This elephant tranquilizer is killing people, but no one knows how many

 “I see her on the floor by her bathroom and she was crumpled up on the floor and I just say ‘Krissy.’ My mind was racing. Maybe she fell asleep on the floor for some odd reason,” Lisa Lutz recalled through tears. “She was cold to the touch when I touched her.”

That’s the way Lisa Lutz remembers the morning she and her husband Jeff found their 21-year-old daughter Kristina in their suburban Northern Virginia home. She had battled anxiety and depression most her life and struggled with addiction for a few years. Police found what they thought was heroin and a syringe in her room. According to an autopsy and toxicology report, their daughter died from a heroin overdose.

In April, eight months after Kristina’s death, the Virginia Medical Examiner’s office retested the drugs found in her room and in her system and made a crucial discovery. They found heroin, fentanyl — and carfentanil, a highly potent opioid used by veterinarians and zoos to tranquilize large animals such as elephants and rhinoceroses. It was never meant for human consumption.

“That was the first time we had heard about carfentanil and I didn’t even know what it was,” Lisa Lutz said. There’s a chance Kristina had never heard of it either when she reached out for heroin and what would be her last high. Users often purchase their drug of choice without knowing carfentanil has been mixed in.

Carfentanil, a white powdery substance law enforcement says entered the drug scene in the summer of 2016, is impossible to see when mixed with other drugs such as heroin or cocaine.

Law enforcement officers, medical examiners and coroners across the country report carfentanil killing people in their communities, but a Scripps News investigation shows the drug remains largely under detected, under tested and under reported.

Fifteen miniature, clear glass vials with ruby red caps sit neatly in a rectangular storage caddy at the Drug Enforcement Administration’s Special Testing and Research Laboratory in an undisclosed location in Virginia.

Wearing safety glasses and extra protective gloves, Jill Head, senior forensic chemist, carefully picks up one of the vials.  She was hesitant to pull out carfentanil in the presence of journalists because of the danger. Carfentanil is a derivative of fentanyl, a synthetic opioid used to treat pain. It’s 100 times more potent than fentanyl and 10,000 times more potent than morphine.

“You can see here a very, very, small quantity at the bottom of a vial. It’s about .6 milligrams of carfentanil. This would likely be a fatal dose,” Head said.

How much is .6 milligrams? Think of it as about the amount of salt that comes from one shake of a salt shaker. 

There isn’t a large legal market for carfentanil, so the total annual production quota in the U.S. is only 10 grams, according to the DEA’s Diversion Control Division. But it is the carfentanil that is illegally produced primarily in underground labs in China and Mexico — often in much larger quantities — that has law enforcement worried.

Carfentanil can be purchased on the dark web, an area of the web that requires special software to access and where users can largely remain anonymous. The drug can be shipped directly to the U.S. by mail or an express shipping service. In a congressional hearing last May, Customs and Border Protection and U.S. Postal Service officials discussed how difficult it can be to detect illicit synthetic opioids. They said the drugs are usually packaged in small quantities and smugglers use a wide variety of techniques to conceal the drugs in order to evade detection.

Customs and Border Protection is tasked with detecting carfentanil and other illicit drugs being smuggled into the country, but because of limited field testing capabilities, a lot of the detection work is done manually. That means the agents would have to go through millions of packages, which can be time-consuming and potentially dangerous.

Customs and Border Protection told Scripps News they made five seizures of carfentanil totalling nearly 2 kilograms from Oct. 22, 2016, when the agency started specifically tracking the drug, to June 27, 2017.

Carfentanil is less expensive to make than heroin and is usually mixed with other drugs to increase potency and provide the ultimate high. If properly cut and mixed, a kilogram of carfentanil purchased for a few thousand dollars can translate into millions of dollars of profit, according to the DEA. 

In March, after months of discussions with U.S. officials, China made carfentanil a controlled substance, regulating and preventing it from being legally shipped to the United States. However, that apparently hasn’t made a difference on the streets. Head and her colleagues are seeing more and more samples of illicit carfentanil and other fentanyl derivatives coming through the lab that have been seized by DEA agents.

