Drug cartels turn to a synthetic opioid 100 times stronger than fentanyl, 'killing hundreds of unsuspecting drug users'

The chemical makeup of carfentanil. The drug is legally used to  
anesthetize large animals such as elephants and rhinoceroses. 

Carfentanil is a deadly "weapons-grade" synthetic opioid that illicit drug makers are adding to other drugs as a potent substitute for fentanyl. The drug, which authorities say is "10,000 times more potent than morphine and 100 times stronger than fentanyl, has seen a drastic resurgence across the U.S., killing hundreds of unsuspecting drug users," report Hallie Golden and Jim Mustian of The Associated Press.

Carfentanil's presence in illegal drugs sold in the U.S. has surged since the Chinese government's more recent "crackdown on the sale of precursors used to make fentanyl," AP reports. "Those regulations are likely prompting traffickers in Mexico to use carfentanil to boost the potency of a weakened version of fentanyl."

The sheer potency of carfentanil is what makes it so dangerous for anyone who takes drugs not prescribed by their doctor. Frank Tarentino, the U.S. Drug Enforcement Administration chief of operations for its northeast region, which stretches from Maine to Virginia, told AP, "You’re talking about not even a grain of salt that could be potentially lethal. This presents an extremely frightening proposition."

While some Mexican drug cartels may be making carfentanil in their own labs, others are purchasing it from darknet marketplaces. Regardless of where it originates, it's making its way onto American streets. Golden and Mustian write, "In 2025, DEA labs identified carfentanil 1,400 times in U.S. drug seizures, compared with 145 in 2023 and only 54 in 2022."

Russia used an aerosol form of carfentanil as a chemical weapon to subdue Chechen separatists in 2002, AP reports. It is legally used to anesthetize large animals, such as elephants.

Michael King Jr., founder of the Opioid Awareness Foundation, told AP, “It’s like a biological weapon. If the world thinks we had a problem with fentanyl, that’s minute compared to what we’re going to be dealing with with carfentanil.”

Newly released data reveals a 'virtual opioid belt' developed over about 15 years in West Virginia, Virginia and Kentucky

Average number of pills distributed per person per year, ranked by county from 2006 to 2019. White is equal to zero pills and scarlet is 120+ pills; shades of pink are ranges between those two. (Post via Openmap, with DEA Automation report data)

America's battle with pain-pill prescriptions might be tapering off, but deaths spawned by its spin-offs, heroin and fentanyl, have increased, and deeply affected regions are still clawing toward a recovery.

A database maintained by the Drug Enforcement Administration shows how the use of pain pills increased dramatically, particularly in Appalachian counties. The database "tracks every single pain pill sold in the United States, tracing the path from manufacturers and distributors to pharmacies in every town and city," reports Steven Rich, Paige Moody and Kevin Schaul of The Washington Post. "These records provide an unprecedented look at the surge of legal pain pills. . . which resulted in more than 210,000 overdose deaths during the 14-year time frame ending in 2019. It also sparked waves of an ongoing and raging opioid crisis first fueled by heroin and then illicit fentanyl."

The information can help people "understand the impact of years of prescription pill shipments on their communities," the Post reports. "A county-level analysis shows where the most oxycodone and hydrocodone pills were distributed across the country over that time — more than 145 billion in all."

The DEA's database, known as ARCHOs, was not willingly shared with the public. The Post and HD Media, which publishes the Charleston Gazette-Mail in West Virginia, "waged a year-long legal battle for access to the database, which the government and the drug industry had sought to keep secret," Rich, Moody and Shaw add. "The initial release of data covered 2006 to 2012, and was later updated through 2014. . . . The Post analysis shows that the volumes of the pills handled by the companies climbed as the epidemic surged, increasing by 52 percent from 8.4 billion in 2006 to 12.8 billion in 2011."

Appalachian counties have maintained that their regions were targeted by pharmaceutical companies' greed. The maps show how those areas suffered more than other areas of the country. The Post reports, "Comparing county-level maps of prescription opioid overdose deaths and pill shipments reveal a virtual opioid belt of more than 90 counties stretching southwest from Webster County, W.Va., through southern Virginia and ending in Monroe County, Ky. This swath includes 18 of the top 20 counties ranked by per-capita prescription opioid deaths nationwide and 15 of the top 20 counties for opioid pills distributed per capita."

The maps show a 'virtual opioid belt' through Appalachia. (Post map, from DEA and CDC data)

Pandemic and fentanyl have driven drug record overdose deaths in the U.S.

Percentage change in all fatal drug overdoses from the 12 months ending in June 2019 to the 12 months ending in May 2020. CDC map; click the image to enlarge it.

