Pubdate: Thu, 12 May 2016
Source: Sacramento News & Review (CA)
Copyright: 2016 Chico Community Publishing, Inc.
Contact:  http://newsreview.com/sacto/
Details: http://www.mapinc.org/media/540
Author: Raheem F. Hosseini

DR. FEEL BAD: RESPONSE TO EMERGING OPIOID EPIDEMIC CREATED CONDITIONS 
FOR FENTANYL TO THRIVE

Bottom-Up Enforcement, Lack of Drug Treatment Preceded Sacramento's 
Deadly Outbreak

Counterfeit pain pills recovered by federal drug authorities and 
masking dangerous amounts of fentanyl bear close resemblance to a 
milder medication.

In February, when Sacramento County started its new opioid task force 
to address an emerging public health crisis gaining traction here, 
the deadly fentanyl outbreak that would eventually kill a dozen 
locally wasn't yet on the radar.

The group's second meeting, on March 21, presented physicians with 
safe prescription tips for opioids, a constantly expanding class of 
pain-relieving medications all derived in some way from the highly 
addictive opium poppy. The well-attended meeting focused on the 
potential threat of these legal medications, which many say are 
dreamed up by profit-minded pharmaceutical companies, overprescribed 
by doctors and blamed for introducing a generation of suburbanites to 
the transfixing lure of a chemical high.

Four days later, as if on cue, people started dying from a bad batch 
of counterfeit pills-illegally peddled and labeled as Norcos, but 
masking fentanyl, a synthetic opioid that can immobilize large 
animals in small doses.

"One of the things we learned with this [outbreak] ... is there is 
this other source that we need to be aware of," said Dr. Olivia 
Kasirye, the county's public health officer, referring to the black market.

Now, as a state bill rekindles tactics of the nation's unsuccessful 
drug war, there's a different hard lesson to be relearned, as well:

Fentanyl ambushed California because of the government's response to 
the opioid crisis, not in spite of it.

The victims help tell the story.

Prior to the ingesting of illicit drugs that crashed their central 
nervous systems, some of the 52 local victims were unable to renew 
legal prescriptions, according to Kasirye and her assistant health 
officer, Dr. Melody Law.

Developing a drug habit at the doctor's office isn't unusual anymore, 
according to the U.S. Centers for Disease Control and Prevention, 
which reported more fatal drug overdoses in 2014 than any previous 
year on record. More than 60 percent of those deaths involved an 
opioid and at least half involved a prescribed opioid. In Sacramento 
County in 2013, the last year for which figures were available, fatal 
opiate overdoses represented more than half of all substance-related 
deaths and an 83 percent increase since 2011.

To the CDC, there's little question what drives the exploding death count.

"We now know that overdoses from prescription opioid pain relievers 
are a driving factor in the 15-year increase in opioid overdose 
deaths," the agency says on its website. "Since 1999, the amount of 
prescription opioids sold in the U.S. nearly quadrupled, yet there 
has not been an overall change in the amount of pain that Americans report."

In terms of enforcement efforts, authorities have mostly concentrated 
on jailing individual doctors and illicit distributors. Meanwhile, 
the companies flooding the market with their products receive 
accommodating fines.

Last October, a doctor in Los Angeles County, Hsiu Ying "Lisa" Tseng, 
became the first in U.S. history to be convicted of murder-related 
charges for overprescribing prescription drugs.

The increased enforcement is being felt closer to home, too. In a 
series of emails, a licensed Sacramento-area doctor told SN&R he gave 
up his Schedule II license to prescribe opiates after federal agents 
raided his practice last year, and says other physicians are following suit.

"Now many of my patients [are] getting meds back off the street, 
using heroin etc.," wrote the doctor, who requested anonymity since 
he's still under investigation. "Huge societal issue. Don't know 
solution. But making opiates users criminals is not going to solve anything."

So far, the drug companies have escaped a commensurate response.

In 2007, Purdue Pharma L.P. paid out $634.5 million in fines for 
misleading the public about the addictive risks of OxyContin, which, 
like Norco, is a potent opioid painkiller. Three years later, Purdue 
cleared $3.1 billion from OxyContin sales, according to a Fortune 
article from 2011.

Kasirye, meanwhile, says the overdoses of people with discontinued 
prescriptions shows their vulnerability to the black market and the 
need for more treatment options.

The county has already acknowledged in a report that it lacks the 
resources to meet the drug treatment demand. Even before the fentanyl 
outbreak, Sacramento County ranked 10th in the state when it comes to 
fatal opioid poisonings, according to figures covering 2013.

This past November, a countywide review of the existing treatment 
system showed that the county had opened many doors for people to 
request help, but couldn't answer that demand for residential and 
detox treatment, which jumped 36 percent last fiscal year. During 
that same time frame, more than 16,000 people in the county received 
some type of substance-addiction service, the report stated.

