The Powder of Death

Marley Fisher walked away from several overdoses during her six years of opioid addiction. The batch that finally killed her left her unable to even stumble out of the Point State Park bathroom stall into which she ducked to shoot up.

In April of 2017, Fisher, 28, accompanied a friend to buy heroin from a dealer Downtown, according to text messages on her phone. The toxicology report showed that what they bought contained five types of fentanyl, a synthetic opioid that is 30 to 50 times more potent than the average street heroin, according to the Drug Enforcement Administration, and often mixed with heroin. The batch that killed Marley Fisher contained some carfentanil, a chemical analog 100 times stronger than fentanyl and nicknamed “the grey death.”

Her friend overdosed in the park. Medics used the nasal-spray OD antidote naloxone to revive him. Fisher, alone in the stall when the drug overtook her body, died there.

For her mother, Jeanna Fisher, a construction manager from Whitehall, it was a heartbreaking end to a six anxious years of zigzagging: When on drugs, Marley would go missing for weeks-long benders. She and a boyfriend once drilled into the family safe and stole her late father’s coin collection to pawn for drug money, Jeanna Fisher said. After stabilizing in rehab, Marley was “a sweetheart” and could keep a job and make progress towards her goal of working in veterinary medicine, she said. Marley was attending Community College of Allegheny College when she died.

“It was constant relapsing, constant being suspicious of where she was going,” her mother said. “Sometimes, we couldn’t find her and she would reappear.” Marley was probably self-medicating due to collapsed discs in her spine. “She had the back of an 80-year-old.”

Her daughter once overdosed in her bathroom. Seeing her turn gray and vacant, Jeanna performed CPR. Marley confessed it wasn’t her only OD in the past year, that friends had called paramedics to revive her.

Jeanna came to fear her daughter would die of an overdose. But she is sure she died that particular April day because someone sold her a drug stronger and deadlier than she would have knowingly used. “Marley was a heroin addict,” she said. “She was not a fentanyl or carfentanyl addict.”

Over the last five years, fentanyl has invaded the drug supply, making a deadly crisis deadlier. First synthesized in 1959 and used as a painkiller in emergency rooms and war zones, the drug has made its way into the black-market opioid market, often discreetly bundled with heroin. It’s killing users who have survived years of addiction and stagnating progress against the tide of overdose deaths.

Dealers and suppliers like fentanyl because it cuts costs. A small batch can be cut up and mixed with weak heroin and filler for a product that has all the strength users want for cheaper production costs. “A lot of drug traffickers are selling it,” says Patrick Trainor, public information officer for the DEA’s Philadelphia field office. “If it’s 50 times more potent than heroin, you can cut it up into 50 more times [than you’d cut heroin] and sell it for the same.”

It has no growing season, unlike the poppy seed used to make heroin. Mexican and Chinese drug labs produce it and send to the U.S., through illicit shipments made over “the dark web” a series of internet channels unfindable to the average web user, said Trainor. A Ziploc bag of fentanyl can be as potent as a car trunk of heroin, making for easier transport.

In its Analysis of Overdose Deaths in Pennsylvania for 2016, the DEA noted that fentanyl and substances that were chemically similar were found in 52 percent of deceased OD victims that year, more than any other drug category, and rising from a mere 14 percent in 2014. More surprisingly, the report stated that “users are now seeking out fentanyl instead of unknowingly purchasing fentanyl disguised as heroin, and street-level traffickers are openly marketing fentanyl to customers instead of disguising it as heroin.”

For some advanced-stage addicts, “it’s more important to stay high than alive,” Trainor said. “There’s no greater endorsement [for a dealer] than when his product kills someone.”

Dr. Mitchell West, medical director of addiction medicine at Allegheny Health Network, said that some of his patients “have a preference for fentanyl,” despite its lethality. “It goes against all reason,” West added. “If there is a batch that people are overdosing on in clusters, that’s the batch they seek out. They think, ‘I have a high tolerance. I’ll be careful.’ ” But many wind up in AHN emergency rooms from overdoses or at the coroner’s office.

“It’s taken a bad problem and turned it into a nightmare,” West said. “We had people who—and I’m using the term loosely—were successful intravenous drug users.” These are people who may have had their personal and professional lives halted by addiction, he said, but managed to stay alive, even as their usage mounted. “I had patients who were using several bags of heroin a day. “They will overdose on a single bag of fentanyl.”

‘This is a particularly strong batch’

The stamp bag is the main unit by which heroin is sold in the Northeast. The wax-paper packets contain about a tenth of a gram, a single dose to most users. They sell for as little as $5 each. This method of sale and packaging is so regional that posters on Facebook groups for former addicts sometimes have to explain references to “stamp bags” to people in other parts of the country. (Users on the West Coast, where black tar heroin reigned supreme, expect more purity in their product.)

Traffickers sometimes “stamp” a name onto packages from a particular batch. DEA and other law enforcement officials are hesitant to give out these names, out of concern over publicizing a brand of sorts. A 2010 “art show” of stamp bags picked up off New York City streets showed names like “Life,” “No Pain” (with a graphic of a coffin) and “Shooters” (with a logo of two guns pointed at each other).

