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Men are dying after opioid overdoses at almost three times the rate of women in the United States. Overdose deaths are increasing faster among blacks and Latino Americans than among whites. And there's a particularly steep rise in the number of young adults aged 25 to 34 whose death certificates include some versions of fentanyl.
These findings, published Thursday in a report by the Centers for Disease Control and Prevention, highlight the start of the third wave of the nation's opioid epidemic. The first was prescription pain medications, such as OxyContin; then heroin, which replaced the pills when they became too expensive; and now fentanyl
Fentanyl is a powerful synthetic opioid that can shut down breathing in less than a minute, and its popularity in the U.S. "It has been reported to be a surgeon at the end of 2013. For each of the next three years, fatal overdoses involving fentanyl doubled," rising at an exponential rate, "says Merianne Rose Spencer, and a statistician at CDC and one of the study's authors  Spencer's research shows a 113 percent average annual increase from 2013 to 2016 (when adjusted for age). That total was first reported late in 2018, but Spencer looked deeper with this report into the demographic characteristics of those people dying from overdoses of fentanyl
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Increased trafficking in drug and increased use are both fueling the spike in fentanyl deaths. For drug dealers, fentanyl is easier to produce than some other opioids. Unlike the poppies needed for heroin, which can be spoiled by weather or a bad harvest, fentanyl's ingredients are easily supplied; it's a synthetic combination of chemicals, often produced in China and packed in Mexico, according to the U.S. Drug Enforcement Administration. And because fentanyl can be 50 times more powerful than heroin, the smaller amounts translate to bigger profits
Jon DeLena, Assistant Special Agent in charge of DEA's New England Field Division, says one kilogram of fentanyl, driven across the southern US
"I mean, imagine that business model," DeLena says. "If you went to any small-business owner and said, 'Hey, I have a way to make your product eight times the product that you have now,' there is a tremendous windfall there."
For drug users, fentanyl is more likely to cause overdose than heroin because it is so potent and because the high fades more quickly than with heroin. Drug users say they inject more frequently with fentanyl because the high does not last as long – and more frequent injecting adds to their risk of overdose
Fentanyl is also showing up in some supplies of cocaine and methamphetamines, which means that some people who do not even know they need to worry about a fentanyl overdose are dying
There are several ways fentanyl can wind up in a dose of some other drug . The mixing may be intentional, as a person seeks a more intense or different kind of high.
Or dealers may be adding fentanyl to cocaine and meth on purpose, in an effort to expand their clientele of users hooked on fentanyl.
"That's something we have to consider," says David Kelley, referring to the intentional addition of fentanyl to cocaine, heroin or other drugs by dealers. Kelley is a deputy director of the New England High Intensity Drug Trafficking Area. "The fact gets more complicated," says Kelley, as dealers develop new forms of fentanyl that are even more deadly. The new CDC report shows dozens of varieties of drug now on the streets
The highest rates of fentanyl-involved overdose deaths were found in New England, according to the study, followed by states in the Mid-Atlantic and Upper Midwest . But fentanyl deaths had barely increased in the West – including in Hawaii and Alaska – as of the end of 2016.
Researchers have no firm explanations for these geographic differences, but some people watching the trends have theories. One is that it is easier to mix a few white fentanyl crystals into the powdered form of heroin that is more common in the eastern states than in the black tar heroin that is more routinely sold in the West. Another hypothesis holds that drug cartels have used New England as a test market for fentanyl because the region has a strong, long-standing market for opioids.
Spencer, the study's principal author, hopes that some of the other characteristics of the wave of fentanyl highlighted in this report will help shape the public response. Why, for example, did the influx of fentanyl increase the overdose death rate among men to almost three times the rate of overdose deaths among women
Some research points to one particular factor: Men are more likely to use drugs alone. In the era of fentanyl, it increases man's chances of overdose and death, says Ricky Bluthenthal, a professor of preventive medicine at the University of Southern California's Keck School of Medicine
"You have stigma around your drug use, so you hide it, "Bluthenthal says.
Traci Green, deputy director of the Boston Medical Center's Injury Prevention Center, offers some other reasons. [If] There is fentanyl in it, then you die. Women are more likely to buy and use drugs with a partner, Green says. And women are more likely to call for help – including 911 – and to seek help, including treatment
"Women go to the doctor more," she says. "We have health issues that take us to the doctor more."
Green notes that every interaction with a health care provider is a chance to bring someone into treatment. So, this finding should encourage more outreach, she says, and encourage health care providers to find more ways to connect with active drug users
As to why fentanyl seems to be hitting blacks and Latinos disproportionately as compared to whites, Green mentions the higher incarceration rates for blacks and Latinos. Those who formerly used opioids are heavily faced with a particularly high risk of overdose when they leave prison or prison and inject fentanyl, she notes;
There are also reports that African-Americans and Latinos are less likely to call 911 because they do not trust first responders, and medication-based treatment may not be  as available to racial minorities. Many Latins say bilingual treatment programs are hard to find
Spencer says the deaths attributed to fentanyl in her study should be seen as a minimum number – there are probably more that were not counted. Coroners in some states do not test for the drug or do not have equipment that can detect one of the dozens of new variations of fentanyl that would appear if sophisticated tests were more widely available
There are signs that fentanyl surge continues . Kelley, with the New England High Intensity Drug Trafficking Area, notes that fentanyl seizures are rising. And in Massachusetts, one of the hardest-hit areas, the state data shows fentanyl present in more than 89 percent of the fatal overdoses through October 2018.
Still, in one glimmer of hope, even as the number of overdoses in Massachusetts continues rise, associated deaths dropped 4 percent last year. Many public health specialists attribute the decrease in deaths to the spread of naloxone, a drug that can reverse an opioid overdose.
This story is part of NPR's reporting partnership with WBUR and Kaiser Health News