There鈥檚 a clear culprit in the rising drug overdose death count in Massachusetts 鈥� the synthetic opioid fentanyl. More powerful and more deadly than heroin, fentanyl has sparked a new set of survival rules among people who abuse opioids.
About 75 percent of the state鈥檚 men and women who died after an unintentional overdose last year had fentanyl in their system, up from . It鈥檚 a pattern cities and towns are seeing and country, in New England and some Rust Belt states.
Fentanyl may be especially lethal because it鈥檚 strong, it鈥檚 mixed with other drugs in varying amounts unknown to the user, and it can trigger an overdose within seconds. 鈥淚t happens so fast, like instantly, as soon as you do the shot,鈥� said聽Allyson, a 37-year-old woman who started using heroin in her late teens.
鈥淚n the past, [an overdose] was something that you saw happening, like, you could see the person start to slow down, their color would start to turn blue, and then they would go out, within 10 minutes or so,鈥� Allyson said. With fentanyl, there鈥檚 no progression, no time to seek help. 鈥淣ow it鈥檚 instant,鈥� she said.
Allyson leaned back in a chair at the in Cambridge, Mass., and tugged the hood of her gray sweatshirt down to her eyes. Kaiser Health News agreed not to use her full name or the full names of any people in this story who buy illegal drugs, to protect their privacy and聽future prospects.
Allyson is a regular client at the needle exchange, where manager Meghan Hynes urges everyone to carry naloxone, the drug that reverses an overdose. Hynes, who has become very skilled at CPR, uses聽her naloxone kit to revive someone every few weeks.
鈥淩ecently we had a guy leave the bathroom and all the color just drained from his face, like immediately, and he just turned blue,鈥� Hynes said, describing聽a typical fentanyl overdose. 鈥淚鈥檝e never seen anyone turn blue that fast. He was completely blue and he just fell down and was out 鈥� not breathing.鈥�
Hynes bent over the man to pump his heart, but she couldn鈥檛. He was hit with 鈥�,鈥� a side effect of fentanyl that may be increasing the death toll.
鈥淵our chest seizes up. You literally have paralysis, and that鈥檚 obviously really dangerous because if someone needs CPR, you can鈥檛 do it,鈥� Hynes said. 鈥淎nd in this situation it spread, so he had lockjaw and his mouth was only open a tiny, tiny bit. And so I could hardly even do rescue breathing for him.鈥�
Breathing for overdose patients is critical because brain cells can die after five minutes without oxygen. Hynes revived the man on the floor with naloxone, which she urges all of her clients to carry. That鈥檚 one of what she calls 鈥渟mart use鈥� rules that she is trying to get the people she trains聽to follow in this era of fentanyl. Others are to stick to a dealer you know and trust, and to use with a buddy, making sure聽your buddy鈥檚 OK before you inject. There鈥檚 also the idea of a test dose, taking a small amount before the full shot.
鈥淏ut it鈥檚 really hard to tell these days, even if you do a tester shot,鈥� Allyson said, because the grains of fentanyl that could kill you aren鈥檛 mixed uniformly in a bag. That鈥檚 a lesson she learned one death-defying night a few months ago.
Allyson, who is homeless, spent the night in a tent with a friend. She woke up and used the last of a bag from the day before to get herself going.
鈥淎nd I actually said to my friend, I said, 鈥榃ow, I can鈥檛 believe I only saved myself this much.鈥� It was a very small amount, like a third of what I did the night before,鈥� Allyson said, shaking her head. 鈥淚 overdosed on it.鈥�
The friend had enough naloxone in the tent, which was far from a road or hospital, to bring Allyson back from the dead.
Fentanyl is an opioid . There鈥檚 a legal, Food and Drug Administration-approved version. But are churning out cheap versions of fentanyl that dealers are selling on the streets mixed with fillers, heroin or other drugs.
Buyers have no idea how much fentanyl they are getting or how much risk they are taking with every injection. So, these days, drug users who frequent this needle exchange program assume there鈥檚 fentanyl in every bag they buy.
鈥淢ost of us know that that鈥檚 what we鈥檙e getting,鈥� said Sean, who started using heroin more than 20 years ago. 鈥淎nd if you don鈥檛 believe it, you鈥檙e living in a fairy tale world.鈥�
There鈥檚 no reliable way for drug users to test the contents of bags bought on the street. Eddie relies on taste.
鈥淚t鈥檚 slightly bitter, but it鈥檚 mainly sweet if it鈥檚 fentanyl. If it鈥檚 heroin, you can tell right away because it鈥檚 got a bitter taste and it鈥檚 a long-lasting aftertaste,鈥� Eddie said. 鈥淚 will not put anything in my arm before I taste it.鈥�
Eddie and Allyson say they try to avoid fentanyl. But when their last dose of drugs starts to wear off, they鈥檒l take anything to avoid withdrawal, which they describe as the flu on steroids with fever, vomiting, diarrhea and high anxiety.
鈥淚t literally feels like your skin is crawling off. You鈥檙e sweating profusely,鈥� Allyson said. 鈥淵our nose is running, your eyes are running. And that鈥檚 all you can focus on. You can鈥檛 think.鈥�
Some drug users seek fentanyl because it鈥檚 a more immediate rush and intense high. But Allyson doesn鈥檛 like it. She says a fentanyl high fades much more quickly than heroin鈥檚, which means she has to find more money to buy more drugs and inject more often, which exposes her to more risk.
When fentanyl fades, she and Eddie say, they are more likely to take other drugs. 鈥淵ou鈥檙e getting a fast rush but it doesn鈥檛 last, so people are mixing,鈥� Allyson said.
At 37, Allyson is having experiences most Americans don鈥檛 face until much later in life. 鈥淎s of two days ago, 30 people that I know have passed away. Basically my entire generation is gone in one year.鈥� Allyson said. 鈥淚t鈥檚 the fentanyl, definitely the fentanyl.鈥�
Older drug users who have been through other epidemics say this moment with fentanyl is the worst they鈥檝e seen.
鈥淎ddicts are dying, like, every day. It鈥檚 crazy, man,鈥� said a man named Shug, twisting a towel in his hands, his eyes filling with tears. 鈥淣obody seems to give a damn.鈥�
Shug is grateful for the needle exchange facility, which hasn鈥檛 lost anyone to an overdose. But on the streets outside, the death toll keeps rising.
This story is part of a partnership that includes , and Kaiser Health News.