COLUMBUS, Ohio - The death toll from fentanyl and other synthetic opioids is falling for the first time since the drugs began flooding America's streets a decade ago. Users and police in this city's beaten-down Hilltop neighborhood credit another drug flooding the United States: the overdose antidote naloxone.
James "Sleaze" Morgan says naloxone has saved him after overdosing - as many as 20 times in the last several years.
The lifesaving nasal-spray medicine is everywhere in the 10 or more Hilltop "trap" houses where users come to buy and take fentanyl. Distributed free by local officials, supplies are abundant at the house where Sleaze smokes fentanyl and works security in exchange for drugs.
On a recent day, a customer heated up a dose of white fentanyl powder, sucked in the smoke through a short straw, and stopped breathing almost instantly. Sleaze says he grabbed several naloxone canisters and sprayed three doses up the comatose man's nose, snapping him back to life.
"It's second nature to me," says Sleaze, whose nickname is tattooed just above his left eye. "I hit him with three canisters, and he came to."
Many narcotics researchers say the widespread availability of naloxone appears to be the main factor in the sharp drop in synthetic overdose deaths this past year. In the 12 months through July 2024, deaths fell 22% percent in the U.S. and 34% in Ohio from the same period a year earlier, according to the most recent data from the U.S. Centers for Disease Control and Prevention. Nationwide, about 17,500 fewer people died than in the prior year.
The drop coincides with the U.S. Food and Drug Administration's move in March 2023 to allow the sale of naloxone without a prescription. Several brands are available at pharmacies and online for between $30 and $45 per kit. Today, Ohio and other states have giveaway programs for the drug. The Columbus Police Department cites naloxone as a prime factor behind a decline in 911 calls for overdose emergencies here.
Dr. Rahul Gupta, director of the White House Office of National Drug Control Policy, says a federal effort to get naloxone and other addiction treatments into communities is driving the steady decline in overdose deaths. Prosecutions of fentanyl suppliers and the drug's ingredient makers have disrupted the entire supply chain, he adds, resulting in less potent fentanyl on the streets.
The death tally remains high, though. As Reuters has documented, illicit fentanyl - synthesized from Chinese-made chemical ingredients smuggled into the U.S. and Mexico - remains cheap and plentiful. In Columbus, it's $10 a fix.
To explore what the drug's intricate global supply chain means for the ultimate consumers, journalists visited Ohio. The state was one of the first overwhelmed by fentanyl fatalities - no one can say why for sure - and is now among the first seeing the wave of deaths ebb. But the stories of Sleaze and other users in Columbus show how even with a powerful antidote on the streets, it's proving difficult to break fentanyl's grip on America.
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Between 50,000 and 60,000 Americans are projected to die from synthetic opioid overdoses this year, most from taking fentanyl or closely related drugs. That would be a roughly sixfold increase over 2015, the year before the fentanyl crisis began. The U.S. is approaching some 450,000 deaths from synthetic opioids since then.
Scott Sanders is executive director of the Hope Resource Center, a haven and support provider for Sleaze and other users in the Hilltop area of Columbus. He hands out roughly 1,000 naloxone kits a month, each with two nasal-spray canisters. But while naloxone is saving lives, Sanders says, the number of substance abusers on Hilltop's streets is growing.
Visits to Hope's drop-in center have risen about a third this year, to about 18,300 in the 12 months through November 2024, up from about 13,400 in the prior 12 months.
"And that scares me to death," Sanders says. "Because all the powers that be are going to be throwing parties. Like, wow, look, it's not a problem anymore," he says of the fatality trendline. "But we're busier than ever."
Beyond naloxone, researchers cite two other possible factors behind the falling toll. Illicit narcotics distributors are increasingly adding "tranq" - veterinary tranquilizers - to the fentanyl they sell. Why they're doing so is unclear. But tranq is less deadly than fentanyl. It also provides a longer-lasting high, potentially delaying the onset of fentanyl withdrawal and the desire for another fix. The fewer times users take fentanyl, the fewer chances they have of overdosing. Some researchers believe tranq may be as big a factor as naloxone in the falling toll.
