How the fentanyl crisis' fourth wave has hit every corner of the US

By Nadine Yousif for BBC News

More Americans than ever are dying from fentanyl overdoses as the fourth wave of the opioid epidemic crashes through every community, in every corner of the country.

It was six years ago that Kim Blake's son Sean died from an accidental fentanyl overdose in Burlington, Vermont. He was 27 years old.

"Every time I hear of a loss to substance use, my heart breaks a little more," Blake wrote in a blog dedicated to her son in 2021.

"Another family shattered. Forever grieving the loss of dreams and celebrations."

That year, the US witnessed a grim milestone: for the first time ever, drug overdoses killed more than 100,000 people across the country in one single year.

Of those deaths, more than 66 percent were tied to fentanyl, a synthetic opioid 50 times more powerful than heroin.

It was a stark difference to a decade ago. In 2010, less than 40,000 people died from a drug overdose across the country, and less than 10 percent of those deaths were tied to fentanyl.

Back then, deaths were mostly driven by the use of heroin or prescription opioids.

The contrast was outlined in a study released this week by researchers at the University of California, Los Angeles (UCLA) that examines trends in US overdose deaths from 2010-21 using data compiled by the US Centers for Disease Control and Prevention.

The data paints a clear picture of how fentanyl redefined drug overdoses in America over the last decade.

"The rise of illicitly manufactured fentanyl has ushered in an overdose crisis in the United States of unprecedented magnitude," the study's authors wrote.

Virtually every corner of the US, from Hawaii to Alaska to Rhode Island, has been touched by fentanyl.

The rise in fentanyl-related deaths was first observed in 2015, the data showed.

Since then, the drug had spread across the US and death rates had grown sharply.

"In 2018, around 80 percent of fentanyl overdoses happened east of the Mississippi river," Chelsea Shover, an assistant professor at UCLA's school of medicine and co-author of the study, told the BBC.

But in 2019, "fentanyl becomes part of the drug supply in the Western US, and suddenly this population that had been insulated from it is exposed, and death rates start to go up," Prof Shover said.

In their study, the researchers sounded the alarm on another growing trend: deaths related to the use of fentanyl and another stimulant drug, like cocaine or methamphetamine.

This trend was being observed across the US, albeit in different ways owing to drug use patterns that differed from region to region.

For example, researchers found higher death rates related to the use of fentanyl and cocaine in north-eastern US states, like Vermont and Connecticut, where cocaine had traditionally been more available.

But for virtually everywhere else in the country, from West Virginia to California, deaths were primarily driven by the use of both methamphetamines and fentanyl.

Blake, who is also a trained physician, said her son sporadically used cocaine, though his toxicology report revealed only fentanyl in his system.

She learned that many use fentanyl along with another stimulant for a prolonged high.

"It's no surprise to me that we're seeing such an increase in stimulant-opioid combinations," Blake told the BBC.

When fentanyl first arrived in the US as part of the illegal drug supply, "a lot of people did not want it", Prof Shover said. But the synthetic opiate became widely available as it was cheaper to produce compared to other drugs.

It was also highly addictive, meaning people who struggled with substance use and were exposed to it often sought it out to avoid painful withdrawals.

Across the US, the study identified states like Alaska, West Virginia, Rhode Island, Hawaii and California as having the highest rates of overdose deaths involving fentanyl and another drug.

These states have historically high rates of drug use, Prof Shover said. With the arrival of fentanyl, drug use in those areas had become more lethal.

No longer just a 'white problem'

The opioid crisis had been traditionally portrayed as a "white problem", Prof Shover said.

Her study, however, revealed that African Americans were dying from a combination of fentanyl and other drug use at higher rates, across age groups and geographical lines.

For Rasheeda Watts-Pearson, an Ohio-based harm reduction specialist, the data reflected what she had seen in her region.

She had been doing outreach work with A1 Stigma Free, a grassroots organisation founded just eight months ago to tackle a notable rise of overdose deaths within the African-American community in Cincinnati.

As part of her work, Watts-Pearson frequently visited barbershops, bars and grocery stores to talk to people about the deadly impacts of fentanyl.

She said she does this because of a lack of awareness, driven partly by historic healthcare disparities experienced by racial and ethnic minority groups.

Even marketing campaigns made to bring awareness to the opioid crisis had not included the experience of black Americans, she said.

"I can drive down Avondale right now, there is a billboard that says 'Opioid Crisis', but there's two white people on that billboard," Watts-Pearson said.

A big blind spot for her community had been fentanyl-laced street drugs, she said, which led to people unknowingly using the deadly, synthetic opioid, and developing a dependency to it.

"The coroner's office is seeing people overdose and die off of cocaine, off of crack, off of pills, with traces of fentanyl," she said.

"It has been infiltrated in the black community now, and not enough people are talking about it."

A fourth wave

The lethal use of fentanyl in combination with other drugs marked the "fourth wave" of the overdose crisis in the US, researchers have said.

And experts like Prof Shover cautioned that treatment options in the US for substance use had not kept up.

"Our treatment system for substance use disorder is often focused on one drug at a time," Prof Shover said. "But the reality is, many people who use drugs use more than one kind of drug."

To keep her son's memory alive, Blake has been outspoken about her loss and helped other families go through their grief of losing a loved one to an overdose.

"Everyone has a story, and for a parent who has lost a child, that is forever," she said.

Her son had been enrolled in treatment a few times during his battle with substance use disorder.

The experience taught Blake that care options varied from state to state, and in many cases, what was available was not enough.

"Ideally, I think we would see something where people would get treatment rapidly, whenever they want it, and long-term," she said.

Blake also raised the idea of overdose prevention sites, where people could use drugs safely and under supervision.

Those sites were widely available in Canada - which has its own fentanyl crisis - but only two sanctioned sites exist in the US.

Above all, Blake called for compassion and understanding for those struggling with substance use.

"Most people I talk to, their kids did not want to die," she said.

- This story was originally published by BBC