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Fentanyl is a synthetic opioid that is a prescription drug. It is used to treat severe pain, usually after surgery. But, it is manufactured and used illegally. Fentanyl is the leading drug involved with drug overdoses. It is also 50 times stronger than heroin and 100 times stronger than morphine.

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Many people struggle with an addiction to fentanyl. Fentanyl blocks the pain receptors in the areas of the brain that control pain and emotion. With feeling of extreme happiness and excitement, people get addicted to the feeling. Excess amounts of dopamine alter the brain over time which makes people dependent on the drug.

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Fentanyl withdrawals are extremely painful such as muscle pain, vomiting, cold flashes, and sleeping problems. Medication and behavioral therapy helps treat people with a fentanyl addiction. Behavioral therapy can help people change their view on drug abuse and encourage them to live a better life. Lofexidine is a medicine that helps opioid withdrawal symptoms.

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"The overdoses in Genesee county are part of a national public health crisis, especially as the use of drugs laced with lethal fentanyl has increased. In 2011, fentanyl was involved in four percent of American drug overdose deaths, according to the Centers for Disease Control and Prevention; by 2016, it was involved in 28.8 percent, first among deadly drugs."

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In the weeks leading up to nineteen-year-old Erika's death, in 2011, her parents had been feeling hopeful. Erika had just been released from prison after her second time in rehab for a heroin addiction, and seemed to finally be doing better. But then Erika relapsed and overdosed, using heroin laced with fentanyl. Her parents found her in bed, motionless and purple, according to her father, Rob. Multiple doses of Narcan could not revive her.

Erika is one of many in mid-Michigan whose life has been claimed by a fentanyl-laced heroin death in recent years. In July 2018, sixteen people overdosed on heroin in Genesee County in a span of ten days. At the time, Genesee County Undersheriff Chris Swanson told the Tri-County Times the drug was "everywhere."

Genesee county's biggest city is Flint, the birthplace of General Motors, which was hit hard by the 2008 recession and the collapse of the auto industry. The county has a poverty rate of twenty percent, compared to 15.5 percent in the state of Michigan as a whole. The overdoses in Genesee county are part of a national public health crisis, especially as the use of drugs laced with lethal fentanyl has increased. In 2011, fentanyl was involved in four percent of American drug overdose deaths, according to the Centers for Disease Control and Prevention; by 2016, it was involved in 28.8 percent, first among deadly drugs.

"[Fentanyl] is highly addictive-you take it and you're addicted," said Fenton Police Department officer Thomas Cole, who is a court-recognized expert in methamphetamines. "Other street drugs don't compare. The addictive qualities are so gripping. It is so debilitating, even if users know it's wrong, they can't stop from doing it."

Rob is not Erika's father's real name-he requested a pseudonym for privacy purposes. After years of retelling the story of his daughter's death, he is tired of people coming up to him and tiptoeing around the elephant in the room.

Erika and Rob were "super close." Whenever Rob would get his boat out, his daughter Erika raced to his side, begging to go with him on a fishing trip. In his words, they were a "good family." They ate dinner together at the table. Erika and her sister participated in activities from Girl Scouts to soccer to volleyball. "She was always a bit rebellious and always wanted to find her own way. She was a free spirit," Rob said. "She got hooked up with a bad girl and her boyfriend...She started hanging around that type of crowd."

Erika's friend and her boyfriend began using heroin, and they introduced Erika to a boy they knew, a fellow heroin user. He and Erika clicked. Given their strong relationship, Rob and Erika were open and honest with each other, and on Erika's sixteenth birthday she expressed a desire to try the drug. Rob urged her not to, and said that using heroin would be a dark alley with "no doors, no windows, and no room to turn around." After tracking her down, finding her at a friend's house and talking to her for two hours straight in the car, Rob was able to convince Erika to not try heroin that evening. His success was short lived. Soon, Rob and his wife began noticing changes to her physical appearance and mood, which led them to believe she had moved on to harder drugs.

After they learned Erika was using, she went to rehab. But her forty-five-day sobriety streak was broken after exiting rehab, and a second ninety-day stint in a different rehab center soon followed. Once again, the sobriety was short lived. Rob ended up turning his daughter in to her probation officer when she narrowly avoided a drug test and confessed to him that she had begun using once more. Rob mouthed the words "I love you, I am trying to save your life" to Erika as she was being wrestled into a state police car, and she was sentenced to nine months in jail.