“There was a batch of the day and they found memorable ways to put insignia on it,” said Jeremy, a former user who spent seven years of addiction in various locations in Pennsylvania and requested his name changed for this article. He recalls “Crazy Train” and “Déjà Vu.” Some batches had a logo, like a thumbs up or Superman’s S. Others were identifiable by the color of the wax paper: purple or blue or red.

The colors of the product inside range from pure white to gray to sandy brown. Increasingly, these bags are not pure heroin, but mixes of drugs meant to have the same effect. Strengths vary and “stamps” become signals of potency.

“I’ve had dealers tell me, ‘This is a particularly strong batch,’” Jeremy said. Often, that means a pinch of fentanyl. “I think a lot of street-level dealers have no idea what they are selling,” Jeremy added. “In [a] city, competing drugs dealers want to have the strongest stuff.”

As part of her dissertation, Kathleen Creppage, at the University of Pittsburgh’s Graduate School of Public Health, analyzed the contents of stamp bags taken as evidence by the Allegheny County Medical Examiner’s Office. The proportion of bags containing some fentanyl or an analog of it jumped from 2 percent in 2014 to 17 percent in 2016. “Historically, heroin was the drug sold in stamp bags, so you didn’t see fentanyl,” Creppage said. “To see it rapidly increase is alarming.”

Jeremy began abusing drugs as an undergrad at Duquesne University in 2009. Prescription painkillers were popular and easy to score, particularly if you bussed to Oakland with its large student population. Fentanyl was like a delicacy. Every so often, epidermal patches, the kind prescribed to severe chronic pain sufferers or to hospice patients, made their way into the black market—the same way bottles of OxyContin or Vicodin did: Someone with a prescription sold them or a dealer obtained them through a break-in of a pharmacy or other medical supply inventory.

“It was not a common thing but everyone was excited when one came around,” Jeremy recalled.

That was how fentanyl was used illicitly—rarely and through misuse of pharmaceuticals—until around 2014, when foreign drug labs started producing it and traffickers bought it via the dark web to spike their heroin. (Trainor, of the DEA, said precursors are carefully controlled in the U.S. and China is the main illicit supplier.) Fentanyl then leapt from obscurity to become the drug most often present in overdoses fatalities, nationally and locally.

“It’s killing people left and right,” said Jeremy, who struggled at a few Pennsylvania universities before getting clean at the Ambrosia Treatment Center in Florida in 2016. He’s since stayed in Florida, but often hears of “people back home dying.”

According to the Centers for Disease Control and Prevention, the opioid epidemic unfolded in three distinct waves: an increase in deaths from overdoses on prescription painkillers starting in the late ’90s, a spike in heroin overdoses starting around 2010 and the rise of synthetic opioids, like fentanyl, starting about 2013.

Synthetic opioids other than methadone were present in 20,145 of the United States’ 64,000 drug overdose deaths in 2016, according to the CDC, outpacing heroin, which showed up in 15,466 deaths. The two categories were about even the previous year.

Fentanyl was the most common drug in Allegheny County overdose fatalities in 2016, 2017 and, so far, 2018, according to data from the Pennsylvania Overdose Prevention Technical Assistance Center, a project of Pitt’s School of Pharmacy. Last year, it was present in 547 of the county’s 737 OD fatalities, dwarfing heroin at 288. Before, fentanyl was a relative rarity, showing up in 30 percent of county deaths in 2015 and 20 percent in 2014.

That 2017 total—737 overdose deaths—is an all-time high for Allegheny County. Drug deaths, which have been climbing across the U.S. since the 1990s, also continue to escalate nationally, from about 40,000 in 2009 to more than 64,000 in 2016.

As a latecomer to a social issue that had already reached a crisis point, fentanyl is frustrating the efforts of officials who have worked to reverse the trend.

Dr. Karen Hacker became director of the Allegheny County Health Department in 2013. She pushed police departments to carry naloxone and, in 2015, issued a standing order allowing any county resident to obtain the OD antidote from a pharmacy without a prescription. She sees progress in the number of users saved by the drug and increased emergency room usage.

Despite increased awareness and preventative measures, both the U.S. and Allegheny County had record death tolls in 2017. How much of that is due to fentanyl? “Most of it, I think,” said Hacker. “The challenge is that it is super strong and the user might not be aware of how much of [their drug] is cut with it.”

Naloxone can reverse a fentanyl overdose but the drug kills so quickly, there is often no time for the victim to signal for help or a medic or police officer to respond.

“A fentanyl overdose is one where we find the needle in the person’s arm,” said Jerry Overman, coroner of Indiana County, where fentanyl was present in 21 of the 39 overdose deaths in 2017. At least three users died from the same batch of carfentanil.

Prevention Point Pittsburgh, a legal needle exchange program and safety resource for active users, began offering fentanyl detection strips last October. Despite the drug’s lethality, Alice Bell, overdose prevention project coordinator, says the strips aren’t particularly popular.

