The latest chart of overdose deaths in Massachusetts shows a climbing blue line labeled 鈥渇entanyl.鈥� Pick a spot on that line in mid-August and picture a big, affable 40-year-old man named Joe Salemi. He died at his mom鈥檚 home in working-class Everett, Mass., after almost 25 years of heroin use.
Salemi had overdosed before. His brother Anthony Salemi said he was pretty sure, at the time, that something besides heroin killed Joe. The medical examiner later confirmed it.
鈥淚 knew, deep in my mind, it was going to be the stuff that everyone鈥檚 talking about now 鈥� fentanyl,鈥� Anthony said. 鈥淏ecause I never thought straight heroin would kill him.鈥�
Anthony Salemi was familiar with fentanyl. He鈥檇 been prescribed the powerful painkiller after surgery in 2006. Anthony had warned his younger brother about reports that dealers were adding an illicit version of the drug to heroin, sometimes promising a more intense high. Fentanyl is more than 50 times than heroin, according the Centers for Disease Control and Prevention.
But people like Joe rarely know for sure if there is fentanyl in the tiny plastic bags of illegal powder they buy 鈥� or how much. Just a few grains of pure fentanyl, doctors say, is enough to kill most users. In Massachusetts, 75 percent of the people who overdosed this year .
鈥淚t just seems like the dealers and the drugs are ravaging the whole country,鈥� said Anthony Salemi. 鈥淭he supply just keeps coming in, no matter how many cops you put at the border, it just keeps coming in. This is scary.鈥�
The Obama administration agreed that the increasing supply of fentanyl on the street is a major challenge and said聽agencies are doing a lot. But reducing the supply is complicated.
Fentanyl is a synthetic opioid, constructed with lab chemicals 鈥� unlike heroin or morphine, which start with of a poppy plant. Drug enforcement agents said clandestine labs across China are the main source of the illegally sold fentanyl.
Producers then ship the drug to Mexico, where drug cartels mix it into heroin or press it into blue, pink or white tablets that look like prescription pills for anxiety or pain. The powder or pills are delivered to dealers, or directly to users, via the internet or darknet, an online area used for illegal purchases.
鈥淪ynthetic drugs are a real winner because they are easy to make, and they鈥檙e cheap to produce,鈥� said聽, director of policy, planning and coordination at the international narcotics and law enforcement bureau of the U.S. Department of State.
鈥淭hey鈥檙e not dependent on a season or the weather like a plant-based drug,鈥� McDonald said. 鈥淎nd with the distribution system 鈥� through mail order 鈥� they can be delivered directly to the door in some cases. Like a pizza.鈥�
The profit margin is huge, said Drug Enforcement Administration spokesperson . He said it costs from $3,000 to $4,000 to produce a kilo 鈥� 2.2 pounds 鈥� of fentanyl. The fentanyl is then cut with cheap fillers to make pills, or mixed into bags and fraudulently sold as pure heroin.
鈥淒rug traffickers involved in the wholesale distribution of those products can yield close to $1.5 million off that one kilogram,鈥� said Baer.
The DEA has six agents who operate out of Beijing and work closely with China鈥檚 Ministry of Public Security, Baer said. Chinese officials established , including 19 that have much the same molecular structure as fentanyl. Baer said that helped reduce the supply of some of these of the drug. (Though each analog drug has a slightly different chemical structure from fentanyl, they work much the same way in the body.)
And in September, the DEA moved to declare聽 illegal. But the producers always seem to be one step ahead of enforcement agencies, Baer said.
鈥淥nce we control a substance, whether here in the U.S. or in China, for example,鈥� he said, 鈥渢he drug manufacturers simply change a molecule, tweak a molecule, in an attempt to circumvent the law.鈥�
Keeping up with the inventive chemists sounds nearly impossible.
鈥淲e鈥檙e identifying one to two new synthetic substances every week,鈥� Baer said.
The international control system is only able to detect, process and outlaw about 10 new psychoactive substances a year, McDonald said. 鈥淚t doesn鈥檛 take a mathematician to identify that we have a real challenge here.鈥�
If a drug compound is similar to fentanyl, or if it produces the same physiological effect, the DEA can file trafficking charges here in the U.S. But these variations are not illegal in many countries. McDonald said the State Department is working, through the United Nations and with individual nations, to make sure police everywhere can identify new drugs and prosecute dealers.
To get in front of production, the State Department and a group of U.S. senators asked the United Nations in October to add to the list of tightly controlled substances . A decision is expected next year.
McDonald and Baer at the DEA said聽slowing demand for illicit uses of fentanyl and other opioids has become an urgent priority. The office of the U.S. Surgeon General last聽week also issued on the growing problem of substance abuse and the need for more widespread implementation of well-recognized, evidence-based treatment programs to address the problem.
In an with NPR鈥檚 Steve Inskeep on Morning Edition, Surgeon General Vivek Murthy called addiction 鈥渁 chronic disease of the brain.鈥�
鈥淲e need to treat it with the same urgency and compassion that we do any other illness,鈥� Murthy told Inskeep.
But some lawmakers, physicians and families who鈥檝e lost loved ones say the Obama administration has done too little too late to tackle the epidemic.
, a Democrat from Massachusetts, said it鈥檚 time to make the illegal production and trafficking of fentanyl the top policy issue in relations with China and Mexico.
鈥淢any more people are going to die from this than [from] any threat from nuclear weapons or any devastation that鈥檚 caused by an imbalance in trade,鈥� Markey said.
Baer said trying to stop the supply of opioids is part of the solution, but so is tackling demand by addressing addiction as a disease.
鈥淭he community needs to embrace these folks, create treatment opportunity,鈥� Baer said. 鈥淲e need to educate the public. It鈥檚 the No. 1 priority and it represents a public health crisis that all of us must work together to try to resolve.鈥�
The CDC offers a . While about 78 Americans will die today after an overdose, another 580 will try heroin 鈥� or what they think is heroin 鈥� for the first time.
This story is part of a partnership that includes , and Kaiser Health News.