Teenagers and young adults have an ages-old tradition of experimenting with illicit drugs, including cocaine, heroin, methadone, a variety of opioids, and more. It has always been dangerous, and in many cases deadly, but law enforcement and the medical community are reporting an alarming new trend. Overdose deaths have doubled in Colorado during the past decade, from 12.3 a year for every 100,000 residents to nearly 25 in 2020 — the last year for which we have federal data. That compares with 21.6 deaths per 100,000 residents throughout the rest of the United States. The soaring death rates track with a trend of teenagers and young adults from all socioeconomic backgrounds dying upon their first experimentation, long before developing substance abuse disorders. Physicians and law enforcement tell of a massive infusion into Colorado and the rest of the United States of the deadly synthetic opioid fentanyl. They say China is flooding the market and using Mexican drug cartels to smuggle fentanyl into the United States. The drug is easy to produce, cheap, and deadly in doses measured in micrograms.

The Gazette’s editorial board met last week to discuss the crisis with Dr. Vikhyat “Vik” Bebarta, M.D. — an emergency physician, medical toxicologist, award-winning military physician and professor of pharmacology at the University of Colorado School of Medicine, Anschutz Medical Campus in Aurora. Dr. Bebarta routinely saves and attempts to save fentanyl overdose victims and shared with us his observations and insights.

The Gazette: Doctor, in 2019 the Legislature passed a bill that reduced from a felony to a misdemeanor the possession of schedule 1 and 2 drugs. Basically, you get something like a traffic ticket for possession of hard narcotic drugs, including fentanyl. This drug is measured in micrograms and milligrams. Are you familiar with this law? If so, how has that affected your practice?

Dr. Bebarta: I am familiar with that law generally, and clearly we’re in a state of crisis. Four grams, as you said, is a misdemeanor, including 4 grams of fentanyl. As physicians, we give 200 micrograms to a patient. And that’s a big dose for pain. That’s 0.2 milligrams. Four grams is enough to kill a lot of people. So that’s not a trivial dose. Four grams of marijuana or methamphetamines may not be a big deal, but 4 grams of fentanyl is a tremendous amount. The significant increase in overdoses this last year, almost all of those are opioid overdoses and a far majority of the opioid overdoses involve fentanyl. We’re seeing a major increase in fentanyl-related doses, overdoses and deaths specifically, which is by far the majority of all the deaths around drug overdoses in Colorado and across the country.

The Gazette: You treat, and sometimes save patients who present in crisis after overdosing on fentanyl. It’s hard to imagine anyone would do this willfully. How does this happen?

Dr. Bebarta: There are multiple common circumstances. Story one would be a young, 20-year-old student who may have been out with friends and been to a party and was given a pill by a friend or family members and told it’s one thing. They took it and it wasn’t what that thought. It wasn’t Xanax, or oxycodone, or a common pain pill. It was a lethal dose of fentanyl. They took the pill, went unconscious and then were found by a friend. Sometimes they are given Narcan in the field and that can help a little bit. Then they’re brought to the emergency department. Some of those pills contain other things, including sedatives.

Case two is someone who may use pain pills on occasion and is being seen by a doctor for chronic pain. They fall short of medication, or maybe their pain is worse that day and they get medication from a friend or a family member or someone else. They think it’s oxycodone or some other pain pill, they take it because of their chronic pain or cancer pain, but it’s something someone got on the street and is laced with a high dose of fentanyl.

The third case is someone we see commonly as well. That’s someone who takes pain pills chronically in some way. Some are in a program of rehab where they’re getting buprenorphine or methadone, some are not. They have the same scenario. They take a pill, which they think is a pain pill. In this case, they have substance abuse disorders. So, they’re trying. They are abusing it or trying to take it to relieve the withdrawal symptoms. They unknowingly take a pill laced with fentanyl, they become blue, unconscious, and almost die. They get rescued and get to the emergency department where we try to save them. I would say folks dying from this fit mostly into one of the three categories. 

The Gazette: Where is all this fentanyl coming from? 

Dr. Bebarta: It’s almost always from China, commonly coming into the United States through Mexico. It is also mailed to people who then decide to sell fentanyl tablets. And now it’s basically democratized. These dealers don’t need to have a trailer or a kitchen like they do to make methamphetamine. They don’t need to bring it across on airplanes from South America. They can make it and package it in our communities and sell it easily and discreetly. 

