John Allen. The Opioid Crisis. Reference Point Press, 2020.
On his last, fifty-three-date concert tour, rock star Tom Petty relied on painkillers and a backstage golf cart to nurse his fractured left hip through a grinding routine. Members of his entourage urged him to cancel the tour and check into a hospital. Instead, Petty turned to a mixture of pain medications, including a synthetic opioid called fentanyl. On October 2, 2017, one week after his last show, Petty died from an accidental overdose of painkillers. His system was found to contain three kinds of fentanyl. One was a slow-release patch, but the other two were much more potent variations of the drug. “Those are illicit,” says Dr. Nora Volkow of the National Institute on Drug Abuse. “Those you get very likely in the black market.”
New Dangers from Fentanyl and Heroin
News of a celebrity’s death from overdose helps bring attention to the dangers of new opioids like fentanyl. Petty’s family hoped to enlighten the public about the drug, whose potency is thirty to fifty times that of heroin. “It is so crazy-strong,” says Petty’s daughter Adria. “We really don’t want this to happen to anyone else. We learned this is the worst feeling you can have: to lose someone you love for no good reason.”
Petty was not the first music legend to succumb to fentanyl. On April 21, 2016, Prince was found alone and unresponsive in an elevator at his Paisley Park studio in Minnesota. Addicted to opioid painkillers since a 2010 hip surgery, the performer apparently had taken fentanyl in pill form in the mistaken belief that it was Vicodin, a less potent drug. “In all likelihood, Prince had no idea he was taking a counterfeit pill that could kill him,” said Carver County district attorney Mark Metz following an investigation. “Prince’s death is a tragic example that opioid addiction, and overdose deaths do not discriminate no matter the demographic.”
President Donald Trump has called for tougher penalties related to fentanyl. He has even suggested the death penalty for dealers found to have sold the drug to the victim of a fatal overdose. Nonetheless, others doubt that tougher law enforcement is the answer. Prince’s sister, Tyka Nelson, did not object when the state of Minnesota declined to arrest anyone for the fentanyl that killed her brother. “I thought, ‘Let’s move on,’” she says. “You can charge 20,000 people and toss them in jail. Will that bring my brother back?”
As fentanyl has gained notoriety as a lethal painkiller, a better-known narcotic has also been contributing to the opioid crisis. Heroin, once considered a drug limited to hard-core junkies in the inner city, today is sold to middle-class suburban addicts who originally fell victim to oxycodone. Some dealers peddle heroin laced with fentanyl to form an even more potent cocktail. Often users have no idea the heroin they are buying is in part or mostly fentanyl. Those who think they have a tolerance for heroin end up overdosing on the vastly more potent combination. According to the National Institute on Drug Abuse, deaths from opioid overdose have jumped as a result. In 2017 there were 29,406 fatal overdoses of synthetic opioids like fentanyl and 15,958 from heroin. Americans are starting to realize that what began as a prescription drug crisis has expanded to include a variety of deadly opioids.
Unintended Consequences
The surge in heroin and fentanyl abuse is partly the result of a change to OxyContin. In 2010 Purdue Pharma introduced a reformulated version of the drug. This change was intended to make the painkiller safer and less likely to be abused by addicts. Instead, according to law enforcement experts, it sent addicted OxyContin users in search of more powerful opioids.
With the original version of OxyContin, addicts could crush the pills into powder and either snort the powder or, in liquefied form, inject it. They would then receive the full dosage almost at once, with no time-release delay. Many street buyers of OxyContin used it in this way to get a rapid and powerful high. This helped make OxyContin a huge success on the black market. To curtail this abuse and discourage street sales, Purdue changed the drug’s formula. Crushing the new pills turns them into a gummy substance that is more difficult for users to snort or inject. Other makers of time-release opioids have introduced similar changes.
