An illicit version of the drug is flooding into communities across America, and casual users are finding out that their fentanyl pills and powder are delivering a powerful high that is easy to overdose on.
The Drug Enforcement Administration and the Centers for Disease Control say we have another national health crisis on our hands. These are just a handful of the people trying to stop it from taking more lives.
Natasha Butler stared hard at the pictures laid out in front of her.
But she averted her eyes when they lit on the one that still takes her breath away. It's the one that makes what happened real.
It's the one where the tubes, needles and respirator are all hooked up to her only son, Jerome, trying to keep him alive. They ultimately didn't.
"I'm dying inside," she said, her voice falling to a whisper and tears streaming down her face. "He was my firstborn. I had him when I was 15. We grew up together."
She had never heard of the substance that killed him. Doctors told her he died from an overdose of fentanyl, which experts say can be 100 times more potent than morphine and 50 times stronger than heroin.
"He came and told me it was an overdose. I'm like, 'An overdose of what?' It wasn't an overdose. This is murder," Butler said. "I taught my kids two things: God, and don't do drugs."
Jerome Butler had not been prescribed the highly controlled narcotic. His mother said she was told that an acquaintance had given Butler what her son thought was a pill of Norco, a less potent opioid-based painkiller, a mix of hydrocodone and acetaminophen.
The sellers knew, Butler alleges, that "the pill had the fentanyl in it, and they killed my son."
Jerome was one of 10 people who died in just 12 days from fentanyl-laced pills in a sudden spike of deaths in Sacramento County, California, in March. More than 50 people overdosed on those pills in the first three months of the year but survived. Investigators are still looking for the source.
Similar clusters of fentanyl-related overdoses and deaths are appearing across the United States.
Like the DEA
, the Centers for Disease Control and prevention has issued a health advisory and is stepping in to get health providers and first responders to report fentanyl-related overdoses as well as expand access to naloxone, the drug that counteracts deadly opioid overdoses.
The latest state statistics on fentanyl-related deaths compiled by the CDC
tell a sobering story.
Ohio reported 514 fentanyl-related deaths in 2014, up from 93 the year before. Maryland reported 185 fentanyl-related deaths, up from 58 in a year's time. In Florida, the number of deaths jumped to 397 in 2014, from 185. New Hampshire had 151 reported deaths due to fentanyl alone in 2015, five times the number of deaths from heroin, according to the office of the state's chief medical examiner.
No one was more stunned to see those numbers than the mother freshly grieving her son's death from the drug. She didn't know that so many other families had suffered its deadly effects long before it hit hers until she started researching it.
"What are we doing? What are we doing about it?" Butler said, exasperated and weeping. "I'm willing to do everything that I can."
And that is just what Butler intends to do. She's on a mission to warn communities about the opioid-based drugs killing people at alarming rates across America.
She is talking to community groups and has called senators, the California governor, even the White House, looking to tell her story and to build a coalition to help stave off more deaths from opioid use, especially fentanyl.
"I'm mad at the person who sold it. I'm mad at the person who is compressing it. I'm mad at the state for not protecting our people," she said.
Since her son's death, she said, she's heard from so many young people who are addicted to painkillers such as Norco.
"If you feel you don't have that much strength, let's get together," she said. "We can build strength. We can make a difference. We have to."
The special agent
Illicit fentanyl is a bestseller on the streets and a prolific killer. It is so potent that when law enforcement goes in to seize it, officers have to wear level A hazmat suits, the highest protection level made, the same kind of suits health care workers use to avoid contamination by the deadly Ebola virus.
"Just micrograms can make a difference between life and death. It's that serious," said DEA Special Agent John Martin, who is based in San Francisco. An amount the size of a few grains of sand of fentanyl can kill you. "All you have to do is touch it. It can be absorbed through the skin and the eyes."
One of the top priorities for Martin and his agency is to stop the flow of fentanyl and other opioids from flooding American communities.
It first showed up in deadly doses on the streets in 2007. The DEA traced the illicit fentanyl to a single lab in Mexico and shut it down. Fentanyl drug seizures subsided for a while, but in 2014, they spiked in 10 states.
It's been an uphill battle. Americans are buying it in record numbers, and highly organized drug cartels are spreading it far and wide.
What is curious is where the drug or elements to make it originate. Its street nickname is "China White" or "China girl," offering a hint at where most of it is coming from.
"DEA investigations reveal that Mexico-based drug cartels are buying fentanyl directly from China," Martin said.
And as far as profits go, the other opioids commonly sold on the streets -- heroin, hydrocodone, OxyContin and Norco -- can't even touch fentanyl.
Hydrocodone sells for about $30 a pill on the street. A fentanyl pill may look and cost the same but requires only a fraction of the narcotic to give users an even stronger reaction.
