The crisis started with mass prescriptions and black-market sales of pharmaceuticals such as OxyContin and Lortab.
It became increasingly dangerous with the addition of street drugs like heroin that promised users a quick and powerful high.
Now fentanyl and other synthetic opioids are at the forefront of a seemingly never-ending struggle by authorities to curtail an international drug trade that feeds addiction in communities large and small. And the substances are proving far more lethal than the drugs commonly seen before.
"We talk about the different waves of opioids that have gone through the country, and those waves are catching up to our community now," said Duluth Police Lt. Jeff Kazel, commander of the regionwide Lake Superior Drug and Violent Crime Task Force.
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Once available only in prescription patches or lozenges for cancer patients and others battling severe pain, fentanyl has become widely available on the streets to people struggling with addiction.
Northland police officers seized at least 479 grams of fentanyl in 2020, more than the three previous years combined. Statewide, the U.S. Drug Enforcement Administration reported a 30% increase in Minnesota fentanyl seizures last year.
Roughly 50 times more potent than heroin and 100 times stronger than morphine, it's a versatile drug found in many forms, from powder to crystals to pills — and it only takes a miniscule amount to kill most people.
"You'll see heroin that's laced with fentanyl," Kazel said. "You'll see straight fentanyl that's being sold, that might be marketed as heroin. Prescription pills are out there — people are thinking they're buying OxyContin off the black market, and it's really just straight fentanyl. You're seeing other drugs being laced with fentanyl: methamphetamine, marijuana. It's a bad thing; it's definitely an issue."
The four-county area served by the task force saw a record 41 fatal overdoses last year — far exceeding the 28 reported in 2019 and the 16 confirmed in 2018.
Particularly troubling to authorities is the fact that synthetic opioids — human-made compounds that mimic natural opioids — were determined to be present in about 85% of all overdose victims last year.
"They are overdosing because they don't know what they are getting," St. Louis County Attorney Mark Rubin said. "It's bad enough when dealers take advantage of those who are addicted, but they're also selling them something that is lethal and can result in death."
A lethal dose of fentanyl for most people is only about 2 milligrams, according to the U.S. Drug Enforcement Administration. That's comparable to a few grains of salt.
Working in quantities that small, authorities said it's nearly impossible for dealers to accurately divide and lace non-fatal amounts into other substances. That means users could receive a killer dose at any time — if they even know fentanyl is present at all.
"The concern is, yes, for those addicted to it, but the other concern is for first responders," said Rubin, who has played an active role in efforts by the Minnesota County Attorneys Association to combat synthetic opioids. "Police, firefighters, emergency responders — they have to take such extensive precautions, just so they don't get exposed to it."
Pandemic adds surge
In 2019, the last year for which complete data is available, synthetics were involved in 309 of the 428 opioid overdose fatalities reported in Minnesota, according to the state Department of Health. For comparison, heroin was present in just 106 cases, and common prescription drugs in 143 of the deaths.
Preliminary data showed a 31% increase in all drug overdose deaths in the first half of 2020, with 80% of all opioid-related deaths statewide involving synthetics, and authorities believe the onset of the COVID-19 pandemic in March 2020 caused many existing addiction issues to be exacerbated.
"Isolation and having a substance-use disorder do not go well together," Kazel said. "That's a deadly combination."
The death numbers are particularly startling, authorities said, as emergency responders and private citizens have widespread access to naloxone, the overdose-reversal drug that has been credited with saving countless lives in recent years.
St. Louis County saw at least 230 documented uses of naloxone, also known under the brand name Narcan, in 2020 — well up from 158 in 2019 and 93 in 2018.
"Our deaths are only being reduced because of the use of Narcan," Rubin said. "We're bringing people back to life who are overdosing, on their way to death."
Feds report more seizures
The DEA reported that investigators seized 6.2 kilograms of fentanyl in Minnesota last year — a 30% increase over 2019. That included 55,000 counterfeit pills — far exceeding the 1,500 pills seized just two years earlier.
