With 14 deaths being linked by Chicago authorities to heroin laced with fentanyl in a two-day period last week, the nationwide death toll in a wave of ODs tied to the powerful synthetic opiate continues to rise. Although precise figures are hard to come by, Chicago authorities believe 75 people have died of the lethal combination there this year, while in Detroit, authorities put the number at more than 130 dead since last fall, including 33 in the past few weeks. Dozens more overdoses and fatalities have been reported in Atlanta, St. Louis, New York, Pittsburgh, Philadelphia, and the New Jersey-Maryland-Delaware region.
Detroit has been one of the hardest hit cities. "I think we had 58 deaths in the three weeks beginning in mid-May," said Ricardo Marble, lead trainer for substance abuse services for Detroit's Community Health Awareness Group, which runs drug user harm reduction programs, including a needle exchange, in the city. "On May 18, we had 12 deaths in one 24-hour-period, and we've had over 130 fentanyl-related deaths since the fall of 2005."
Marble and substance abuse workers across the state are hitting the streets in an effort to lessen the toll. On Thursday, there was an "emergency call to arms" for outreach workers, with workers across the state going out onto the streets to provide information about fentanyl and overdose protection where it is most needed.
"We went out with 30 people here in Detroit and targeted areas with high rates of injection drug use," said Marble. "We're distributing pamphlets we got from the Harm Reduction Coalition and getting that information into the hands of the community," he told DRCNet.
Two weeks ago, the Substance Abuse and Mental Health Services Administration (SAMHSA) issued a nationwide alert to outreach workers, treatment providers, and hospitals warning of the deadly problem. "Individuals involved in the public health need to be aware of this new dangerous drug combination," Dr. Westley Clark, director of SAMSHA's Center for Substance Abuse Treatment (CSAT), said in the letter. "They need to be prepared to alert patients, clients and others to help save lives. After all, fentanyl is 50-100 times more powerful than morphine. When mixed with cocaine or heroin, the results can be lethal."
"We sent the letters to treatment providers, hospitals, and the like, alerting them to the existing problem and identifying both prevention and quick intervention methods," said a SAMSHA spokesperson. "We are encouraging people to work as part of a community, to share information," she told DRCNet.
The Centers for Disease Control and Prevention (CDC) in Atlanta have also been involved, although less so than some might imagine. While the CDC sent a team to investigate the situation in Detroit two weeks ago, that is the limit of the agency's participation, said CDC spokeswoman Bernadette Burton. "The Michigan Department of Community Health requested our assistance, and we sent members of our epidemiological intelligence service to Detroit to assist state and local officials with autopsy reports and analysis to help them understand the overdoses and formulate prevention guidelines for clinicians and educators and the like," she told DRCNet.
That work is still ongoing, Burton said. As for help with the wave of overdoses, all the states have to do is ask. "We will be returning a final report to Michigan authorities, but no other state or municipality has asked for our assistance," she said.
"The public health response has been very disorganized," said Harm Reduction Coalition medical director Dr. Sharon Stancliff, who also runs the group's SKOOP (Skills and Knowledge on Overdose Prevention) program, which teaches users how to administer the opiate antidote naloxone. "I am glad to see that it has risen to the level of attention where SAMSHA has finally responded and the CDC has been involved, but it is disturbing that it takes a spike in deaths to get everyone's attention," she told DRCNet. "ODs are a fact of life, and we need to focus on the ODs in general, not just dealing with fentanyl, but dealing with overdoses as a true public health problem."
State and federal law enforcement has also been hard at work. After an early round of ODs in the Philadelphia and Camden areas last month, police cracked down on dealers peddling the fentanyl-heroin combo, and last week, federal drug czar John Walters held a loudly ballyhooed press conference to announce that DEA agents working with Mexican lawmen had busted a lab in Guadalajara that may -- or may not -- have been the source of the lethal combo.
This week, the DEA organized a two-day, invitation only, no-press brainstorming session Wednesday and Thursday in Chicago to "coordinate worldwide investigative efforts aimed at identifying and dismantling the drug trafficking organizations responsible for the diversion, illicit production, and/or distribution of fentanyl," according to the DEA's announcement. The conference brought together representatives from more than a dozen states, Mexico, the drug czar's office, and the CDC. While the DEA confab paid lip service to actually preventing and reducing overdose deaths through public health measures, its overwhelming emphasis was on law enforcement.
That is part of the problem, said Dan Bigg of the Chicago Recovery Alliance (CRA), an organization that does needle exchange, mobile methadone maintenance, and other harm reduction programs in the Windy City. "What we think is going on is that the destabilization of drug markets by the police has produced the more regular use of fentanyl as a public relations move by dealers to attract new users, and that's caused a one or two notch increase in the purity of heroin on the streets," said Bigg. But the abnormal rate of overdoses has occurred only in the past few weeks, he told DRCNet, suggesting there is an element of hype involved. "We don't really know what's going on," he said. "We don't have the evidence that this is a new problem."
A law enforcement focus will not solve the problem, said Bigg. "They haven't seemed to have achieved anything with enforcement. DEA street level buys will show increased purity, and that's the same as them basically acknowledging they are losing. In recent weeks, we've seen a genuine increase in the overdose rate, and that is most probably related to the purity level of the heroin."
There are measures that have been proven to work to reduce overdoses and overdose deaths, Bigg suggested. "We need a massive expansion of opiate substitution therapy," he said. "There is clear evidence that that does more to reduce overdose levels than anything else. We also need the development and proliferation of safe injection sites. There is substantial evidence from around the globe that the sites reduce community overdose levels. And we need opiate antidotes, but the government won't fund them, even though we've seen 400 heroin OD death reversals with these drugs since we started in 2001."
But CRA wasn't part of the DEA-sponsored fentanyl conclave. "We are the most hands-on group in the city on this, and they didn't even invite us to the meeting," said Bigg.