Cover Story: Metro Atlanta heroin growing more dangerous

Say hello to fentanyl, the synthetic opiate on the rise in metro Atlanta

On March 3, Atlanta Police officers entered an upscale Poncey-Highland apartment along the Atlanta Beltline. In a bathtub, they found the dead body of a 34-year-old male.

Armed with a search warrant, officers discovered approximately $215,000 cash stashed in safes. They also found about 30 grams of Adderall and hydrocodone, two pounds of Xanax and oxycodone, and, in an unprecedented find for the APD, four pounds of fentanyl.

Fentanyl is an extremely potent synthetic opiate — 50 to 100 times stronger than morphine and 30 to 50 times more potent than heroin. It was engineered to go above and beyond morphine as a treatment for severe pain. It's also become one of the many opiates to which people, young and old, rich and poor, have become hooked on or might be taking if they abuse heroin.

According to the medical examiner's report, the man's accidental death was caused by the "combined toxic effects" of a mix of fentanyl, alprazolam (Xanax), and methamphetamine.

Four pounds of fentanyl "would OD thousands and kill probably hundreds of people," APD Narcotics Lt. Rick Mason says.

A few years ago fentanyl was a rare find, even for the cops, dealers, medical examiners, addicts, and social workers who know what's for sale in metro Atlanta's hard drug market. But those paying attention from the Bluff to the 'burbs have witnessed fentanyl's spread. After years of barely registering on medical examiners' toxicology screens, the drug is now showing up in double-digit numbers. Last year, fentanyl was detected in more than 40 bodies at the Fulton morgue.

Atlanta has typically been more of a cocaine town. That started changing in the late 2000s after the rise of prescription narcotics, specifically opiates, created a new generation of drug addicts. New state laws clamping down on pill mills have made it more challenging for users to access the drugs. When addicts couldn't get their hands on pills, they sometimes turned to heroin.

Over the past two years, the dangerous drug has become more prevalent. According to last year's Fulton County Medical Examiner's annual report, "Deaths due to heroin have skyrocketed in the past few years and heroin is now the most common fatal drug ingestion in the county." The report adds that heroin deaths involving fentanyl, the most potent opioid available for use in medical treatment, according to the DEA, "are also on the increase." This was seen most recently in a triple heroin overdose in April in Little Five Points that resulted in one man dying at Atlanta Medical Center from a mix of heroin and fentanyl.

Fentanyl is supposed to be used as a prescription to treat the most severe pain. It's usually legally dispensed out of pharmacies as a patch or a lollipop or made by illicit labs. Dealers or users then mix it with heroin to increase the high, sometimes with deadly results. There are those who use fentanyl by itself, sometimes by chewing patches. According to the Centers for Disease Control and Prevention, even small amounts can be lethal. Blood tests of people who died from fentanyl overdoses have shown as little as three nanograms per milliliter in their blood. In the case of the man found in the Poncey-Highland apartment, the concentration was above five.

In 2011, the Fulton County Medical Examiner's office counted 19 total heroin-related deaths. In 2014, that number had increased to 77 heroin-related deaths in Fulton County. Of those, 23 involved fentanyl. 2015's fentanyl numbers look on track to beat last year's. In the first three months of this year alone, the medical examiner's office has counted 22 heroin-related deaths, 16 of which involved fentanyl. That number could rise pending the results of ongoing toxicology reports.

"We used to hardly ever see heroin, and the fentanyl is a relatively new thing," says Randy Hanzlick, the county's chief medical examiner. "It looks like we are at least at last year's pace if not exceeding it."

"The days of shooting heroin are over. Now you're shooting heroin mixed with any other array of chemicals ... and it's become so much more dangerous," Mason says.

Xanax, oxycodone, hydrocodone. For at least five years, each of these drugs has appeared in the GBI's autopsies of overdose cases roughly two to three times more often than fentanyl. But fentanyl is closing the gap. Fentanyl "is becoming more prevalent as far as what we're seeing in deaths in Georgia," says Dr. Kris Sperry, the GBI's chief medical examiner, whose jurisdictions and numbers cover the state outside metro Atlanta.

