Hidden Fentanyl Is Driving a Fatal New Phase in US Opioid Epidemic

The rise of fentanyl has brought on the most dangerous phase yet in the US’s decades-long opioid epidemic, causing a surge in overdose deaths and crippling efforts to end a devastating addiction crisis.

Covid-19 helped pave the way for fentanyl’s ascent. Driven into boredom and isolation by the pandemic, many Americans turned to illegal drugs – and in 2020 and 2021, more people than ever were killed by fentanyl.

Fentanyl is claiming the lives not just of people with an opiate addiction, but also users of cocaine, black-market Adderall, methamphetamine, marijuana and other substances. Originally developed to meet a need for stronger painkillers and used in hospitals for surgeries, fentanyl is now a cheap and abundant street drug. It is often used to strengthen or stretch stockpiles of other illicit drugs, or make counterfeit versions of other frequently abused prescription drugs.

Fentanyl’s creeping ubiquity means many unsuspecting users risk being killed by the drugs they consume. And it means that in places where it seemed like the long-running opioid epidemic might be relenting, a new wave of overdoses and deaths is tearing at the social fabric.

In Florida’s Volusia County, a collection of bedroom communities and sun-kissed beach towns about an hour northeast of Orlando, synthetic drugs like fentanyl were responsible for 272 deaths in 2020 – triple the number from a year earlier. In 2021, a drug overdose killed a person in the onetime Spring Break capital nearly every day.

Michael Chitwood took over the Volusia County Sheriff’s Department in 2017. He calls fentanyl “instant death.”

“Everything’s got fentanyl in it,” said Chitwood. “You think you’re buying marijuana, you think you’re buying Adderall, you thought you bought cocaine – and in reality, what you’re purchasing is 50% or 100% fentanyl.”

Since the pandemic began, more than 165,000 people have died from opioid overdoses, while more than a million have been killed by Covid-19. The dual health crises have helped shear about three years off of US life expectancy, bringing it to the lowest level in 25 years.

With fentanyl use spiraling upward, who opioids kill is changing. Nationally, the rate of deaths among Black people has overtaken the rate among White people, and deadly overdoses among Native Americans are also increasing disproportionately. However, in Florida, which skews older and is more than a quarter Hispanic, roughly 90% of those dying are White. About 60% of opioid overdose victims are younger than 45 years old.

Opioid Overdose Disparities

In the US, Black people are now dying at the highest rate from opioid overdoses

Largely because of the deadliness of fentanyl, and its increasingly far-reaching capacity to kill, opioids have reemerged as a political flashpoint nationally and in the Sunshine State. The drug has intensified a debate over how to deal with addiction and substance use, and it has inflamed long-simmering conflicts over issues like crime and immigration.

Florida Governor Ron DeSantis, a potential candidate for the Republican presidential nomination in 2024, has cast the matter as a problem of law enforcement and border control.

“Law and order also means having strong borders,” DeSantis said in his State of the State Address in January. “We have a crisis at the US-Mexico border over the past year that’s witnessed staggering amounts of illegal migration and a massive influx of narcotics such as fentanyl.”

More than 20 years after abuse of prescription painkillers metastasized into a national scourge, the trajectory of the crisis has shifted: Where oxycodone once flooded cities and towns through pharmacies and doctors’ offices, now a tide of synthetic opioids is flowing across the US’s southern border.

Much illicit fentanyl is manufactured abroad and smuggled into the US through Mexico, according to the Drug Enforcement Administration. To prevent more Americans from dying, policy makers must reduce the supply of synthetic opioids and work with countries like Mexico to strengthen oversight, a bipartisan US Commission on Combating Synthetic Opioid Trafficking said in February.

Yet precursor chemicals used to make the drugs are globally available, and with the opportunity for large profits, new suppliers will likely emerge. In 2019, for instance, China moved to declare fentanyl-related substances as controlled substances at then-President Donald Trump’s urging, but the change ended up diverting more of the trade through Mexico.

That makes efforts to treat those struggling with opioid-use disorder and raise awareness of the dangers of illegal drug use even more urgent.

“The supply of illicit fentanyl cannot be permanently stopped through enforcement alone — only temporarily disrupted,” the commission said. “Of deepest concern is that most consumers are not — at least not initially — seeking fentanyl specifically.”

Some 20 miles down the road from the famous speedway that is home to NASCAR’s Daytona 500, Jeff Hardy is waiting in the rain in his silver minivan for his first pickup of the day. The 63-year-old retiree helps transport Volusia County residents to opioid addiction treatment four days a week.

For Hardy, trying to ease the suffering means a tight schedule. After waiting for a few minutes outside a low-rise apartment building in Orange City, he checks he has the right address and then makes a call. No one picks up. Hardy hops out and knocks on the door. A man answers and says Hardy’s expected passenger won’t be coming.

“It’s a waste of time, a waste of gas,” Hardy says, sounding frustrated but not entirely surprised. “You have to wonder” whether the passenger returned to drug use, he says. The client hasn’t returned to the clinic.

Patients who get into Hardy’s van are taken to the SMA Healthcare clinic in Daytona Beach, where nurse practitioner Carol Davis is ready to get them into recovery. But sometimes fentanyl is getting to people first.