The coronavirus pandemic and an influx of fentanyl have driven record drug overdose deaths in the U.S. between June 2019 and June 2020, according according to a report from the Centers for Disease Control and Prevention released in December 2020. "

"The Ohio Valley, an early epicenter of the opioid crisis, saw overdose fatalities soar, and in parts of the region the rate of increase surpassed the national average," Corinne Boyer reports for Ohio Valley ReSource.

Overdose deaths spiked in 10 Western states as well, driven mainly by fentanyl. "The increases are particularly troubling for rural counties in those states, some of which have the highest rates of opioid overdose deaths in the country," Liz Carey reports for The Daily Yonder. 

Overdose deaths related to synthetic opioids such as fentanyl increased more than 98%, according to the report. Out of 38 jurisdictions, 37 saw increases in such deaths from the 12-month period ending in June 2019 to the 12-month period ending in May 2020, Carey reports.

The geographic shift is noteworthy, the report says: "Historically, deaths involving illicitly manufactured fentanyl have been concentrated in the 28 states east of the Mississippi River…In contrast, the largest increases in synthetic opioid deaths from the 12-months ending in June 2019 to the 12-months ending in May 2020 occurred in 10 western states (98.0% increase)."

People in Western states who use opioids recreationally tend to use a heroin variety that reacts poorly with fentanyl, so fentanyl hasn't been as deadly there. But starting in 2018 fentanyl deaths began rising in Western states because fentanyl was contaminating other drugs or disguised to look like it. So someone might believe they were taking a Xanax but were actually taking fentanyl, Carey reports.

Some public officials say the coronavirus pandemic has also contributed to the increase in overdose deaths, Carey reports. Tom Jeanne of the Oregon Health Authority said in a recent statement: "Food insecurity and disruptions in access to safe housing and mental health services have compounded stress from job losses, school and social isolation, and other problems brought on by the pandemic." Jeanne noted that the pandemic had also made it more difficult for people with substance use disorder to attend 12-step programs or access addiction clinics.

Many addiction treatment programs moved to a virtual setting after pandemic shutdowns, but that's not practical for people with limited or no internet access, Boyer reports. One clinic in Lexington, Ky., provided wi-fi access so people could participate in group therapy sessions from their cars. For those without a phone or internet, the clinic created an isolated space in the clinic with computers for telehealth visits.

Analyst: Rural-urban divide in criminal justice is widening

Rural people can have a harder time with criminal justice than urban or suburban residents, and the gap is widening, Marc Levin writes for The Crime Report, published by the Center on Media, Crime and Justice in the John Jay College of Criminal Justice at the City University of New York.

"First, rural areas are less equipped to deal with the spike in drug overdoses in 2020, many of which are fatal. In recent years, overdose death rates in urban areas matched or exceeded rural areas, reversing a prior pattern. More recent data by type of jurisdiction is not available; but many of the states, such as Ohio and Pennsylvania, that saw significant declines from 2017 to 2018 have lost ground so far this year," Levin reports. "While addiction knows no boundaries, research has found that rural areas are less likely to have accessible treatment options. Rural and smaller law enforcement agencies and paramedics may have longer response times and be less likely to carry naloxone, the opioid overdose reversal drug." Levin is chief of policy and innovation for Right on Crime, an initiative of the Texas Public Policy Foundation.

Many justice systems have turned to virtual court appearances and probation check-ins, but that could be more difficult in rural areas with poor connectivity. "Fortunately, text messaging and phone applications that do not require this level of connectivity provide an alternative for pretrial services and community supervision officers to keep in touch with those they are supervising," Levin reports.

Indigent defense has long been a challenge in rural areas, and the pandemic "has made it more difficult for defense lawyers to meet with their clients, whether that is due to protocols limiting access to defendants in jail or the challenge of maintaining a safe office environment with frequent visitors," Levin reports. "Rural areas have largely been left behind by advances in urban areas such as holistic defense, through which organizations like Bronx Defenders connect their clients to services and treatment, resulting in better outcomes by solving the challenges that led them to be involved in the justice system."

Another inequality, Levin notes, is that 54% of prisons are in rural areas, which increases the risk of coronavirus transmission among the incarcerated as well as staff and the community beyond.

A recent report from the Southern Methodist University Law School's Deason Center has some recommendations for closing the rural-urban gap in criminal justice. Their suggestions include "innovations in technology and training, law school legal clinics serving Native American tribes and other rural communities, and a combined undergraduate and law program for students seeking to practice in rural areas," Levin reports.

Meth from Mexican drug cartels is on the rise in Appalachia, fueled partly by officials' efforts to cut off opioid access

Central Appalachia has been long known as a hotbed of opioid addiction, but, aided by Mexican drug cartels, methamphetamine abuse has been surging in the area for the past few years, presaging a nationwide increase in abuse of a more powerful form of the drug.

