Fight­ing fen­tanyl

Trump called the opi­oid epi­demic a pri­or­ity, but deaths soar as re­sources fail to keep pace

The Washington Post Sunday - - FRONT PAGE - BY SARI HOR­WITZ, SCOTT HIGHAM, STEVEN RICH AND SHELBY HANSSEN

wash­ing­ton court house, ohio — In a dun­geon-like jail in the cen­ter of this de­pressed farm­ing town, 18 women in orange-and-white-striped prison uni­forms are crammed into a two-story cell­block. Many of them are with­draw­ing from fen­tanyl.

The jail, built in 1884 to hold 24, now houses 55 men and women, a num­ber that can swell to as many as 90. The inmates are sprawled on metal bunk beds and mat­tresses that line the floors as they wait for court ap­pear­ances or serve time on lowlevel drug of­fenses.

The med­i­cal exam room, used to treat mi­nor ail­ments, is tucked into a broom closet be­neath a con­crete stair­well. With few drug treat­ment op­tions, pris­on­ers strung out on fen­tanyl go through days of with­drawal with lit­tle help, shiv­er­ing and curled up on the beds and floors of the jail.

“It’s def­i­nitely our de­tox cen­ter right now. They just sit there, and they with­draw there,” Fayette County Deputy Health Com­mis­sioner Leigh N. Can­non said. “Treat­ment is where we need help. We keep hear­ing that money is com­ing, but we haven’t re­ally seen it.”

The inmates here are at least alive — un­like so many drug users in this part of cen­tral Ohio, 40 miles south­west of Colum­bus. Fayette County has the sev­enth-high­est num­ber of fen­tanyl over­dose deaths per capita in the na­tion, ac­cord­ing to in­ter­nal data from the Cen­ters for Dis­ease Con­trol and Preven­tion ob­tained and an­a­lyzed by The Wash­ing­ton

Post.

While the Trump ad­min­is­tra­tion has made the opi­oid epi­demic a pri­or­ity, peo­ple in com­mu­ni­ties across the coun­try con­tinue to die in record num­bers from fen­tanyl, and health of­fi­cials are strug­gling to pro­vide treat­ment for tens of thou­sands more, like the men and women ware­housed in­side this jail.

Pres­i­dent Trump has taken a num­ber of steps to con­front the cri­sis, stem the flow of fen­tanyl into the coun­try from China and Mex­ico, and step up pros­e­cu­tions of traf­fick­ers. Congress also has in­creased spend­ing on drug treat­ment.

“Ev­ery­one here to­day is united by the same vi­tal goal — to lib­er­ate our fel­low Amer­i­cans from the grip of drug ad­dic­tion and to end the opi­oid cri­sis once and for all,” Trump said at a drug abuse sum­mit in At­lanta on April 24. “It’s hap­pen­ing. It’s hap­pen­ing.”

But health pol­icy ex­perts say drug treat­ment fund­ing is not nearly enough, and the ad­min­is­tra­tion’s re­sponse was hob­bled by the fail­ure to ap­point a drug czar in its chaotic first year and con­fu­sion over who was in charge of drug pol­icy. The depth of the prob­lem con­tin­ues to over­whelm the gov­ern­ment’s re­sponse, and the ad­min­is­tra­tion has yet to pro­duce a com­pre­hen­sive strat­egy that is legally re­quired by Congress.

John P. Wal­ters, di­rec­tor of the White House Of­fice of Na­tional Drug Con­trol Pol­icy dur­ing the Ge­orge W. Bush ad­min­is­tra­tion, said that af­ter two years and a pres­i­den­tial com­mis­sion to study the prob­lem, the Trump ad­min­is­tra­tion is still strug­gling to con­front the dead­li­est drug cri­sis in U.S. his­tory and is not ded­i­cat­ing nearly enough fed­eral re­sources.

“What other threat that is pre­ventable is go­ing to kill tens of thou­sands of Amer­i­cans?” Wal­ters said. “We’re spend­ing much more money on ter­ror­ism, as we should, but we’re not spend­ing a sim­i­lar amount on the source of death to many more Amer­i­cans right now.”

In 2017, the first year of the Trump pres­i­dency, a record 28,869 peo­ple died from syn­thetic-opi­oid-re­lated over­doses, a 46.4 per­cent in­crease from the year be­fore. Most were from fen­tanyl, which is 50 times more pow­er­ful than heroin. Es­ti­mates for the first eight months of 2018, the most re­cent avail­able, show that an ad­di­tional 20,537 Amer­i­cans died — a toll on pace to ex­ceed the pre­vi­ous year’s.

“The scale of death here is re­ally un­prece­dented, and so you have to judge the re­sponse against the scale of the prob­lem,” said Joshua M. Sharf­stein, vice dean at the Johns Hop­kins Bloomberg School of Pub­lic Health. “You can have some progress, but it’s re­ally in­suf­fi­cient if you are not up to the scale of the prob­lem.”

Sharf­stein and other pub­lic health ex­perts also note that the ad­min­is­tra­tion is seek­ing to re­peal the Af­ford­able Care Act and cut $1.5 tril­lion over 10 years from Med­i­caid. More than 500,000 peo­ple ad­dicted to opi­oids could lose their drug treat­ment cov­er­age if the ACA is re­pealed, ac­cord­ing to the Kaiser Fam­ily Foun­da­tion. The pro­posed Med­i­caid cuts could fur­ther re­duce cov­er­age.

Trump of­fi­cials said they are mak­ing progress against the epi­demic on a range of fronts, in­clud­ing in­ter­dic­tion, pros­e­cu­tion and treat­ment, but they ac­knowl­edge that it re­mains a huge chal­lenge.

“We didn’t get into this cri­sis

Syn­thetic opi­oid over­doses in the U.S. be­tween Jan­uary 2017 and Au­gust 2018

overnight. We’re not go­ing to get out overnight,” Kellyanne Conway, coun­selor to the pres­i­dent and the ad­min­is­tra­tion’s lead­ing voice on the epi­demic, said in an in­ter­view.

