In nine days in early December, eight young people died of overdoses in Fairfax County, Va., the second-richest of the 3,007 counties in the United States. Mass events like these happen frequently and in all sorts of places. A half-dozen people died in the small Rhode Island town of Burrillville in the first weeks of 2015. Twenty-eight people overdosed in a single afternoon in Huntington, West Virginia, in 2016, though all but two survived. We describe them as “mass” overdoses, but of course the life of a heroin addict is a solitary one, and most of those involved die alone in alleys, in cars, in the bedrooms they grew up in. Sixty-four thousand Americans died of overdoses in 2016, and early statistics for 2017 hint at a 21 percent rise. It is perhaps natural that observers link the problems to economic or social hard luck, as Bill Clinton did a couple of years ago, when he described white working-class people as “dying of a broken heart.” To look at prosperous Northern Virginia is to see a different sociological picture, in which the drugs are more a cause than an effect.
Americans are beginning to understand what the lobbyists for pharmaceutical companies successfully concealed from them for two decades: Factory-made prescription opioids like Vicodin, Percocet, and Oxycontin are basically the same drug as the heroin that street addicts buy from their dealers and inject into their veins. When unsuspecting people get prescribed oxycodone for a knee injury or a surgery, a certain percentage will become addicted. That percentage is high: The Centers for Disease Control reported last March that 13.5 percent of people prescribed eight days of opioids were still using them a year later. Unwarned, any patient can get hooked. It happened to quarterback Brett Favre and to radio host Rush Limbaugh. And the over-prescription of these pills created a massive recreational market. Everyone “knew” that pills, which respectable people took, could never be as dangerous as heroin, which respectable people did not. People of modest means who became addicted to these pills discovered they were prohibitively expensive on the streets. Heroin was affordable.
It is usually the arrival of a “bad batch” of heroin or, increasingly, of fentanyl that causes a mass poisoning of the sort Fairfax just underwent. About three years ago, the street heroin market began to be shaped by a pharmaceutical revolution. Organized crime groups got access to fentanyl, an opioid that had been used since the early 1960s to treat people with terminal cancer. They began to substitute it for heroin, wholly or in part. It was chemists and pharmacists in China and Mexico who produced most of the stuff. An investigation by Britain’s Guardian newspaper found that 80 percent of the fentanyl in the New York area came from Mexico’s Sinaloa cartel, while most of Philadelphia’s was Chinese-made, shipped through Mexico. Between 2014 and 2016 fentanyl seizures sextupled in the United States.
Fentanyl could more easily be substituted for heroin east of the Mississippi than west, because it looks like a slightly paler version of the cream-colored powder that is the form East Coast heroin has traditionally been sold in. In the west, most heroin is not “white powder” but “black tar.” To an addict out west, fentanyl doesn’t look trustworthy or right. Fentanyl fatalities doubled nationwide between 2015 and 2016, and those deaths were concentrated in Appalachian states (including Ohio and Pennsylvania) and New England.
When we talk about a “bad batch” of drugs, we usually mean one that is too concentrated. The basic problem with fentanyl is that, fresh out of the lab, it is about 50 times stronger than heroin, and there is no standard process for reliably “stepping on” the drug, to use the dealers’ term for diluting it. Dealers will cut the drug with almost any white powder: inositol (a synthetic, powdered version of the sugar found in cantaloupes and oranges); creatine (an acid body-builders use to gain muscle mass); ground-up Tylenol; meat tenderizer (although it “tenderizes” human flesh, too, and gives people boils). In Baltimore they sell a kind of heroin called “scramble,” which is cut with quinine and various powders and packed into gelcaps.
By the time it arrives on the streets, heroin is usually 6 to 12 percent pure. At levels higher than that, overdoses happen. It is a distressing thing for better-off addicts that one of the only ways to be absolutely certain of opioid dosage— using the pills manufactured by the pharmaceutical companies—is now less reliable. Dealers have learned to press fentanyl into realistic-looking molds of existing pills, with trademark and all.
What went wrong in Fairfax was likely the mistake of a local distributor, involving fentanyl. Most of the heroin in the county comes from Baltimore or Southeast Washington, D.C. Had the miscutting occurred higher up the chain, there would probably have been similar overdoses throughout those two metropolitan areas, and there were not. Although suburbs of Washington are not saturated with fentanyl, as New England is, they have a lot of it. In October, the Fairfax County police submitted to their labs 36 “exhibits” of real heroin, versus 17 of fentanyl. At the time of this writing, the lab reports were not back for the early December overdoses.
It didn’t take long after the early December wave for Fairfax police to understand—by looking at the clinical evidence of the dead and the paraphernalia (needles, powders) left on the scene—that opioids were involved. They soon got another lead. Police in neighboring Loudoun County (the only American county richer than Fairfax) reported three (nonfatal) overdoses of carfentanil. This was striking. Carfentanil is an opioid developed in 1974 by Janssen Pharmaceuticals (now part of Johnson & Johnson) for quieting big animals. Five thousand times as concentrated as heroin, it is often called an “elephant tranquilizer.” The Russian military almost certainly used an aerosolized version of it to knock out the Chechen terrorists who took 850 hostages at a musical theater in Moscow in 2002.
One is tempted to ask, in frustration: How big can the market for elephant tranquilizers be? Who is making this stuff? But we are probably not talking about the American commercial elephant-tranquilizer market. We are more likely talking about Chinese labs that have pirated the formula and now export something like carfentanil into the United States. Until 2017, it was not illegal to manufacture in China. In the American northeast, it sometimes arrives over the Canadian border and goes under the name W-18. Where a toxicologist might see concentrated poison, a criminal sees portability. If you are crossing borders with it, the concentration of carfentanil is a tremendous boon. Indeed it would be surprising if carfentanil didn’t come to dominate the market.
Heroin is what is known as a “respiratory suppressant.” It makes your breathing shallower over time, and if you take too much, you fade away. There are antidotes that sometimes work to jolt people out of this slow suffocation, such as Narcan, a trademark for naloxone, which can be administered by syringe or spray. Many states, including Virginia, have passed laws giving a “standing order” to pharmacies to prescribe Narcan to any comer. Such plans are generally embedded (they are in Virginia) in a “good Samaritan” law, which gives the pharmacist immunity from any civil lawsuits arising from the dispensation and may offer criminal immunity to any fellow user of the overdosing person who calls the police. With heroin, there might be a window of 15 to 45 minutes during which naloxone can be used to rescue a person. With fentanyl this window is dramatically narrower—maybe a matter of a couple minutes.
One of the assumptions that goes into making drug policy is that there is always a business logic underneath the transaction between dealer and pusher. There is, however, a rather frightening truth about the nature of the street market in opioids, and it arises from the nature of the drug. The first couple of times a person uses opioids, he gets an extraordinary high. Unfortunately, that high never comes again. Users develop a tolerance for the drug very quickly, so that feeling anything except relative normality from the drug requires higher and higher doses. In fact, the dosage required to replicate that first high exceeds the fatal dose. Heroin addicts are in the habit of walking up to death’s door. That being the case, a death from an overdose reported in the media, far from scaring addicts away from a certain pusher or neighborhood, often attracts them. One hears this from addict after addict: “He must have the good stuff.” Business booms.
One does not need to believe that a drug pusher is utterly indifferent to his clients’ well-being. But one can still be troubled that incentives exist to water the tree of profit with the blood of addicts.
Christopher Caldwell is a national correspondent at The Weekly Standard.
