WASHINGTON—For many people, all it takes is a few painkillers, often obtained through a friend or family member.
America’s opioid crisis is built on prescription pills—80 percent of new heroin users start their habit this way. Once hooked, the addict typically exhausts all options to obtain more prescription pills, until heroin, then fentanyl, becomes the cheaper, more accessible option.
In 2016, more than 64,000 Americans died of an accidental drug overdose, now the leading cause of death for those under the age of 50. Powerful synthetic opioids like fentanyl are driving overdose rates so high that the death toll for 2017 is on track to eclipse 2016 by another half in some areas. Still, in 2015, nearly half of all opioid overdose deaths involved a prescription opioid, according to the Centers for Disease Control and Prevention.
President Donald Trump is set to declare the opioid crisis a national emergency—the equivalent to the designation a state may get during a natural disaster. National emergency status will free up funding and give agencies authority to shift resources to hone in on combating the crisis.
Sheriff Phil Plummer of Montgomery County, Ohio, said it’s a welcome move, albeit a long time coming.
Plummer has been calling for help for four years—his county, population 532,000, has been hit hard by the opioid crisis and has a higher number of overdoses per capita than any other county in the nation.
His deputies have been responding to an average of 10 overdoses a day for most of the year.
So far this year, the county has had 517 overdose deaths, according to the Montgomery County Coroner’s Office (as of Oct. 20). Seven years ago, there were 127.
The numbers are up again from last year, mostly due to a spike in fatal overdoses from the synthetic opioid fentanyl and its analogues.
“We’re glad the federal government’s realized the problem and we just need to get on it,” Plummer said on Oct. 23. “The problem is getting worse every year, so it’s time it gets properly addressed.”
He said additional resources are needed to fight the supply coming into the country, as well as treatment, prevention, and education.
“We’re all strapped for resources, so maybe they’ll send us some.”
In a somewhat hopeful turn of events, Plummer said overdoses in his county have halved in the last month.
“Because they’re using a different drug of choice. I think they figured out heroin and fentanyl are killing them, so they’re migrating toward methamphetamines and crack cocaine again,” he said. “Which is good—they’re not dying as quick, so we have more time to get them into treatment.”
Plummer said addicts don’t often overdose on methamphetamines.
“They just get sores and lose their teeth, and it’s kind of a slower death process,” he said. “That instant death [with heroin and fentanyl], that’s the problem. Now we’ve got time to get them into treatment, get them fixed up.”
Fentanyl, originally developed as a painkiller and an anesthetic, is 50 times more potent than heroin and 100 times more powerful than morphine. Two milligrams of fentanyl is a lethal dose for a non-opioid user.
Carfentanil is less common but much more deadly; it is used as an elephant tranquilizer and is 10,000 times more powerful than morphine, according to the DEA. Even a few specks of airborne powder can be fatal.
Fentanyl is being produced clandestinely in Mexico and China, according to the DEA. Mexican heroin accounted for 79 percent of the total weight of heroin analyzed by the DEA in 2014.
Dayton, the county seat of Montgomery, has become a drug trafficking hub due to its proximity to major interstates going both north-south and east-west. Plummer said the drugs now come up directly from Mexico. Or they are sent directly through the postal system, ordered online.
Factories in China
The Justice Department announced on Oct. 17 its first ever indictments against two Chinese manufacturers of fentanyl and other opiate substances.
“[They] have been using the internet to sell fentanyl and fentanyl analogues to drug traffickers and individual customers in the United States,” said Deputy Attorney General Rod Rosenstein in a statement.
In the first case, over a period of at least six years, Xiaobing Yan operated websites advertising and selling acetyl fentanyl and other deadly fentanyl analogues directly to U.S. customers in multiple cities across the country, according to the DOJ.
“Yan operated at least two chemical plants in China that were capable of producing ton quantities of fentanyl and fentanyl analogues,” Rosenstein said. “Yan monitored legislation and law enforcement activities in the United States and China, modifying the chemical structure of the fentanyl analogues he produced to evade prosecution in the United States.”
The second case was traced back to Jian Zhang in China, who manufactured fentanyl in at least four labs in China and sold it to customers in the United States using the darkweb and the crypto-currency bitcoin.
“Zhang’s organization would send orders of fentanyl and other illicit drugs, and pill presses, stamps, and dies used to shape fentanyl into pills, to customers in the United States through the mail or international parcel delivery services,” Rosenstein said. “Zhang sent many thousands of these packages since January 2013.”
Rosenstein said fentanyl is sold in many forms in the United States—all of which are deadly.
“It can be purchased as pure fentanyl; fentanyl mixed with heroin, cocaine, or even marijuana; and fentanyl pressed into pill form and falsely sold as prescription opioids. Users often have no idea that they are ingesting fentanyl until it is too late,” he said.