Conway said Trump views his han­dling of the cri­sis as a “legacy is­sue” and con­tin­u­ally asks her for up­dates about what is tak­ing place in the states.

“It can’t all be gloom and doom. You can’t just have the neg­a­tive, har­row­ing, so-sad sta­tis­tics of grief and loss and dev­as­ta­tion. We have to start talk­ing about so­lu­tions,” she said. “The bat­tle­ship is start­ing to turn in the other di­rec­tion.”

The CDC data ob­tained by The Post doc­u­ments for the first time the 10 places with the high­est per capita fen­tanyl-re­lated over­dose death rates: five coun­ties in Ohio, two in West Vir­ginia and one in Ken­tucky and the cities of Bal­ti­more and St. Louis. Lo­cal health of­fi­cials told The Post they are still not re­ceiv­ing enough fed­eral money to fund drug treat­ment pro­grams to wean peo­ple off highly addictive opi­oids or launch preven­tion pro­grams to warn peo­ple of the dan­gers of fen­tanyl.

In Ca­bell County, W.Va., the county with the high­est fen­tanyl over­dose death rate in the na­tion, there are long wait­ing lists for treat­ment.

“When some­body is say­ing, ‘I’m ready for treat­ment’ and they want help, they shouldn’t have to wait six months, six weeks or six days,” said Steve Wil­liams, mayor of Hunt­ing­ton, the county seat of Ca­bell. “They should be able to get in a treat­ment pro­gram within six hours.”

In Ohio, deaths from fen­tanyl have rav­aged vast sec­tions of the state. In 2015, there were 1,255 syn­thetic-opi­oid-re­lated deaths, most from fen­tanyl. By the end of 2017, that num­ber had nearly tripled to 3,572.

In ru­ral coun­ties of Ohio, fed­eral money re­cently ap­pro­pri­ated by Congress has started to ar­rive, but health of­fi­cials there say it is not enough.

“The sit­u­a­tion four years ago was look­ing des­per­ate. To­day, it’s look­ing dire,” said Scott Gehring, pres­i­dent of the Com­mu­nity Health Al­liance, a drug treat­ment fa­cil­ity in But­ler County, Ohio, which has the ninth-high­est fen­tanyl over­dose death rate in the na­tion. “Peo­ple are sicker. More peo­ple are dy­ing.”

‘Let’s do it’

Be­tween Jan­uary and April 2017, 9,442 peo­ple died from fen­tanyl and other syn­thetic opi­oids. El­iz­a­beth Lo­ranzo, 25, a mother and beau­ti­cian from Mid­dle­town, Pa., was one of them.

In the run-up to the 2016 pres­i­den­tial elec­tion, Trump promised to halt the flow of heroin into the United States. He men­tioned that drug, not fen­tanyl, at least 57 times dur­ing his speeches and ap­pear­ances, and he tied the cri­sis to the need to build a wall along the bor­der with Mex­ico. On the cam­paign trail, Trump was moved by the peo­ple he met who had lost fam­ily mem­bers to the epi­demic, Conway said. As he left one stop, some­one called out: “Please fol­low through on the drugs and opi­oids. You promised.”

Trump also said ad­dic­tion was a deeply per­sonal is­sue for him. His older brother, Fred Jr., who suf­fered from al­co­holism, died in 1981 at age 43.

On March 29, 2017, two months af­ter his in­au­gu­ra­tion, Trump in­vited then-New Jersey Gov. Chris Christie to the White House.

Christie had told Trump that his ad­min­is­tra­tion was in­her­it­ing an out-of-con­trol opi­oid epi­demic that blew up with the ar­rival of fen­tanyl dur­ing the Obama ad­min­is­tra­tion — be­tween 2013 and 2017, more than 67,000 peo­ple died from the syn­thetic drug.

The opi­oid epi­demic had be­gun in the late 1990s when a gen­er­a­tion of Amer­i­cans be­came ad­dicted to pre­scrip­tion pain pills. Af­ter the gov­ern­ment started to crack down on doc­tors, pain clin­ics, and drug man­u­fac­tur­ers and distrib­u­tors in the mid-2000s, ad­dicts turned to heroin and then fen­tanyl.

In just a few years, the syn­thetic painkiller be­came the dead­li­est drug ever to hit U.S. streets. Man­u­fac­tured in Chi­nese and Mex­i­can labs, il­licit fen­tanyl has played a sig­nif­i­cant role in re­duc­ing the over­all life ex­pectancy of Amer­i­cans. It is so pow­er­ful, just a few flecks the size of grains of salt can cause acute res­pi­ra­tory fail­ure and rapid death.

Obama ad­min­is­tra­tion of­fi­cials were slow to ad­dress the fen­tanyl epi­demic. The ad­min­is­tra­tion saw fen­tanyl as an add-on to the over­all opi­oid cri­sis, rather than a sin­gu­lar dan­ger that re­quired a strat­egy of its own be­cause it was so deadly and was com­ing into the coun­try largely unim­peded through the mail. Se­nior White House and Jus­tice Depart­ment of­fi­cials, mo­ti­vated by a de­sire to rec­tify racial in­equal­ity in sen­tenc­ing, em­pha­sized drug treat­ment over in­car­cer­a­tion, and drug pros­e­cu­tions fell off as fen­tanyl coursed through sec­tions of the coun­try.

By the time Trump came into of­fice, the dan­gers of fen­tanyl were well known. The Drug En­force­ment Ad­min­is­tra­tion and the CDC had is­sued nu­mer­ous warn­ings. The fa­tal over­dose rate was stag­ger­ing.

“I said to [Trump] that I thought there was a lack of ur­gency to the way Pres­i­dent Obama’s ad­min­is­tra­tion had dealt with this is­sue, and that as a re­sult, the prob­lem had got­ten worse,” Christie re­called in an in­ter­view. “We needed to go af­ter this in a re­ally ag­gres­sive way.”

Trump signed an ex­ec­u­tive or­der es­tab­lish­ing the Pres­i­dent’s Com­mis­sion on Com­bat­ing Drug Ad­dic­tion and the Opi­oid Cri­sis.

