The naked truth: a drug you’ve never heard of is killing thousands of Americans a year.
By: Cristina Costantini, Darren Foster, and Mariana Van Zeller
If you want to understand how bad the opiate epidemic in America has become, look no further than New Hampshire. Presidential candidates are crisscrossing the Granite State and being inundated with questions about addiction and overdoses. For voters in the nation’s first primary election, killer narcotics are the No. 1 concern, above the economy or education.
"I was not prepared to hear from so many about what was happening in the families of New Hampshire -- addiction, the heroin epidemic, which is at one of the highest rates in this state of any in the country,” Hillary Clinton told attendees at a town hall in Manchester on Jan. 22.
“The first question I was asked in my first town hall meeting was about the heroin epidemic,” Jeb Bush told interviewers from the New Hampshire Union-Leader last year. “And I was like, ‘Really? Tell me about it.’”
But presidential hopefuls and the media are largely behind the curve on an epidemic that has grown for two decades. It’s not heroin alone that’s killing people at such alarming rates in New Hampshire and surrounding states. There’ssomething far more dangerous and worrying in the mix: a powerful opiate called fentanyl.
351 people overdosed fatally on opiates last year in New Hampshire, according to data provided to Fusion by the state’s medical examiner. Twenty-eight of those victims overdosed on heroin alone; fentanyl was a factor in 253 of the deaths.
Fentanyl is 50 times stronger than heroin. It’s so potent that an amount the size of three grains of sugar is lethal to an adult. First synthesized in the 1960s by Janssen Pharmaceuticals, fentanyl was initially used as a general anesthetic during surgery. Its only acceptable, “on-label” use is for reduction of severe pain in cancer-sufferers.
Today, the drug has two main sources: the prescription drug industry, and Mexican drug cartels.
In our new documentary, “Death by Fentanyl,” we investigate the rise of fentanyl in all its forms, and we examine how one of the deadliest drug epidemics in American history just got worse.
This documentary began with a trip to Sinaloa, Mexico days after drug lord Joaquin “El Chapo” Guzman’s escape from prison. While reporting on the hunt for the world’s most wanted man, we heard about illicit drug labs in the heart of El Chapo’s territory that were making a drug so dangerous dealers were calling it el diablito -- or the little devil.
El diablito was fentanyl-laced heroin.
Three weeks before El Chapo was re-captured, we returned to Sinaloa to meet with heroin producers who were mixing the drug into their product.
“There’s almost nobody making pure heroin anymore, because el diablito is so much stronger,” one trafficker told us. His family sourced the precursor chemicals from China, he said, and paid a Colombian chemist $50,000 to teach them how to cook up fentanyl.
While the majority of the fentanyl causing overdoses across the U.S. is from this illegal stockpile produced by Mexican cartels, a portion of it also comes in legal pharmaceutical forms, according to the DEA.
But it's hard to get accurate numbers on just how much of the deadly fentanyl is from prescriptions -- most medical examiners and coroners are unable to tell the difference between pharmaceutical and black-market versions of the drug, the CDC points out.
Well before traffickers in Mexico started mixing fentanyl into their heroin, there were kids on the streets of Massachusetts doing the same thing, Fusion found.
For the documentary, we interview two young addicts who also sold drugs to support their habit. To gain a competitive edge over other dealers, they started to lace their heroin with fentanyl -- but not the stuff that comes from clandestine labs in Mexico. Rather, they used stuff that comes from pharmaceutical companies and is prescribed to treat severe pain.
Both men described how they would squeeze the gel out of a prescription fentanyl patch and mix it into their dope.
“You can make your heroin seem so much more explosive,” said David Harak, 27.
Harak said it was easy to find pharmaceutical fentanyl. He would buy it off a neighbor who was prescribed the drug, use a quarter of it himself, and then mix the rest into the heroin he was selling.
“I would microwave the fentanyl patch to get it soft. I'll suck it right up in my needle and put it right in my arm with just a little water added,” Harak said. “The fentanyl is the purest form. It's a pharmaceutical.”
The black market for pharmaceutical fentanyl has grown alongside the black market for all prescription opioids, like oxycodone. Between 1999 and 2010, prescriptions for opioids in America quadrupled, growing hand in hand with rising rates of addiction and overdoses, according to the CDC.
“These are drugs that are indistinguishable from the effects produced by heroin,” said Dr. Andrew Kolodny, the chief medical officer at the New York-based Phoenix House rehab center and a doctor who campaigns against opioid overprescription. “We're essentially talking about heroin pills.”
Today, some studies estimate that as many as 80 percent of new needle-heroin addicts used opioid prescription pain medicine first.
In our investigation, we found multiple fentanyl companies have facing investigations and indictments for allegedly driving doctors and patients to prescribe the drug “off-label,” for reasons other than its approved use. Fentanyl companies have also gotten in trouble for paying kickbacks to doctors to get them to prescribe more of their potent drugs.
One whistleblower at a pharmaceutical company called INSYS Therapeutics told Fusion that she was encouraged to mislead insurance companies to get their fentanyl drug, Subsys, covered.
“It's real simple: It's only FDA approved for cancer patients with breakthrough cancer pain. If you don't have cancer, and breakthrough cancer pain, no insurance company is going to pay for this medication,” whistleblower Patty Nixon told us.
But most -- 90 percent -- of the patients referred to Nixon and her colleagues for Subsys sales were cancer-free, she said. “When 10 percent of the patients’ charts that came over or less were cancer patients, that's not a lot of money. Nobody's going to get rich off of that,” she said.
“But you have this whole other world of everybody. That ‘my back hurts’ money, ‘my knee hurts’ money,” said Nixon. The solution, she said, was for company reps to tell insurance companies that patients had cancer when they did not.
According to more than a dozen INSYS employees Fusion spoke with, the company has pushed doctors to prescribe their drugs off-label for patients and has even paid kickbacks to medical professionals to get them to prescribe more. The company has faced investigations in six states, and settled for $1.1 million without admitting wrongdoing in a case in Oregon.
Only 2.4 percent of all Subsys prescribed to patients from 2012 to 2015 was prescribed by cancer doctors, Fusion has learned from medical data firm Symphony Health.
One fentanyl company estimated that there are fewer than a million Americans with the kind of cancer pain for which their product was approved. If the company could sell fentanyl for more common conditions, like back pain or arthritis, they figured that their customer base could grow thirtyfold.
Fusion asked INSYS what percentage of Subsys was prescribed to cancer patients; we also asked about a spate of allegations against the company related to its sale and marketing of Subsys. The company did not directly address any of those questions.
Instead, a PR rep sent us an email linking to two press releases they had previously written to deny allegations of misconduct. The email added that "INSYS takes patient safety very seriously” and works with the healthcare community “to help ensure proper prescribing.”
Prescription-fentanyl companies are the ones “making away with murder,” in the words of Harak. At the same time, he says some addicts like him prefer the pharmaceutical grade drug to the street version.
“It's like your name-brand cereals and your non-name brands. Pharmaceutical fentanyl was just the name brand [as black-market fentanyl],” he said. “they both have the same ingredients, just different wrapping.”