“We have seen samples that are carfentanil mixed with heroin, carfentanil with heroin and fentanyl, the combination of the three,” Head explained. “It really requires analysis here in the laboratory to identify what substance is present.”

The agency’s Diversion Control Division has been notified of 1,220 reported cases of carfentanil from June - December of 2016, and 1,058 reported cases this year through July, across fifteen states. Dealers aren’t just mixing carfentanil with heroin, it’s also showing up in cocaine, Xanax and methamphetamine.  

Gordon Merry, director of Cabell County Emergency Medical Services in West Virginia, remembers the day the terror of carfentanil came to his community. It was Aug. 15, 2016.

“I was in a staff meeting and we started getting all these calls,” Merry said. “The initial calls said ‘there’s people dead everywhere in this house.’”

Before long “every ambulance that we had in the city of Huntington went to this neighborhood because we had so many people overdosing,” he said.

In a four-hour period, 27 people overdosed from carfentanil-laced heroin. First responders saved each life with Narcan, one of the brands of naloxone, a medication that is used to reverse an opioid overdose.

“We’ve carried Narcan on the ambulance for years, since the 1980s. It used to be a drug that would expire and we never used,” Merry said. “We have almost doubled the amount of Narcan we carry on the ambulance now because there are so many overdoses and we cannot get back [to the station] to restock.”

Last year, the Cabell County EMS responded to 1,217 drug overdose calls, Merry said. This year, the county has responded to 1,388 calls as of Sept. 1, and Merry believes it is because of carfentanil and other potent opioids.

“Heroin obviously is the big problem,” he said. “Now they’re lacing it with fentanyl and carfentanil and that’s really a bigger challenge. … My hope is that as a nation we address the problem and we address it aggressively.”

Trendy bars, high-end boutiques and casual coffee shops line the downtown streets of Delray Beach on Florida’s Atlantic coast, but there’s another side to the popular town that is less apparent.

“If you just drove around out here you wouldn't know that there was an opioid crisis going on,” Delray Beach Police Chief Jeff Goldman said. “Heroin is a huge problem and when the dealer starts adding fentanyl and carfentanil, it causes a lot of problems for public safety.”

Despite the high chances of dying from drugs laced with the extremely toxic carfentanil,  dealers continue to roll the dice mixing the drug with heroin or cocaine and addicts continue to chase the elusive ultimate high.

“The dealers found that the users want such a high, they want to be like, almost dead,” Goldman said. “I mean when you talk to them [the user] they tell you we want to be almost dead – and if you almost die that’s like the best thing.”

Law enforcement officers in Delray Beach, which has hundreds of drug recovery facilities, spend much of their time arresting drug dealers and those in possession of drugs, but Chief Goldman said the city can’t arrest its way out of this crisis. Community education and life-saving tactics are being combined with law enforcement to combat the issue, he said.

In 2016, there were 118 carfentanil-related deaths in Palm Beach County, which includes Delray Beach, according to the Palm Beach Medical Examiner’s office. The county is experiencing one of the highest known rates of carfentanil-related deaths in the country. As of June 30 this year, the county’s medical examiner has reported 38 deaths attributed to carfentanil, with many toxicology reports still needing to be finalized.

“It has changed police work,” Goldman said. “When there's needles and stuff, you're going to have to think it’s a heroin case. And knowing it's a heroin case, there's a pretty good chance that it's laced with something.”

Unaware of what they might encounter during a drug investigation, officers have changed their protocols. Because carfentanil can be deadly when simply inhaled or absorbed into the skin, Delray Beach officers — like frontline law enforcement and emergency personnel in many communities across the country — wear gloves and masks to protect themselves and use extreme precaution when bagging evidence. They also no longer test drug samples out in the field.  Even dogs in the K9 units wear protective gear, like paw gloves and masks, and naloxone is kept on hand for them as well as the officers.

To help combat the rising number of overdoses, Delray Beach police department became the first law enforcement agency in Palm Beach County to distribute naloxone to all of its officers.

Naloxone has been instrumental in saving lives, however it doesn’t address the crisis. While Delray Beach has not been quiet about its challenges with the opioid crisis and educating the community on the dangers of carfentanil- and fentanyl-laced heroin, Chief Goldman knows there’s still work to be done.

