A powerful painkiller that can be fatal even in small doses is the latest front in a nationwide epidemic of street drug abuse, recently becoming the prime suspect in a rash of overdoses that killed six people in less than a week in Sacramento County.
Experts say the rise of fentanyl is fueled by widespread prescription drug abuse that claims thousands of lives each year. Since 1999, more than 165,000 people in the U.S. have died of causes related to painkiller use.
Once centered on the East Coast, use of the drug now seems to be spreading west, probably through Mexican drug cartels, medical and law enforcement officials said.
"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.
During a seven-day period ending Tuesday, health workers in Sacramento reported 28 overdoses, six of them fatal, from pills that appeared to contain fentanyl. The painkiller offers an intense, euphoric high and is sometimes used to cut heroin and cocaine or passed off as another drug.
The pills resembled Norco, a prescription painkiller similar to Vicodin and Percocet. But lab tests didn't find Norco's active ingredients and the tablets were likely fentanyl pills manufactured to resemble Norco, Sacramento County Division of Public Health spokeswoman Laura McCasland said Wednesday.
One official said the street price of the pills was no more than $5.
A few grains of the odorless, white powder, often called "China White" or "Apache," can be enough to kill.
Prescribed to cancer patients for decades, fentanyl is the most powerful painkiller available for medical treatment, up to 100 times stronger than morphine. It's typically administered as a lozenge, patch or injection to patients with severe pain.
In recent years, an illegally manufactured version of the drug has begun spreading, with cases concentrated in the eastern half of the United States.
Between 2012 and 2014, the number of seizures of illegally used fentanyl nationwide increased more than seven-fold to 4,585, according to federal officials.
Sgt. Salvador Robles of the Sacramento County Sheriff's major narcotics impact division said investigators have a "strong lead" on a Sacramento County home where two of the overdoses occurred and are hoping to trace the cases back to the source of the fentanyl.
Robles said he didn't know whether this was a single bad batch, or a larger problem.
"My only tip is, if you're addicted to Norco or any pills, do not take them right now," he said.
An increase in doctor-prescribed painkillers over the last decade has left many patients addicted to opiates, intensifying a heroin epidemic that is ravaging many towns nationwide, experts said.
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.
In Sacramento County, heroin use has increased within the last decade as use of methamphetamines have 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)."
There's no typical customer for the drug, he said. "We've seen individuals meeting street-level dealers that are homeless," and then those same dealers "meet people who are driving in Mercedes and BMWs," he said.
John Martin, special agent for the U.S. Drug and Enforcement Administration's San Francisco division, said the agency is taking the Sacramento incidents "very seriously," but couldn't comment on the specifics.
The cases appear to be the latest wave of the heroin epidemic sweeping across the country, he said.
"Obviously it's been big on the East Coast and Midwest, it's possible that it could be coming this way," Martin said.
Fentanyl is a new wrinkle in the drug trade, he said. Approximately 700 people died from fentanyl and its analogs nationwide between late 2013 and late 2014, according to a recent report from the DEA.
Past investigations have revealed that Mexican cartels are purchasing fentanyl produced in China then using traditional trafficking routes to bring it into 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."
Earlier this month, officials from the U.S. Centers for Disease Control and Prevention 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.
"We know of no other medication routinely used for a nonfatal condition that kills patients so frequently," wrote CDC director Dr. Tom Frieden and a colleague in the New England Journal of Medicine.
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 when doctors tried to wean her off of them.
She had dropped out of school and couldn't overcome her addiction, her mother remembers. Casey Jo began smoking fentanyl and buying heroin.
"It brought her into a world she was not prepared for," she said. "Everyday, we didn't know if we were going to get a call that she was arrested, assaulted, raped, everything. We were so afraid for her all the time."
One day in August last year, Elkington got that fated call: Her daughter had been found dead in her apartment. She was 26.
"I watched my daughter virtually slip away from us," she said.