Dr. Feel Bad

In February, when Sacramento County started its new opioid task force to address an emerging public health crisis gaining traction here, the deadly fentanyl outbreak that would eventually kill a dozen locally wasn’t yet on the radar.

The group’s second meeting, on March 21, presented physicians with safe prescription tips for opioids, a constantly expanding class of pain-relieving medications all derived in some way from the highly addictive opium poppy. The well-attended meeting focused on the potential threat of these legal medications, which many say are dreamed up by profit-minded pharmaceutical companies, overprescribed by doctors and blamed for introducing a generation of suburbanites to the transfixing lure of a chemical high.

Four days later, as if on cue, people started dying from a bad batch of counterfeit pills—illegally peddled and labeled as Norcos, but masking fentanyl, a synthetic opioid that can immobilize large animals in small doses.

“One of the things we learned with this [outbreak] … is there is this other source that we need to be aware of,” said Dr. Olivia Kasirye, the county’s public health officer, referring to the black market.

Now, as a state bill rekindles tactics of the nation’s unsuccessful drug war, there’s a different hard lesson to be relearned, as well:

Fentanyl ambushed California because of the government’s response to the opioid crisis, not in spite of it.

The victims help tell the story.

Prior to the ingesting of illicit drugs that crashed their central nervous systems, some of the 52 local victims were unable to renew legal prescriptions, according to Kasirye and her assistant health officer, Dr. Melody Law.

Developing a drug habit at the doctor’s office isn’t unusual anymore, according to the U.S. Centers for Disease Control and Prevention, which reported more fatal drug overdoses in 2014 than any previous year on record. More than 60 percent of those deaths involved an opioid and at least half involved a prescribed opioid. In Sacramento County in 2013, the last year for which figures were available, fatal opiate overdoses represented more than half of all substance-related deaths and an 83 percent increase since 2011.

To the CDC, there’s little question what drives the exploding death count.

“We now know that overdoses from prescription opioid pain relievers are a driving factor in the 15-year increase in opioid overdose deaths,” the agency says on its website. “Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled, yet there has not been an overall change in the amount of pain that Americans report.”

In terms of enforcement efforts, authorities have mostly concentrated on jailing individual doctors and illicit distributors. Meanwhile, the companies flooding the market with their products receive accommodating fines.

Last October, a doctor in Los Angeles County, Hsiu Ying “Lisa” Tseng, became the first in U.S. history to be convicted of murder-related charges for overprescribing prescription drugs.

The increased enforcement is being felt closer to home, too. In a series of emails, a licensed Sacramento-area doctor told SN&R he gave up his Schedule II license to prescribe opiates after federal agents raided his practice last year, and says other physicians are following suit.

“Now many of my patients [are] getting meds back off the street, using heroin etc.,” wrote the doctor, who requested anonymity since he’s still under investigation. “Huge societal issue. Don’t know solution. But making opiates users criminals is not going to solve anything.”

So far, the drug companies have escaped a commensurate response.

In 2007, Purdue Pharma L.P. paid out $634.5 million in fines for misleading the public about the addictive risks of OxyContin, which, like Norco, is a potent opioid painkiller. Three years later, Purdue cleared $3.1 billion from OxyContin sales, according to a Fortune article from 2011.

Kasirye, meanwhile, says the overdoses of people with discontinued prescriptions shows their vulnerability to the black market and the need for more treatment options.

The county has already acknowledged in a report that it lacks the resources to meet the drug treatment demand. Even before the fentanyl outbreak, Sacramento County ranked 10th in the state when it comes to fatal opioid poisonings, according to figures covering 2013.

This past November, a countywide review of the existing treatment system showed that the county had opened many doors for people to request help, but couldn’t answer that demand for residential and detox treatment, which jumped 36 percent last fiscal year. During that same time frame, more than 16,000 people in the county received some type of substance-addiction service, the report stated.

While public health officials acknowledge the need for additional treatment options, the only offer on the table is for more enforcement.

State lawmakers are currently considering a bill that would increase prison sentences for those possessing commercial amounts of fentanyl, similar to what’s in play for heroin and cocaine base. Under Senate Bill 1323, getting busted with a kilogram of fentanyl would tack on three more years. Possessing 80 kilos would bring 25 additional years.