On March 29, Trump announced the formation of the President’s Commission on Combating Drug Addiction and the Opioid Crisis, led by New Jersey Gov. Chris Christie.
The commission published an interim report on July 31 and said the national emergency declaration is its “first and most urgent” recommendation.
“Your declaration would empower your cabinet to take bold steps and would force Congress to focus on funding and empowering the Executive Branch even further to deal with this loss of life,” the report states.
The report also includes recommendations to rapidly increase treatment capacity through waivers within the Medicaid program; increase funding for medication-assisted treatment; fund fentanyl detection capabilities within the U.S. Postal Service; enhance interstate data sharing; and provide pain management training for medical staff.
“We have an enormous problem that is often not beginning on street corners; it is starting in doctor’s offices and hospitals in every state in our nation,” the report states.
The commission said that only 10 percent of the nearly 21 million citizens with a substance use disorder receive any type of specialty treatment; and although more than 40 percent of people with a substance use disorder also have a mental health problem, less than half receive treatment for either issue.
“The reasons for these treatment gaps are many, including lack of access to care, fear of shame and discrimination, and lack of motivation to seek treatment,” the report says.
Treatment centers are popping up all over the place, Plummer said, but there is no standard of care.
“I know there is no one-size-fits-all model, but there’s got to be a standard of care, instead of people just popping up treatment shots and chasing Medicaid dollars,” he said.
“We need a serious medical evaluation to see what works. How long does it take to detox somebody? How long does it take to get their brains clean and back to normal?”
Plummer said a lot of people in his community are upset that his deputies use the opioid-blocker Narcan to revive addicts when they overdose.
“They’re like, ‘This is a waste of tax dollars. If they want to be addicts, that’s their problem,’” Plummer said. “Our approach is, they are human beings, this is an addiction, and we are going to do the best we can to get them into treatment, to keep them alive.”
He said there is a real stigma that the addict created the problem and they should have to deal with it on their own.
“I tell those people, ‘What if it’s your daughter? You want us to help your daughter?’” Plummer said.
Success stories are few and far between.
“It is a terrible addiction. People are relapsing six, seven, eight times,” he said. “And when people go to treatment and they get out and they go back into the same environment—where everybody is doing heroin—it’s tough for them to change.”
Plummer’s department has several initiatives that focus on treatment. Deputies, faith-based volunteers, and other volunteers will go to the home of an addict who has overdosed and required Narcan to be revived.
“We go out in your neighborhood, knock on your door, and we educate your family on the dangers of the stuff and what kind of resources are out there for treatment,” he said.
Since 2013, the department has had its Front Door program, in which a deputy would go to pick up the addict.
“We had agreements with treatment centers, so we would drive them right to the treatment center, no questions asked, start the treatment, and we would figure out how to pay for it later,” Plummer said.
“Realize this [opioids] changes the chemistry of your brain—you’re not the same person. We have to get you dried out, get your brain back to normal. Then we have to find out what the underlying problems were that forced you into addiction.
“You can’t arrest all of them. That isn’t going to fix anything. We have been arresting people for years and the problem is worse.”
In 2016, Congress passed legislation to improve access for opioid addiction treatment, including authorizing $1 billion for the states to provide increased access to treatment and overdose prevention. The first $500 million was appropriated in 2016, and Trump’s fiscal year 2018 budget includes a request for the second $500 million.
On the law enforcement side, Attorney General Jeff Sessions announced in August the formation of a unit that will investigate the overprescribing of opioids within the health care system.
He also said that $58.8 million has been earmarked to strengthen drug court programs and to help public health agencies address prescription drug and opioid abuse.
“Combatting this poison is a top priority for President Trump and his administration, and you can be sure that we are taking action to address it,” Sessions said on Sept. 22.
Sessions said around $24 million will be awarded to 50 cities, counties, and public health departments to create “comprehensive diversion and alternatives to incarceration programs for those impacted by the opioid epidemic.”
An additional $3.1 million will be awarded by the National Institute of Justice for research and evaluation on drugs and crime. The research priorities are heroin and other opioids and synthetic drugs.
Another $22.2 million will go toward treatment for veterans and $9.5 million toward juvenile programs.
What Does a National Emergency Mean?
The National Emergencies Act of 1976 authorizes the president to declare a “national emergency” in the event that the nation is threatened by crisis, exigency, or emergency circumstances (other than natural disasters, war, or near-war situations).
Declaring a long-term problem such as the opioid crisis a national emergency sets a new precedent. Modern public health emergency declarations typically focus on rapidly spreading infectious diseases such as the West Nile virus (2002), severe acute respiratory syndrome (2003), H1N1 influenza (2009), Ebola virus (2014), and Zika virus (2016), according to an article in the Journal of the American Medical Association.
Emergency declarations terminate automatically after one year unless the president formally continues them for another year. The declarations can be terminated earlier by either the president or Congress.