Five or seven years ago, Sperry rarely encountered fentanyl. But last year Sperry and his team attributed 102 deaths to either fentanyl alone or fentanyl plus one or more other drugs. In 2015, Sperry's office has so far completed 19 cases where fentanyl was found either as a cause of death or a contributing factor.

The numbers may only hint at all of the fentanyl coming into the GBI's lab. If a GBI screen confirms heroin — a drug that carries heavier criminal charges and has no legal medical use — the scientists will not necessarily conduct a second full screen to confirm any fentanyl presence suggested in the preliminary data.

Fentanyl is stocked in hospitals, pharmacies, and ambulances. Last April, fentanyl was part of the kit thieves lifted from an unlocked Grady Memorial Hospital ambulance on Monroe Drive. A drug of fentanyl's strength can easily find a second life on the black market.

In the Poncey-Highland apartment, police discovered more than 50 ID cards, all bearing the deceased's picture, but different names. According to the report, his girlfriend said he used the cards to purchase drugs at pharmacies. She said he had drug-related seizures. Cold showers helped him during the events.

"Generally young people get stuck on Percocet ... or some opioid derivative prescription pill," Mason says. "They get expensive and the alternative to that is heroin, which is cheaper and makes you higher than the prescription pills."

That's when users move from clean, well-lit pharmacies to streets or websites. Heroin bought in the U.S. usually comes from Mexico, according to Sperry and law enforcement officers. Atlanta police say they're seeing fentanyl from China and possibly Canada. The DEA says Mexican authorities have closed labs there — the agency says illegal fentanyl from Mexican labs contributed to approximately 1,000 overdose deaths in six states between 2005 and 2007 — and that chemicals used to make fentanyl have come from China, Mexico, Germany, and Japan.

Sperry's office sees about 650 to 700 bodies a year that reveal drugs as either a cause of death or a contributing factor. The vast majority — some 85 percent — are due to prescription drugs, either from honest mistakes or knowing abuse.

"There has been an increasing trend" in deaths due to all illegal drugs, Sperry says, adding that it's worse in other parts of the country, especially New England. He suspects the trend might have something to do with geography, with shipping and smuggling routes, and that maybe metro Atlanta, despite being a logistics hub, has yet to become a major exit on the fentanyl highway.

Still, heroin use is picking up, particularly in Fulton County. For several years, the county medical examiner's office has noted in its annual reports that heroin use was increasing, particularly among people in their 20s. For drug dealers, cutting heroin with fentanyl makes business and economic sense.

"Once you're addicted to heroin, believe it or not, all of these addicts, if somebody ODs, that's who they want to buy their heroin from because it's the strongest and it must be the best," Mason says. "The word's gotten out that you can get fentanyl from overseas. You'll spend $100,000 on a kilo of heroin but you can spend a tenth of that maybe on four pounds of fentanyl, so you're making so much more money by putting fentanyl in your heroin. You're making a strong product that people are craving more and more."

In March, the DEA sent out an alert to law enforcement across the country saying fentanyl is causing "significant problems" nationwide. It listed about 200 fentanyl-related deaths in Pennsylvania since 2013; four deaths in New Hampshire over two months; and 80 in New Jersey over six months.

Cracking down on fentanyl's availability is tough in a world where Amazon-like sites on the dark Web sell high-quality heroin and DIY sites supply recipes for the home cook. Silk Road, the online black market of all things illicit ranging from weed to heroin and LSD, and its successor, Silk Road 2.0, were shut down in 2013 and 2014, respectively, by federal law enforcement. Evolution, another online drug bazaar that gained users after those shutdowns, abruptly vanished in mid-March. Today Agora is the largest anonymous online marketplace.

"We're seeing a lot more overdosing because people have to guess what they can handle, what their tolerance is, and a lot of times they guess wrong or their tolerance is down because they haven't used for a few weeks," says Dr. Michael Fishman, Director of the Young Adult Program at Talbott Recovery, a rehab center with locations in Atlanta, Dunwoody, and Columbus. Government statistics dealing with treatment center admissions do not treat fentanyl as a separate category. According to 2012 data from the Substance Abuse and Mental Health Services Administration, Georgia treatment centers reported almost 3,100 admissions related to opioid dependency. More than 650 heroin-related admissions were reported.

