On a humid Saturday afternoon in West Philadelphia, near 40th Street and Lancaster Avenue, a group of middle-aged Black men swapped grapevine stories about acquaintances who had recently “fallen out” after taking a hit of what they thought was their everyday crack cocaine.
Little did they know it contained fentanyl, the deadly synthetic opioid that has spurred an overdose crisis across the country, attributing to more than two-thirds of Philadelphia’s 1,217 unintentional drug overdose fatalities last year.
Over the last two weeks, at least 20 people in the Powelton Village and Mantua neighborhoods landed in the hospital with fentanyl overdoses, the Philadelphia Department of Health confirmed. Two of the overdoses proved fatal, officials wrote in a memo. The victims were predominantly African American, two-thirds male, most between 40 to 50 years old. And according to health officials, many of them had more in common: they were adamantly cocaine users – not opioids.
“But you don’t know what you’re smoking anymore,” said one crack cocaine user, who declined to give his name.
Dr. Jeanmarie Perrone, the director of medical toxicology at the University of Pennsylvania’s emergency medicine department, said that patients’ response to overdose-reversing naloxone were consistent with that claim. While this was the first reported outbreak of fentanyl-contaminated crack cocaine in Philly, street testing has revealed a handful of the powder cocaine bags in Kensington have also tested positive for fentanyl over the past several months.
But the prospect of fentanyl’s leap into the city’s crack markets – where users are less likely to be opioid tolerant – has the potential to be devastating. And that has health professionals, harm reduction advocates and drug users themselves questioning whether the rash of crack-related overdoses that hit a small pocket of West Philly is an aberration or a prophecy of things to come.
“This might be the tip of the iceberg,” Perrone says.
Just across the Delaware River, in Camden, N.J., emergency room staff and addiction physicians confirmed numerous cases in recent months in which cocaine users found their supply had been tainted with the ultra-potent opioid.
“My patients are blown away by the fact that they have fentanyl in their urine when they said they’ve just used cocaine,” says Dr. Kaitlan Baston, medical director of addiction medicine at Cooper University Healthcare.
In light of these cases, more people are encouraging all street drug users, regardless of what they use, to carry naloxone. The opioid overdose reversal drug should be standard issue, “even for people who only use cocaine,” Baston said.
Cheap to produce, difficult to detect and exponentially more potent than heroin, fentanyl now has a grip on nearly every corner of North American heroin markets. Nevertheless, cases of fentanyl-contaminated cocaine and crack cocaine have been more scattered.
News reports of fentanyl-contaminated cocaine and crack cocaine have appeared as close as New Jersey and as far California and Massachusetts. In 2016, Canadian health officials in British Columbia witnessed a string of 43 overdoses over four-day period. Like Philadelphia, they occurred within a small geographic region and among users who were predominantly crack cocaine users. In Montgomery County, Ohio, tests of nearly 1200 samples of cocaine found that nearly 10 percent of the city’s cocaine supply was contaminated with carfentanil, a powerful fentanyl analog that is believed to be responsible for a spike in cocaine related deaths around the Dayton area last year.
But such data is in short supply. Most of the information we currently have on fentanyl-contaminated cocaine comes from post-mortem toxicology reports – which experts say are an unreliable metric for determining what’s actually in illicit narcotics being sold on the street.
"Any toxicologist making the claim based on tox alone should be questioned directly about it, and chastised," said Kevin Shanks, a forensic toxicologist and consultant with Axis Forensic Toxicology in Indianapolis, in a conversation several months ago when headlines first began appearing about fentanyl-contaminated cocaine.
“The only way to make that claim is to show it occurs in solid dose evidence or paraphernalia,” he added.
According to Dr. Caroline Johnson, Philadelphia’s Deputy Health Commissioner, no drugs were found on any of the non-fatal overdose victims in West Philly. But even if they were, she said, as far as she's aware, only drugs or paraphernalia found at the scene of a fatality are passed on to the Philadelphia Police for forensic analysis. A police official who commented on the condition that their name and position be withheld told Philly Weekly that in the absence of an arrest there is little political will to analyze seized drug samples.
"They rarely ever test paraphernalia," the source said. "It's pretty frustrating the overall lack of interest in this."
