fentanyl analog called U-47700 illegal. But there, says Baer, is the catch.

"Once we control a substance, whether here in the U.S. or in China, for example, the drug manufacturers, they simply change a molecule, tweak a molecule, in an attempt to circumvent the law," Baer said.

Keeping up sounds nearly impossible.

"We’re identifying one to two new synthetic substances every week," Baer said.

The United Nations counted more than 600 new psychoactive drugs last year. Not all of those are fentanyl-related compounds. Some are cannabinoids, based on chemicals found in marijuana or cathinones, based on the khat plant, commonly called “bath salts.”

If a drug compound is similar to fentanyl, or if it produces the same physiological effect, the DEA can file trafficking charges here in the U.S. But the new drugs are not illegal in many countries. McDonald says the State Department is working, through the United Nations and with individual nations, to make sure police everywhere can identify new drugs and prosecute dealers.

"The international control system is working at about a rate of 10 per year to control these new psychoactive substances so it doesn’t take a mathematician to identify that we have a real challenge here," McDonald said.

To get in front of production, the State Department and a group of U.S. senators have asked the United Nations to ban two key ingredients used to make fentanyl. A decision is not expected until next year.

McDonald and Baer at the DEA say slowing demand for the supply of fentanyl and other opioids has become an urgent priority. But some physicians, families who’ve lost loved ones and lawmakers, say the Obama administration is doing too little too late to tackle the epidemic.

U.S. Sen. Ed Markey of Massachusetts says it’s time to make the illegal production and trafficking of fentanyl the top policy issue in relations with China and Mexico.

"Far many more people are going to die from this than any threat from nuclear weapons or any devastation that’s caused by an imbalance in trade," Markey said.

On the topic of trade, there’s one thing about adding fentanyl to bags of heroin or to pills that just doesn’t make sense to Salemi, whose brother Joe overdosed in August.

"I don’t get it, I guess these guys want dead customers, cause that’s what’s happening," Salemi said. "One by one they’re losing all their customers to death."

The Centers for Disease Control offers a sobering perspective. While about 78 Americans will die today after an overdose, another 580 will try heroin, or what they think is heroin, for the first time.

Baer says trying to stop the supply of opioids is part of the solution, but so is tackling demand by addressing addiction as a disease.

"The community needs to embrace these folks, create treatment opportunity, we need to educate the public. It’s the No. 1 priority and it represents a public health crisis that all of us must work together to try to resolve," Baer said.

Law enforcement agents across Massachusetts are working on prevention and reaching out to patients who've overdosed, but they are desperate to reduce the flow of fentanyl.

"It's really a new wildcard in the scheme of things that has become very deadly," said Salisbury Chief of Police Tom Fowler.

A wildcard thrown into a mix of rising supply and demand.

This segment aired on November 8, 2016.

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Martha Bebinger Reporter
Martha Bebinger covers health care and other general assignments for WBUR.

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