"The region where Kentucky meets Ohio and West Virginia has served as a harbinger of national drug trends," Timothy Williams reports for The New York Times. Pain pills like OxyContin, stimulants known as bath salts, prescription anti-anxiety medications like Xanax and, more recently, heroin and fentanyl were all adopted by drug users here before gaining wider use nationally."

Efforts to end opioid abuse, along with increasing awareness of the dangers of adulterated opioids, have led to the resurgence of crystal meth. "Doctors and hospitals have unwittingly accelerated the switch to methamphetamine by significantly reducing their patients’ access to pain medication; opioid users, increasingly fearful about overdosing on heroin and fentanyl, have been desperate for a substitute," Williams reports. Mexican drug cartels such as Sinaloa or the Jalisco Nueva Generación have "sought to fill the vacuum by targeting Appalachia, federal drug officials say. The traffickers follow the same business model that allowed them to inundate the nation with heroin: make meth potent and sell it cheap to ensure a steady customer base, and ultimately, mass addiction."

Until recently, meth was mostly a locally made product that varied widely in strength, but the newer Mexican version is often mixed with cocaine and/or fentanyl. Because fentanyl is cheap and a little goes a long way, it and cocaine enhance the user's high and hasten addiction, Williams reports. But it also makes overdoses more likely.

Colorado brings medication-assisted therapy for opioid users to rural areas with recreational-vehicle clinics

One of the RVs and two of its staff in Holyoke, Colorado.
(Photo by The Holyoke Enterprise)

Medication-assisted therapy (MAT) is widely acknowledged to be the most effective way to treat opioid addiction, but it can be difficult for rural residents to access it. Colorado is trying to make it a little easier by deploying six RVs to circulate among small towns with no access to MAT.

"Each RV will have a nurse, an addiction counselor and a peer coach who is in recovery from addiction," Jennifer Brown reports for The Colorado Sun. "The rigs — with satellite capacity — will use telehealth to connect a patient with a doctor who can write prescriptions" for the synthetic opioid buprenorphine. The RVs will also have a bathroom to collect urine samples, a nurse's station, and a private room for counseling sessions.

Buprenorphine can be prescribed for a month at a time, unlike methadone, which must be dispensed at clinics daily for those just beginning their recovery. That means the RVs can help more patients and cover more ground, Brown reports.

Three of the six RVs are already on the road, and the other three are still being retrofitted. "The goal is that each of the six vehicles eventually will see at least 50 patients per week, providing medication-assisted treatment for those who are addicted to heroin or prescription opioids," Brown reports. "Visits are by appointment or walk-in, and staff have been spreading the word at medical clinics, hospitals and shelters."

The RV staff say that being out-of-towners is an asset because it helps bring drug users out of the woodwork who wouldn't admit to locals that they needed help, Brown reports. That may help local leaders realize that their communities have an opioid problem and take action, said Robert Werthwein, director of the state Office of Behavioral Health. He had the idea for the RVs after hearing about a similar effort in New York state.

The Office of Behavioral Health in the Colorado Department of Human Services is funding the project with $6.7 million from a federal State Opioid Response grant. The grant has also paid for almost 42,000 overdose kits, provided naloxone to 16 county jails, helped open clinics, and trained doctors to prescribe buprenorphine.

Some small-town police try a new tactic in fighting the opioid epidemic: helping drug abusers instead of arresting them

Officer John Cacela of Ware, Mass., and Emily Ligawiec take a weekly pottery class. Rather than arrest Ligawiec last winter when she took heroin and stole her mom's car, he offered her help. (New England Public Radio photo by Karen Brown)

Law-enforcement officials in small-town Massachusetts and a few other states are trying a new tactic in fighting the opioid epidemic: reaching out to drug abusers with offers of help instead of arresting them, Karen Brown reports for NPR.

"It's based on the idea that, for many drug users, a call to the police — for a nonfatal overdose or a drug-related crime such as theft — is the first time they get on the radar of any authority," Brown reports. "So after the immediate crisis is over, officers follow up and offer help. That could be a warm bed for the night, a referral to a recovery coach or needle-exchange program, a ride to detox. At the very least, they'll give out the overdose-rescue drug Narcan and talk about how to stay alive."

Officer John Cacela of Ware, Mass., summed it up: "We can't arrest our way out of this problem."

Last year, Emily Ligawiec took heroin and stole her mother's car. But instead of arresting her, Cacela repeatedly reached out to Ligawiec and offered her help. She initially resisted, but soon Cacela was able to talk her into meeting with him and recovery coach Susan Daley at a nearby donut shop. After Ligawiec later overdosed at home, she saved herself with the Narcan Daley left her, and then agreed to go to rehab. "It was like a tornado went through and all that was left in the center was me and a vast land of ruin," Ligaweic told Brown. "And having Susan and Officer Cacela there — it's life changing."