“They only tell you yes or no,” said Bell, “whether or not there is fentanyl in the product, not how much.” Only a few users want to test their products and refuse fentanyl at any dosage. Most of the users she encounters know they will get some fentanyl and are resigned to it.

‘She never had a chance’

In response to Marley’s death, Jeanna Fisher started Pittsburgh Won’t Forget U, an advocacy group for the families of those who died of a drug overdose. Part of its mission is to encourage law enforcement officials to charge dealers with homicide because of the increasing lethality of their products.

When I asked her to pass my name to anyone else in her organization who lost someone to fentanyl, she said, “That would be everyone. That’s the drug that’s been killing people.”

I received about a dozen Facebook messages, texts and phone calls that began with some variation of “My son…” or “My daughter died of a fentanyl overdose.” Perhaps the cruelest twist of the proliferation of fentanyl is its tendency to kill people who have already survived years of their personal and our societal struggle against opioids.

Catherine Slane, of West Deer, lost her daughter Alexandra at age 26 in October of 2016 to a fentanyl overdose. Alexandra had been using since age 16. Like many people susceptible to addiction, she struggled with chronic pain. She had scoliosis, a sideways curvature of the spine.

Alexandra had overdosed at least five times prior to her death, including once in their family home on Christmas Eve. They kept naloxone at their house and sent her to several rehabs across the country, throughout a relapse/recovery cycle.

At the time of her death, Alexandra was fresh from a stint of treatment and studying to become a nurse at CCAC. She called her sponsor for a ride to a Narcotics Anonymous meeting and then apparently injected a fentanyl-laced blend. Her sponsor found her slumped over on a sofa. She died before the ambulance got to her.

“Regardless of all of that, I know in my heart and soul that she would have beaten this awful disease, had it not been for her deadly encounter with fentanyl,” said Catherine Slane. “She never had a chance.”

Linda Estep’s son, Jesse, died of a fentanyl overdose at age 28 in August of 2017. Both she and her son struggled with chronic pain: Linda from knee and back problems and Jesse from dental issues. “He ended up with dentures at age 24,” she said. She used to let him take Percocets from her purse, unaware of the addiction it would unleash.

At the high point of his life, Jesse Estep owned a truck, was renting his childhood home in the Knoxville neighborhood from his parents and held a job as a custodian at Pittsburgh Public Schools’ headquarters in Oakland. He also was father to one daughter, Mia. He lost the vehicle, home and job and wound up in a court-ordered treatment program that curtailed his parental rights due to issues stemming from his addiction. At his lowest point, Jesse had sold his Play Station, hats and even his shoes to pay for heroin and crack cocaine.

Before his fatal overdose, Jesse Estep neglected to attend a court-ordered drug test, Linda Estep said. He understood this to mean he would lose visitation rights to his daughter.

She knew he later bought drugs to ease that emotional blow. Linda Estep saw him go to a familiar corner. “I thought he was buying crack cocaine and I was grateful, at that point, it wasn’t heroin,” she said. During his period of being monitored by the court system, Jesse had developed a crack habit because it usually didn’t trigger a positive drug test.

He retreated to the basement suite where he lived with his parents. The next day, his father found him dead on the toilet, from a drug combo that included fentanyl. Like Marley Fisher and Alexandra Slane, he died before he could signal for help from people either a short distance or short car ride away.

“I don’t know why I didn’t check on him or why I didn’t go to ask if he wanted something to eat,” said Linda Estep, through tears. “I just thought he wanted to be left alone.”

‘Overdosing is just part of the process of using fentanyl’

For every fatality, there are countless non-fatal overdoses, said Hacker. The spread of naloxone means that more people are walking away from overdoses, but also the spray is being used by friends, family and even passersby to revive opioid users in incidents that never make it into a police or coroner report. “We know Pittsburgh is using it very frequently,” based on the prescription fill rate, Hacker said.

The current rate of overdoses is shocking and unprecedented to West, medical director of addiction medicine at Allegheny Health Network. “In the past, for an experienced heroin user, an overdose was a rare occurrence,” he said. “Overdosing is just part of the process using fentanyl.”

West, a 20-year medical veteran who once worked at Gateway Rehab, said people shoot up and overdose in the bathrooms of the hospitals where he works, trying to stave off withdrawal symptoms in the short time before they receive methadone.

Patients who don’t die injure themselves from continual intravenous drug usage. He’s readying a patient for replacement of a heart valve into which she injected. In his patients, knee joints and parts of the spinal column are displaced because they are near infected injection sites. He’s seen permanent brain damage from lack of oxygen during an overdose and one of his patients had to endure the amputation of a leg into which he injected.

“It is beyond what I imagined,” West said. “This is what the face of this looks like. It’s not what it looked like five years ago.”

He traces the state of affairs to fentanyl. “This is because of a little powder,” he said, “where a little bit in the bottom of an envelope is enough for a thousand doses.”