While public health officials acknowledge the need for additional 
treatment options, the only offer on the table is for more enforcement.

State lawmakers are currently considering a bill that would increase 
prison sentences for those possessing commercial amounts of fentanyl, 
similar to what's in play for heroin and cocaine base. Under Senate 
Bill 1323, getting busted with a kilogram of fentanyl would tack on 
three more years. Possessing 80 kilos would bring 25 additional years.

SB 1323 has passed both the public safety and appropriations 
committees, but was placed on the latter committee's suspense file, 
stalling its progress for now.

Groups including the American Civil Liberties Union, California 
Attorneys for Criminal Justice, California Public Defenders 
Association and Legal Services for Prisoners with Children have all 
opposed the bill, and argue that lengthening sentences would only 
aggravate California's still-crowded prisons and runs counter to 
bipartisan efforts to reduce the amount of drug offenders doing hard time.

It's not like fentanyl doesn't have its benefits.

First synthesized in Belgium in the 1950s, medical practitioners 
began using the compound as an intravenous anesthetic a decade later. 
Today, even the Sacramento Fire Department administers it to treat 
pain. The drug is cheaper and much stronger than morphine, says 
department spokesman Chris Harvey.

For firefighters and paramedics responding to an accident scene, a 
little fentanyl can eliminate the pain of a snapped fibula. But that 
same potency allows drug-traffickers to stretch out their profits by 
stepping on fentanyl-i.e. taking extremely small doses and mixing it 
with other drugs and binders.

According to Casey M. Rettig, a spokeswoman for the U.S. Drug 
Enforcement Administration's San Francisco division, this process 
allows traffickers to purchase a kilo of fentanyl at a wholesale 
price of approximately $3,300 and sell it off on the black market for 
about $1 million.

"So a little goes a long way," she said.

While illicit demand for fentanyl is more widespread on the East 
Coast, it's starting to find its way here in larger quantities, says 
William Ruzzamenti, director of the Central Valley High-Intensity 
Drug Trafficking Area. He says Mexico is being flooded with cheap 
fentanyl from China, and pushing it up north.

"We're seeing a tremendous increase," he said.

In March, federal drug authorities raided a Los Angeles County pill 
mill, arresting four men for allegedly using imported fentanyl from 
China to produce and distribute bulk quantities of pressed pills.

Still, up until recently, fentanyl-driven overdoses were fairly rare 
and typically occurred when mixed with black-tar heroin, which is 
common here, as opposed to the powdered heroin on the East Coast.

"With black tar heroin, you get it in chunks, and it's cut with a 
million different things," explained Melinda Ruger, executive 
director of Harm Reduction Services in Oak Park. "Everything from 
shoe polish to Folgers coffee-anything that might look sticky and black."

When fentanyl is part of that doctored stew of elements, its tricky 
density prevents it from being equally distributed, she says. That 
means a user could buy multiple doses off the same drug package, and 
suddenly keel over from one fentanyl-saturated hit.

"There's an uncertainty there, even when you're getting it from the 
same person," said Ruger, a former heroin user who has been sober for 
eight years.

Most of the overdoses that HRS tracks involve users who mixed 
substances-like heroin and alcohol or opiates and benzodiazepenes. 
Some of the overdoses did feature fentanyl, including people who 
intentionally took it because of its heralded potency. But no one 
interviewed by SN&R could recall a spate of overdoses as bad as the 
one that raced across six counties in less than four weeks.

The DEA has taken point on the investigation, and there remain 
several perplexing questions to answer. One might as well fall under 
Basic Drug Dealing 101: If fentanyl has a higher street value than 
Norcos, why sell it as the cheaper drug?

Rettig suggested the reason may have to do with an area drug market 
that has an appetite for milder painkillers, and is less aware of 
fentanyl. "So the drug trafficker is just making a product that is 
wanted on the street, but using existing ingredients" to do so, she suggested.

Rettig called the case her office's "No. 1 priority in the region" 
and said agents were "making progress." But she said she couldn't 
discuss the nature of their work since the investigation remained 
ongoing. Rettig did note similarities in the 61 fentanyl overdoses 
that have now touched the Sacramento and Bay areas. For instance, one 
of the doctored pills recovered in San Francisco bore close 
resemblance to a counterfeit tablet that the DEA seized here, she 
said. "So we are looking to connect the dots if we can."

Ruzzamenti isn't convinced the bad batch originated from a single 
source, but said he thinks it's possibly the work of "somebody who 
doesn't particularly know what the hell he's doing, because it's not 
good policy to want to kill off your clients."

In other words, incompetent drug dealers, not malicious ones.

"They're not chemists," Ruzzamenti added. "They're not pharmacists. 
They have recipes like your mom would have for chocolate pie."

Whoever the suspects are, Kasirye says they made very good counterfeits.

"Whoever was doing this went to a lot of trouble to make it look like 
a milder pill," she said.
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MAP posted-by: Jay Bergstrom