Mail-based syringe exchanges could help rural drug users

Mail-order syringe exchanges may help intravenous drug users in rural and other underserved areas access clean needles, Emma Coleman reports for Route Fifty.

Syringe exchanges have been proven a safe and effective way to reduce the spread of contagious diseases from intravenous drug users without increasing drug use, but some people, especially in rural areas, have a hard time accessing such services, Coleman reports. Sometimes it's because there are no local syringe exchanges—15 states ban them, and in some other states the can't get required local approval—and sometimes it's because of transportation problems or fear of stigma or lack of confidentiality.

New York-based nonprofit NEXT Distro is trying to help such people by shipping them safe injection supplies like syringes, alcohol pads, tourniquets, gauze, sharps disposal containers, fentanyl test strips, antibiotic ointment, and syringe clippers, Coleman reports. The organization's FAQ page says it also sends clients materials on drug-user health, wound identification and care, family planning, and overdose prevention. It isn't a needle exchange; users don't mail back their sharps. 

"If you live in a rural area, or you’re poor, you should have the same access to support and harm reduction. You can order syringes from online marketplaces like Amazon and people do that—people who have money," NEXT Distro founder Jamie Favaro told Coleman. Favaro got the idea of mailing harm reduction supplies from activist Tracey Helton, who mails the opioid overdose reversal drug naloxone to people who ask her for it on a Reddit forum. NEXT Distro also mails naloxone.

The organization was initially supplied by the New York Department of Health, but now relies partly on a GoFundMe page and support from other nonprofit organizations, according to the website.

Transportation, fear of stigma and lack of confidentiality biggest barriers to use of rural syringe exchanges: Ky. study

Counties in study are in red; click on the image to enlarge it.

Rural residents who inject drugs say they are less likely to access syringe exchange programs because of transportation problems, inability to get to the service at times it's open, and concerns about stigma, lack of confidentiality, and law enforcement. So says a newly published study examining barriers that can prevent people who inject drugs (PWIDs) from accessing syringe service programs (SSPs) in Appalachian Kentucky.

The researchers surveyed 186 PWIDs who used their local health department SSPs in three rural counties in 2018: Clark, Knox and Owsley (though Clark is in a metropolitan area, much of it is rural). Kentucky leads the nation in the number of SSPs, partly because it has 120 counties. As of July 2019, it had 52 SSPs that aim to reduce the spread of HIV and hepatitis C by giving PWIDs clean needles and disposing of dirty ones, and often offer more information about addiction treatment services when the person is ready.

Among the study's participants, 53.2 percent were male, 92.5% were non-Hispanic whites, and 78.5% had Medicaid coverage. About 39% said they injected more than one drug; methamphetamine was the single most popular drug, with 45.2% reporting it as the primary drug they inject. The next most popular was non-prescribed buprenorphine, which is sold legally as Suboxone for drug treatment (25.8%), followed by heroin (16.1%), other non-prescribed opioids (11.3%), and various other drugs (1.6%).

The biggest barrier to SSP use was the lack of transportation, with 18.3% reporting it as the primary barrier. Other barriers were: inability to access the program during operating hours, which are often limited (12.9%); concerns about stigma, privacy, and/or law enforcement (9.1%), not enough syringes (5.4%); and the location of the program (4.8%).

Participants' concerns varied based on the degree of their county's rurality. In Clark and Knox counties, the least rural, transportation was the most frequently cited barrier. But in Owsley, the most rural county, fear of stigma and lack of confidentiality ranked highest.

Rurality also factored into participants' consistency in accessing the SSPs. Participants in Knox and Owsley were more likely to consistently use the program than participants in Clark. The researchers believe the more consistent uptake in rural areas is because people in rural areas tend to have higher residential stability. However, Clark County participants may be less likely to consistently use SSPs because they're more likely to have an alternate means of accessing clean needles.

The study is part of a larger National Institutes of Health-funded effort to learn about SSP uptake in rural areas. This study's authors recently published another study about PWIDs in the same three counties, focused on what kind of interventions are most effective and which drug users are most likely to seek treatment.

How rural and urban opioid deaths differ; one group of rural areas' overdoses are driven by many different drugs

A recently published study provides a comprehensive picture of the changing geography of the opioid epidemic. Researchers from Syracuse University, the University of Iowa, and Iowa State University tracked opioid deaths in the 48 contiguous states and cross-referenced that info with data from the Centers for Disease Control and Prevention to break down deaths not just by geography, but by the type of opioid that caused the death.

