image

health as it happens

Tennessee's drug crisis has no end in sight, and fentanyl is making it far deadlier - The Tennessean

Fentanyl is low-cost and highly potent. On the street, it's being mixed with drugs like meth and heroin to increase profits, but it's also made its way into the recreational market disguised as pills.

A 22-year-old woman stepped off a plane at Nashville International Airport on a cold January day, hoping to make $1,000. 

Her task was simple: Deliver the two suitcases she had checked on the flight from Phoenix to Music City, and the cash was hers.

She never managed to get paid. In fact, she didn't even make it out of the airport that day.

Instead, agents with several agencies seized her luggage and found two kilograms of fentanyl. She was carrying nearly one million doses of the synthetic opiate worth around $20 million.

The year was 2018, and Tennessee's fentanyl epidemic was picking up speed. 

In hindsight, Tennessee's illegal drug epidemic was bound to happen. As the state cracked down on prescribing legal opioids like Vicodin and OxyContin in the early 2010s, more and more people turned to the street to feed their addictions. 

What was unpredictable was how fast drug dealers would exploit the properties of fentanyl to skirt authorities and increase profits while also increasing the lethality of their products. Data shows 2018 as the crossover year, the first time fentanyl became the leading cause of overdose deaths in Tennessee.

Dr. Stephen Loyd, Tennessee's opioid czar under Gov. Bill Haslam, said he first noticed fentanyl overdoses in 2015, but it was "nothing" like it is now.

"I can't remember the last time I've looked at a drug screening of a new patient coming off the street that didn't have fentanyl in it," Loyd said.

'Dopesick' on Hulu: Michael Keaton's character is based partly on Nashville addiction doctor Stephen Loyd

Beware: Tennessee officials warn of increase in lethal counterfeit pills

Fentanyl, and its variant carfentanil (originally used to tranquilize elephants), is low-cost and highly potent. On the street, it's being mixed with drugs like meth and heroin to extend supplies and increase profits, but it's also made its way into the recreational market, disguised in MDMA and Xanax pills. 

A fear is sinking in among addiction specialists and law enforcement agencies alike that these factors, which led to a spike in overdose deaths in Tennessee in 2020, mean the fentanyl epidemic is only beginning.

Between 2019 and 2020, overdose deaths increased from 2,089 to 3,032, or 45%.

Some could attribute the increase to COVID-19 and early pandemic restrictions, but in Nashville, for example, overdose deaths in the first 10 months of 2021 already exceed 2020. 

Despite bleak statistics, there may be a glimmer of hope: The growing acceptance of harm reduction policies, like increased naloxone training and prescribing of Suboxone, are buying drug users more time to find the help they need.

'Tennessee's never had a drug supply problem'

For most of the 1990s and 2000s, law enforcement in Tennessee focused on busting meth labs and cracking down on the importing and selling of heroin and cocaine. 

Tommy Farmer, a special agent with the Tennessee Bureau of Investigation Dangerous Drug Task Force, said the state did a remarkable job shutting down meth labs, but that didn't change its problem with drugs. 

For years, state and federal laws alike seemed oblivious to a worsening addiction crisis caused by prescription opioid painkillers.

It wasn't until the state passed the Tennessee Controlled Substance Monitoring Database Program in 2012 that Tennessee's current drug epidemic started to take shape.

Farmer, who spent nearly two decades on drug task forces in Tennessee, said with easy access to pills no longer an option, people addicted to prescription opioids turned to the streets.

Farmer and other addiction specialists agree it was a predictable outcome but necessary to tackle the state's opioid crisis.

"Tennessee's never had a drug supply problem," Farmer said. "We have an addiction problem."

Following the monitoring database's creation and subsequent enforcement, addiction deaths continued to climb at a predictable pace. The state had prepared for this, but it hadn't for fentanyl.

Antwon Bailey, an addiction counselor in Madison, said fentanyl made its way onto doctors' radars in the early 2010s, but no one thought it would make its way to the streets. 

"There was a period where professionals talked about fentanyl and carfentanil like 'It's going to be how much stronger than heroin? That's ridiculous. Everyone would die. That would never happen,'" Bailey said. 