Although Purdue’s reformulation of OxyContin was aimed at curbing addiction, the effort seems to have backfired. The reformulated drug costs more than older versions, which might lead some individuals to seek cheaper—and more dangerous—alternatives on the street. Additionally, opioid addicts grown accustomed to almost immediate highs turned to other, more potent substances that could satisfy their needs. Rates of overdose from heroin began to climb, even quadrupling in several areas. A 2018 study published by the National Bureau of Economic Research suggests that Purdue’s efforts were mostly wasted. “As people decided OxyContin was too much of a hassle, some former OxyContin users moved on to heroin,” says science reporter German Lopez. “The subsequent rise in heroin overdose deaths may have been enough, the researchers argued, to match or even outweigh any good that the reformulation of OxyContin did in terms of preventing painkiller overdose deaths—at least in the short term.” Overall the attempt to head off one epidemic has led to the growth of another, centered on heroin and fentanyl.
Heroin’s Comeback
News reports stress that heroin is making a comeback on American streets as part of the opioid crisis. In reality, heroin never left. It has a long history in the United States, dating back more than a century. “The current opioid crisis may have been jump-started with prescription drugs, but heroin came long before OxyContin,” says Roger Chriss, a Washington State University technical consultant who has studied patterns of prescribing painkillers in America. “It is better to view OxyContin as gasoline tossed on a smoldering fire.”
The National Institute on Drug Abuse estimates there are onehalf million heroin addicts today in the United States. Experts say this is roughly the same level as in the 1990s and 1970s. What has made the problem worse today is the wide availability of other opioids that can act as a gateway to heroin use. Sales of heroin may have dropped off temporarily when prescription painkillers became plentiful on the street. But they have roared back in response to efforts to control distribution of OxyContin and other opioid pain pills. Addicts desperate to ward off the agony of withdrawal have turned to heroin for less expensive fixes. According to Beth Macy, author of Dopesick, a book about the opioid crisis, “Four out of five heroin addicts come to the drugs … through prescribed opioids.”
Users also are introduced to heroin by pill dealers who tout heroin as a cheap substitute offering more potency. Erin Marie Daly, a journalist who has interviewed dozens of young opioidusers, says friends often relay the advice: “The minute one friend said, ‘Hey, my dealer hooked me up with this awesome, super cheap stuff—try it,’ the kids would try it. Once they tried heroin, there was no going back. Even if they wanted to stop, they were physically unable.”
Typical is the case of Andi Peterson, a middle-class young woman in Weber County, Utah. Peterson first took opioid painkillers at age sixteen. A couple of years later, she and a boyfriend would share a bottle of Percocet over the course of a week. “I remember feeling really good and comfortable in my own skin for once,” says Peterson. “I felt like I could talk to people.” Soon, at her boyfriend’s suggestion, they moved on to smoking heroin. After six months her highway patrolman stepdad noticed her fidgeting and sweating. Confessing her heroin use, Peterson agreed to enter a rehab program. At first her cravings overcame her good intentions. She returned to her boyfriend and her heroin habit, this time via injection. It took Peterson several tries before she was finally able to take advantage of treatment and escape the drug’s powerful grip.
Deadly Risks for a Rush
Among the world’s most addictive narcotics, heroin is derived from opium, which is made from the seeds of the poppy plant. Heroin is produced in three major regions of the world: eastern Asia, western Asia, and Latin America. Afghanistan, a country of 34 million people in western Asia, is the world’s largest supplier. Most heroin distributed and sold in the United States comes from Latin America. A less pure version frequently found on the streets, called black tar heroin, is manufactured in Mexico.
Like OxyContin, heroin was originally considered a wonder drug, safe enough to be prescribed for colds and headaches. In 1924, after scientists established its highly addictive nature, Congress banned the sale and use of heroin. Since it was outlawed, heroin has been a profitable drug for illegal trafficking in the United States.
In appearance, heroin can be a fine white or brown powder or a sticky black goo. Most users snort or smoke the drug. Opioid addicts seeking the quickest, most potent high inject it directly into a vein, a process called mainlining or shooting up. Once in the bloodstream, the drug delivers its rush of euphoria within seconds. After the initial rush comes a period in which the user thinks and moves more slowly, as if in a dream. Heart rate and breathing also slow down, sometimes dangerously so. An overdose can stop a person’s breathing altogether.