"The study finds that the opioid crisis takes different forms in urban and rural America," Richard Florida reports for CityLab. "While the urban opioid crisis is a crisis of heroin and illegal drugs, the rural opioid crisis of prescription drugs is largely a story of growing spatial inequality and of places left behind, most often occurring, as the authors note, in places that tend to have a declining industrial base."

Opioid overdose deaths have increased more than 700 percent in the most rural areas, compared to a less than 400% jump in urban areas. The epidemic can be characterized by three "waves." The first wave, in the early 1990s, involved mostly prescription opioids, mainly in rural areas. During the second wave, heroin deaths began increasing, largely in urban areas. The third wave is synthetic opioids, and is also disproportionately urban. "Such deaths are expected to soon eclipse deaths from opioid overdose in rural, non-metro areas," Florida reports.

Some areas, both rural and urban, fall into a fourth category: their overdose deaths come from many different sources, including prescriptions, heroin, synthetics, and sometimes more than one. The study calls this a "syndemic" crisis, and 4% of U.S. counties (129) fall into this category. "This syndemic opioid epidemic is concentrated in the eastern third of the nation: in Maryland, Massachusetts, rural Appalachia, stretching into Indiana, and in Michigan," Florida reports. "A third cluster is located around Santa Fe, New Mexico. Nearly two-thirds (64 percent, or 82 counties) of syndemic counties are in metropolitan areas, with 36 percent (47 counties) in rural or non-metro areas."

Many believe the opioid crisis developed from over-prescription and abuse of legal opioids, but the study found that was only true in rural areas, Florida reports.

Rural HIV infection rates rise as urban rates fall; crisis 'can't be ignored any longer,' journalism professor writes

HIV infection rates are falling in many large U.S. cities, but rates are rising in much of rural America.

"There have of course always been cases of HIV in sparsely populated parts of the country, but in these places far from cities, the conditions that lead to HIV transmission are now intensifying — and rural America is not ready for the coming crisis," Northwestern University journalism professor Steven Thrasher writes for The New York Times. "Unlike large urban areas that have dealt with similar health and substance crises in the past, and that have networks of service providers and consumers in place, small rural health jurisdictions often lack the infrastructure to confront the crisis and have little history of dealing with comparable health issues."

The opioid epidemic is a major factor in the explosion of rural HIV infections, since opioid users are more likely to engage in risky behavior such as having unprotected sex while high or sharing needles. (Prescription opioid abusers often turn to higher-octane intravenous opioids like heroin.) In West Virginia's Cabell County and Huntington, for example, where there is a massive prescription opioid addiction problem, 80 new HIV infections have been diagnosed over the past year. "This avoidable crisis has been exacerbated by unemployment, declining coal mining production and economic pressures on regional press to act as effectively as a watchdog," Thrasher writes.

Most frustratingly, the rise in rural HIV infection rates was predictable, Thrasher writes: "After a hepatitis C and HIV outbreak in Scott County, Ind., in 2014 and 2015 that was fueled by deindustrialization and opioids, the CDC released a list of 220 counties similarly vulnerable to such outbreaks among people who use intravenous drugs. The densest concentration of those counties is along the Appalachian Trail, with 28 of them in West Virginia — more than half of the state’s 55 counties."

However, many rural areas are ill-equipped to prevent or deal with an HIV outbreak because they frequently refuse to effective policies such as needle-exchange programs, more comprehensive sex education, and LGBTQ+ public health efforts, Thrasher writes. Rural HIV patients also may be reluctant to admit they're infected or seek treatment because of the stigma associated with it. That leads to worse health outcomes and more infections. Thrasher says the problem "can't be ignored any longer."

DTN launches series on rural opioid epidemic

Rural America is a "key battlefront" where the opioid epidemic is growing, but struggling rural economies don't have the resources to make health-care infrastructure improvements that could help, Todd Neely reports for DTN/The Progressive Farmer, in the first of a special series examining the impact of opioid addiction on rural America, its roots, and what's being done about it.

The 15 states with more than half the population living in rural areas (Alaska, Montana, Wyoming, North Dakota, South Dakota, Iowa, Oklahoma, Arkansas, Mississippi, Alabama, Kentucky, West Virginia, Vermont, New Hampshire and Maine) went from 2,854 opioid overdose deaths in 2013 to 4,162 deaths in 2016, a 46 percent increase, Neely reports. Another 19 states with populations more rural than average (Oregon, Idaho, New Mexico, Kansas, Nebraska, Minnesota, Missouri, Louisiana, Tennessee, Indiana, Wisconsin, Michigan, Ohio, Pennsylvania, Vermont, Virginia, North Carolina, South Carolina and Georgia) went from 9,633 opioid deaths in 2013 to 17,365 deaths in 2016, an 80 percent jump.