The Gazette: There have always been people on the street looking for opioids. That’s why we had a heroin crisis. But heroin does not kill in doses of micrograms. It must take highly skilled pharmaceutical lab professionals to get the dose right for legitimate medical applications of fentanyl. I’m guessing a lot of drug dealers aren’t trying to kill anyone, but they don’t know how to measure the small doses that can kill. 

Dr. Bebarta: That’s absolutely right, and, again, a lot of these people overdosing were merely getting a tablet or pill from a friend. They’re told it is Xanax, oxycodone, hydrocodone, codeine, Tylenol 3, or maybe even methamphetamine, ecstasy, or cocaine and it happens to have a lot of fentanyl and they stop breathing. The person giving them the drug got it on the street, or through some non-medical channel, and they don’t know it contains fentanyl. There really is no safe dose of illicit fentanyl.

The Gazette: So, this stuff must be cheap and abundant or they wouldn’t be putting it in everything. It sounds like a filler, almost. Who is doing this in China, and why? Who are the responsible parties creating this massive supply?

Dr. Bebarta: As a physician, I don’t know, but that’s a good question. It’s well reported that it’s coming through with and in collaboration with Mexican cartels. It’s flooding the country, not just Colorado, even though we have a significant rise in our deaths statewide from fentanyl. Why is it predominantly originating in China? I don’t know. But, as I mentioned, it is tied into the general democratizing of drug abuse. It’s sort of the Uberization of selling drugs, where anybody in any community can easily do it. It’s easy to obtain fentanyl and it’s easy to distribute it quickly. One doesn’t need a meth cook. They get the drug and in a small batch, which is, as we’ve discussed, a lot. They can get a lot of the drug cheaply and easily transport and distribute it.

The Gazette: Fentanyl is considered a synthetic opioid, is that correct? Does that mean that it is not actually an opium derivative, and it doesn’t require a plant-based origin, it’s all made in a lab? Is that what that means?

Dr. Bebarta: Absolutely. That’s right. If you’re making tequila, you got to do it with agave plants over a certain amount of time. You’re sort of controlled by that. But if you make something synthetically, you can just and crank it out as much as possible. There’s no natural control, there’s no duration of waiting for something to grow. In fact, there are really no rules or anything about making fentanyl.

The Gazette: You know, in a conversation with Gov. Jared Polis the other day we suggested he and the Legislature should not have downgraded the penalties for schedule 1 and 2 narcotics. For example, the 2019 legislation made this all a misdemeanor. He seemed to agree that this is no longer a drug abuse issue. This is something that is a public health threat in a different way than traditional drug abuse It almost seems more like Anthrax than a recreational drug. I mean, are we now looking at something that is a public health threat in a whole new way?

Dr. Bebarta: I do a lot of research on chemical threats and do a lot of policy direction with that, but I’ll speak just from open-source information on this. Opioids are obviously a threat of substance abuse, a threat of these singular deaths of people who take it unknowingly. But fentanyl is a concern as a threat like, as you said, anthrax. It’s a chemical threat or a public health threat for intentional use against a number of people. This is just again open-access information… There’s a threat generally that fentanyl could be used as a chemical threat to a community on American soil.

The Gazette: How about the water supply? Is fentanyl water soluble?

Dr. Bebarta: Yes. It could threaten the water supply as well. It has to be a contained water supply. Like if I dumped it into the city of Aurora’s water supply, it would be so diluted you would not have an effect. But if I entered it into a water supply, it somewhat contained to a house or building, it could kill. You could create some significant effects from that, or from aerosolizing it.

The Gazette: We used to hear about people going postal. You’re mad at your former employer, for example, and shoot the place up. You could more easily pollute the water cooler with fentanyl. You could hurt or kill a bunch of current or former co-workers with this drug?

Dr. Bebarta: That’s exactly right. There has been some publicly reported information on using an arsenic campaign at a wedding. Everyone drank it and was contaminated. Luckily, they didn’t die. It would be easy to pollute a water pitcher or a coffee mug with fentanyl. And because it’s so potent and you need such a small amount that you could kill a small group of people very easily, so there is a national security threat. Again, it’s so easy to get, it’s so easy to aerosolize. It’s easy to put in a coffee pot or water container or lemonade pitcher.

The Gazette: As a practicing physician who tries to save people who come into your trauma center looking blue, you must have to deal with families in the waiting room when a loved one doesn’t make it. What is this like for you and the survivors of these fentanyl victims?

