The rise of the more potent fentanyl in its place has put a generation of older users, who had managed their addiction, at far greater risk of overdose. Abby Goodnough of The New York Times investigates.
Heroin has ravaged this city since the early 1960s, fuelling desperation and crime that remain endemic in many neighbourhoods. But lately, despite heroin's long, deep history here, users say it has become nearly impossible to find.
Heroin's presence is fading up and down the Eastern Seaboard, from New England mill towns to rural Appalachia, and in parts of the Midwest that were overwhelmed by it a few years back. It remains prevalent in many Western states, but even New York City, the nation's biggest distribution hub for the drug, has seen less of it this year.
The diminishing supply should be a victory for public health and law enforcement alike. Instead, in cities like Baltimore, longtime users who managed to survive decades injecting heroin are now at far higher risk of dying from an overdose. That is because synthetic fentanyl, a deadlier drug that is much cheaper to produce and distribute than heroin, has all but replaced it.
The dramatic rise of fentanyl, which can be 50 times stronger than heroin, has been well documented. But its effect on many older, urban users of heroin, who had been able to manage their addiction for years, has been less noticed. The shift from heroin to fentanyl in cities has contributed to surging overdose deaths among older people and African-Americans and deeply unnerved many like William Glen Miller Sr., who first tried heroin as a 13-year-old in West Baltimore.
"It doesn't take a second for it to hit you," said Miller, 64, describing the unfamiliar punch of fentanyl. "All I remember is pushing in the needle, and three hours later I am getting up off the ground."
He was speaking from a nursing home bed in northern Baltimore, where he spent several recent months recovering from pneumonia and contemplating addiction treatment in another state. Heroin had a lulling effect, he and others said, but fentanyl is killing many of their peers. The claim is backed by federal data showing that the rate of overdose deaths involving fentanyl increased by nearly 54 per cent in 2017 for people 55-64 — more than for any other age group.
"Clients we've known for years are dying," said Derrick Hunt, director of the Baltimore City Needle Exchange Program, which has two vans that serve 17 locations around the city. "Everywhere I go, this person passed, that person passed."
The reason fentanyl is everywhere is economic: Dealers and traffickers can make far more money from it than from heroin. Instead of waiting months for poppy fields to grow in Mexico and farmers to harvest the brownish-black gum, which then gets refined into powder and shipped north, traffickers here and in Mexico can order fentanyl from China, or precursor chemicals to make it in clandestine labs, generating far more doses with far less labour.
This is not an elegy for heroin, a dangerous drug in its own right that spread from cities into suburbs and rural areas about a decade ago, when addictive prescription painkillers became harder to get. But for longtime urban users like Miller, many of them African-American, its disappearance is taking a particular toll. From 2016 to 2017, the fatal overdose rate from fentanyl and other synthetic opioids increased by 61 per cent among black Americans, compared with a 45 per cent increase for whites.
The number of overdose deaths involving heroin has been dropping, even as overdose deaths overall have kept climbing because of fentanyl. In Maryland, deaths involving heroin fell by 38 per cent from 2016 through 2018, according to preliminary data. In Massachusetts, heroin or likely heroin was present in 71 per cent of opioid-related deaths in 2014; in the third quarter of 2018, it was present in only 34 per cent.
And in New Hampshire, which did not have a robust heroin market until the painkiller-fueled crisis of the past decade, the drug has almost completely vanished. Only four of the 397 opioid deaths in New Hampshire in 2018 involved heroin, according to preliminary data; 363 involved fentanyl.
"In this situation, heroin looks protective compared to the fentanyl," said Dr. Daniel Ciccarone, a family physician and researcher at the University of California, San Francisco, who has studied both drugs.
Nationally, there were 7 per cent fewer deaths involving heroin in the year ending in September than there were in the previous year, according to preliminary data from the Centers for Disease Control and Prevention. The smaller overall decline may be a reflection of heroin's continued strong presence in Western states like California and Arizona.
