A year ago this month, Barb Walsh was enjoying a feeling of pride for which every parent longs.
Sophia, the second of her four daughters, had come through the COVID-19 pandemic, graduating from Appalachian State University’s business school in 2020 and getting a good job with Milwaukee Tool.
Driven, competitive and self-sufficient, Sophia was never the sort of kid her mother had to worry about. While many in her generation struggled in their early 20s, Sophia had just been promoted, from working in a territory in Myrtle Beach to one in Charlotte. She had her own apartment there and was proud of having saved $20,000 toward a down-payment on her own home and $5,000 in a growing 401K.
“She was at the beginning,” Walsh said. “And she had a bright future.”
On the weekend of Aug, 14, Sophia was visiting someone in Banner Elk, just outside her college town of Boone. Exactly what happened there is still the subject of an open investigation. But early on the morning of Aug, 16, two police officers knocked on the door of the family home in Cary. Sophia was dead. A drug overdose.
“They had no details,” Walsh said. “There were no signs she had a drug habit, that she had been depressed, that her death was intentional. Nothing added up.”
It took nearly five months for the toxicology results to come back. When they did, Sophia’s cause of death was revealed. A word her mother couldn’t have spelled or properly pronounced before then. Fentanyl.
“You heard about the opioid epidemic,” Walsh said. “But what you heard about was pills or heroin. What was fentanyl?”
Though it killed more than 3,000 North Carolinians last year, fentanyl isn’t widely understood by the public. The drug’s unique characteristics and ubiquity in illicit drug manufacturing has led to overdose deaths in long-time, habitual drug users, as well as college students doing their first line of cocaine at a party. Many don’t even know they’re using it.
As communities across North Carolina decide how to spend $758 million from the historic national opioid settlement, much of the conversation has centered on prescription painkillers and heroin. But state medical experts, recovery advocates and those who have lost loved ones say fentanyl is a problem even more difficult to address.
Cheaper, stronger, deadlier
Fentanyl is a synthetic opioid created in the 1960s and widely used in anesthesia and to manage pain, especially after surgeries and cancer treatment. Its popularity among doctors came from its utility. It can be taken by mouth, via the skin or intravenously. Its potency was also attractive for medical pain management, roughly 100 times stronger than morphine, studies have shown.
In the ’90s and early 2000s an emphasis on patient satisfaction and pain management led doctors to overprescribe opioids in general, said Dr. Abhi Mehrotra, clinical professor at the UNC School of Medicine’s Department of Emergency Medicine.
When that contributed to a nationwide epidemic of opioid addiction, the pendulum swung in the other direction, Mehrotra said. Doctors began to rethink how they helped patients manage pain. Policy changes and lawsuits curbed overprescription.
But opioid demand didn’t go away.
“That opened the door for the manufacturing of synthetic opioids on the illicit market,” Mehrotra said.
Fentanyl’s chemical structure makes it massively adaptable. Change a chemical group here, get a fentanyl analog that is three times less potent. Make a different change there, get one that is 100 times more potent.
The same factors that made the drug popular in medicine — ease of use, potency, adaptability — quickly made fentanyl and its analogs popular in the illicit drug trade. Cheaper and easier to produce than heroin — and up to 50 times more potent — fentanyl allows illicit drug manufacturers and traffickers to adulterate drugs like heroin, cocaine and methamphetamine, reaping greater profits from products that could be far less pure but dramatically more powerful. Pills sold as Molly (MDMA), or even Vicodin are increasingly found to be substantially or entirely fentanyl.
“It’s cheap and easy for them to manufacturer powdered and liquid fentanyl and add it to cocaine, heroin, anything to add potency and fill it up,” said Dr. Padma Gulur, anesthesiologist, pain medicine specialist with Duke Health. “You hear about it all the time, 35 people overdosing because they were doing what they thought was cocaine but it had been adulterated with fentanyl. They didn’t know any better until they stopped breathing.”
Illicit drugs have never come with reliable quality control or ingredient lists, Gulur said. But with fentanyl, people getting something for which they are unprepared can quickly become fatal.
“People who may just be at a party and think ‘What’s one time?’ or who may even take it unknowingly because someone dropped in their drink, those people end up dying because they don’t have the knowledge or awareness of what is in there,” Gulur said.
In the first decade of the new century, medical examiner’s offices in the nation’s largest cities began reporting fentanyl’s presence in an overwhelming number of overdose deaths. Even those who had successfully managed drug habits for years were overdosing from drugs they didn’t realize were now far more potent.
Before long, it was being seen nationwide.
U.S. opioid overdose deaths quadrupled from 8,050 in 1999 to 33,091 in 2015, according to statistics from the Centers for Disease Control and Prevention. They accounted for 63% of drug overdose deaths in the United States in 2015, driven by heroin and illicitly manufactured fentanyl.
