Abstract
Illicit heroin and fentanyl are infecting North Carolina's communities, and causing an increasing number of overdose deaths. These trends in drug trafficking and opioid misuse represent a dramatic shift, necessitating a new and coordinated law enforcement response. The North Carolina Attorney General's Office is committed to working toward increased enforcement, prevention, and treatment to address this epidemic.
Every day, at least 4 North Carolinians die of an accidental drug overdose, the majority of which are caused by opioids, including prescription painkillers such as OxyContin and illicit opioids such as heroin and fentanyl [1]. How are these drugs making their way to our state? Who is responsible? What can we do to try to address the largest public health and safety crisis North Carolina has ever faced? These are the questions that North Carolina's law enforcement community must address every day. As destructive as prescription opioid addiction is, a greater danger lies in the increasing reliance on illicit narcotics to feed the addiction of those who suffer from opioid use disorder. Heroin and fentanyl are killing our citizens at an alarming rate, largely because the average user does not know what exactly they are ingesting. Much has been written about overuse, misuse, and diversion of prescription opioids, but to fully understand the scope of this problem, and the law enforcement response, it is important to understand the origins of heroin and fentanyl trafficking—both in the United States and in North Carolina.
The History of Heroin and Fentanyl in the US
For many years, doctors have used opioids to treat pain, and people have sometimes become addicted to them. Whether doctors prescribed morphine, laudanum, or heroin itself, the medical use of opioids, and their potential for misuse, is not new. After Purdue Pharma began aggressively marketing OxyContin and the medical community universally recognized pain as the 5th vital sign [2], however, the abuse of prescription opioids dramatically increased. When those who misused prescription opioids could no longer afford them, or sought a more powerful drug to satisfy the intense cravings that accompany opioid use disorder, they began to turn more and more frequently to heroin.
Initially, Americans sourced almost all heroin from southern Asia [3]. Over the past two decades, however, the heroin market has changed dramatically. Most of the heroin that we now see on our streets is South American, and increasingly, Mexican [3]. For a long time, Colombian drug trafficking organizations had the corner on the heroin market [4]. West of the Mississippi River, law enforcement primarily encountered black tar and brown powder heroin from Latin America, while east of the Mississippi the trend was toward white powder [4].
By 2014, 79% of the heroin seized and analyzed by the DEA was Mexican white powder [5]. Mexican cartels, which had well-established transportation routes for marijuana and cocaine trafficking, now turned their focus toward the increasingly lucrative heroin trafficking business [3, 4, 5]. The Mexican cartels began to coordinate trafficking with the South American heroin producers, and also began to produce their own white powder heroin [3, 4, 5]. Today white powder heroin markets in the northeast are the largest and most lucrative and are dominated by the Mexican cartels [4, 5]. Mexican traffickers are the most prevalent source for the heroin market in New Jersey (see Figure 1) which, in turn, is the source of supply for most of the white powder heroin in North Carolina (Atlanta-Carolinas High Intensity Drug Trafficking Area 2018 Strategy, unpublished data, 2018).
Where 7 Mexican Drug Cartels are Active Within the US
The purity of heroin has dramatically increased over the past 3 decades. In the 1980s, heroin purity was approximately 10%, but by 2000, it had increased to almost 40% [5]. At the same time, the price of heroin began to decrease—from over $3,200 per gram in 1981, to just over $600 per gram in 2012 [5]. Figures 2 and 3 show this ratio has remained the same and is at the root of today's heroin epidemic [5].
Heroin Today is Much Higher in Purity and Lower in Price
Heroin misuse has also become more prevalent because the method of use has changed. Traditionally, heroin had to be injected, but because the newer formulations are more easily snorted or smoked, heroin appeals to a larger number of users (Atlanta-Carolinas High Intensity Drug Trafficking Area 2017 Threat Assessment, unpublished data, 2017). Without the stigma often associated with injection, heroin is now used by the young and the old, the suburban and the rural, the wealthy and the poor, and people of all races.
Over the past several years, drug traffickers have begun to cut their heroin with synthetic opioids such as fentanyl to increase the high and decrease the cost [4]. Because fentanyl and white powder heroin look alike, users often do not know that the heroin they have purchased contains fentanyl [5]. This can prove deadly, because it removes the user's ability know the potency of the drug and prevents them from correctly dosing in keeping with an established tolerance level.
Pharmaceutical fentanyl (transdermal patches or lozenges) can be diverted and misused, but there is growing concern over clandestinely produced fentanyl, which is responsible for the increasing number of overdose deaths in the United States [7]. Fentanyl analogues (types of fentanyl) and precursors (chemicals used to make fentanyl) are illicitly manufactured in Chinese labs and then sold on the dark web—the part of the World Wide Web that is only accessible by means of special software, allowing users and website operators to remain anonymous or untraceable. Once ordered on the dark web, drugs are shipped in bulk to the United States and Mexico, where they are used to cut heroin (Atlanta-Carolinas High Intensity Drug Trafficking Area 2017 Threat Assessment, unpublished data, 2017). The anonymity and decreased exposure to law enforcement interdiction make the use of the dark web a preferred method of fentanyl trafficking (Atlanta-Carolinas High Intensity Drug Trafficking Area 2018 Strategy, unpublished data, 2018).