Data on drug seizures similarly suggest a diminishing of heroin. Here in Baltimore, Todd Edwards, spokesman for the Drug Enforcement Administration's local district office, said law enforcement was now seizing more fentanyl than heroin. And in a Philadelphia neighbourhood called Kensington, which has been hit particularly hard by opioid addiction, users report that "they can't find heroin anymore," said Patrick Trainor, a spokesman for the DEA there. "It's pretty much been replaced."
On a street corner in East Baltimore one recent morning, a van distributed clean needles to about 25 clients, most of them older black men. Some leaned on canes or walkers; all said they missed heroin and its relative predictability. On the front of the van was a sticker showing a needle aimed at an arm and the words "GO SLOW," a warning to inject only a little fentanyl at a time.
Each person took a paper bag full of needles and Narcan, the overdose reversal drug. The vans now also offer test strips, which people can use to check their drugs, including cocaine, for fentanyl. But some clients don't see the point.
"Most people, they're not using no test strips," said Miller, who helped start a local group that hands out fentanyl strips and naloxone. "Because fentanyl is in daggone everything now."
Fentanyl may still be mixed with heroin or other drugs, but increasingly, it arrives pure — either as powder or pressed into counterfeit pills resembling Percocet or Xanax. It can be diluted with more filler than heroin can, because it takes far less fentanyl to have a powerful effect.
"At the dealer level right now, fentanyl is like a magic dust — it's a moneymaker," said Jon DeLena, associate special agent in charge of the DEA's New England field division.
"We were hearing people start to say, 'I want the old stuff again, I want the brown,' meaning heroin," he continued. "But traffickers just started mixing fentanyl with something that had a brown tinge to it. They're never, ever, ever going to go back to selling heroin around here again."
Mexican poppy cultivation reached a high in 2017, according to the DEA. But several news outlets have reported that the price of opium paste — the part of the poppy that gets turned into heroin — has dropped sharply over the past year, a sign that criminal organisations are increasingly focused on fentanyl.
Ray Donovan, who leads the DEA's New York office, said he believed China's recent decision to ban all variants of fentanyl as a class could ultimately force traffickers to refocus on heroin. But because China has not banned many of the precursor chemicals needed to make fentanyl, others believe the effect could be minimal.
Tino Fuentes, a former heroin user who teaches people how to test their drugs for fentanyl, said only half the samples he tests in New York these days are positive for heroin — much less than even a year ago.
"I have people telling me all the time, 'If you find something that's heroin, let me know,'" Fuentes said.
Still, law enforcement officials are continuing to seize heroin coming across the border. From January through April, US Customs and Border Protection officers seized 1,585 pounds of heroin at official ports of entry, along with 921 pounds (417kg) of fentanyl.
"The notion that heroin is disappearing altogether is false," said Katherine Pfaff, a spokeswoman for the DEA, adding that the drop in heroin-related deaths could be a result of Narcan saving more heroin users. Still, she said, there is definitely more demand now for fentanyl than heroin in some regions, including New England.
That could be because most users in those regions took up heroin only after crackdowns on prescribing opioids took hold, and were just as happy with fentanyl, DeLena said.
Not so for Miller and many other longtime heroin users.
"I'd rather have the straight heroin from back in the day," said Duane Coleman, 67, who was among those seeking needles from the health department van. "The fentanyl comes on you too strong. Thank God I'm still holding on."
Even if heroin were to proliferate again, Miller said, the high it provided would not suffice for most users because the fentanyl they have gotten used to is so much more potent. Miller said he had had to use fentanyl 10 times a day to avoid withdrawal, up from two or three times a day for heroin.
At the Baltimore needle exchange, Wayne Hall, 65, accepted a handful of strips to test his drugs for fentanyl, along with his batch of clean needles. He had gone to the emergency room recently, he said, after injecting what he assumes was fentanyl. He had woken up trembling, with his heart racing.
"When I was doing heroin I never shook like that," he said, leaning on a cane, his paper bag of supplies tucked under his arm. "I do miss it."