Dr. Bebarta: I can give you dozens of examples. I just had a high school student who was at a park with a couple of friends, and he took a tablet. I’m not sure what he thought it was, but it came from a friend. He was quickly unconscious, stopped breathing. Someone gave him Narcan or naloxone to reverse most of the effects. Unfortunately, he was unconscious for several minutes and stopped breathing so he did not fully wake up. So even though he was young, and they got to him quickly, he was unconscious and not breathing for a long time. And so, he ended up having a brain injury he will live with forever. Any of our kids from good families could choose to make a bad decision that involves taking just one tablet or pill.

The Gazette: We hear there’s quite an epidemic of Adderall abuse among medical students because it helps with academic performance. This could show up in an Adderall pill you are taking to help ace a test. Right?

Dr. Bebarta: Yes, absolutely.

The Gazette: How much more serious is this than our previous drug nightmares, which were heroin, crack, methamphetamines, and such? I mean, if you got addicted to pain medication as a teenager or a young adult because you had an injury or something and your supply runs out, then you go out and you get black tar heroin or something like that on the street. How much worse is this?

Dr. Bebarta: Heroin, as we know, is natural. You also have a little bit of a limit on how much supply you can make because of where it originates from. It’s easier to distribute a nice white powder that can mix in any tablet. Fentanyl is far more potent than heroin. You buy five tablets, spread them out, and give them to five buddies. Now we’ve got a problem.

The Gazette: How urgent is it for the Legislature and governor to resolve this problem? We’ve talked to a lot of law enforcement from all around the state and all have told us that their hands are tied on this issue because they can’t arrest people for possession of fentanyl.

Dr. Bebarta: I’m not law enforcement, so I don’t know the exact rules of who they can arrest and keep behind bars. But the fact is, data show the numbers are just skyrocketing. And that’s just up through 2020. They’ve been going up since then. It’s a hockey stick curve now, and we’ll see that when we get numbers for 2021 and ’22. It’s going straight up, doubling and tripling at times.

The Gazette: When COVID began spreading in 2020 it was hard to find anyone who knew a COVID patient. Now everybody knows a COVID patient. Almost everybody knows someone who has died from this disease. Is that where we’re going with the fentanyl epidemic? Are we all going to know somebody who lost a kid or a young adult?

Dr. Bebarta: I hope not. I hope we can get some of this fixed. I hope through many layers of effort we rescue a lot of patients if they come to us. We always talk about when someone’s falling off a bridge into a river and dying. I can pull them out of the river. But it would be nice if we could fix the hole on the bridge, so they don’t keep falling through it. So, we need to stop fentanyl from coming in and stop the use of it. That would be helpful rather than us having to give Narcan, which doesn’t always work. And, even when we get patients breathing again it doesn’t mean they can be normal again.

The Gazette: We saw a report yesterday of an illegal crossing on the southern border. An individual, when searched, was carrying large amounts of pills. You mentioned that these pills are currency. Would that be accurate that somebody may be coming across the border only able to carry what they can carry on their person? If they have a large amount of fentanyl, then that would be valuable on the street. I think they said that this person had about $80,000 to $100,000 worth of fentanyl on him.

Dr. Bebarta: Yes, so it’s a currency you can sell, buy, and trade. As we mentioned, since it’s so potent, just a small amount that can go a long way. It’s like platinum. A small amount of fentanyl can be sold for whatever the cost is at the time, $15, $30, $45 a pill that adds up quickly with a small amount of the drug. Whereas most other drugs require a large amount of the drug to get any meaningful amount of money.

The Gazette: Do you think this crisis is really connected to the pandemic and the isolation and the kind of despair that has overwhelmed people at this time? Or do you think that that’s basically just an excuse? We blame everything on the pandemic. You know, it’s like even people blame their poor choices and finances. They’re not going to the doctor when they’re not feeling well. It has become a catch-all excuse.

Dr. Bebarta: It’s a little bit of both. There’s been a general rise in opioid deaths and abuse and that’s because substance abuse is related to stress, anxiety, and isolation. They probably do have a relationship. But the fentanyl abuse trend was going up before the pandemic. Someone put their foot on the gas during the pandemic, and it’s going to continue after it. From a national security perspective, from a death perspective, the fentanyl line is going up, It’s unequivocally related to the pandemic. But the fentanyl piece is just taking off, even probably beyond the pandemic proportionately.

The Gazette: Thank you for taking so much time with the editorial board. This may e the most important public policy issue we have right now in Colorado, probably nationwide, but certainly here. We are grateful for your work