Like most opiates, fentanyl has its roots in legitimate medical use, primarily for cancer patients in around-the-clock pain. 

But the properties of fentanyl made it appealing to drug dealers as it could elude the system designed to fight well-known illegal drugs, like heroin, cocaine and meth. Its production is relatively simple compared to cocaine or heroin, which require many materials, like coca or poppy plants, to produce.

Fentanyl also doesn't require a large dose to get high. Traditionally drugs are measured in gram or milligram dosages; dealers count fentanyl in micrograms. 

Farmer said the dosage size and synthetic nature of fentanyl are critical, as the drug can be produced anywhere and smuggled into North America.

The two ways fentanyl is killing

In the drug community, fentanyl is a "get rich quick" drug, according to Trevor Henderson, who runs a small staff at the Nashville Metro Health Department focused on tracking and responding in real-time to the opioid crisis. 

"Even if they aren't in the drug dealing game for the long haul, there's this idea you can make a lot money in a short time," he said.  

Dealers make money off fentanyl by using it to stretch illegal drug supplies or substituting it for expensive drugs, like pills. 

Often a dealer will cut drugs like meth or heroin with fentanyl, allowing them to sell smaller amounts with stronger potency. It's a simple process: A dealer takes a portion of fentanyl they've bought, mixes it with other drug components in a blender, and then presses out pills. 

The mixing process is amateurish, meaning it can be unclear how much fentanyl is in each pill, leading to fears about bad batches. 

Sometimes the user is aware fentanyl is incorporated, and sometimes they aren't.

Josh Love, an epidemiologist on Henderson's team, said the unfamiliarity has led to more overdoses among drug addicts and recreational users alike.

Recreational drug users tend to be younger, like teenagers taking MDMA at a music festival. They take the pills thinking it's what they were told when in reality, they're fentanyl. These users tend to have lower tolerances to drugs in general, so the potency of fentanyl can cause overdoses.

It's these situations that concern law enforcement the most.

"The pool of people susceptible to this drug has widened," Love said. 

Metro Health's biggest fear is a high potency batch of fentanyl pills making its way to Tennessee during an event like Bonnaroo. Hundreds of unsuspecting people could take the pills thinking they're one thing, only to overdose because they contain fentanyl.

'Can't treat people if they're dead'

To combat the growing fentanyl crisis, some addiction specialists have started to promote harm-reduction policies. 

"You can't treat people if they're dead," Loyd said, so one has to reduce the chance of dying.

One way to partially tackle the unknown pill problem is through fentanyl test strips that let users know if what they bought contains the drug. 

A small study conducted in Rhode Island found that 77% of those who used fentanyl test strips altered their drug use behaviors, including discarding their supply, using with someone else, or keeping naloxone nearby.

But there are still barriers. Tennessee law bans the strips because they would be considered drug paraphernalia and the Food Drug Administration hasn't approved any of the strips used in other countries as safe for use in the United States.

Naloxone, sold under the name Narcan, is an emergency use drug that counters an opioid overdose. Anybody can buy it, including addicts, and it has become widely adopted by first responders to save lives. 

However, naloxone is considered a harm reduction tool as it doesn't solve the underlying addiction. Often, chronic drug users are revived with naloxone multiple times before seeking help or dying of overdoses.

Suboxone is the other, more controversial drug in the addiction treatment world. It's a combination of opiate and naloxone, with the idea that it addresses addiction cravings while still allowing a person to function.

Some use Suboxone as a transition to complete sobriety, while others use it for extended periods. 

Bailey said there is a divide in the addiction community over its usefulness.

For decades, the way to fight addiction was through sobriety and group therapy. But in these places, Suboxone tends to be stigmatized, with many considering its users not to be "truly sober."

Bailey said this can serve as a barrier to people seeking help.

"Some people don't think it counts as a treatment," he said. "But people are dying really fast from fentanyl, and it can make the difference in some cases. It can keep people alive."

Fentanyl-related overdose deaths in Tennessee

Adam Friedman is The Tennessean’s evening reporter covering breaking news, crime, cops and a little bit of everything else. If you have a news tip, he wants it. Email him at [email protected] or call him at 731-431-8517.