When Erika was released from prison just before Christmas, the family began to feel like everything was getting better, and Erika was on the right track. She was clean and under strict parental rules. But just before Valentine's Day, Erika's parents discovered that she had been lying to them about where they were dropping her off. She was still using.

Then, on Valentine's Day, one of Erika's friends fatally overdosed. Erika was "distraught," Rob said. The night before the funeral, she begged to go out. Rob refused, but finally agreed to let her have a friend over. He had no idea that this friend was a dealer.

Two milligrams of fentanyl is often a lethal dose. The typical dose of heroin is 100 milligrams, which means that if only two percent of the dose contains fentanyl, the user may die. According to the DEA, fentanyl is an opioid that is "80-100 times stronger than morphine." This can lead to overdoses because "many users believe that they are purchasing heroin."

Fentanyl overdoses are not a new problem, says Thomas Cole, who worked undercover for the Flint Area Narcotics Group (FANG) from 2010 to 2013 and now works for Fenton High School in Genesee County as the district officer.

"People were overdosing big time with fentanyl back then," Cole said. "I dealt a lot with methamphetamines, dismantling the meth labs and testifying in court. Even then, you could see the fentanyl epidemic was huge, it affected everyone."

Fentanyl's intended use is to treat pain in cancer patients. The drug is applied as a patch on the skin to improve quality-of-life for cancer patients undergoing chemotherapy, radiation, or surgery. But now it has taken over the streets.

Erin McClelland, director of clinical services at New Paths, Inc., an adult treatment center in Flint, MI, said that it's not hard to get fentanyl online; as the DEA chases and shuts down one site, another opens up. "You don't need much of it at all. It's the smallest amount that can kill somebody." McClelland said. "And that's one of the issues that first responders are having. If they even touch it mouth-to-mouth, it can be transferred. And so there's some paranoia there from first responders with regards to the fentanyl. They're also have to use multiple Narcan doses. With fentanyl it takes at least four or five doses of Narcan to be revived. For heroin or opiate pills, one to two doses of Narcan would revive the individual."

While fentanyl is commonly associated with heroin, it can be laced in all types of drugs, including marijuana, methamphetamine, cocaine, and opioid pills. Vox recently reported that in 2012, there were around 4,400 cocaine-related overdoses, with 180 of those deaths related to fentanyl or other synthetic opioids. But by 2016, total cocaine overdose deaths had more than doubled, and nearly 4,200 people died from cocaine overdoses that were related to fentanyl or other synthetic opioids.

While Erika and Dylan were hanging out, Rob's wife came home. Rob asked if she had had trouble parking with Erika's friend's car in the driveway, but she said there were no extra cars. Rob knew something was wrong-where had her friend gone? They went to check on her and found a parent's worst nightmare.

"Beth ran upstairs and she just started screaming," Rob said. "I ran upstairs and saw Erika in her bed with her open bedside arm outstretched and she was already purple. I could see all the blood vessels and veins in her arms popping out." Paramedics tried to revive her, but did not succeed.

After his daughter died, Rob began working with other families who were dealing with a relative who overdosed. They created a program called "Chasing the Dragon," and spoke to gyms full of high school students around the state about addiction. Over two years, they spoke to about 150,000 Michigan students. Rob always had something prepared to say and threw it all out the window once he began speaking. He was known in the group as the one who pulled on the heartstrings of the audience.

"I'd look at a six-foot-two, 270-pound football guy and I'd talk directly to him and I'd have him crying before it was all over with," Rob said. "And I cried. I cried every single time."

Speaking was emotionally draining-Rob was "pretty much useless" the day before and after the presentations, he said. Up until a couple of years ago, it was tough for Rob to even think about Erika without breaking down. "Two years ago, I wouldn't even be able to get through this conversation" Rob said. "I used to have to pull over while driving. I'd think about Erika and I'd just start crying so hysterically bad that I couldn't see the road. I'd have to pull over to the shoulder and get my composure back."

Since Erika's death, Rob has thrown himself into his many businesses. He does landscaping, apartment remodeling, and snowplowing. "Ever since we lost Erika, I have probably tripled my business I used to think it was her looking down on me trying to help me out, and I think that's been part of it," he said. "I buried myself in work to keep my sanity. I constantly have my nose to the grindstone. It's kept me sane."

