FENTANYL-LACED STREET DRUGS "KILL HUNDREDS"

With street names such as Drop Dead, Flatline, and Lethal Injection,
fentanyl-laced heroin and cocaine are marketed by drug dealers as the
ultimate high. But these drugs are so dangerous that hundreds have
died. From Chicago, one of the hardest hit US cities, David Boddiger reports.

Mike Wickster, a bald and tattooed 34-year-old, has been brought back
from death's door ten times after overdosing on heroin, most recently
on heroin he believes was laced with the powerful synthetic opiate
fentanyl. He survived and eventually wound up in jail where he had to
go "clean". With help, he has stayed off drugs for 7 months and now
works in a harm-reduction programme trying to help drug users. But
friends from his drug-using past still call when they have found a
source for heroin with fentanyl.

"Just yesterday someone said, 'I know where to get fentanyl.' People
want it because it's powerful and extreme. Deaths are like an
advertisement--for every 10 people that die, 100 more will go looking
for it", he says.

Fentanyl is not new to veteran abusers, but in the past it had been
obtained by diverting prescriptions. According to Timothy Ogden,
Chicago's top Drug Enforcement Administration (DEA) official,
clandestine fentanyl labs were occasionally discovered in the 1980s
and 1990s. But those operations were nowhere near the size and scope
of today's fentanyl networks controlled by international drug traffickers.

"In 30 years of law enforcement experience, I haven't seen this much
of a threat before", Ogden says. "It's like a game of Russian
roulette, only you're putting five bullets in the chamber."

Health workers began to notice a spike in opiate overdoses and
overdose deaths late last year. When sophisticated toxicology tests
of autopsy material revealed the presence of fentanyl, police started
testing the heroin from street dealers finding the synthetic opiate.

By May this year, fentanyl overdoses had spread to cities in eight
states, including Chicago, Detroit, St Louis, Philadelphia,
Pittsburgh, and Camden, New Jersey. Fentanyl has been linked to 130
deaths in Detroit and 100 in Chicago in only a few months. In New
Jersey, the drug cocktail killed three and hospitalised 42 in one
weekend alone.

"The May numbers are the highest we've seen yet, and we expect that
trend to continue", says Edmund Donoghue, medical examiner for
Chicago's Cook County. "This is something we haven't seen in Chicago
before. We're really stunned by it. We have had problems where
ambulances were called for multiple overdoses, entire groups of
people in the same place."

Compounding the problem, the demographics of heroin abuse in the USA
are starting to shift. While overall demand for heroin has remained
stable in recent years, what once used to be considered an urban drug
is now showing up in suburban areas and attracting younger users.

In June, a recent high school graduate and son of a suburban Chicago
police officer was found dead in his car from a fatal overdose of
fentanyl-laced heroin. In a suburb of Detroit, police arrested a
dealer and charged him with the fatal overdose of a 17-year-old female student.

"[Heroin] is no longer considered just an inner city drug. It's out
in the suburbs, and that's why it's becoming such a big issue", says Wickster.

A 2005 report by the US Justice Department's National Drug
Intelligence Center noted an increase in heroin abuse in Chicago
suburbs, "resulting in a rise in the consequences of heroin abuse in
Chicago, a primary market area". This increase is attributed
particularly to an increase in the number of users under the age of 25 years.

Many health-care workers who help treat substance abusers believe the
USA's traditional focus on "supply-side" law enforcement, which
emphasises the prosecution over treatment, is futile. The supply-side
approach, critics charge, fails to address the root of the problem:
demand. Money is poured into enforcement, they say, while effective
outreach and addiction treatment programmes go under-funded.

Access to methadone programmes is one of the most pressing problems
for heroin users who want help, says Sarz Maxwell, medical director
for the Chicago Recovery Alliance (CRA), which runs a mobile
methadone clinic and needle-exchange programme. The clinic is
operated out of a large van that travels around the city distributing
methadone for 2 hours a day, 7 days a week.

"Methadone is one of the best researched tools we have. It's
incredibly safe and effective, and without it, the relapse rate is
95%. Yet it continues to be unbelievably regulated", she says.

US Congressman Danny Davis, whose Illinois district has been one of
the hardest hit by the fentanyl crisis, agrees that regulation of
public methadone programmes is far too restrictive. 600 people are on
a waiting list for methadone treatment in Chicago's Cook County alone, he says.

According to Jennifer Smith of the John H Stroger Hospital, Chicago's
largest public hospital system, between April, 2004, and June, 2006,
906 patients in three Chicago hospitals were forced to wait an
average of 17 days for entry into methadone maintenance programmes.
Only 18% actually entered the scheme. When methadone treatment was
made available the day after hospital discharge, 67% of patients
entered treatment.

In 2003, some 10 000 people seeking publicly funded substance-abuse
treatment in Illinois were turned away, says Melody Heaps, president
of Treatment Alternatives for Safe Communities, an Illinois
non-profit group that provides behavioural health services to people
with substance abuse and mental-health disorders.

Wickster was one of the statistics. "I'm calling around to get on
methadone and they said they were full. I said, 'I'm gonna die' and
they told me, 'You're not the only one'," he recalls. Westley Clark,
director of the Center for Substance Abuse Treatment at the Substance
Abuse and Mental Health Services Administration (SAMHSA), part of the
federal government's Department of Health and Human Services, noted
that during the past 3 years, Illinois received $22 million in
federal funding for addiction recovery programmes. "We are trying to
enhance the availability of treatment and prevention strategies. We
hope by the end of the fiscal year to have 40 states with more
money", Clark says.

Clark adds that SAMHSA also encourages doctors to use methadone and
provide behavioural treatment, as well as educating them about
buprenorphine, which helps decrease heroin craving.

But many heroin users who lack health insurance coverage have had
difficulty affording buprenorphine, says the CRA's Maxwell.

The epidemic also points to the need to pursue a much more aggressive
harm-reduction strategy, including providing drug users with the
opiate-antagonist naloxone so they can administer the drug to their
friends on the spot, says Maxwell. Since the recent spike in overdose
deaths, most emergency responders now carry naloxone. But
distributing it freely to users has met some resistance.

Maxwell believes her organisation's naloxone distribution programme
has saved 450 lives through "peer revival" since the initiative was
started in 2000. Wickster, whose life was saved more than once by
naloxone injections, including once when his wife injected the drug,
now helps distribute it along with clean needles and information on
the same street corners where he once bought and sold drugs.

"People need to be educated about naloxone, especially now with
fentanyl everywhere", Wickster says. "Saving someone's life just may
motivate them to say, 'that's enough'. That's what happened to me."

Federal drug authorities, however, currently do not support naloxone
distribution to drug users. "I'm not sure that's a rational strategy
in and of itself. Local jurisdictions should be permitted to use
whatever strategies they believe are important...but it is not a
federal position", SAMHSA's Clark says.

According to the European Centre for Drugs and Drug Addiction,
trafficking of illegally produced fentanyl is on the rise, noting
that seizures of the drug has been reported in a number of countries
bordering the Baltic Sea and the Russian Federation. In Estonia, for
example, fentanyl appeared on the drug market as a heroin substitute in 2001.

US officials warn that where there is heroin abuse and fentanyl,
overdose epidemics like those being seen in US cities are likely to
follow. "Other countries should know this can happen and they need to
have the resources to address it. If it's not recognised, it's
costly", says SAMHSA's Clark.

Donoghue, the Chicago medical examiner, agrees. "We need to warn
other countries that if you have a market for heroin and cocaine, you
may begin to see this happen."