He put the New Jersey gover­nor in charge.

“Let’s do it,” the pres­i­dent told Christie that day.

A dra­matic mo­ment

Be­tween May and Au­gust 2017, an ad­di­tional 9,487 peo­ple died from fen­tanyl and other syn­thetic opi­oids. Matthew Sut­ton, 39, a bar­ber from Pasadena, Md., was one of them.

At the Jus­tice Depart­ment, Trump’s first at­tor­ney gen­eral, Jeff Ses­sions, launched his own as­sault on fen­tanyl.

For Ses­sions, fen­tanyl could be met only by the kind of tough law-and-or­der tac­tics he de­ployed as a fed­eral prose­cu­tor in Alabama dur­ing the “War on Drugs” of the 1980s and 1990s. While a mem­ber of the U.S. Se­nate for 20 years, Ses­sions was one of the few law­mak­ers to rail against bi­par­ti­san ef­forts to roll back the harsh drug sen­tenc­ing poli­cies of that era.

Ses­sions promised to make fen­tanyl a sig­na­ture is­sue af­ter his first trip to New Hamp­shire, a state that had ex­pe­ri­enced one of the high­est fen­tanyl-re­lated death rates in the coun­try. He at­tended a “youth sum­mit” on

opi­oids at Manch­ester’s down­town arena with Gov. Chris Su­nunu (R) on March 7, 2017.

“One of the most dra­matic mo­ments for me was the first trip to New Hamp­shire where Gover­nor Su­nunu had 8,000 high school stu­dents gath­ered and 50 moth­ers stood be­fore them hold­ing large pic­tures of their chil­dren who died from drug over­doses,” Ses­sions said in an in­ter­view.

On May 12 that year, in one of his first ac­tions, Ses­sions re­versed what had be­come known as the “Holder Memo.” The 2013 doc­u­ment writ­ten by then-At­tor­ney Gen­eral Eric H. Holder Jr. di­rected fed­eral pros­e­cu­tors to stop pur­su­ing low-level, non­vi­o­lent drug charges that would trig­ger manda­tory min­i­mum prison sen­tences. Over decades, U.S. drug pol­icy had re­sulted in long prison terms and in­creased in­car­cer­a­tion for first-time of­fend­ers, most of them young black men, and Holder wanted to re­verse what he saw as a his­toric in­jus­tice.

Ses­sions di­rected his pros­e­cu­tors to give high pri­or­ity to drug cases, par­tic­u­larly aim­ing at fen­tanyl. Those found guilty would face the most se­vere penal­ties pos­si­ble, ac­cord­ing to a memo he sent to each U.S. at­tor­ney.

In July 2017, the Jus­tice Depart­ment shut down the largest dark-web dis­trib­u­tor of il­licit drugs. Called Al­phaBay, the site al­lowed users to sell and buy drugs, in­clud­ing fen­tanyl. At the time of the take­down, there were 250,000 list­ings for il­le­gal drugs and toxic chem­i­cals on the site, ac­cord­ing to the Jus­tice Depart­ment.

That fall, the depart­ment brought its first crim­i­nal charges against Chi­nese na­tion­als ac­cused of sell­ing fen­tanyl to Amer­i­cans over the In­ter­net in cases that were filed in fed­eral courts in North Dakota and Mis­sis­sippi.

Ses­sions used an emer­gency dec­la­ra­tion to make all chem­i­cal vari­ants of fen­tanyl, known as ana­logues, il­le­gal on a tem­po­rary ba­sis; Congress must pass leg­is­la­tion to make the ban per­ma­nent. Chi­nese and Mex­i­can chemists and drug traf­fick­ers in the United States had been evad­ing the law by tweak­ing the chem­i­cal com­pounds that make up fen­tanyl and pro­duc­ing prod­ucts that don’t fit the pre­cise chem­i­cal for­mula for a banned sub­stance.

Ses­sions also ramped up fed­eral pros­e­cu­tions of all fen­tanyl of­fenses and sent ad­di­tional pros­e­cu­tors to 10 ar­eas in the coun­try with the high­est num­ber of over­doses.

Christie, how­ever, was grow­ing frus­trated with Ses­sions’s ex­clu­sive fo­cus on law en­force­ment ac­tions. He said he called the at­tor­ney gen­eral sev­eral times, invit­ing him to speak at the com­mis­sion’s pub­lic hear­ings. In­stead, Ses­sions sent his deputy at­tor­ney gen­eral.

Ses­sions said he has long be­lieved in preven­tion and treat­ment pro­grams, but as the at­tor­ney gen­eral, he was re­spon­si­ble for fo­cus­ing on drug traf­fick­ing cases.

“I didn’t find him help­ful at all on the is­sue,” Christie said. “He only had one tune, which was en­force­ment. He didn’t want to talk about the other parts of the is­sue. I wanted him to en­gage on treat­ment, on drug courts, and he had no in­ter­est in en­gag­ing in that. So, af­ter a while, I just stopped call­ing be­cause, what was the use?

“He was a one-trick pony.”

‘Rein­vent­ing the wheel’

Be­tween Septem­ber and De­cem­ber 2017, an ad­di­tional 9,940 peo­ple died from fen­tanyl and other syn­thetic opi­oids. Sa­man­tha Hunt­ley, 20, a tan­ning salon em­ployee from Spring­field, Mo., was one of them.

Dur­ing Trump’s first months in of­fice, the ad­min­is­tra­tion shunted aside its White House Of­fice of Na­tional Drug Con­trol Pol­icy. The of­fice, whose di­rec­tor is known as the “drug czar,” is re­spon­si­ble for co­or­di­nat­ing anti-drug ef­forts across 16 fed­eral agen­cies and pro­duc­ing the Na­tional Drug Con­trol Strat­egy, an an­nual drug pol­icy plan man­dated by Congress.