Others are examining the drop in the number of "susceptibles" - the possibility that the huge number of overdose deaths in recent years, about 280,000 since 2021, has so sharply culled the population of potential fentanyl abusers that the number of overdoses was bound to fall.
But on a November visit by Reuters to Ohio, it's naloxone that most everyone is talking about. Users here refer to the overdose-reversal drug as Narcan, the first brand to hit the market with a nasal spray.
Sleaze is one of 10 Ohio users who told Reuters they have been revived numerous times by naloxone. Their individual stories couldn't be confirmed, but Sanders of the Hope center says he knows of a number of people who've been revived multiple times.
Sleaze and others repeatedly saved by naloxone also describe a dark side to the miracle drug. It immediately plunges them into a harrowing withdrawal from fentanyl, a drug 50 times more potent than heroin - spurring an instant need for another fix.
The case for naloxone
Ohio has been at the forefront of the fentanyl crisis since the drug appeared on the streets of nearby Dayton in 2017. State and local authorities distributed nearly 320,000 two-dose naloxone kits in the first 10 months of this year. That's 20,000 more than in all of 2023 and 110,000 more than in 2022. Synthetic overdose deaths in Ohio dropped about a third to 2,676 in the year ending in July, CDC figures show, the fewest since 2016.
In Columbus, Sanders encourages visitors to the Hope center to take as many free naloxone kits as they want. On a damp and chilly day in mid-November, Ryan Hall pokes his nose into Sanders' office to say hello. Hall, who says he has 13 kids by "six baby mamas," has come by to celebrate his 41st birthday. He has gone in and out of addiction treatment repeatedly in recent years and has been "Narcan-ed" numerous times, Sanders says.
Hall says he's clean; Sanders is dubious. Sanders - who kicked his own crack addiction in 2017 - encourages Hall to call him later, promising to get him back into treatment when he's ready. (On Dec. 9, Sanders would take Hall to a rehab center.) Much of what Sanders does is arrange for people to get into treatment and sober housing.
A few minutes later, Sleaze, 40 years old, walks into Sanders' office and sits down.
"I love getting high," he says.
But he doesn't love being Narcan-ed. A fentanyl overdose kills by causing respiratory failure. Naloxone works by pushing the fentanyl molecules off the brain's opioid receptors and then blocking any further fentanyl from attaching to the receptors.
The result is immediate: The user starts breathing and comes to. But the downside kicks in, too: For those addicted to opioids, the craving begins anew. Police say revived overdose victims sometimes react by violently flailing their arms and legs. Others vomit uncontrollably.
Sleaze says he finds himself in agony when he's dosed with naloxone, and often sprints away from the spot in a panic. Someone Narcan-ed him just a few weeks ago, he says.
His first brush with naloxone came in 2022, which was also the first time he took fentanyl. He had just been released from prison after serving seven years on a burglary conviction for stealing TVs from a Walmart. Even behind bars, he says he managed to continue taking opioids, an addiction acquired in early adulthood.
But he'd never taken "fetty": Too many of his own friends had died of overdoses. He was homeless and sleeping in his girlfriend's car. His mother had just been sent to prison for dealing cocaine.
"My whole (expletive) world just crumbled," he says. That day, someone had given Sleaze a small bag that once contained fentanyl powder. Sleaze injected residue from the bag and passed out immediately. "I didn't even get the needle out of my arm."
He was brought back when his girlfriend sprayed naloxone up his nose. Withdrawal kicked in. He'd never experienced such intense "dope sickness."
"I hurt so bad," he says.
Sleaze's now-former girlfriend and his mother couldn't be reached to talk. His mother is serving a minimum nine years at the Dayton Correctional Institution on the drug charges.
Five minutes after talking with Reuters, Sleaze is outside in an alleyway near the Hope center, looking over his shoulder. This past summer, after his latest release from prison, he cut off his ankle monitor and stopped reporting to his probation officer. He pulls his knit cap down over his forehead, and smokes a dose of powder.
Fifty yards behind him, a man on a red bicycle watches. Sleaze glances his way. The guy isn't a cop.
Two weeks after that hit in the alleyway, two Columbus police officers would pick up Sleaze on felony probation violations.
Is fentanyl changing?
