Before this summer, the word meant absolutely nothing to most Ohioans, unless you happened to work at a zoo. Even there, though, it's not exactly an everyday term.
But then a flash flood of headlines rolled in and suddenly the general public was very well aware of what carfentanil is: an opiate used to knock out elephants during surgery. They knew that because the heroin crisis has gotten worse. An entire generation of addicts is dying in American bedrooms and bathrooms and cars, in fast food restaurants and bars.
In July 2016, Akron alone saw 236 overdoses in three weeks. The numbers were shocking, which is saying something — Cuyahoga County, Summit County, Ohio and America at large are subjected to numbing and record-setting overdose stats every month at this point. But an abrupt spike of 200 was unheard of in Akron.
Something was different.
That difference was highlighted publicly when Akron police chief James Nice announced that carfentanil was suspected in some cases. The word blindsided observers. Long used as a sedative for large animals like elephants and rhinoceroses, carfentanil had somehow seeped into the heroin supply.
The opiate problem is becoming worse with each passing day. The introduction of the powerful prescription painkiller fentanyl into the heroin chain had a lot to do with that. But that process unfolded slowly over decades. The potency in 2016 is advancing tenfold, thanks to tiers of American drug dealers "stepping on" their product and cutting a buffet of chemical analogs of fentanyl, like carfentanil, into the supply.
And so we come to the next wave of the opiate overdose crisis. This summer introduced addicts and the general public alike to carfentanil, the most powerful commercial opiate in the world. (It's prohibited from use in war under the Chemical Weapons Convention.) And it's killing Americans in droves.
Carfentanil, marketed under the brand name Wildnil, has a long and mostly niche history in the annals of American pharmaceuticals. For years, the drug rested on the shelves of zoologists and veterinarians specializing in large animals. It's a uniquely powerful sedative.
"There's no human use for carfentanil," Keith Martin says. "None."
Martin is the resident agent in charge of the Cleveland office of the Drug Enforcement Agency. His office has been closely tracking the movement of carfentanil in Ohio.
"And even when they use carfentanil for [sedating large animals], it's used in small doses," Martin says. "And it's not always guaranteed that they'll be able to bring that animal back to life. For someone to be putting into their body or their system carfentanil, knowing that it can possibly kill a large animal — I mean, it's almost like playing Russian roulette."
Carfentanil is 100 times more powerful that fentanyl, which itself is 80 times more powerful than heroin. That comparison can be found in any number of news articles, but it's hard to grasp what that even means. In very simple terms: When it comes to carfentanil, all it takes is a snowflake-sized amount to kill a human, even through seemingly benign skin contact. Unwitting heroin addicts, duped by dealers with dollar signs in their eyes, are shooting this stuff into their veins. (Animal clinicians and, now, first responders must wear protective gloves and masks when dealing with the stuff.)
The U.S. Department of Defense has long identified the drug as a potential weapon in the hands of enemy nations. Lately, the U.S. has grown concerned that ISIS operatives could begin using the drug in various biological attacks. It's a grave and known concern. In 2002, Russian special forces deployed gaseous carfentanil in a counterattack at a Moscow theater; there, some 40 Chechen terrorists had taken 850 hostages. The opiate killed all of the attackers, along with 133 hostages. (Naloxone was used to save some hostages.) The U.S. later deemed the actions justifiable.
But when it comes to American addictions, the drug falls in line with a trend toward synthetic opioids — a different beast altogether than Oxycontin and Vicodin prescriptions, which, through government regulations and public stigma, are on the decline nationally.
For the most part, carfentanil is being created in clandestine laboratories in China, where oversight remains far more lax than in the States. The drug can be purchased online via the "dark web" on the encrypted Tor network and shipped right to one's doorstep here in the U.S. (Go ahead and Google it. See for yourself how easy it is to find.) The drug is a Schedule II controlled substance, according to the DEA's oversight, and remains illegal to possess outside of properly outfitted animal clinics, such as the zoological medicine department at the Cleveland Metroparks Zoo.
Because the drug is coming in through the mail, like an Amazon Prime order, the standard investigations that end with indictments against a ring of regional dealers don't really work in this new climate. Still, investigators say that cartels play a role. The manufacturers in China may not be directly in cahoots with them, but Mexican cartels long familiar with the opiate business are getting their hands on these uniquely powerful synthetics and introducing them into the supply.
The U.S. and China continue to discuss the matter of rising overdose deaths and border seizures — the DEA maintains an office in Beijing where agents work to clamp down on clandestine manufacturers — though it's unclear how far along those talks have progressed. China has not yet scheduled the control of the drug. This year, the Associated Press took a close look and identified 12 Chinese businesses that said they would export carfentanil to the United States, Canada, the United Kingdom, France, Germany, Belgium and Australia for as little as $2,750 per kilogram.
As part of that investigation, the AP contacted business owners in China. "We can supply carfentanil ... for sure," a saleswoman from Jilin Tely Import and Export Co. wrote to reporters in a September email. "And it's one of our hot sales product."
It's debatable when, precisely, the synthetic opioid wave began in the U.S., but by 2014 the problem was certainly clear. In Ohio, according to the Centers for Disease Control and Prevention, fentanyl-related deaths rose 526 percent, from 84 to 526, between 2013 and 2014.
Martin points out that, naturally, money has driven this trend. The profit margin on fentanyl and carfetanil (and other analogs, like acetyl fentanyl and U-47700) is dramatic. Only a small amount is needed; you can smuggle in a brick of carfentanil and have enough supply to cut a mountain of heroin. The drug that you're selling becomes stronger, and there's more to go around. More money.
