Pennsylvania officials worry that a potentially deadly drug is making a comeback in the region. So far this year, 50 people have died from fentanyl-related overdoses in the state.
Fentanyl is an opiate, more powerful than morphine, that's often given to cancer patients in extreme pain. In 2006, an illicit, non-prescribed version led to hundreds of overdose deaths in Philadelphia.
The memory still haunts several veteran health and drug enforcement leaders, who are trying to get ahead of the curve this time.
An unusual occurrence
Public health leaders first suspected something might be going on this spring, but the clues came far from Philadelphia.
Lebanon County's drug and alcohol abuse services coordinator, Carol Davies, got a call one morning, notifying her that four people had overdosed. One died. She said it was an unusual occurrence for the small community.
"We were thinking it was really kind of scary because they could tell they were dealing with a different kind of substance," Davies said.
Tests confirmed the substance was fentanyl. Davies and others then contacted the state to see if this was a problem elsewhere. Within weeks they'd identified related overdose deaths in more than a dozen other counties. One was in Philadelphia. It triggered a public health alert, advising medical examiners and doctors to test for the drug.
The alert worries Roland Lamb, head of addiction services in Philadelphia, though he and others haven't observed anything out of the ordinary lately in Philadelphia. Lamb said the problem is, when produced illicitly, fentanyl can look like heroin, white and powdery, but it's far stronger.
"That poses significant problems in terms of overdose," said Lamb. "If they're naïve to that drug, to the potency of that drug, which can be anywhere from the pharmaceutical, which is four to eight times more potent than the heroin in the streets, to the illicitly produced, which is 40 times more potent."
Memory of 2006 episode still raw
Lamb remembers all too well when fentanyl got mixed into Philly's heroin supply in 2006. It's still hard for him to talk about it. Fentanyl-linked drug overdoses killed a thousand people nationwide, including more than 250 people in Philadelphia.
Nidia Flores could have been one of them.
Pointing to a corner on Somerset Street in the Kensington neighborhood, Flores recalls rushing out of a friend's house after injecting what she thought was pure heroin, and immediately passing out in the snow between two cars. Paramedics heeded her friend's 911 call. Had they arrived minutes later than they did, Flores was told, she wouldn't have survived.
"For me to still be here is God's grace," said Flores.
Flores said others weren't so lucky. Some who she knew sought out the more intense "high" they thought fentanyl offered. But the drug was so potent, people were overdosing with needles still in their arms.
"So many women died because they didn't know what was in it," said Flores.
Flores, who's 41 now, says that was a dark period for her. She still lives nearby, but instead spends her time reaching out to people, connecting them with services.
Drug enforcement and public health officials, meanwhile, are still trying to make sense of what happened in 2006, and hope to prevent it from happening again.
Finding the source
Inside a nondescript office park miles away from Flores' home, Jeremiah Daley, director of the Philadelphia Camden High Intensity Drug Trafficking Areas, scans the Internet and internal documents for clues to what's leading to a possible resurgence of fentanyl use. Daley, a former narcotics officer, said he takes this concern and combating the widespread use of heroin and other drugs very seriously.
"I've seen heroin abuse as a major threat to public health for a number of years now, since I was with the Philadelphia Police Department, working the streets, seeing people that had overdosed on heroin, had lost loved ones to heroin, had had been arrested for heroin trafficking and such," said Daley.
Daley says he got a call this spring, notifying him of some of the fentanyl overdoses. He described it as an "oh, crap" moment because 2006 is also still fresh in his mind. He's not absolutely sure why it became such a problem then, but he has some theories.
Fentanyl is hard to make, and drug enforcement officers tracked much of it then to one production plant in Mexico. Daley thinks heroin producers were experimenting, mixing fentanyl with heroin, to try and make a "better" drug that could make them more money. He wonders if someone's experimenting again.
Daley said drug and health leaders have become a lot more organized.
"I would say in '06 I didn't have one person in my Rolodex list from poison controls or the emergency medical side," said Daley. "Now I have dozens and I think that speaks well for all of us, we can pick up the phone and talk to each other."
Daley hopes the improved coordination will help them catch any sort of problem sooner, preventing anything from reaching the magnitude that it did in 2006.
While it's too soon to say whether fentanyl is making a comeback in Philly, it has been blamed for 14 overdose deaths in Rhode Island. The Centers for Disease Control and Prevention has also issued an alert.
Daley and others, meanwhile, see this fentanyl scare as an acute issue that's part of a much bigger, endemic problem they're struggling to address: an across-the-board increase in heroin and prescription drug abuse in the last few years. Emergency responders received 900 drug overdose calls in Philadelphia last month, for example, compared with 750 calls this time last year.
And even without fentanyl, drugs claim more lives each year in Philadelphia than homicides.