New Paths Inc, the Flint recovery center where Erin McClelland works, continues to search for solutions to help heroin users like Erika. New Paths provides short-term and long-term programs for people with addiction. New Paths also hire former addicts, put them through a training program to become "recovery coaches," and then pair them with patients. Government funding supports recovery coach programming at New Paths and other agencies.

The New Paths recovery coaches also act as first responders for people who enter the hospital for overdoses or withdrawal. Recovery coaches stay linked with patients for sixty to ninety days, helping them transition to recovery programs. The coaching program gives the addicts currently struggling a mentor who knows what they've been through.

New Paths also works with hospital staff, including nurses, doctors, and social workers, to help them understand addiction better. "This has been amazing because they are seeing addiction in a different way now," McClelland said. "We're seeing individuals get treated with compassion and more empathy"

Since April, the center's opioid overdose recovery program has treated more than 200 people and placed over half of them in treatment programs in their facility. In recent years, "there has definitely been more specific attention to programs who are willing to provide additional service for opioid treatment," McClelland said. "We need more detox facilities. We need more residential facilities. We need more agencies to provide medication-assisted treatment."

Medication-assisted treatment involves giving medications like methadone or buprenorphine to help recovering addicts with the symptoms of withdrawal. Hospitals and treatment centers in the Genesee County area have increased their methadone programs in response to the opioid epidemic. McClelland said that in Genesee County alone, there are over 600 clients on methadone through the two methadone providers, and the state was still looking for more providers.

"You definitely see growth in those areas," McClelland said. "I think it's going to continue to expand, I know the need is there. I really honestly feel that gaps in services are being recognized. The federal, state, and local authorities are trying to accommodate those by providing additional dollars and support."

McClelland has learned throughout her career that treating addiction is not "cookie cutter." A relapse doesn't mean you should give up, because successfully treating addiction can take "a lifetime," McClelland said. "Making the decision to just not use one day is not that simple. It takes time." ■

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In the weeks leading up to nineteen-year-old Erika's death, in 2011, her parents had been feeling hopeful. Erika had just been released from prison after her second time in rehab for a heroin addiction, and seemed to finally be doing better. But then Erika relapsed and overdosed, using heroin laced with fentanyl.

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China's export of fentanyl to the U.S. has caused thousands of overdose deaths. China announced that it would ban all forms of fentanyl to slow the export to the United States.

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Chinese officials said in Beijing on Monday that they would treat all variants of the opioid fentanyl as controlled substances, fulfilling a promise President Xi Jinping made to President Trump last year. Credit Credit Reuters

BEIJING - China announced on Monday that it would ban all variants of the powerful opioid fentanyl, a move that could slow the supply of a drug that in recent years has caused tens of thousands of overdose deaths in the United States.

By declaring that all varieties of fentanyl are now controlled substances, China made good on a pledge that the Chinese leader, Xi Jinping, made to President Trump late last year.

China's export of the drug, which American officials say accounts for the vast majority of the fentanyl that ends up in the United States, has long been a source of tension in relations. More recently, it has also become tangled up in the continuing trade war.

China already treats more than two dozen variants of fentanyl and its precursors as controlled substances, thus strictly regulating their production and distribution, but it has banned those variants only after reviewing them case by case, a process that can be lengthy. And because so many more variants exist, and new ones are constantly being created, banning them as a broadly defined class could be far more effective.

The latest step would expand restrictions to all "fentanyl-related substances," effective May 1. That could plug gaps that, experts and American officials have said, allowed manufacturers in China to make novel variations of the drug that were not technically illegal.

But the ban does not cover all of the precursor chemicals used to make fentanyl and its analogues, according to a spokesman for Mr. Trump's Office of National Drug Control Policy.

That could be problematic because these chemicals are often sent from China to Mexico, where traffickers use them to make fentanyl that ends up in the United States. China has banned some of them, but not all, which the spokesman said would be nearly impossible.

The spread of fentanyl in the United States over the last five years has resulted in record numbers of overdose deaths; it became the leading cause of overdose deaths in 2016 and contributed to 28,466 of the roughly 72,000 that the Centers for Disease Control and Prevention counted in 2017.

Its march across the country, and particularly its penetration of the Northeast and Midwest, has resulted in a higher death toll by overdoses than H.I.V., car crashes or gun violence caused at their peaks.