But how do rural opioid deaths compare with urban deaths? In 1999 the opioid overdose death rate in urban areas was 6.4 per 100,000 residents, compared to 4.0 in rural areas. But by 2015 rural opioid overdose death rates were 17.0 per 100,000 compared to 16.2 in urban areas, Neely reports.

About 80 percent of people addicted to opioids don't receive treatment, according to a 2015 study. The reasons are various: fear of stigma, lack of money, or limited treatment options nearby. All three can be concerns for rural residents, especially lack of nearby treatment: 92 percent of treatment facilities in the U.S. are in urban areas. Click here to read more of DTN's deep dive into the rural opioid epidemic.

Fentanyl drove record high drug overdose deaths in 2017

New York Times chart; click on the image to enlarge it.

New numbers from the Centers for Disease Control and Prevention show that drug overdoses killed more than 70,000 Americans in 2017, a record high, and that use of synthetic opioids like fentanyl drove the increase.

Since 2013, the number of overdose deaths associated with fentanyls and similar drugs has grown to more than 28,000, from 3,000." Josh Katz and Margo Sanger-Katz report for The New York Times. "Deaths involving fentanyls increased more than 45 percent in 2017 alone. Overdose rates have been especially high in the Northeast, the Midwest, and mid-Atlantic states.

Drug overdoses are now the leading cause of death for adults under 55. The increase in drug overdose deaths has been so great that it's contributed to a four-month reduction in the average American's life expectancy; that kind of reduction hasn't been seen since World War II, Katz and Sanger-Katz report.

The federal government's recent efforts to fight the opioid epidemic have focused on prescription abuse, but some public health researchers say that fighting fentanyl requires a different approach. Synthetic drugs tend to be more potent, and therefore deadlier, since small measurement errors can lead to an overdose. "The blends of synthetic drugs also tend to change frequently, making it easy for drug users to underestimate the strength of the drug they are injecting. In some parts of the country, drugs sold as heroin are exclusively fentanyls now," Katz and Sanger-Katz report.

Preliminary data from the CDC indicate that 2017 could be the peak of the overdose epidemic, with nationwide death rates leveling off in early 2018, but it's too soon to tell.

Chinese President Xi Jinping Xi recently agreed to designate fentanyl as a controlled substance and to crack down on illicit shipments of the deadly opioid, but the Chinese have said that before.

Some rural areas are slow to embrace legal marijuana

Michigan voters will decide in November whether they want to legalize recreational marijuana. Supporters of the initiative say it could help the economy in rural parts of the state, but it's been a "mixed bag" for other states, Steve Carmody reports for Michigan Public Radio.

Pueblo County (Wikipedia map)

In Pueblo County, Colorado, so many cannabis businesses have opened in recent years that local lawmakers have put a moratorium on new licenses. "The growing marijuana industry is changing people’s perception of Pueblo County. For many years, steel mills and agriculture – in particular green chiles – defined the county. But now the county is becoming synonymous with cannabis," Carmody reports.

Marijuana has brought more jobs and business investment to Pueblo, but some say it has brought problems too. Rod Slyhoff, CEO of the Greater Pueblo Chamber of Commerce, said people more frequently fail local employers' drug tests. "Since legalization, the county has seen an increase in property crime and homelessness," Carmody reports. "There has also been an increase in seizures of drugs like heroin and amphetamines. And in the first six months of this year, Pueblo County sheriff’s deputies busted more than 40 illegal grow operations." Some Pueblo residents tried and failed to make recreational cultivation and sales illegal in 2016.

Rural Nevada is also slow to embrace recreational marijuana. Representatives in several rural counties said "they either have ordinances on their books that prohibit marijuana sales locally or have not seen any interest in local sales," Wade Millward reports for the Las Vegas Review-Journal. Other counties and towns said they allow medical dispensaries but no cultivation or sales of recreational marijuana. And some rural Californians protest legalized marijuana, saying that cultivation will damage the land, use up scarce water and bring crime.

Study says a much more comprehensive approach is needed to fight the epidemic of opioid overdose deaths

A study just published in the American Journal of Public Health says U.S. policies are not doing enough to curb the opioid epidemic, and predicts that 510,000 Americans will die from opioid-related causes over the next decade. Using mathematical models and expert opinions, the researchers assessed the likely impact of different policy initiatives on the epidemic. Though some policies will help more than others, the researchers say no single policy will end the epidemic on its own, so a much more comprehensive approach is needed.

“The model, for example, estimated that wider availability of naloxone could reduce opioid-related deaths by 21,200 over 10 years; that medication-based treatments for opioid addiction like buprenorphine and methadone would reduce deaths by 12,500; and that reductions in painkiller prescribing for acute pain would reduce deaths by 8,000,” German Lopez reports for Vox. “On the harm-reduction and treatment front, the model suggested that several interventions — more naloxone, more needle exchanges, more medication-based treatment, and more psychosocial treatment — would have unambiguously good effects, reducing both heroin and painkiller deaths over the next 10 years. But none of them would have giant effects on their own.”