For­mer Trump ad­min­is­tra­tion of­fi­cials said the White House did not trust the ca­reer staffers at the of­fice. One for­mer of­fi­cial, who spoke on the con­di­tion of anonymity to dis­cuss in­ter­nal de­lib­er­a­tions, said the pres­i­dent and his aides wanted to “tran­scend the drug czar” and “raise the is­sue to a higher level.”

White House of­fi­cials treated the drug czar’s of­fice as a back­wa­ter. They staffed it with po­lit­i­cal op­er­a­tives who had lit­tle or no drug pol­icy ex­pe­ri­ence and in­stalled a 24-year-old cam­paign worker as the deputy chief of staff. Se­nior staffers with years of ex­pe­ri­ence were side­lined. In May 2017, the ad­min­is­tra­tion pro­posed cut­ting the of­fice’s bud­get by 95 per­cent.

No one was im­me­di­ately nom­i­nated to be­come the drug czar. As the Trump pres­i­dency en­tered its sev­enth month, there was no per­ma­nent of­fi­cial in charge of co­or­di­nat­ing drug pol­icy across myr­iad fed­eral agen­cies — the CDC, the Na­tional In­sti­tute on Drug Abuse, the Jus­tice Depart­ment and the Depart­ment of Home­land Se­cu­rity.

Law­mak­ers on Capi­tol Hill were grow­ing im­pa­tient with the ad­min­is­tra­tion’s lack of plans to con­front the opi­oid epi­demic. On July 26, the House Over­sight and Re­form Com­mit­tee sum­moned then-act­ing drug czar Richard Baum, who had been in his job for four months, to ex­plain why he had not sub­mit­ted a com­pre­hen­sive plan to op­er­ate and fund the of­fice.

“Any idea when it might be sub­mit­ted?” Rep. Ger­ald E. Con­nolly (D-Va.) asked Baum.

“I don’t want to give you a time­line,” Baum replied. “But I can tell you this. I’ve stud­ied the is­sue very closely.”

“Like­wise, we need a strat­egy,” Con­nolly said. “Any idea when a strat­egy will be sub­mit­ted to the Congress?”

“We’re de­vel­op­ing a strat­egy now,” Baum said.

The opi­oid over­dose death rate, by then al­most en­tirely fueled by il­licit fen­tanyl, con­tin­ued to climb. In 2017, fen­tanyl for the first time be­came the lead­ing cause of over­dose deaths in Amer­ica.

On Sept. 1, Trump nom­i­nated Rep. Tom Marino (R-Pa.) to be his first per­ma­nent White House drug czar. Marino, a for­mer prose­cu­tor, had been one of Trump’s ear­li­est and most ar­dent sup­port­ers in Congress.

But Marino’s nom­i­na­tion quickly fell apart. A joint in­ves­ti­ga­tion by The Post and “60 Min­utes” dis­closed that Marino had close ties to the opi­oid in­dus­try. The in­ves­ti­ga­tion found that the con­gress­man had spon­sored leg­is­la­tion that made it harder for the DEA to pe­nal­ize drug distrib­u­tors and man­u­fac­tur­ers when they failed to re­port sus­pi­cious or­ders and ship­ments of nar­cotics.

On Oct. 17, a lit­tle more than a month af­ter his nom­i­na­tion, Marino with­drew, cre­at­ing even more un­cer­tainty within the drug czar’s of­fice.

A week later, Trump men­tioned fen­tanyl pub­licly for the first time as pres­i­dent; he had been in of­fice for nine months Trump also took Christie’s ad­vice by declar­ing the opi­oid cri­sis to be a pub­lic health emer­gency — a step Obama of­fi­cials had de­cided not to take in May 2016, when health pol­icy ex­perts asked for the dec­la­ra­tion for fen­tanyl.

“As Amer­i­cans, we can­not al­low this to con­tinue,” Trump said in an Oct. 26, 2017, White House speech. “It is time to lib­er­ate our com­mu­ni­ties from this scourge of drug ad­dic­tion. Never been this way. We can be the gen­er­a­tion that ends the opi­oid epi­demic.”

But two things were miss­ing: money and a de­tailed plan.

“When you say this is an emer­gency, you would ex­pect to hear what they plan

to do about the emer­gency,” said An­drew Kolodny, co-di­rec­tor of opi­oid pol­icy re­search at Bran­deis Uni­ver­sity. “When Pres­i­dent Trump des­ig­nated the opi­oid cri­sis a pub­lic health emer­gency, at the very same time, he should have said, ‘Here’s what we’re go­ing to do about it,’ and put out a de­tailed plan out­lin­ing what ev­ery fed­eral agency was go­ing to do.”

A top Trump of­fi­cial would later tes­tify be­fore Congress that the pub­lic health dec­la­ra­tion was in­tended “to bring aware­ness.”

On Nov. 1, Christie’s com­mis­sion re­leased its fi­nal re­port, with 56 rec­om­men­da­tions on the opi­oid cri­sis. Some drug pol­icy ex­perts crit­i­cized the com­mis­sion for tak­ing too long and repack­ag­ing old ideas in­stead of craft­ing a new strat­egy.

“They spent a year rein­vent­ing the wheel on opi­oid pol­icy with things we al­ready knew,” said An­drew Kessler, a pol­icy con­sul­tant who spe­cial­izes in be­hav­ioral health. “It’s all been rec­om­mended be­fore.”

Some health pol­icy ex­perts said the re­port, while not ground­break­ing, did pro­vide a blue­print for the Trump ad­min­is­tra­tion to fol­low.

It called for launch­ing an anti-opi­oid pub­lic re­la­tions cam­paign, pro­vid­ing more fund­ing for drug treat­ment and con­tin­u­ing to tar­get traf­fick­ers. The re­port also called for ac­cess to medicine de­signed to wean peo­ple off opi­oids and to nalox­one, an ex­pen­sive med­i­ca­tion that re­verses over­doses.

Christie said the com­mis­sion’s work was an im­por­tant start.