And while the first wave of opiate addiction, via legally prescribed painkillers, filled hospital waiting rooms to the brim, this second wave has driven patients to the streets. That, combined with the profit motive, has prompted the flash flood of fentanyl- and carfentanil-laced heroin. Demand soars, and supply follows. Ohio, once ground zero for opiate prescriptions in the late 20th century, has become the "test tube" for high-powered synthetic opiates, according to a theory pushed by Hamilton County coroner Lakshmi Sammarco.
"The very intense and focused spike brought up a lot of fears ... that our community was being used as a test tube," she said. "What are [the dealers] learning from it? Are they looking to see how many people it's going to kill or how quickly our first responders can respond? And how many customers is that going to generate for them?"
The answers to those questions are unclear. (Martin maintains that the fight against opiates in Ohio is a "'Let's see what happens today'-type thing." There's no telling what's on the horizon.) But the bottom line is clear: Last year in Hamilton County, which includes Cincinnati, there were more deaths attributed to fentanyl than to heroin.
And while Ohio may be the "test tube," it's not alone; carfentanil was linked to 19 recent deaths in and around Detroit, two indictments near Louisville, Kentucky, and, for the first time ever, Alberta, Canada.
Which led us to this summer in Ohio. By September, carfentanil had become the buzzword of a crisis.
The drug was so off-the-radar that Sammarco's office and the federal government had to leap through hoops simply to acquire a testing sample of the stuff to verify what had killed victims. With the help of U.S. Sen. Rob Portman and the Cleveland Metroparks Zoo, a sample of carfentanil was acquired, and coroner's offices around the state could begin testing recent overdose victims for the presence of this powerful elephant sedative. Right away, Sammarco said, her Cincinnati office began confirming that carfentanil was involved in at least eight recent overdose deaths, with more to come. She began the process of retroactively testing other victims.
What that meant in real terms for EMS personnel, for instance, was a need to double-down on reactive efforts like the use of naloxone, the drug that counteracts the effects of an opioid overdose. To bring a victim back from a heroin overdose, a paramedic might need to use 4 milligrams of naloxone in what's become a frighteningly common routine for first responders. But when carfentanil is involved in the overdose, paramedics may need to use 12 milligrams of naloxone or more.
Even then, nothing's guaranteed. To return to Martin's point: Sometimes even elephants don't come back from the drug.
"I've not seen anything like I'm seeing today," Martin says. After 22 years with the DEA, he says, this year has quickly become the most harrowing era in the country's relationship with drugs.
With the introduction of elephant sedative into both the heroin supply and the heroin conversation, the American public has begun to slowly reframe the problem: Replacing the word "epidemic" with "public health crisis" is a start.
"If I was to describe it like a triage situation, we're bleeding profusely and we need a tourniquet. It's not going to take a Band-Aid and it's not going to take someone telling us to put pressure on the wound and it will all be better. We need real action and we need it now," said Newtown police chief Tom Synan. He leads the Hamilton County Drug Coalition Task Force, a new type of intergovernmental organization that's popping up in counties around the country, including here in Cuyahoga County. "The time for talk is done. We need action."
What's going to happen?
There's an adage that will come up in any conversation about the crisis: You can't arrest your way out of the problem. "I've said it a thousand times, but it's true," says Aaron Marks, a member of the Cuyahoga County Heroin and Opioid Task Force. "Even with the fentanyl now, people are like, 'Oh, we've got to get these dealers off the street!' They'll just keep coming. You've got to figure out other things."
The group looks at the problem from both a macro and a micro angle: addressing individuals' addictions and health problems while working to stop the runaway train of society's addiction to opiates.
"It's very frustrating," Marks says, "because you're trying to figure out what to do. And laws start to change, and things you work on for a year and a half are finally starting to get implemented — and then a whole new piece of the puzzle shows up. And of all the sudden you're going, 'Oh, wait. Naloxone's not working for people who are on carfentanil. Now what?'
"This thing's going to be a decade long," Marks says. "It keeps evolving and changing."
As of Oct. 6, 385 people have fatally overdosed in Cuyahoga County this year. Stakeholders anticipate that we'll see 500 by year's end. The crisis is becoming visible and unavoidable, in all corners of the county and state. Pictures of addicts passed out in cars spread like wildfire.
This month, the Cuyahoga County Heroin and Opioid Task Force will be honored with the Attorney General's Award, the "most prestigious award within the Department of Justice," according to U.S. attorney Carole Rendon. Her office works closely with the task force to craft new drug policy and prevent the public health crisis from getting worse. The Attorney General's Award recognizes that the task force is doing great work against profound odds.
Earlier this year, the DEA seized 900 oxycodone pills in Ohio.
"But it wasn't oxycodone. It was fentanyl, disguised as oxycodone. Imagine that: Somebody pulls out a bag of what they think is oxycodone and gives it to 10 kids. You're dead," Martin says. "I hate to be doom and gloom, but that's my world right now."
At least one problem that makes this crisis unique is that the people who are dying do indeed know that these drugs are becoming less and less predictable. They're aware of the heightened dangers contained in a bag of heroin. "At the same time, opioid addiction is extremely powerful," Steven Kurtz, the director of Nova Southeastern University's Center for Applied Research on Substance Abuse and Health Disparities, told Fast Company last month, "so having them stop isn't usually an option."