Scott Oulton, head of forensic sciences at the U.S. Drug Enforcement Administration, says DEA testing of seized fentanyl powder and pills since late summer of 2023 has shown a consistent drop in purity.
Over the last two fiscal years, the DEA tested about 9,200 samples from across the U.S. The average purity in fentanyl powder dropped from 19.5% in 2023 to 15.2% in 2024. In that time, he says, the average amount of the drug in each fentanyl tablet has dropped from 2.3 milligrams to 2 milligrams. Oulton says the drop in purity is closely correlated to the fall in synthetic opioid deaths.
Some scientists familiar with the DEA study are skeptical that its results reflect the drugs on the streets. Different samples they've tested at their own labs show that drugs being sold to users contain as much fentanyl as ever.
Alex J. Krotulski, who runs the toxicology and chemistry lab at the Center for Forensic Science Research & Education in Horsham, Pennsylvania, analyzes samples for police and other clients. He says the purity of the fentanyl and closely related drugs he's measuring in samples has remained around 10% for the last three years. Nabarun Dasgupta, a senior scientist at the University of North Carolina's Injury Prevention Research Center, says his lab also hasn't detected a drop in fentanyl potency.
But there is another significant change, Krotulski and Dasgupta say.
They've found an increase in a key class of adulterant drugs mixed in with the fentanyl: veterinary tranquilizers, or "tranq," used to anesthetize dogs, horses and other animals. These include the best-known tranq, xylazine, and, more recently, a longer-lasting one called medetomidine, which is used on both animals and humans. In the third quarter of this year, medetomidine became more common than xylazine in samples from Philadelphia, Krotulski says.
Xylazine horrified health officials when it started showing up in fentanyl in 2021 in Philadelphia and other cities. Users reported grotesque necrotic wounds that eat away at their skin and even the underlying flesh - a side effect of the veterinary drug. If untreated, the wounds can require amputation.
Today, some health researchers theorize there's a silver lining in the presence of these dangerous tranquilizers. They appear to have the potential to reduce opioid overdoses.
Fentanyl is extremely addictive. Users need more fixes a day than with heroin or other opioids. It delivers a fleeting high, often only an hour or two for experienced takers, so users soon crave another hit. Xylazine and sister drugs are longer-lasting anesthetics that delay opioid withdrawal, so users need fewer fixes - and thus take fewer rolls of the dice with death.
Xylazine and medetomidine also don't cause respiratory arrest - the usual cause of death from a fentanyl overdose. They aren't nearly as addictive, either. And when added to street fentanyl, tranqs can reduce withdrawal sickness as the opioid wears off. Some experts now believe they play a contributing role to the drop in overdose deaths.
New York City, like Ohio and Philadelphia, is another place that was slammed early by fentanyl. In June, medetomidine was detected in the local drug supply for the first time.
Sam Rivera, executive director of OnPoint NYC, a support center for substance abusers and other vulnerable people, says opioid users have long had strategies for keeping dope sickness away. In what's commonly called "speedballing," users will take a stimulant such as methamphetamine or cocaine to "balance" an opioid high and delay the desire for another fix.
Sleaze, for example, says he likes to inject meth and then coke after smoking fentanyl.
Dasgupta of the University of North Carolina says it isn't yet clear precisely how xylazine and similar drugs might reduce overdoses. But if they translate into more time between each hit for users, that would cut the opportunities to die.
Some doubt tranq is a factor in the falling toll.
Dr. Bonnie Milas, an intensive care anesthesiologist at the University of Pennsylvania in Philadelphia, uses fentanyl in combination with a drug similar to medetomidine on heart and lung surgical patients. She says it's unlikely that similar combinations on the streets are helping keep users alive, because the dosages of the active ingredients in the illicit narcotics aren't precisely controlled. She says the drug combo may be more dangerous than fentanyl alone.
Milas cites an alert the Philadelphia health department issued on Dec. 10 about the fentanyl-medetomidine mix: It causes some users to wake with severe withdrawal that requires emergency medical treatment.
"I know about this in the clinical setting," Milas says. "From the personal side, I know what it looks like to see somebody overdosing."
Milas lost her two sons to fentanyl. Twice, she pulled the younger son back from an overdose by giving him naloxone. She wasn't there the last time.