According to data from the Philadelphia Medical Examiner’s Office, 221 people fatally overdosed on a combination of fentanyl and cocaine last year in the city. Toxicology data indicate another 166 had a combination of fentanyl, heroin and cocaine in their bloodstream.
The fact that only two users out of 20 who overdosed in West Philadelphia died as a result would indicate the potency of the fentanyl they ingested was low. However, one especially troubling piece of evidence adds a nefarious wrinkle to the story: according to the Department of Health, at least two victims tested negative for cocaine, indicating whatever they took may not have been adulterated crack at all.
"Cocaine will be detectable in blood minutes after smoking," said Shanks, during a recent follow up interview. "I would expect that if the person overdosed [had ingested] cocaine, then it would be present in their blood or urine. [This] sounds like a case of straight-up substitution."
Using rapid response drug testing strips, reporters tested eight crack-cocaine samples last Saturday in the the pocket of West Philadelphia where the rash of overdoses occurred. All results were negative for fentanyl.
Health Department officials advised healthcare providers to remain vigilant for signs of opioid overdose “even if the drug consumed is reported to be a non-opioid.” Officials are also encouraging clinical toxicology testing to test reported cocaine users for fentanyl as well. So far, clinical toxicology tests for two patients confirmed that fentanyl was the only substance detected, health department officials said, while further tests are pending.
Meanwhile, in the opioid-plagued Kensington area, health officials are seeing another alarming trend in self-described heroin users: the absence of heroin.
While fentanyl is often mixed with heroin in street markets, some five-dollar bags are now strictly synthetic. Dr. Joseph D’Orazio, the director of the Division of Medical Toxicology in the hospital’s North Philadelphia emergency department, says drug tests in overdose patients have shown no signs morphine-based narcotics.
“This is a phenomenal shift within the last month of so,” D’Orazio says. “I’ve had a couple cases in the ICU of people who tested negative for opioids but positive for fentanyl.”
Public health experts’ ability to track trends in drug-mixing is undermined by a lack of universal reporting. While the Philadelphia Department of Health collects anonymized overdose information from hospitals, there are no standard reporting requirements at the local and state level.
Rhode Island hasa law requiring its hospitals to report all suspected opioid overdoses to the state’s health department within 48 hours – but that’s the exception to the rule. Pennsylvania enforces mandatory reporting requirements for epidemic diseases – like syphilis and gonorrhea, for example – but drug overdose has not made its way to that class.
New data via Philly DOH: 597 unintentional drug deaths in 2017 had cocaine in their system, 490 in combination with opioids. 107 were cocaine w/o opiates. These 2 powder bags and 1 crack bag from Kenzo (obtained yesterday) are negative. pic.twitter.com/wxPod1QYv3— Christopher Moraff (@cmoraff) June 24, 2018
“Mandatory reporting of all overdose with all hospitals in the city with mandatory testing would greatly enhance our knowledge of what’s going on,” Perrone says, noting that Penn voluntarily reports overdose data to the Philadelphia Poison Center.
One piece of good news is that, for the time being at least, cocaine contaminated with fentanyl is rare in Pennsylvania. The most comprehensive study was released earlier this year by the Drug Enforcement Administration, which tested more than 30,000 individual samples and found fentanyl or its analogues present in fewer than one percent of samples between 2015 and the second quarter of 2017.
But it still remains unclear how and why the two drugs – which produce radically different highs – would be winding up in retail drugs packaged for street sale. Most experts on drug markets suspect cross-contamination may be a culprit. Given the potency of fentanyl and its numerous relatives, and the sensitivity of modern testing technology, even trace amounts – such as might be picked up from a hastily cleaned cutting and bagging table – are capable of producing a positive result.
“It’s pure speculation at this point,” says Patrick Trainor, spokesman for the Drug Enforcement Administration's Philadelphia Field Division. “We monitor current drug trends in the area and we’re aware that opioid drugs such as heroin and fentanyl have been combined with other classes of drugs, but we don’t necessarily understand why it’s being done or if it’s being done intentionally...but it certainly does pose a significant risk to people who are dealing with a substance abuse disorder.”