Similarly, non-pharmaceutical fentanyl is increasingly being manufactured in Mexico and transported into the United States via well-established Mexican drug trafficking routes. It is also used to cut heroin with the same result. Because fentanyl and its derivatives are much more potent than heroin, it increases the high that users are able to obtain (Atlanta-Carolinas High Intensity Drug Trafficking Area 2017 Threat Assessment, unpublished data, 2017). Additionally, fentanyl is much cheaper to produce than heroin because it can be manufactured in a laboratory, rather than grown on a farm. Thus, like heroin, an increase in purity and a decrease in price have led us to a very dangerous crossroads.
Heroin and Fentanyl Trafficking in North Carolina
North Carolina is home to 4 of the 25 American cities where opioid abuse is the worst, including number one: Wilmington. Fifty-eight percent of opioid deaths involve heroin, fentanyl, or fentanyl analogues [1]. Beginning in 2014, and sharply increasing in 2015, heroin traffickers across the country began to cut their heroin supply with fentanyl (Atlanta-Carolinas High Intensity Drug Trafficking Area 2017 Threat Assessment, unpublished data, 2017). In North Carolina, law enforcement is not only seeing heroin cut with fentanyl, but also seeing cocaine and methamphetamine being cut with fentanyl, and bulk fentanyl being sold as heroin. This is especially problematic given the potency of fentanyl when compared to heroin and has led to an increase in overdose deaths across the state. Law enforcement officers project that this trend will continue because of the increasingly varied users and the large number of persons addicted to prescription opioids switching to heroin.
It is not just the composition of heroin that is problematic in North Carolina. The diverse transportation routes across the state make it very easy for drug traffickers to move their product. Much of the heroin that we see in North Carolina comes through the distribution hub of Atlanta via Interstate 85. Increasingly, however, Mexican cartels are transporting the heroin directly to the eastern part of the state via Interstate 95. Traffickers mainly use low-level organization members who travel by personal vehicle, equipped with hidden compartments—or “traps”—to store the drugs. In addition, North Carolina has 452 airports and 2 deep-water international ports used by traffickers to move their product.
Clandestinely produced fentanyl and its analogues originate in China. Once in the United States, heroin traffickers in New Jersey package heroin and fentanyl into “bindles,” “bundles,” and “bricks,” and ship them to North Carolina for re-sale. A “bindle” is a glassine baggie that is generally marked with a batch stamp. A “bindle” is one tenth of a gram, a “bundle” is usually 10 bindles, and a “brick” usually contains 50 “bundles.” Because the heroin arriving in North Carolina is pre-packaged for sale, North Carolina drug traffickers do not know the chemical composition of their product, causing users to accidentally overdose from their inability to properly gauge tolerance to quantity. Once a user overdoses on a particular “brand” of heroin it is commonly labeled as “fire,” and others flock to that dealer so that they can obtain the same high. While a gram of heroin typically sells in North Carolina for $125 to $175, heroin cut with fentanyl sells for $60 to $120 per gram. This illustrates 2 problems: First, the combination of heroin and fentanyl—which produces a greater high—is cheaper for users to obtain. Second, by cutting heroin with fentanyl, drug traffickers can stretch their heroin supply and obtain a larger profit. The increase in demand, coupled by the increase in supply, has contributed to the large and growing number of opioid overdose deaths in our state (Atlanta-Carolinas High Intensity Drug Trafficking Area 2017 Threat Assessment, unpublished data, 2017).
What Can Law Enforcement Do About This Problem?
No more than 5 years ago, law enforcement conversations centered on bulk cocaine shipments and methamphetamine labs. Now, we are faced with a growing number of deaths and an endless supply of illicit opioids flooding our state.
This abrupt shift has changed the way we approach drug trafficking investigations. First and foremost, these investigations have become a danger to our officers. Traditionally, after seizing narcotics as a part of an ongoing investigation, law enforcement would conduct a field test of the substance to make a presumptive determination of content—cocaine, methamphetamine, heroin, or another substance. Now, however, because of the lethality of fentanyl and the inability to visibly distinguish it from other narcotics, law enforcement officers must consider other factors, conduct additional investigation, and take a more comprehensive look at their cases before charging the defendant with a crime.
Investigations now center upon the dark web, and members of law enforcement are forced to look for ways to circumvent the anonymizing software that shields traffickers' locations. Law enforcement must also adapt to investigations that have no boundaries. Opioids affect every subset of our society. Traditional drug investigation techniques will not work in an opioid death investigation, just as traditional homicide techniques will not be enough to ferret out the source of supply responsible for killing an opioid overdose victim. We must work together to create a new normal so that we can adequately protect our citizens and hold accountable those who promote and profit from this epidemic.
The shift in law enforcement focus has also necessitated creative partnerships and solutions to try to stem the tide of the opioid epidemic. Now, more than ever, law enforcement is partnering with community groups, nonprofits, and treatment providers to try to attack this problem from all angles. It is not a problem that we can arrest our way out of. We must create a coordinated approach with a strong focus on enforcement, prevention, and treatment to ensure the continued vitality of our North Carolina communities. The North Carolina Department of Justice is committed to this fight, and we ask all of you to join us.
Acknowledgments
Potential conflicts of interest. L.C.D. has no relevant conflicts of interest.
- ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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