Federal officials said the DEA’s Fentanyl Signature Profiling Program found that 26% of pills examined in 2019 contained potentially lethal doses of fentanyl and that it can be hard for users to tell the difference from legitimate medications because they often are often marketed as "M30s," "Perc30s," "Blues" or "Mexican Oxy."
“We’re continuing to see a sharp increase in counterfeit pills across Minnesota,” Justin King, special agent in charge of the DEA Omaha Division, which includes a Duluth office, said in a statement.
“Within the first 10 weeks of 2021, joint DEA investigations conducted along with federal, state and local counterparts have resulted in the seizures of close to 21,000 pills. We want people to be aware of the dangers these counterfeit pills carry with them. The only prescription medication people should take are those prescribed by a licensed physician and coming directly from a pharmacy,” the statement said.
Authorities said China is the primary source of fentanyl and other synthetic opioids, which are often distributed in the mail. Much of the supply in the Northland is believed to have made its way from Mexico through trafficking networks that include hubs in Chicago and the Twin Cities.
"The problem is it is such a profitable drug because the amount that is needed to produce an effect is so minimal, but it is so lethal," Rubin said.
Stronger penalties sought
Rubin testified in March before state legislators who are attempting to strengthen Minnesota's criminal penalties for the possession and sale of fentanyl, which is considered a Schedule II narcotic due to its legitimate medical uses.
That county attorney noted that, under existing law, a suspect must have five times as much fentanyl to be convicted of a first-degree sale charge as compared to heroin, which is Schedule I because it has no approved use. He described it as a "ridiculous" legal flaw that has prompted his office to charge many cases under the stronger heroin provision.
"It's the fentanyl, actually that's causing the overdose," Rubin told the Senate Judiciary and Public Safety Finance and Policy Committee. "It's the fentanyl that's becoming the cause of death."
The bill, which has earned bipartisan support, seeks to establish the same thresholds for heroin and fentanyl. That would include making the possession of a small amount of fentanyl a felony instead of a gross misdemeanor.
The legislation also seeks to close loopholes that allow so-called "street chemists" to chemically alter fentanyl, creating analogues and derivatives that aren't explicitly covered but can be just as, if not more, dangerous.
One analogue, carfentanil, is reported by the DEA to be 100 times more potent than fentanyl — 10,000 times the strength of morphine. It apparently has not gained a significant footing in the Northland, but has been found in the Twin Cities.
"You have people out there willing to take things off the shelf that have been there for a while and put it into things and sell it," Kazel said of the amateur chemistry efforts. "The Legislature's trying to catch up to what's going on out there."
The bill was cleared by the first legislative panel and was set to be taken up by the Senate Finance Committee on Friday. A companion bill in the House, authored by Rep. Julie Sandstede, DFL-Hibbing, has not yet moved forward.
Additional resources needed
Officials have acknowledged that enforcement alone won't be enough to solve the issue. Duluth police officials have often spoke of a three-pronged approach, adding education and treatment resources to go along with traditional law enforcement strategies
To that end, they've added opioid technicians to follow up with overdose survivors and worked to speed up chemical dependency assessments required to get people into treatment programs.
Rubin, who has seen a variety of controlled substances emphasized in more than 40 years as a prosecutor, acknowledged that authorities are not likely to fully root out the underlying causes of addiction.
Addressing concerns that increased penalties could lead to further incarceration and criminalization of addiction, he noted that, generally, people caught with a small amount of heroin are going to be offered deferred prosecution and the opportunity to keep a conviction off their records.
He agreed that more work is needed to help people who are struggling get on the right track, citing the work of treatment courts as a successful measure.
"The goal isn't to lock people up," Rubin said. "Yes, people need to be held accountable. But people are not addicts by their own choice. And they're the ones paying the price. You want to do what you can to help them be safe, and at the same time hold people accountable."