Opiates work by triggering the brain to produce more dopamine, one of the brain chemicals that carries messages about movement, emotional response, and pain and pleasure. Drugs like heroin and fentanyl trick the brain into producing much more dopamine than it naturally would. That dopamine is the source of the high. But sometimes people buying the heroin don't know it contains fentanyl. And even if they do, it's hard to gauge whether the dose is too strong.

"They get heroin, they use what they thought was their normal dose, and they die because it's got fentanyl in it," Fishman says. "The high is quicker and more intense but it doesn't last as long."

Heroin has been being spiked with fentanyl for a long time, he says. But it was not seen in such large numbers. In about the last six to eight months, nearly all his heroin patients who have been tested have come back positive for fentanyl.

The DEA says it will continue trying to break up distribution networks in an effort to halt the increasing availability of fentanyl. But experts say it will take a concerted effort on the part of policymakers, first responders, and recovery and medical specialists to properly reduce the number of overdoses.

Narcan is a trade name for naloxone, a drug that can reverse the effects of overdoses from heroin and other opioids, including fentanyl. It's squirted into the nose or injected into the upper arm or thigh. Stopping fentanyl's effects takes two doses three minutes apart.

Waiting three minutes is not necessary if the heroin contains fentanyl, says Mona Bennett, associate director of the Atlanta Harm Reduction Coalition, a nonprofit that operates metro Atlanta's only needle-exchange program. She is a fan of naloxone because she's trying to save lives. She says making the overdose-reversing drug more available is part of what will be necessary to end the ODs landing in Georgia's morgues. Once you hear the word "fentanyl," Bennett says, it "would be great to have a two-vial kit of naloxone around."

Holly Springs, a small city in Cherokee County, became the first Georgia police department to carry naloxone when it equipped its officers with kits in 2014. APD officers in Zone 1's west side neighborhoods, including English Avenue, home to the Bluff, and Vine City, started carrying Narcan in a pilot project this year. APD officials say the program won't roll out to the rest of the city at least until testing is complete sometime later this year. APD Spokesman Sgt. Greg Lyon says officers have administered the kit five times since the program began. In each case, the overdose victim was "revived."

Even some drug dealers have turned to the drug, police say. "We actually have some dealers in the Bluff now that actually carry Narcan kits so when somebody ODs they inject them," Mason says.

A relatively new law called the 9-1-1 Medical Amnesty Law, or Good Samaritan Law, allows callers or victims to avoid prosecution for small amounts of drugs if they are seeking help with an overdose. Families and friends who've lost loved ones to overdoses advocated for the bill, which sped through the state Legislature in about 10 weeks in early 2014. A total of 22 states plus Washington, D.C., have similar medical amnesty laws, according to the nonpartisan National Conference of State Legislatures.

It's not just a junkie's concern. Plenty of people take legal opioids for legitimate pain. Bennett thinks that those people should keep naloxone in the house in case of an accidental overdose. Bennett also thinks doctors should be co-prescribing naloxone along with whatever opioid prescriptions they're writing. Naloxone rescue kits and training are available from several places including Georgia Overdose Prevention.

Another solution is to keep addicts from continuing to use. Hundreds of 12-step and support-group meetings are held each week in metro Atlanta in a variety of locations. And recovery centers in metro Atlanta have specialists and doctors trained in helping people live with opiate addictions.

If Fishman had a magic wand, he would like doctors to better understand addiction, see policymakers put more of a focus on treatment rather than incarceration, more parental involvement in children's lives, and "dealing with poverty and social problems as well." But first to his mind: for society to see addiction "as the disease it is." It will take numerous solutions to help prevent more overdoses and abuse of a drug, and its amped-up additive, that can be found in low-income neighborhoods, gated communities, and everywhere in between.

"I see whites, blacks, young and old using this stuff," Fishman says.

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