Since then, she has advocated that naloxone be handed out as widely as possible and be part of every home's first-aid kit. She says it is the best way to keep people alive until they are ready for treatment.
The 'susceptibles'
Charles Fain Lehman, a fellow specializing in policing and public safety at the Manhattan Institute think tank, offers another explanation for the fatality trend: the "depletion of susceptibles."
Lehman cites surveys that show young Americans are shying away from hard drugs, with consumption of narcotics by high school seniors now at one-fourth its peak in the 2000s. He also points to the vast number of synthetic opioid overdose deaths in recent years as reason to believe the population of at-risk people is way down.
Only so many people ever use narcotics, leaving "a fixed population of people who are at risk for overdose death," Lehman says. "To be a little morbid, if you die early, you can't die later." Because of the high "burn rate" of people dying in recent years, he argues the U.S. toll has begun trending down as the susceptible population has shrunk.
The Hilltop section of Columbus remains overrun by fentanyl. And it still has plenty of susceptibles. Strung-out women sell sex at most intersections along Sullivant Avenue, the area's main street. The homeless and drug users camp out in wooded areas along nearby railroad tracks, in abandoned houses and in doorways.
Many of the visitors to the Hope center trace their addiction back to drug-abusing parents and relatives, Sanders says. Their arc often follows a common trajectory, from abusing prescription painkillers to heroin to fentanyl.
Angel Mccallister walks into the office wearing a black sweatshirt and black stockings with large holes in the legs. Her auburn curls hang over her shoulder. She hasn't smoked fentanyl yet this day, leaving her edgy from dope sickness. It's lunchtime, but food isn't on her mind.
Angel, 32, says she has been addicted to drugs for two decades. Her mother used prescription pills such as oxycodone. By the time Angel was 12, she was addicted herself, taking illicit prescription pills and snorting powdered heroin. One day she went to babysit for a couple she knew. Angel was dope sick and needed a fix. At some point that day, the wife offered to help: She injected Angel with heroin.
It was the first time she'd taken opioids intravenously. The needle was way better than snorting the stuff. Everything changed.
"Like, that's all I wanted," she says. "It was like my boyfriend, you know? It was always by my side and was always there when I needed it."
Eleven years ago, she had a son. When fentanyl appeared on the streets a few years after he was born, Angel started injecting that instead of heroin. These days, she smokes the drug.
The boy lives with Angel's grandmother. Angel says her mother is still addicted. An aunt died of a fentanyl overdose. Angel's mother and grandmother couldn't be reached.
Angel says she turns tricks several times a week to pay for drugs. She says she has been raped more times than she wants to count.
She turns away and hides her eyes behind her hair. Tears drip from her nose. Sanders reaches over and touches Angel on her shoulder.
She draws a deep breath and brushes the hair from her face. She has been Narcan-ed dozens of times, she figures. At least once, she says, she was revived after trying to kill herself with an intentional overdose.
How to save a life
Naloxone is an over-the-counter nasal-spray medication that can save an overdose victim by rapidly reversing the effects of fentanyl, heroin and other opioids.
Doctors urge all people - especially those with prescription opioids at home or a substance abuser in the household - to keep naloxone in their first aid kits or even in their bags. Anyone can experience an opioid emergency, including small children who accidentally ingest the drugs.
Naloxone is sold under brand names such as Narcan and RiVive. It can be bought online or at major pharmacies for between $30 and $45 a kit. Each kit contains two nasal spray applicators. Sometimes, multiple doses must be administered.
Many health departments and community groups give kits away, no questions asked. A web search for "free naloxone" returned hundreds of results.
Milas, the intensive care anesthesiologist at the University of Pennsylvania, uses fentanyl in combination with other drugs to treat critical patients. She also lost two sons to accidental fentanyl overdose. She's the face of the American Society of Anesthesiologists' REVIVEme.com program, which offers an instructional video and other guidance on how to use naloxone to revive an overdose victim.
Milas often talks about her experience with groups of people who have lost loved ones to fentanyl. "I tell them that you should not have a sense of guilt or responsibility," she says. "They tried. You tried. And ultimately, the outcome was out of your control ... But you did your best. And I think you should really take comfort in knowing that you did what you could."
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