The DEA estimates that drug traffickers can buy a kilogram of fentanyl powder for $3,300 and sell it on the streets for more than 300 times that, generating nearly a million dollars.
Fentanyl is often trafficked through the cartels' standard maze of routes through Mexico and into the U.S. But sometimes it's simply ordered on the notorious dark web and shows up straight from China in the buyer's mailbox.
"We're using countless resources to deal with the threat," Martin said.
Seizures of the drug have jumped dramatically, which would seem to be good news for the DEA. But what it indicates is that there is more of it to seize than ever before.
"Everywhere from the Northeast corridor, down to New York, the Midwest and now we're seeing it here out on the West Coast. Fentanyl is everywhere right now," Martin said.
On the East Coast and in the Midwest, it's often sold as powder and mixed with heroin. On the West Coast, it is showing up mostly in pill form.
"It's feeding America's addiction to opioids," Martin said, adding that the cartels have figured out a way to make it more cheaply and easily than heroin.
The forensic scientist
"They look like what you're getting from the pharmacy," forensic scientist Terry Baisz said. She was taken aback by just how much the counterfeit pills look like the ones sold by pharmaceutical companies.
After 26 years in the Orange County crime lab, south of Los Angeles, she has never seen anything like what is coming in these days. It worries her.
"I was shocked the first time I tested this stuff and it came back as fentanyl. We hadn't seen it before 2015," Baisz said, "and now we're seeing it a lot."
Fentanyl had entered Orange County, and it was killing people.
Wearing gloves and a lab coat, Baisz looked down at a tiny clear plastic bag under a glass hood with a ventilation system. It was pure fentanyl. A sneeze or deep breath could end in a deadly overdose, so testing it calls for strict protocols. But Baisz said it's the pills that worry her the most as a public threat.
"I wouldn't hold those in a sweaty palm for long. You're bound to get dosed," she said.
In her lab coat and gloves, she pointed to pills spread across a table. They were all labeled as various well-known pharmaceutical drugs. They looked like perfect replicas of the real deal. None was labeled as fentanyl, but that is what most of them actually were.
"Just one could kill you," Baisz said. "We have to test them. We can no longer rely on the database and our naked eye."
"It's so dangerous and so lethal, I had to get involved," California state Sen. Patricia Bates said. "Two minutes, and you could be in respiratory arrest and be dead. It's kind of like, get high and die."
Bates knows those details because the fentanyl overdose deaths started racking up in one of the areas she represents, South Orange County. She is trying to push through a bill that would put harsher penalties on high-volume sellers of fentanyl.
The bill "will enhance the penalties, by weight," Bates said. "We're talking about ... catching the big guys, because when you take them out of the food chain, you really do reduce the incidents of the trafficking and what's available on the streets."
She knows it's a tough sell in a time when California voters have passed laws to lessen prison sentences for nonviolent offenders. And, of course, there is the matter of prison overcrowding in the state. But Bates is pushing it forward because she is certain this is the next epidemic, similar to what is happening with heroin but more deadly.
"Addicts are migrating to fentanyl," she said, "They are driven to it because it's a quicker, bigger high. Yet it is something that you don't recover from when you get that super-high."
The drug counselor
When fentanyl began showing up in San Francisco in 2015, Eliza Wheeler helped get the word out on the streets about a new, very potent drug in town.
In San Francisco, the drug showed up in the form of white powder and then as pills labeled as Xanax. It turned out to be pure fentanyl. A health advisory warned that more than 75 people had experienced an overdose in July that year.
"People didn't know what it was," Wheeler said. They thought it was heroin, which is far less potent.
Though San Francisco has seen a sudden rise in fentanyl overdoses, the city did not experience the large number of deadly overdoses that other cities have.
Wheeler is a project manager at the DOPE Project (Drug Overdose Prevention and Education
) in San Francisco. In cooperation with the city's health department, DOPE and other organizations flooded the streets with fliers warning that "white heroin,"
promising a super high, was super potent and potentially deadly. The fliers also advised drug users to carry around Narcan, the brand name for naloxone, which blocks or reverses the effects of opioid-based drugs. It is supposed to be used in an emergency such as an overdose.
Since 2003, DOPE has trained about 6,000 people on how and when to use Narcan. It can be administered with a needle or as a nasal spray. "We saved countless people by giving easier access to (Narcan) and informing them about the dangers right away," Wheeler said.
The San Francisco Department of Public Health sent out a health advisory crediting groups like DOPE with saving lives.
"If you want to do something that will keep people from dying and impact the crisis immediately, then lawmakers should help make more naloxone and training available to the public," Wheeler said.
Natasha Butler, who continues to grieve her only son, would like to see something else, too.
"We have an Amber alert to save children. Why not have a Jerome alert to warn people about this drug?"