Some interventions could trigger an increase in overdoses of other drugs even as they reduce painkiller deaths. When addicts lose access to prescription opioids, some begin using illegal opioids like heroin or fentanyl and may overdose on them, Lopez reports.

Study shows urban, rural access to illegal drugs the same; researcher says more studies needed in rural areas

Habecker

Though popular media often depicts illegal drug use as an urban problem, a new University of Nebraska-Lincoln study shows it's just as easy to get drugs in rural areas. The study was published in July in the Journal of Drug Issues.

Sociologist Patrick Habecker, who led the study, found that more than one-third of both urban and rural residents could get marijuana through someone they know. "The study also found that 18 percent of Nebraskans surveyed in the Nebraska Annual Social Indicators Survey reported access to prescription pills, including opioids. Nine percent reported access to methamphetamine and 5 percent said they knew at least one person from whom they could obtain heroin," Deann Gayman reports for the university's press shop.

Habecker said the study only examined social access, so the actual accessibility of illegal drugs in Nebraska is probably much higher. It didn't account for other sources such as internet delivery.

While social access was about the same for both rural and urban residents, other factors did make a difference in people's ability to access marijuana: older people and regular churchgoers were less likely to know a marijuana source. Regular church attendance also reduced the odds of knowing a prescription-pill source in rural areas. And lesser-educated people were more likely to know a prescription-pill source, Gayman reports.

Habecker and colleauges have been tracking rural drug-use trends and say this study could help authorities understand more about how to fight it. "There has not been a lot of focus on rural substance use in general," Habecker told Gayman. "It’s largely been city-focused, and it’s clear that should probably change."

Fewer U.S. workers are using prescription opioids, but more are using cocaine, methamphetamine and marijuana

Fewer U.S. workers are using prescription opioids, but more are using methamphetamines, cocaine, and marijuana, according to data released by Quest Diagnostics, which conducts workplace drug testing, Katie Zezima reports for The Washington Post.

The overall percentage of workers who tested positive for drug use remains unchanged since 2016 at 4.2 percent, but it's higher than the 3.5 percent return in 2012. Positives for meth have increased 167 percent in the South and Midwest in the past five years, and cocaine positives have increased dramatically in some areas: there was a spike of 91 percent in Nebraska and 88 percent in Idaho from 2016 to 2017. Marijuana positives have increased in states where recreational use of the drug has been legalized, such as Nevada, Massachusetts, and California. Those states also saw a bump in positive marijuana tests among safety-sensitive workers such as pilots and truck drivers, Zezima reports.

"The increases come as the number of workers testing positive for prescription opioids and heroin have declined, even though the opioid crisis continues to ravage the United States," Zezima reports. "The rate of drug tests that were positive for a prescription painkiller declined by 17 percent from 2016 to 2017. Tests for a metabolite that is in heroin dropped by 11 percent from 2016 to 2017, a three-year low." Part of that may be because Quest doesn't test for synthetic opioids such as fentanyl, which is driving the increase in drug overdose deaths.

Barry Sample, senior director of science and technology at Quest, told Zezima: These changing patterns and geographical variations may challenge the ability of employers to anticipate the 'drug of choice' for their workforce or where to best focus their drug prevention efforts to ensure a safe and healthy work environment."

Click here for a handy guide for journalists on how to cover rising meth use, from Journalist's Resource at Harvard University.

USDA opioid roundtable makes a stop in Utah; one concern is lack of detoxification centers, reliance on jails

A U.S. Department of Agriculture official met with state and local leaders at the Utah state Capitol this week to hear their input on the opioid epidemic. Wednesday's stop was the second of five visits Assistant Secretary for Rural Development Anne Hazlett is making to better understand local concerns about the crisis. The first session was in Pennsylvania, and the remaining three will be in Kentucky, Oklahoma and Maine this summer.

USDA has good reason to listen to rural concerns about the epidemic: "Federal health officials say drug overdose death rates continue to rise in less-populated regions of the country, and a recent national poll found that 3 in 4 farmers and other agricultural workers have been directly affected by opioid abuse," Luke Ramseth reports for The Salt Lake Tribune. Hazlett has said the opioid crisis is "a matter of rural prosperity."

Many who spoke with Hazlett had ties to Carbon County, a rural area with the state's highest opioid overdose death rate. Debbie Marvidikis of the Southeast Utah Health Department told Hazlett the county needs more resources to follow up with addicts. "Medical first-responders, she said, face a vicious cycle of saving an addict from an overdose one Friday night — then having to make the exact same life-saving maneuvers with the opioids-overdose drug naloxone a week later," Ramseth reports. Because Carbon County doesn't have a detoxification center, the only way for area residents to get clean under supervision is to get arrested and detox while in jail.

