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The Fentanyl Failure

Despite mounting deaths and warnings, the Obama administration did not take extraordinary measures to confront an extraordinary crisis, experts say

Washington Post — Judith Varone, 53, a waitress, died of a fentanyl­related overdose on March 23, 2013, in Lincoln, R.I. She was one of 3,220 people to die from synthetic opioids that year.

In May 2016, a group of national health experts issued an urgent plea in a private letter to high-level officials in the Obama administration. Thousands of people were dying from overdoses of fentanyl — the deadliest drug to ever hit U.S. streets — and the administration needed to take immediate action. The epidemic had been escalating for three years.

SALWAN GEORGES/THE WASHINGTON POST The 11 experts pressed the officials to declare fentanyl a national “public health emergency” that would put a laserlike focus on combating the emerging epidemic and warn the country about the threat, according to a copy of the letter.

“The fentanyl crisis represents an extraordinary public health challenge — and requires an extraordinary public health response,” the experts wrote to six administration officials, including the nation’s “drug czar” and the chief of the Centers for Disease Control and Prevention.

The administration considered the request but did not act on it.

The decision was one in a series of missed opportunities, oversights and half-measures by federal officials who failed to grasp how quickly fentanyl was creating another — and far more fatal — wave of the opioid epidemic.

In the span of a few short years, fentanyl, a synthetic painkiller 50 times more powerful than heroin, became the drug scourge of our time. Fentanyl has played a key role in reducing the overall life expectancy for Americans.

If current trends continue, the annual death toll from fentanyl will soon approach those from guns or traffic accidents. Among the dead are the anonymous and the famous, including musicians Prince and Tom Petty. It is so powerful that just a few flecks the size of grains of salt can cause rapid death.

Between 2013 and 2017, more than 67,000 people died of synthetic-opioid-related overdoses — exceeding the number of U.S. military personnel killed during the Vietnam, Iraq and Afghanistan wars combined. The number of deaths, the vast majority from fentanyl, has risen sharply each year. In 2017, synthetic opioids were to blame for 28,869 out of the overall 47,600 opioid overdoses, a 46.4 percent increase over the previous year, when fentanyl became the leading cause of overdose deaths in America for the first time.

“This is a massive institutional failure, and I don’t think people have come to grips with it,” said John P. Walters, chief of the White House Office of National Drug Control Policy between 2001 and 2009. “This is like an absurd bad dream and we don’t know how to intervene or how to save lives.”

Federal officials saw fentanyl as an appendage to the overall opioid crisis rather than a unique threat that required its own targeted strategy. As law enforcement began cracking down in 2005 on prescription opioids such as OxyContin and Vicodin, addicts turned to heroin, which was cheaper and more available. Then, in 2013, fentanyl arrived, and overdoses and deaths soared.

“Fentanyl was killing people like we’d never seen before,” said Derek Maltz, the former agent in charge of the Drug Enforcement Administration’s Special Operations Division in Washington. “A red light was going off, ding, ding, ding. This is something brand new. What the hell is going on? We needed a serious sense of urgency.”

But for years, Congress didn’t provide significant funding to combat fentanyl or the larger opioid epidemic. U.S. Customs and Border Protection didn’t have enough officers, properly trained dogs or sophisticated equipment to curb illegal fentanyl shipments entering the country from China and Mexico. The U.S. Postal Service didn’t require electronic monitoring of international packages, making it difficult to detect parcels containing fentanyl ordered over the Internet from China. CDC data documenting fentanyl overdoses lagged behind events on the ground by as much as a year, obscuring the real-time picture of what was happening.

Facing hotly contested midterm elections in 2018, Congress finally passed legislation aimed at addressing the increasingly politicized opioid crisis, including a measure to force the Postal Service to start tracking international packages.

“How many people had to die before Congress stood up and did the right thing with regard to telling our own Post Office you have to provide better screening?” Sen. Rob Portman (R-Ohio), sponsor of the legislation, asked on the Senate floor last fall.

Local and state leaders in hard-hit communities say the federal government wasted too much time at a cost of far too many lives.