“I think we have to un­der­stand the fact that even the steps that we take to­day, as ag­gres­sive as they are com­pared to where we were, it’s still go­ing to take time to catch up with the prob­lem,” Christie said. “Fen­tanyl deaths go­ing higher are com­pletely pre­dictable be­cause fen­tanyl is so much stronger and more lethal than street heroin.”

One of the six mem­bers of the com­mis­sion, for­mer con­gress­man Pa­trick J. Kennedy (D-R.I.), a re­cov­er­ing ad­dict, said he was disappoint­ed that Trump did not do more to pro­mote the re­port.

“We just never got the pres­i­dent to re­ally give it the fire­power and to el­e­vate it,” Kennedy said in an in­ter­view.

He also hoped that Trump would use the re­port to press Congress for sig­nif­i­cant fund­ing to fight the opi­oid epi­demic, com­pa­ra­ble to the $28 bil­lion the fed­eral gov­ern­ment spends each year to fight the HIV/AIDS epi­demic in the United States.

An­other mem­ber, Bertha Madras, said she was proud of the work. While she un­der­stood the im­por­tance of get­ting buy-in from the fed­eral agen­cies, she was frus­trated by the amount of time it took. The com­mis­sion had to wait sev­eral months for of­fi­cials to re­spond to the rec­om­men­da­tions be­fore the re­port could be is­sued, she said.

“In the mean­while, peo­ple are dy­ing, and that’s haunted me,” said Madras, a Har­vard Med­i­cal School pro­fes­sor who served in the drug czar’s of­fice dur­ing the Ge­orge W. Bush ad­min­is­tra­tion.

‘Keep the damn drugs out’

Be­tween Jan­uary and April 2018, an ad­di­tional 10,017 peo­ple died from fen­tanyl and other syn­thetic opi­oids. Amanda Gray, 24, a psy­chol­ogy stu­dent from Man­has­set, N.Y., was one of them.

The White House drug czar’s of­fice was still lead­er­less when Christie’s com­mis­sion is­sued its re­port in Novem­ber 2017. A few weeks later, Trump named Conway, a for­mer Repub­li­can Party poll­ster, to be his point per­son on the opi­oid epi­demic. A highly skilled po­lit­i­cal op­er­a­tive with no drug pol­icy ex­pe­ri­ence, Conway was now in charge of co­or­di­nat­ing the gov­ern­ment’s re­sponse to the epi­demic.

She was par­tic­u­larly drawn to the is­sue af­ter see­ing dev­as­tated fam­i­lies on the 2016 pres­i­den­tial cam­paign trail and the toll the epi­demic had taken in places like Ohio, Penn­syl­va­nia and New Hamp­shire. She also had at­tended the pub­lic hear­ings held by Christie’s com­mis­sion.

“There was such a sense of ur­gency to lit­er­ally stop the bleed­ing and try to stem the losses that peo­ple were feel­ing, that we worked as hard as we could work, as as­sid­u­ously and as quickly as we could to get our arms around, ‘Why now, why this?’ ” Conway said.

The epi­demic was a key is­sue in im­por­tant swing states. The Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion found a cor­re­la­tion be­tween chronic use of pre­scrip­tion painkiller­s and re­gions that sup­ported Trump. Medi­care re­im­burse­ments for opi­oid pre­scrip­tions also doc­u­mented the epi­demic’s dis­pro­por­tion­ate im­pact on ar­eas where Trump polled well.

“Coun­ties and states with the high­est opi­oid use were of­ten ar­eas car­ried by the Repub­li­can can­di­date,” the re­searchers found. “In many ar­eas with high rates of drug over­dose, voter turnout in 2016 ex­ceeded that in 2012, with Don­ald Trump over­whelm­ingly fa­vored.”

As Conway took con­trol of the opi­oid is­sue, con­fu­sion spread within the drug czar’s of­fice and across the gov­ern­ment, ac­cord­ing to for­mer staffers who spoke on the con­di­tion of anonymity be­cause they feared reprisals from the ad­min­is­tra­tion. Staffers in the of­fice said they would fre­quently field calls from other agen­cies and con­gres­sional of­fices, re­quest­ing di­rec­tion on how to in­crease fund­ing for treat­ment or how to launch anti-opi­oid pub­lic ed­u­ca­tion cam­paigns. They said they had no au­thor­ity to make de­ci­sions on their own, and the queries lan­guished.

Conway said their crit­i­cism was un­founded.

“Some of the ca­reer peo­ple there, re­spect­fully, should be re­ally ex­cited to fi­nally have an ad­min­is­tra­tion who cares enough to try to break the back of the worst drug cri­sis in our na­tion’s his­tory,” Conway said.

On March 19, 2018, Trump and Ses­sions trav­eled to Manch­ester, N.H., to high­light the fight against opi­oids. The pres­i­dent told the crowd gath­ered at Manch­ester Com­mu­nity Col­lege that Congress was work­ing on leg­is­la­tion that would set aside bil­lions to fight the epi­demic. He said he planned to in­crease fund­ing to de­velop non­ad­dic­tive painkiller­s. He also said he was work­ing to shut down il­le­gal on­line mar­ket­places to block fen­tanyl com­ing in from China.

What he said next over­shad­owed his other re­marks.

“Drug traf­fick­ers kill so many thou­sands of our ci­ti­zens ev­ery year,” Trump said. “And that’s why my Depart­ment of Jus­tice will be seek­ing so many much tougher penal­ties than we’ve ever had, and we will be fo­cus­ing on the penalty that I talked about pre­vi­ously for the big push­ers, the ones that are re­ally killing so many peo­ple. And that penalty is go­ing to be the death penalty.”

As he did on the cam­paign trail, Trump then tied the epi­demic — and his drug strat­egy — to im­mi­gra­tion at the south­ern bor­der.

“Ninety per­cent of the heroin in Amer­ica comes from our south­ern bor­der, where, even­tu­ally, the Democrats will agree with us, and we’ll build the wall to keep the damn drugs out,” he said.

“Build that wall! Build that wall! Build that wall!” the au­di­ence chanted.