Jail can be an effective venue for treatment, says Cam Williams, a medical provider at the Carbon County Jail. A jail program provides inmates with the addiction-management drug Naltrexone, and officials follow up with recently released inmates to make sure they're still taking the drug. "Williams said he believes there are 60 to 70 people now sober and finding jobs because of Naltrexone treatment and subsequent follow-up," Ramseth reports.

Tiffany Van Sickle, a prevention coordinator for Four Corners Behavioral Health, which operates treatment clinics, said it can be difficult to convince rural residents to try new strategies or devote more resources to fixing the problem; even when a new treatment is science-based, Van Sickle said "there's a lot of 'We've tried that 20 years ago, and it didn't work, so we're not going to try it again,'" Ramseth reports.

Patrick Rezac said his needle-exchange and recovery-support group program One Voice Recovery has had a hard time helping in Carbon County because some residents live too far away to consistently come to meetings or have to navigate unpaved roads. He recommended more treatment and detox centers in rural Utah, and said rural residents who seek help often have to wait for days. The wait "can mean the difference between getting clean and dying of an overdose," Rezac said.

Lee Peacock, president of the Utah Petroleum Association, said oil and gas companies are having difficulty hiring rural residents because so many are addicted to opioids.

Utah Attorney General Sean Reyes, who created a task force on opioids in conjunction with the U.S. Drug Enforcement Agency last year, said Wednesday that many Utahns' independence and strong religious sentiment can sometimes prevent them from asking for help with addiction. He urged addicts to stop worrying about judgment from others and get the help they need.

At Wednesday's meeting, Hazlet "urged state and local officials to apply for grants the federal agency is offering. These include cash for telemedicine and distance learning to be used to address opioid issues, and other funds for new community facilities, such as mobile treatment clinics," Ramseth reports.

FarmTownStrong website, created by Farm Bureau and National Farmers Union, aims to fight rural opioid addiction

The American Farm Bureau Federation and its sometime adversary, the National Farmers Union, have created campaign to provide rural communities with resources to address opioid addiction, according to a Farm Bureau podcast.

The campaign is anchored with a website, FarmTownStrong.org, with confidential hotline numbers, links to local treatment programs and centers, and physicians authorized to treat addiction. There are also addiction prevention resources and information on how and where to dispose of medication.

Though opioids affect communities of all sizes, resources are often harder to access in rural areas. "Three in four farmers are, or have been directly impacted by opioid abuse, and three in four say it would be easy for someone in their community to access prescription pain killers illegally," Farm Bureau Director of Strategic Communications Ray Atkinson said.

Ban on methadone vans seen as barrier to treatment

A patient talks to a nurse and the driver of a methadone
van parked in Baltimore. (Pew Charitable Trusts photo)

Mobile methadone vans have served people with opioid addiction in rural areas and inner-city neighborhoods for nearly 30 years, but federal reluctance to approve new vans is hampering agencies' ability to fight the current opioid epidemic.

"The U.S. Drug Enforcement Administration, which regulates dispensing of the FDA-approved addiction medicine, has refused to license any new methadone vans since 2007 over concerns about potential diversion of the medication," Christine Vestal reports for Stateline, the news service of the Pew Charitable Trusts.

The federal Substance Abuse and Mental Health Services Administration and some state and local addiction agencies are asking the DEA to lift the moratorium. Mark Parrino, head of the methadone industry's professional organization, the American Association for the Treatment of Opioid Dependence, questioned the ban, saying that no security breach of a methadone van licensed before the moratorium was ever reported. Regulations that would allow methadone vans to be licensed is months away from completion, DEA official James Arnold said at a recent AATOD meeting.

Of the three medications used to treat opioid addiction, methadone is the oldest, most researched, most widely used, and the most tightly regulated. Unlike buprenorphine and naltrexone, which can be prescribed and taken at home, methadone must be taken at one of about 1,500 dispensing locations. Seattle area behavioral health official Brad Finegood told Vestal, "Mobile treatment vans are critical to addressing the opioid epidemic . . . As this epidemic grows and changes, concentrations of people who are affected by it can be found in shifting locations within the city and county. If we’re going to be effective, we need to be nimble and bring the medication to them instead of asking everybody to trudge across town to get their daily dose at a fixed facility." Many opioid addicts seeking treatment say they can't find a treatment program within commuting distance, according to Pew research.

Officials in Connecticut, Maryland, New Jersey, New York and Washington state want new methadone vans but have been blocked by the moratorium. Parrino said Puerto Rico needs vans badly, since Hurricane Maria destroyed most of the island's transportation infrastructure and medical facilities.