“Everybody was slow to recognize the severity of the problem, even though a lot of the warning signs were there,” said New Hampshire Gov. Chris Sununu (R), whose state has one of the highest fentanyl overdose rates in the United States.

In Sununu’s state, Narcan, which delivers an opioid-overdose antidote, has become standard issue for some school districts. Addicts overdose on the sidewalks and in public parks of Manchester and are found slumped over the steering wheels of cars in traffic. Firefighters and paramedics are called nearly every day to fentanyl overdoses and have opened their station houses to addicts seeking treatment.

“In the city of Manchester, we saw 20 overdoses to 80 overdoses a month. We were like, ‘What the heck is happening with these overdoses?’ ” said Manchester Fire Chief Dan Goonan.

He said politicians and policymakers held numerous roundtable discussions to talk about solutions, but there was little action.

“I said, ‘If I had to go to another roundtable, I’m going to jump out the window myself because we’re going nowhere with these roundtables,’ ” he said.

Drug treatment experts compared the government’s slow response to an earlier failure to face the AIDS epidemic.

“There was a stigma about being gay,” said Luke J. Nasta, executive director of the largest drug treatment facility on Staten Island, N.Y. “There is also a stigma about being addicted to drugs. The entire society is suffering and the government can’t seem to get their arms around this epidemic.

“If it’s an epidemic, then treat it like an epidemic.”

The first wave of the opioid epidemic began in 1996 after drug manufacturer Purdue Pharma introduced what it claimed to be a wonder drug for pain — OxyContin, a powerful opioid that was aggressively marketed to physicians as less addictive than other prescription narcotics. As the medical community embraced the new drug, it became a blockbuster for Purdue, generating billions in sales.

Over the next decade, doctors and corrupt pain management clinics prescribed massive amounts of opioids. To meet the demand, drug manufacturers and distributors flooded communities across the country with opioid pills, including oxycodone and hydrocodone. Drug users and dealers diverted hundreds of millions of doses to the streets.

The DEA started to crack down on the illegal trade in 2005. Two years later, Purdue paid $600 million in fines and its executives pleaded guilty to federal criminal charges for claiming the product was less addictive than other painkillers. The company agreed to make its marketing conform to federal rules and has launched programs to combat opioid abuse.

“It is deeply flawed to suggest that activities that last occurred 18 years ago are responsible for today’s complex and multi-faceted opioid addiction crisis,” the company said in a recent statement.

The federal government also fined the largest drug distributors and pharmacies tens of millions of dollars over allegations that they failed to report suspicious orders of pain pills.

As the supply of prescription opioids began to tighten, America’s pill addicts became desperate. Street prices soared. Mexican drug cartels saw an opening to sell more heroin, a cheaper, more potent way to get high. That set off the second wave of the epidemic by 2010 and a rise in overdose deaths.

Then fentanyl hit the streets. A synthetic opioid developed in 1960 by a Belgian physician, fentanyl is normally reserved for surgery and cancer patients. It is up to 100 times more powerful than morphine, its chemical cousin.

For traffickers, illicit fentanyl produced in labs was the most lucrative opportunity yet, a chance to bypass the unpredictability of the poppy fields that produced their heroin. The traffickers could order one of the cheapest and most powerful opioids on the planet directly from Chinese labs over the Internet.

It was 20 times more profitable than heroin by weight. By lacing a little of the white powdery drug into their heroin, the dealers could make their product more potent and more compelling to users. They called it China White, China Girl, Apache, Dance Fever, Goodfella, Murder 8 or Tango & Cash.

The third wave of the opioid epidemic was about to begin. Ground zero was Rhode Island, already reeling from a crippling prescription pill and heroin problem.

The first signs were detected in the spring of 2013 when overdose deaths spiked at the state morgue in Providence. Then-Rhode Island Health Director Michael Fine wondered: What was killing so many so quickly?

Fine was surprised to learn when the toxicology reports came back that 12 people who overdosed between March and May had died from fentanyl. They ranged in age from 19 to 57, and most were from the northern part of the state.

Fine notified the CDC about the cluster. On Aug. 30, 2013, the CDC in its Morbidity and Mortality Weekly Report highlighted the unusual spike in Rhode Island. It didn’t attract much national attention.