A spokeswoman for the Drug Enforcement Administration described China's announcement as "significant," saying in a statement that it would "eliminate Chinese drug traffickers' ability to alter fentanyl compounds to get around the law."

"We look forward to our continued collaboration with China to reduce the amount of this deadly poison coming into our country," the spokeswoman, Mary Brandenberger, said.

Illicitly produced fentanyl is smuggled into the United States primarily from China by way of Mexico, according to the D.E.A. But it is also shipped directly to the United States from China, in smaller quantities. It used to be mostly sold mixed with heroin, but is increasingly showing up in counterfeit prescription pills and other drugs, though users often do not realize it.

In December, Mr. Trump announced a promise that Mr. Xi had made to him at the Group of 20 meeting in Buenos Aires, saying then that the step formalized on Monday could be a "game changer." He had previously taken to Twitter to excoriate China over the issue, accusing it of "killing our children and destroying our country."

Officials from three Chinese agencies, including the Ministry of Public Security, announced the change at a news conference that included representatives from foreign embassies, including the American Embassy. As before, however, the officials denied that China was causing the scourge of fentanyl-related deaths in the United States, saying the blame lay there.

Liu Yuejin, vice commissioner of the National Narcotics Control Commission, said that accusations by American officials lacked evidence, and that China cooperated closely with the United States on cases of illegal trafficking, which he called "extremely limited."

"We believe that the United States is the main cause of the problem of the abuse of fentanyl in the United States," he said, citing weak enforcement and a culture of addiction. He noted that the United States consumed 80 percent of the world's opioids while making up only 5 percent of the world's population.

Weak regulation of China's sprawling chemical industry has raised the possibility that a new ban to cover all forms of fentanyl might not be entirely effective. Mr. Liu, however, promised that China would strictly enforce the new rules.

Dr. Daniel Ciccarone, a family physician and researcher at the University of California, San Francisco, who has studied fentanyl, questioned whether China's regulatory agencies could truly identify and crack down on all illicit production.

"Do they have the capacity?" he wrote in an email. "Or will they, like U.S. regulatory agencies often do, brag about the 'one they got' while whitewashing the ones that got away?"

Since fentanyl is so powerful, Dr. Ciccarone said, small amounts go a long way, making it harder to intercept than heroin and cocaine. "Stopping production and shipping of a much smaller-volume drug is wishing big," he said.

But he added, "This effort is worthwhile even if it has a small chance of success."

He and others who study the opioid epidemic said certain changes in American policy would be equally if not more helpful, such as expanding access to buprenorphine, a medicine that treats opioid addiction, by no longer requiring doctors and nurse practitioners to get special training and licenses to prescribe it. And the United States still needs to make major progress in monitoring for fentanyl slipping through legal border crossings in trucks and cars, or arriving through the mail from China.

While American officials have long complained about China's commitment to previous pledges, the announcement appeared to be a sign that China is prepared to make compromises to resolve at least some of its differences with the United States in hopes of closing a deal on trade. Negotiators met in Beijing last week to continue hashing out an agreement and are scheduled to meet in Washington again on Thursday and Friday.

"It may very well be something that we end up writing into this agreement," Robert Lighthizer, Mr. Trump's top trade negotiator, said in congressional testimony in late February, referring to efforts to get China's commitment on fentanyl in writing. "But it clearly is something the president views himself as having a commitment on. And that we are monitoring to see in fact if there are changes."

Steven Lee Myers reported from Beijing, and Abby Goodnough from Washington. Claire Fu contributed research.
Follow Steven Lee Myers on Twitter: @stevenleemyers.

A version of this article appears in print on , on Page A6 of the New York edition with the headline: China Moves to Ban All Types of Fentanyl to Slow Supply of Drug to U.S. . Order Reprints | Today's Paper | Subscribe

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China Bans All Types of Fentanyl, Cutting Supply of Deadly Drug to U.S. and Fulfilling Pledge to Trump

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BEIJING - China announced on Monday that it would ban all variants of the powerful opioid fentanyl, a move that could slow the supply of a drug that in recent years has caused tens of thousands of overdose deaths in the United States.

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https://www.drugabuse.gov/publications/drugfacts/fentanyl
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Fighting Fentanyl, Belt Magazine, March 13,2019

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China Bans All Types of Fentanyl, Cutting Supply of Deadly Drug to U.S. and Fulfilling Pledge to Trump, The New York Times, April 01, 2019