“I’ll be sitting here waiting for someone to come in. I’m like, what the hell happened to him?” said Davis. “Next day, I come in, I find out his brother found him dead in the bathroom.”

How Much Does It Take to Kill?

Just 2mg of fentanyl in a counterfeit pill can cause a fatal overdose

○ 0.25mg

Deadly dose of fentanyl

100 mg

○ 0.25mg

Deadly dose of fentanyl

100 mg

○ 0.25mg

Deadly dose of fentanyl

100 mg

Fentanyl is up to 100 times more powerful than the prescription opioid morphine, and 50 times more powerful than heroin. Just two milligrams, equal to a few grains of salt, can cause a fatal overdose.

Some people who overdose in Volusia County have “hundreds of nanograms per millimeter” of fentanyl in their bodies, enough to kill 30 or 40 people, the county’s medical examiner testified to the county council in fall 2021.

In early 2020, when county residents were told to stay at home because of a frightening new virus everything closed, except the drug market, Chitwood, the sheriff, said. Faced with the dawn of the Covid-19 pandemic, locals were bored, isolated and fearful  — a recipe for substance use.

As the coronavirus’s spread upended the rhythms of everyday life, people in addiction treatment lost much-needed in-person support for their recovery. Some support groups stopped meeting; SMA Healthcare began seeing patients virtually. The lack of contact and accountability led many people to relapse.

Helena Girouard, 38 years old with long, red hair and a bright smile, works in overdose prevention for the Florida Department of Health in Volusia County. Girouard says she got sober about a decade ago while pregnant with her daughter. She says she knows many people who have died from overdoses, including this year.

“There was just so much isolation and especially loss of control, and that affected every person. But when you’re already trying to manage what coping skills you can use, if some of those are taken away because you can’t leave your house…”  she said, trailing off.

When local addiction support groups tried to get back to normal, it didn’t always work. For example, many groups let participants stay anonymous. But in Ormond Beach, a local church one group was using required them to collect detailed identifying information for Covid contact tracing. So the group kept meeting virtually, and never returned to in-person meetings.

Similar disruptions extended to in-person medical care, likely contributing to a decline of about 24% across the US in admission to addiction-treatment facilities from 2019 to 2020, even as overdose death rates rose, according to RAND Corporation researchers.

“You could not have designed anything worse than this if you wanted to exacerbate the opioid crisis,” says Keith Humphreys, a former senior advisor to the White House Office of National Drug Control Policy who now chairs the Stanford-Lancet Commission on the North American Opioid Crisis.

As the pandemic marched on, the damage continued to mount in Volusia County. In the hallway outside her office, Girouard has a sign showing all the county’s suspected overdoses from 2021. Each overdose is represented by a dot, and each dot is a potential death.

There are 2,447 dots. They take up five sheets of printer paper.

Florida is right in the middle of the national opioid death trend. During the pandemic it had the 19th highest rate of fentanyl deaths in the country. While other states, mostly along the West coast, have seen their deadly fentanyl overdose rates skyrocket in recent years, they have yet to approach the death rates in Florida.

Tracking the Spread of Fentanyl

During the pandemic, fentanyl overdose death rates more than doubled in many western and southern states.

DeSantis has responded by increasing Florida’s penalties for opioid sale and distribution. He also recently announced a new program that connects patients with medication-assisted treatment.

That program, called Coordinated Opioid Recovery, or CORE, is rolling out in as many as 12 counties, including Volusia, and Florida will spend about $1 million on average per county each year. Medication-assisted treatment utilizes buprenorphine, naltrexone or methadone, which are opioids that have been approved by the US Food and Drug Administration to help treat addiction. The goal is to reduce the likelihood patients will instead use drugs like heroin and overdose.

“There’s no other lifelong, chronic, life-threatening relapsing disease where we expect the patient to take nothing,” said Kenneth Scheppke, Florida’s deputy secretary for health.

Florida officials haven’t, however, embraced all tools that can reduce the risks and chance of death when people do use drugs, an approach known as harm reduction.

Some harm-reduction techniques have been rejected by conservative elected officials who say they enable drug use. Harm reduction includes practices such as syringe exchanges, which provide sterile needles to stem the spread of HIV and hepatitis C. Florida allowed counties to implement those in 2019, but only five have operational programs.

Another tactic aimed at stopping overdose deaths is the distribution of fentanyl strips, which can be used to test drugs for the high-powered substance. The strips are considered illegal drug paraphernalia in about half of US states, including Florida, according to Kaiser Health News. Florida’s Republican-controlled legislature recently shut down an effort to change that.

Public health officials and local groups like Karen Chrapek’s Volusia Recovery Alliance are working to make naloxone, the overdose-reversal medication, more available. At a two-day conference organized by Girouard and attended by Chitwood and others in early June, locals proposed setting up naloxone dispensers in public parks.

Having naloxone and other tools more available could help prevent overdoses among people with an opioid addiction, recovering users who relapse, and those who are exposed to fentanyl because of its presence in other kinds of street drugs. Last year, a 28-year-old in recovery who Chrapek knows bought medication from a drug dealer to help him sleep – and never woke up.

What he thought was Xanax was mostly fentanyl, she said. She wishes he’d had access to a test strip.

“You can’t recover if you’re dead,” she said.