DEA of­fi­cials have said that most of the fen­tanyl pour­ing into the United States is com­ing from China through the U.S. Postal Ser­vice and overnight ex­press ser­vices. The ma­jor­ity of Mex­i­can heroin and fen­tanyl is con­cealed in cars and trac­tor-trail­ers that come into the United States through le­gal ports of en­try along the south­ern bor­der, ac­cord­ing to a 2018 DEA Na­tional Drug Threat As­sess­ment. Fed­eral agents say they are also seiz­ing in­creas­ing amounts of fen­tanyl that is com­ing across the bor­der be­tween the le­gal ports of en­try.

The day af­ter the Manch­ester speech, Ses­sions di­rected his pros­e­cu­tors to pur­sue the death penalty against ma­jor drug traf­fick­ers.

As Trump was call­ing for the death penalty, one of the cities that had a high fen­tanyl over­dose death rate was run­ning out of money to pur­chase nalox­one, an over­dose re­ver­sal drug. In Bal­ti­more, fen­tanyl deaths had risen by nearly 5,000 per­cent be­tween 2013 and 2017, and the death toll was con­tin­u­ing to climb.

Leana Wen, the health com­mis­sioner in Bal­ti­more at the time, had to choose who could re­ceive the life­sav­ing medicine.

“We are ra­tioning the med­i­ca­tion that would save peo­ple’s lives at the mo­ment that they’re over­dos­ing,” Wen re­called in a re­cent in­ter­view. “How is that pos­si­ble?”

In a May 3, 2018, let­ter to Conway, Wen pleaded with the Trump ad­min­is­tra­tion to use its in­flu­ence to lower the price of nalox­one. The brand name of the drug, Nar­can, cost $75 for two doses. In the pre­vi­ous three years, nalox­one had re­versed more than 10,000 over­doses in Bal­ti­more, Wen said.

“We re­quest that the Trump Ad­min­is­tra­tion es­tab­lish a na­tional pro­gram to pro­cure nalox­one treat­ments and sup­ply them to state and lo­cal health and law en­force­ment pro­grams,” the let­ter said.

“Noth­ing hap­pened,” Wen said. “We never heard back.”

Conway said she never saw the let­ter.

‘It’s all fen­tanyl now’

Be­tween May and Au­gust 2018, an ad­di­tional 10,520 peo­ple died from fen­tanyl and other syn­thetic opi­oids, the most re­cent time pe­riod for which CDC data is avail­able. Colton Gutknecht, 20, a fash­ion de­sign stu­dent from Peo­ria, Ariz., was one of them.

Sev­eral nights a week, Chris­tine Birhanzl drives the streets of Hamil­ton, a for­mer pa­per and steel mill town in south­west­ern Ohio, hand­ing out blan­kets, food and clothes to ad­dicts.

Birhanzl is a re­cov­er­ing ad­dict her­self. She is now a di­rec­tor at Sojourner Re­cov­ery Ser­vices, a treat­ment fa­cil­ity in But­ler County. One man she tried to help was James Prof­fit, 40, who had lived on the streets for years. His path to fen­tanyl was typ­i­cal. He started by tak­ing large doses of OxyCon­tin and then turned to heroin, not know­ing it had been laced with fen­tanyl.

“It’s all fen­tanyl now,” Prof­fit said in an in­ter­view. “The county is flooded with fen­tanyl.”

He over­dosed four times but kept us­ing.

“It takes all the pain away,” Prof­fit said. “You get numb, and you don’t feel noth­ing. That lasts about five hours, and then it starts to wear down, you get cold chills, start cramp­ing up and get sore. And then you have to do it again.”

Birhanzl fi­nally suc­ceeded in get­ting Prof­fit help, but only be­cause he was ar­rested and faced the prospect of six months in jail. He re­mem­bered meet­ing Birhanzl on the street and how she tried to con­vince him to seek treat­ment. He asked the judge whether he could get into her pro­gram.

“Chris­tine was my guardian an­gel,” said Prof­fit, who has been clean since Fe­bru­ary. “She never gave up on me. They turned me around 180 de­grees.”

Med­i­caid paid for his stay at Sojourner Re­cov­ery Ser­vices. Ohio was one of the states that ex­panded Med­i­caid un­der the ACA — also known as Oba­macare — which cov­ers drug treat­ment for thou­sands like Prof­fit.

Last Au­gust, four cities sued the ad­min­is­tra­tion for un­der­min­ing the act. The cities — Bal­ti­more, Chicago, Cincin­nati and Colum­bus, Ohio — ac­cused the ad­min­is­tra­tion of ac­tively dis­cour­ag­ing en­roll­ment, rais­ing rates and lim­it­ing health-care ser­vices.

In March, the Jus­tice Depart­ment sided with 20 Repub­li­can-led states seek­ing to in­val­i­date the en­tire act as un­con­sti­tu­tional. Trump then said Se­nate GOP lead­ers were writ­ing leg­is­la­tion to re­peal and re­place the ACA. But Repub­li­cans quickly sig­naled that they had lit­tle ap­petite for rais­ing an ex­plo­sive is­sue just as the 2020 po­lit­i­cal sea­son was get­ting un­der­way.

That same month, the White House pro­posed slash­ing Med­i­caid by $1.5 tril­lion over 10 years, which could fur­ther un­der­cut drug treat­ment cov­er­age na­tion­wide.

Trump’s as­sis­tant sec­re­tary for health, Adm. Brett P. Giroir, said if Med­i­caid is cut and the ACA is de­clared un­con­sti­tu­tional, those pro­grams would have to be re­placed so tens of thou­sands would not be left with­out cov­er­age.

“If you did some­thing like elim­i­nated cov­er­age for ev­ery­one, that would not cer­tainly be pos­i­tive, un­less it’s re­placed with some­thing that pro­vided equal or more cov­er­age,” said Giroir, se­nior opi­oid ad­viser to the sec­re­tary of the Depart­ment of Health and Hu­man Ser­vices.

In Ohio, fen­tanyl is rav­aging parts of

the state and “over­whelm­ing the sys­tem,” Sen. Rob Portman (ROhio) said in an in­ter­view.