From May 2020 to April 2021, that overdose death number topped 100,000 for the first time, with 64% of deaths involving synthetic opioids other than methadone — mainly fentanyl and its analogs, either as an adulterating agents in other drugs or on their own.
“We had no idea this was going on here in North Carolina,” Barb Walsh said. “It wasn’t something we heard about.”
In North Carolina, death certificates don’t have a specific code for fentanyl’s involvement in a drug overdose. There is a code – T40.4 — for “other synthetic narcotic overdose.” The Epidemiology, Surveillance and Informatics unit of the NC Division of Public Health’s Injury and Violence Prevention Branch notes that most of these cases are “due to illicitly manufactured fentanyl and fentanyl analogues,” but can also include prescription fentanyl and other, less potent synthetic narcotics like Tramadol.
An analysis of statistics from the NC Office of Chief Medical Examiner finds overdose deaths with that code went from 442 in 2016 (the first year for which the office had such statistics) to 3,163 last year — an increase of 616%.
As of May of this year, there have been 1,342 deaths bearing the code — on track to beat last year’s record number.
“This is becoming more and more common in North Carolina, these overdoses — in Wilmington, in Fayetteville, all over the state,” Gulur said. “And this isn’t going to be a bad time. This will kill you.”
The empathy gap
Stories like those of Barb Walsh’s daughter Sophia tend to catalyze the public and policy makers — a sudden, shocking death in the white middle-class in which there was no known history of drug use or addiction.
But doctors and recovery advocates say that’s indicative of an “empathy gap” by which the deaths of those who struggled for years with substance abuse are shrugged off as the inevitable result of moral weakness, a fate common to people who don’t want to get better.
Patricia Drewes bristles at that. Like Walsh, she lost a daughter — Heaven Leigh Nelson — at 24. But when her daughter died of a fentanyl overdose in 2019, it was after several tough years of battling addiction, including a stint in rehab in Kentucky.
Like Walsh, Drewes didn’t know what fentanyl was before it killed her daughter. Now, as co-founder of the group Forgotten Victims of Vance, Granville, Franklin and Warren Counties, NC, she is working to increase awareness around the dangers of fentanyl and to change the way people think about addiction and those who struggle with it.
“Everybody just thinks, ‘Well, they were drug addicts,’” Drewes said. “That’s their stance. I don’t even say ‘addicts.’ This is substance use disorder. To me, addict is a nasty, ugly word.”
In Vance, a county of about 45,000 people, 38 people died of overdoses in the last two years. Of those, 28 — or about 78% — involved fentanyl.
That’s far too many lives to write off, Drewes said.
“There are the sudden, one-use overdoses,” said Dr. Robyn Jordan, an addiction medicine specialist and assistant professor at the UNC School of Medicine. “But fentanyl is also a huge problem for people who are in recovery and doctors trying to help them.”
That’s because drugs used in medical assisted treatment for addiction, like buprenorphine, the active ingredient in Suboxone, react very differently depending on what analog of fentanyl someone may have taken.
“What people are using is so unpredictable,” Jordan said. “We don’t know who is using prescribed fentanyl vs. the fentanyl analogs vs. the fentanyl in heroin. Some people might not have any trouble getting onto buprenorphine while other people might have a huge amount of trouble.”
Raising awareness, finding solutions
One thing doctors do know is that Naloxone, a drug used to treat overdoses in an emergency, is a vital tool in saving lives in the ongoing opioid epidemic. That holds true for fentanyl overdoses. Unfortunately, they say, it is not available widely enough among law enforcement and the public.
“I have three other daughters,” Walsh said. “I want them to have it with them all the time. Not just for them, but in case they’re somewhere at a party or anywhere and someone overdoses. It could save a life. But between the price and just getting your hands on it, it’s hard for people to do that.”
Making it easier to get and to use is an essential step in curbing overdose deaths, said Dr. Mehrotra.
“Price, price gouging, availability, prescription access, learning how to use it, what situation to use it in, those are all barriers,” Mehrotra said. “We need to make it easier.”
Parents and loved ones of those who have overdosed will advocate for these issues on Sunday, Aug. 21, from 2 to 4 p.m. at a rally at the State Capitol Building. Walsh and Drewes are among the mothers helping to organize the event, which they hope will bring awareness to the public and pressure on lawmakers and law enforcement to address a danger they didn’t see until it was too late.
“There are things we can be doing that we’re not, from the sheriff’s offices and the DAs to the lawmakers and the hospitals and pharmacies,” Drewes said. “This shouldn’t be costing any more of our children their lives.”
In the next few weeks, Policy Watch will talk with lawmakers, law enforcement officials, medical professionals and others on the front lines of addiction and recovery in a series of stories examining ways to address the large and growing number of opioid deaths in North Carolina.
We’ll look at the potential benefits and pitfalls of various approaches to dealing with the problem, including how North Carolina communities plan to spend hundreds of millions in opioid settlement dollars over the next 18 years.