“We had that epidemic with fentanyl, then we clamped down a little bit on the fentanyl. And now the carfentanil is coming in,” Goldman said. “It’s not a Delray Beach thing; it’s happening all through America.” 

On the other side of the state, Dr. Russell Vega, chief medical examiner for Florida’s 12th District, knows first hand how deadly carfentanil can be. He sees it all too often on the slab.

In the past 16 months, Dr. Vega and his colleagues have been inundated with drug overdoses. In two of the three counties in his district, the overdose deaths are driven partly by carfentanil’s growing presence. Since June 2016, Sarasota County has had 33 carfentanil deaths, Manatee has seen 114 through May of this year, and so far DeSoto County has had no carfentanil overdose deaths. However, there are a number of tests still pending in each of the counties. It can take three to five months to process a case suspected of involving carfentanil.

“Everybody in my office — doctors, investigators, clerical staff and autopsy technicians here in the facility — is working harder. They're working under more stress,” Dr. Vega said. 

A record number of 52,404 drug overdose deaths occurred in America in 2015, the most recent year for which numbers are available, according to the Centers for Disease Control and Prevention. More than 63 percent — or 33,000 — of those cases involved an opioid, including heroin, prescription painkillers, or synthetic opioids such as carfentanil.

Last summer when law enforcement in Manatee County began to see a wave of drug overdose deaths, they turned to Dr. Vega’s office for help.

At the time, Dr. Vega generally only conducted standard toxicology testing that would detect most of the more common drugs of abuse – testing that can cost anywhere from $150  to $200 per sample. Testing for some of the newer, more potent opioids, including carfentanil, was not even available then, but a few select laboratories developed and validated a test over the next few months.  Those advanced testing procedures can now identify carfentanil and other similar opioids, but can cost as much as $1,000.

“The test to identify the drug in biological samples, say if we were going to test someone's blood to see if that drug caused an overdose, didn't exist [for us] at that time when we were first made aware of carfentanil,” Dr. Vega said.  “So we were sorta caught between a rock and a hard place for a while.”

Like many medical examiner and county coroner offices across the country, Dr. Vega’s facility does not have an in-house toxicology lab, so he worked with the University of Florida which had reference samples of carfentanil.

It took four months, from June until October of last year, before the university lab could begin testing cases. Dr. Vega and his team went back and tested earlier cases they suspected involved carfentanil and eventually concluded 95 deaths in Manatee County were caused by carfentanil in 2016. 

Despite the growing presence of carfentanil in communities across the country, many county coroners and medical examiner offices don’t test for the drug.

Currently, there’s no centralized national database that tracks carfentanil deaths, there's only a patchwork reporting system that makes it difficult to know the total number of people who are dying. 

“Having a centralized place for that information would ultimately, not only improve our response but improve public health response, improve messaging in communities,” said  Terry Boos, chief of the DEA’s Diversion Control Division’s Drug and Chemical Evaluation Section.

To get a sense of carfentanil’s impact, Scripps News  surveyed medical examiners and coroners across 18 states. The survey revealed that there have been at least 865 carfentanil overdose deaths across72 counties. And 189 counties out of 389 reported they have never tested for carfentanil. Some respondents said they’re unable to afford the more expensive tests and struggle with staffing shortages.

The rise in overdose cases has led to backlogs in processing autopsies in a profession that already has a national shortage of forensic pathologist who are involved in conducting autopsies.  And some jurisdictions don’t test because carfentanil apparently has not infiltrated their community.

 “If we are missing the drugs then we are missing the source of the drug and the potential to get at that source whether that's just from a law enforcement distribution kind of perspective or a prosecution perspective,” Dr. Vega said. “And it also means we're not getting a full understanding of what the additional problem is that's out there.”

Yet Dr. Vega suspects that even when medical experts do test for the drug they’re not getting the full story.

“I think it's fair to say whatever numbers we have for carfentanil locally or statewide or nationally, they're underestimates because there's no question there are cases we are missing either because we don't have the resources to do the testing in certain cases or cases fall under the radar.”