While the over­all drug over­dose death toll de­clined by 21 per­cent in the state be­tween 2017 and 2018, deaths from fen­tanyl con­tinue to rise. The se­na­tor has spon­sored leg­is­la­tion to in­crease fed­eral fund­ing to help the hard­est-hit ar­eas of the coun­try. Since 2017, Ohio has re­ceived $140 mil­lion from the fed­eral gov­ern­ment, but he said he knows it’s not enough.

“I’m just try­ing to fight to keep the fund­ing in­creas­ing ev­ery year,” Portman said. “I got some push­back from some of my col­leagues on the Repub­li­can side of the is­sue, say­ing, ‘Where’s the money com­ing from?’ I said, ‘This is a cri­sis. This is a na­tional emer­gency.’ ”

In Clark County, out­side Day­ton, fen­tanyl over­doses are fu­el­ing large cost over­runs for gov­ern­ment ser­vices — fos­ter care, paramedics and po­lice.

“It’s very stress­ful for my deputies. They’re see­ing more death than they’ve ever seen,” said Deb­o­rah K. Burchett, the sher­iff of Clark County, which had the sixth-high­est fen­tanyl over­dose death rate in the na­tion. “Our big­gest prob­lem is, our drug ad­dicts also have men­tal health prob­lems, and all the hos­pi­tals have been closed. They all wind up in the jail.”

Health-care of­fi­cials and drug treat­ment ex­perts in Clark County say they are start­ing to see drug treat­ment money from Wash­ing­ton, but more is needed. End­ing the ACA or cut­ting Med­i­caid, they said, would be dis­as­trous.

“I can’t even imag­ine a world like that,” said Greta Mayer, who runs the Men­tal Health & Re­cov­ery Board of Clark, Greene and Madi­son Coun­ties in Ohio. “All of what we’ve gained would be lost.”

‘We’ve got to move quickly’

On Jan. 2, 2019, the Se­nate con­firmed James W. Car­roll Jr. to be Trump’s first per­ma­nent drug czar. A for­mer Wash­ing­ton­based coun­sel to the Ford Mo­tor Co., Car­roll had served as Trump’s deputy chief of staff. It had been two years since Trump took of­fice.

“You’ve got the worst drug cri­sis we’ve had ever, and it takes you two years to get some­body in the White House who wakes up ev­ery day think­ing about the prob­lems?” said Keith Humphreys, who served as a drug pol­icy ad­viser to the Ge­orge W. Bush and Obama ad­min­is­tra­tions. “That to me is just an as­tound­ing dere­lic­tion of duty.”

Car­roll, who had been ap­pointed act­ing drug czar in Fe­bru­ary 2018, dis­puted that char­ac­ter­i­za­tion and said the ad­min­is­tra­tion has taken nu­mer­ous steps to com­bat the opi­oid cri­sis. He noted that the drug czar’s of­fice is only one of sev­eral agen­cies that are try­ing to bat­tle the epi­demic and that he is in close con­tact with them. De­spite the re­peated at­tempts by the Of­fice of Man­age­ment and Bud­get to slash his bud­get, Car­roll said he has the full sup­port of the White House. He also said he has pro­posed spend­ing an ad­di­tional $1.3 bil­lion on an­tidrug ef­forts.

“This is a pri­or­ity for the pres­i­dent,” Car­roll said in an in­ter­view.

He ac­knowl­edged that the gov­ern­ment needs to spend more money and move faster.

“I am fis­cally con­ser­va­tive, but I also be­lieve that it’s go­ing to re­quire more of a fi­nan­cial in­vest­ment, spent wisely, to get our arms around this,” he said. “We’ve got to move quickly.”

Conway agreed and said the ad­min­is­tra­tion is mak­ing im­por­tant strides.

She pointed out that the ad­min­is­tra­tion had launched an opi­oid preven­tion ad cam­paign. Dogs are be­ing trained to de­tect fen­tanyl at ports of en­try. Congress di­rected the U.S. Postal Ser­vice to start elec­tron­i­cally track­ing pack­ages from for­eign coun­tries. The CDC has be­gun im­prov­ing over­dose col­lec­tion data to pro­vide a clearer pic­ture of what is hap­pen­ing on the ground. The ad­min­is­tra­tion has formed an “opi­oid cabi­net” with rep­re­sen­ta­tives from key gov­ern­ment agen­cies, and Conway said they se­cured an ad­di­tional $6 bil­lion from Congress to com­bat the cri­sis.

Trump also signed a bi­par­ti­san leg­isla­tive pack­age weeks be­fore the 2018 midterm elec­tion that cre­ates, ex­pands and re­news pro­grams de­signed to fight the epi­demic.

Last month, the pres­i­dent se­cured a prom­ise from Chi­nese Pres­i­dent Xi Jin­ping to ban all vari­ants of fen­tanyl, al­though gov­ern­ment of­fi­cials said it is too early to tell whether the Chi­nese gov­ern­ment will fol­low through amid the es­ca­lat­ing trade war.

For Rep. Eli­jah E. Cum­mings (D-Md.), the fen­tanyl epi­demic has hit home; he has rep­re­sented Bal­ti­more both in the state cap­i­tal and in Wash­ing­ton for the past 36 years. He has in­tro­duced leg­is­la­tion that calls for spend­ing $100 bil­lion to com­bat the opi­oid epi­demic.

While the fen­tanyl epi­demic has mostly af­fected white Amer­i­cans, the drug is in­creas­ingly claim­ing more African Amer­i­can lives in cities like Wash­ing­ton, Philadel­phia, St. Louis and Bal­ti­more. Be­tween 2013 and 2017, 1,261 peo­ple died from fen­tanyl over­doses in Bal­ti­more, which has the sec­ond-high­est num­ber of fen­tanyl-re­lated over­dose deaths per capita in the coun­try. The Mary­land Depart­ment of Health found that an ad­di­tional 566 peo­ple died in the first nine months of 2018, the most re­cently avail­able data for the city. That far ex­ceeds the num­ber of homi­cides com­mit­ted dur­ing the en­tire year, when 309 peo­ple were mur­dered in Bal­ti­more.