SB 1323 has passed both the public safety and appropriations committees, but was placed on the latter committee’s suspense file, stalling its progress for now.

Groups including the American Civil Liberties Union, California Attorneys for Criminal Justice, California Public Defenders Association and Legal Services for Prisoners with Children have all opposed the bill, and argue that lengthening sentences would only aggravate California’s still-crowded prisons and runs counter to bipartisan efforts to reduce the amount of drug offenders doing hard time.

It’s not like fentanyl doesn’t have its benefits.

First synthesized in Belgium in the 1950s, medical practitioners began using the compound as an intravenous anesthetic a decade later. Today, even the Sacramento Fire Department administers it to treat pain. The drug is cheaper and much stronger than morphine, says department spokesman Chris Harvey.

For firefighters and paramedics responding to an accident scene, a little fentanyl can eliminate the pain of a snapped fibula. But that same potency allows drug-traffickers to stretch out their profits by stepping on fentanyl—i.e. taking extremely small doses and mixing it with other drugs and binders.

According to Casey M. Rettig, a spokeswoman for the U.S. Drug Enforcement Administration’s San Francisco division, this process allows traffickers to purchase a kilo of fentanyl at a wholesale price of approximately $3,300 and sell it off on the black market for about $1 million.

“So a little goes a long way,” she said.

While illicit demand for fentanyl is more widespread on the East Coast, it’s starting to find its way here in larger quantities, says William Ruzzamenti, director of the Central Valley High-Intensity Drug Trafficking Area. He says Mexico is being flooded with cheap fentanyl from China, and pushing it up north.

“We’re seeing a tremendous increase,” he said.

In March, federal drug authorities raided a Los Angeles County pill mill, arresting four men for allegedly using imported fentanyl from China to produce and distribute bulk quantities of pressed pills.

Still, up until recently, fentanyl-driven overdoses were fairly rare and typically occurred when mixed with black-tar heroin, which is common here, as opposed to the powdered heroin on the East Coast.

“With black tar heroin, you get it in chunks, and it’s cut with a million different things,” explained Melinda Ruger, executive director of Harm Reduction Services in Oak Park. “Everything from shoe polish to Folgers coffee—anything that might look sticky and black.”

When fentanyl is part of that doctored stew of elements, its tricky density prevents it from being equally distributed, she says. That means a user could buy multiple doses off the same drug package, and suddenly keel over from one fentanyl-saturated hit.

“There’s an uncertainty there, even when you’re getting it from the same person,” said Ruger, a former heroin user who has been sober for eight years.

Most of the overdoses that HRS tracks involve users who mixed substances—like heroin and alcohol or opiates and benzodiazepenes. Some of the overdoses did feature fentanyl, including people who intentionally took it because of its heralded potency. But no one interviewed by SN&R could recall a spate of overdoses as bad as the one that raced across six counties in less than four weeks.

The DEA has taken point on the investigation, and there remain several perplexing questions to answer. One might as well fall under Basic Drug Dealing 101: If fentanyl has a higher street value than Norcos, why sell it as the cheaper drug?

Rettig suggested the reason may have to do with an area drug market that has an appetite for milder painkillers, and is less aware of fentanyl. “So the drug trafficker is just making a product that is wanted on the street, but using existing ingredients” to do so, she suggested.

Rettig called the case her office’s “No. 1 priority in the region” and said agents were “making progress.” But she said she couldn’t discuss the nature of their work since the investigation remained ongoing. Rettig did note similarities in the 61 fentanyl overdoses that have now touched the Sacramento and Bay areas. For instance, one of the doctored pills recovered in San Francisco bore close resemblance to a counterfeit tablet that the DEA seized here, she said. “So we are looking to connect the dots if we can.”

Ruzzamenti isn’t convinced the bad batch originated from a single source, but said he thinks it’s possibly the work of “somebody who doesn’t particularly know what the hell he’s doing, because it’s not good policy to want to kill off your clients.”

In other words, incompetent drug dealers, not malicious ones.

“They’re not chemists,” Ruzzamenti added. “They’re not pharmacists. They have recipes like your mom would have for chocolate pie.”

Whoever the suspects are, Kasirye says they made very good counterfeits.

“Whoever was doing this went to a lot of trouble to make it look like a milder pill,” she said.