Taking heroin in any manner is hazardous, but shooting up heroin carries with it a number of terrible risks. A user may contract HIV, hepatitis, or some other blood-borne disease from a shared needle. Further, introducing such a powerful narcotic straight into the bloodstream is a recipe for overdose. If the heroin is mixed, or cut, with other drugs, injecting it only increases the chance of a fatal mistake.
An Even More Dangerous Opioid
The deadliest addition to heroin today is fentanyl. Dealers seeking to maximize profits from a supply of heroin often mix it with cheaper fentanyl that is manufactured illicitly. That way they can dilute the heroin and still maintain the overall potency. The ever-present danger to users comes from not knowing exactly what they are getting. They may actually be purchasing a dose of fentanyl more powerful than anything they have ever taken. Those who believe they have a tolerance for straight heroin may shortly be lying in an unresponsive heap after overdosing on fentanyl-laced heroin. “Dope is cut so many different ways now that you don’t know … [what is] in it,” says Tony Parilla, a New Yorker who began shooting heroin as a teenager. “And with fentanyl, you can’t really tell until you shoot it.”
Fentanyl was created in 1959 to manage postsurgical pain or treat patients with severe chronic pain. It consists of a specific formula and is only made in certified labs. The fake fentanyl found on the streets today is mostly made in hidden laboratories in China, Mexico, and Latin America. With no controls, it can be cooked up to almost any strength. Dealers sell this illicit brand of fentanyl in many forms, including a powder, a tablet that resembles milder painkillers, or a blotter paper. Users swallow, snort, or inject the powder or crushed tablets. The blotter-paper dose is placed in the user’s mouth and absorbed through the mucous membrane.
Experts say fentanyl’s potent punch is responsible for the spike in overdose deaths in many regions of the nation. Fentanyl is many times more powerful than heroin because of its chemical structure. It pierces the fatty blood-brain barrier, which helps keep harmful substances away from the brain, much more quickly than heroin. This enables it to impact the user’s central nervous system very rapidly. More important, it takes very little fentanyl to get a lethal dose—micrograms, as opposed to milligrams with other opioids. For example, a lethal amount of heroin looks like half a packet of sugar; a lethal dose of fentanyl, like a few scattered granules. Users overdose from depressed breathing, as with other painkillers, except with fentanyl it happens very fast. Victims suddenly are gripped by what seems like paralysis. “If anything can be likened to a weapon of mass destruction in what it can do to a community, it’s fentanyl,” says Michael Ferguson, the special agent in charge of the US Drug Enforcement Administration’s New England division. “It’s manufactured death.”
A Grim Reputation
There is no shortage of stories about first-time users of fentanyl or fentanyl-laced heroin succumbing to overdose. Even among opioid addicts, fake fentanyl has acquired a grim reputation. As a precaution, some get testing strips from a needle-exchange center that enable them to test a drug for the presence of fentanyl. A few even carry their own kits of Narcan, an effective antidote for opioid overdose, in case they encounter a dangerously strong dose of fentanyl. They know that dealers now also mix fentanyl with cocaine, meth, and other drugs. They have learned the signs of fentanyl overdose: confusion, choking, vomiting, seizures, blue-tinted lips or nails, and shallow breathing.
Yet opioid addicts often are too woozy or addled to discern when a dealer is slipping them fake fentanyl. Small dealers who are users themselves may not be fully aware of what they are selling. Other dealers routinely add fake fentanyl to their latest supply of heroin. For drug gangs and dealers, the economics of peddling fentanyl are hard to resist. A kilogram of heroin brings about $200,000 on the street. Cutting the heroin with a few thousand dollars’ worth of fake fentanyl can easily boost those proceeds into the millions. If a certain number of customers overdose from the mixture, there are always new ones ready to make a connection.
As painkiller users have migrated to heroin and fentanyl, the opioid crisis in the United States has gotten worse. Attempts to stop the overprescribing of OxyContin and other pain pills has inadvertently spurred the sales of other, more deadly opioids. According to preliminary figures from the CDC, 2017 was the worst year yet for drug overdose deaths in the United States. As long as more and stronger opioids continue to be distributed on the street, this trend seems likely to continue.