At a Metro stop in West Bal­ti­more re­cently, down the block from an open-air drug mar­ket, mem­bers of the non­profit Bmore Power handed out free doses of Nar­can. Steve Diggs, 47, said he had ped­dled drugs on the streets of the city for nearly 30 years. Now in re­cov­ery and work­ing for the group, he and other for­mer drug deal­ers and users are try­ing to pre­vent more deaths, which he said started to soar with the ar­rival of fen­tanyl in 2015.

“I’m just try­ing to help peo­ple on the streets,” Diggs said. “They trust me be­cause I lived the life. I know what they’re go­ing through.”

On March 7, Cum­mings, as the new chair­man of the House Over­sight and Re­form Com­mit­tee, sum­moned the White House’s newly con­firmed drug czar to tes­tify be­fore his panel. He said he was an­gry it had taken Car­roll so long to ap­pear.

“Last year, I re­peat­edly asked for Mr. Car­roll to tes­tify be­fore us as the act­ing di­rec­tor of [the drug czar’s of­fice], but he re­fused,” Cum­mings said, list­ing the times Car­roll had de­layed ap­pear­ing.

Cum­mings also was fu­ri­ous that the White House had not pro­duced its Na­tional Drug Con­trol Strat­egy to Congress. It was two years past the con­gres­sion­ally re­quired dead­line. In­stead of sub­mit­ting a strat­egy that nor­mally con­sisted of more than 100 pages of de­tailed plans, Car­roll had given the com­mit­tee what Cum­mings called a 23page “pam­phlet” that did not out­line spe­cific goals or mea­sur­able ob­jec­tives. At the hear­ing, Tri­ana McNeil, a di­rec­tor of the Gov­ern­ment Ac­count­abil­ity Of­fice, said the doc­u­ment failed to meet con­gres­sional re­quire­ments.

“The White House of­fice charged with lead­ing our na­tion’s ef­forts to com­bat the drug cri­sis has been miss­ing in ac­tion as deaths con­tinue to mount,” Cum­mings said. “The White House had no Na­tional Drug Con­trol Strat­egy. None. None. All while tens of thou­sands of peo­ple were dy­ing and the cri­sis was es­ca­lat­ing ev­ery day.”

Car­roll said he was per­son­ally com­mit­ted to fight­ing the drug cri­sis, not­ing that a mem­ber of his own fam­ily was strug­gling with ad­dic­tion.

“I want ev­ery fam­ily to have a suc­cess story that I re­ally hope and pray that my fam­ily is hav­ing,” Car­roll said.

Car­roll also promised to pro­vide the panel with a more com­plete drug strat­egy with “quan­tifi­able met­rics.” Two months later, on May 9, Car­roll and McNeil re­turned to the com­mit­tee. Car­roll sub­mit­ted sev­eral new doc­u­ments, which he said met con­gres­sional re­quire­ments.

McNeil told the panel she had re­viewed the doc­u­ments and asked rhetor­i­cally whether the GAO could say that the drug czar’s of­fice has fi­nally pro­duced the con­gres­sion­ally man­dated drug strat­egy.

“Not at this time,” she tes­ti­fied.

SAL­WAN GE­ORGES/THE WASH­ING­TON POST

Inmates sit in the women’s cell­block at the Fayette County Jail in Wash­ing­ton Court House, Ohio, where fen­tanyl has hit hard. The county has the sev­enth-high­est num­ber of fen­tanyl-re­lated over­dose deaths per capita in the na­tion, ac­cord­ing to CDC data.

PHO­TOS BY SAL­WAN GE­ORGES/THE WASH­ING­TON POST

ABOVE: A deputy sher­iff re­moves an in­mate’s belt at the Fayette County Jail in Wash­ing­ton Court House, Ohio, in April. TOP LEFT: The jail, built in 1884 to hold 24 peo­ple, now houses 55 and some­times up to 90, many of whom are with­draw­ing from drugs such as fen­tanyl. TOP RIGHT: Fayette County Sher­iff Ver­non P. Stan­forth opens the door to the women’s fa­cil­ity.

AARON WIL­LIAMS/THE WASH­ING­TON POST

CLOCK­WISE FROM ABOVE: A man at the en­trance of Bal­ti­more’s Penn-North Metro sta­tion in April snorts fen­tanyl, ac­cord­ing to the man who gave it to him, from a credit card. He was stand­ing a few feet from where the non­profit Bmore Power was hand­ing out free doses of Nar­can, an opi­oidre­ver­sal med­i­ca­tion. The man was asked for his name but did not pro­vide it. Ohio’s But­ler County has the ninth-high­est num­ber of fen­tanyl-re­lated over­dose deaths per capita in the United States, ac­cord­ing to CDC data. Whit­ney Mil­lay, sec­ond from right, heads into a res­i­den­tial re­cov­ery fa­cil­ity in Wash­ing­ton Court House, Ohio, the only one for women in Fayette County. She said she over­dosed 10 times on fen­tanyl: “It was a fine line be­tween obliv­ion and death.” James Prof­fit, 40, hugs a friend af­ter help­ing him get a spon­sor at a Sojourner Re­cov­ery Ser­vices treat­ment fa­cil­ity in Hamil­ton, Ohio. Amanda Busa, 27, at a res­i­den­tial re­cov­ery fa­cil­ity in Wash­ing­ton Court House, where she had been in the treat­ment pro­gram when she was us­ing fen­tanyl.

PHO­TOS BY SAL­WAN GE­ORGES/THE WASH­ING­TON POST

SAL­WAN GE­ORGES/THE WASH­ING­TON POST

Sher­iff Richard K. Jones of But­ler County, Ohio — with the coun­try’s ninth-high­est fen­tanyl over­dose death rate — says too much is be­ing spent on drug treat­ment pro­grams and not enough on preven­tion and ed­u­ca­tion: “Any politi­cian who says we’re win­ning this bat­tle with drugs is telling you a lie.”

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