When the fifth overdose patient rolled into the emergency room at UC Davis Medical Center last week, doctors knew they were dealing with something out of the ordinary.
They were used to heroin overdoses. But the patients admitted in the wee hours of March 24 showed symptoms of opiate toxicity that were far more pronounced than usual.
In about a week, 36 people overdosed, at least nine of them fatally, from street drugs in the greater Sacramento region. Doctors compared notes and quickly closed in on the prime suspect: fentanyl, a painkiller that is up to 100 times stronger than morphine and lethal even in very small doses.
Officials are now frantically searching for the source of the drug, which is being produced in counterfeit tablets that can be bought for as little as $5 each on the street.
The federal Drug Enforcement Administration issued a public safety alert Friday warning that fentanyl-related overdoses are "occurring at an alarming rate" and urging the public to take only drugs prescribed by a physician and from a reputable pharmacy. The Sacramento-area overdose victims ranged from 18 to 59 years old and comprised equal numbers of men and women, according to the alert.
Authorities fear the rash of cases portends the move west of rampant fentanyl abuse that had largely been centered on the East Coast, its spread probably channeled through Mexican
drug cartels, medical and law enforcement officials said.
In Los Angeles County, fatal overdoses related to fentanyl increased to 62 in 2014 — the most recent year for which data is available — from 42 in 2011, according to coroner's data. While not matching East Coast levels, the rise is troubling, officials said.
"The prescription drug issue hasn't touched us in the same way," said Dr. Gary Tsai, medical director and science officer for the L.A. County Department of Public Health's office of Substance Abuse Prevention and Control. "Our concern is that it will, that it's only a matter of time."
Directors of West Coast drug treatment programs have been bracing for problems related to fentanyl, which can lower blood pressure, heart rate and respiratory function and lead to seizures, said Rachel Anderson, executive director of the Sacramento-area needle exchange Safer Alternatives Thru Networking & Education.
Prescribed to cancer patients since the 1960s, fentanyl is the most powerful painkiller available for medical treatment, and is typically administered as a lozenge, patch or injection. But an illegally manufactured version of the drug, often called "China White" or "Apache," has begun spreading recently.
Between 2012 and 2014, the number of seizures of illegally used fentanyl nationwide increased more than sevenfold to 4,585, according to federal officials.
The painkiller offers an intense, euphoric high and the odorless, white powder is sometimes used to cut heroin and cocaine or passed off as another drug. Dealers mix it in to give their product an extra kick or to cheaply produce more usable heroin, Anderson said.
"Is it new? Yes and no. We've been aware of what's going on the East Coast and expecting it to show up in one form or another," Anderson said.
Health officials in Sacramento County say that many of the recent overdoses occurred after people purchased pills they believed to be Norco, a less potent opiate, but were in fact fentanyl. Officials are urging the public to be cautious about intake of any street drugs.
Sgt. Salvador Robles of the Sacramento County sheriff's major narcotics impact division, said investigators have a "strong lead" on a home where two of the recent overdoses occurred and are hoping to trace the cases back to the source of the fentanyl.
Robles was unsure if the cases stemmed from a single bad batch or were indicative of a larger problem.
"My only tip is, if you're addicted to Norco or any pills, do not take them right now," he said.
Experts say the rise of fentanyl is fueled by an increase in doctor-prescribed painkillers over the last decade that has left many patients addicted to opiates and intensified a heroin epidemic that's ravaging many towns nationwide.
In 2014, 28,647 people died of overdose deaths from opioids, including heroin, the highest toll ever recorded, according to the U.S. Centers for Disease Control and Prevention. The number of deaths involving synthetic opioids — mostly fentanyl, experts say — nearly doubled between 2013 and 2014 to 5,500 deaths, the largest increase in opioid deaths.
"This is just another face of the opioid epidemic," said Dr. Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness.
In Sacramento County, heroin use has increased within the last decade as use of methamphetamines has dropped, Robles said. Fifteen years ago, seizing a few ounces of heroin in Sacramento County was rare, he said, but "now we're finding it in [kilos]."
Officials across the country report similar trends, but fentanyl is a new wrinkle in the drug trade. About 700 people died from fentanyl and its analogs nationwide from late 2013 to late 2014, according to a recent report from the DEA.
In California, legislation was introduced in February to increase criminal penalties for dealing the drug.
Past investigations have revealed that Mexican cartels are purchasing fentanyl produced in China, then using traditional trafficking routes to bring it to the United States. In 2014, DEA officers seized 26 pounds of fentanyl in a stash house in Los Angeles.
Alexander, the Johns Hopkins physician, said that demand will remain strong until the prescription drug epidemic is under control. He said doctors should limit how often they prescribe opiates to patients and expand treatment programs for those who are already addicted.
"Do we need to be worried about it? Yes," Alexander said. "But I don't think ... these deaths can be separated from the surge in overuse of prescription opioid. It's part and parcel of the same problem."
President Obama has asked for more than $1 billion in the federal funding to help expand access to treatment programs.
Earlier this month, CDC officials released new guidelines strongly discouraging doctors from prescribing opiates, including OxyContin and Vicodin, for patients with chronic conditions such as back problems, migraines and arthritis.
Shelly Elkington, 49, thinks stricter guidelines could have saved her daughter's life. While in college, Casey Jo was diagnosed with Crohn's disease, an incurable bowel disorder that can require repeated surgeries.
She was prescribed painkillers, including fentanyl.
"I always want to say her doctor meant well," said Elkington, who lives in Montevideo, Minn. "His intentions were always good — to make her feel better."
But Casey Jo quickly became addicted to opiates, eventually turning to street drugs. She dropped out of school and began smoking fentanyl and buying heroin.
"Everyday, we didn't know if we were going to get a call that she was arrested, assaulted, raped, everything," Elkington said. " We were so afraid for her all the time."
In August last year, Elkington got that fated call: Her daughter was found dead in her apartment. She was 26.
"I watched my daughter virtually slip away from us," she said.
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