CLEVELAND — The nation's opioid addiction crisis has largely been considered a problem for white people, many of whom have fallen prey to abuse of prescription painkillers and have migrated to fentanyl and heroin, often in rural areas such as Appalachia.
But in the communities around this Ohio metropolis on the southern shore of Lake Erie, there is evidence of a disturbing turn: Last year, 58 of Cuyahoga County's 399 fatal fentanyl overdoses were African Americans, killed by a synthetic opioid that is now responsible for almost two-thirds of the county's overall deadly overdoses. Officials believe the introduction of fentanyl and carfentanil — an extremely powerful animal tranquilizer — into the cocaine sold in the region is responsible for the rise in black overdose deaths.
That black overdoses in the Cleveland area are surging is a shocking outlier in the epidemic, alarming county medical examiner Thomas Gilson so much that he highlighted the deaths when testifying at a Senate hearing in May.
"The covert introduction of fentanyl into the cocaine supply has caused a rapid rise in fatalities, and in 2017, the rate of African American fentanyl related deaths has doubled from 2016," Gilson said.
Overdose deaths have been on the rise overall in Cuyahoga, and they are now seeing a major surge again, with a total of 43 fatal overdoses since Memorial Day, the medical examiner's office said Wednesday. But the rise in fentanyl-related deaths among black drug users has been particularly stunning, with a nearly 900 percent increase from 2014 to 2016.
Six African Americans in Cuyahoga died from fentanyl-related overdoses in 2014, and the toll was 24 in 2015. In 2016, 58 black people died from fentanyl-related drug use, and through the first half of this year, 50 have died. Gilson expects to see more than 125 victims by year's end.
Cuyahoga County's 52 municipalities include Cleveland and a host of suburbs, with a population of more than 1.2 million. The Cuyahoga River, which runs through the city's center, has defined the racial composition of the county: blacks live to the east while whites went west. The new drug trend is hitting African American neighborhoods on Cleveland's east side, as well as in relatively middle-class municipalities.
U.S. Rep. Marcia L. Fudge, a Democrat who represents parts of Cleveland and its east-side suburbs, recently reintroduced a bill in Washington that aims to break the addiction she has seen ravaging her district, with a focus on funding for treatment. As she sees hundreds of her constituents overdosing, she believes talking about the problem isn't enough.
"We have to find a way to get some control over the sales of fentanyl" and "find out where it's coming from," Fudge said in an interview, noting that many people — especially in black communities — don't know what the drug is or that it could be laced into other drugs. "We have to start to educate people . . . who are less educated about the drugs, who have less resources and who tend to be treated at a lower rate."
Cleveland, which is predominantly African American, is now experiencing the spikes in overdoses that have dogged the majority white suburbs, said former police chief William M. Denihan, who also is chief executive of the county's Alcohol, Drug Addiction and Mental Health Services Board, which coordinates mental health, addiction and recovery services.
"We always looked at this as a Cleveland suburb problem," Denihan said. "But now the numbers are reversing themselves."
The most common journey to opioid addiction begins when users get hooked on a prescription drug. When pills becomes too costly or inaccessible, abusers look for a substitute they can purchase on the illicit market.
"It's more predictable to see somebody transition from oxycodone to heroin to fentanyl because they have similar effects," Gilson said. "If you're addicted to opioids and your biggest determinant is economics, whatever one of those three is cheapest is probably what you're going gravitate towards."
But that's not the pathway black overdose victims are following. Gilson believes drug dealers have been lacing their cocaine product with opioids, creating something that will attract new customers and addict them, sustaining their sales. Gilson said the county's African Americans are more likely to use cocaine than heroin, which he believes explains the sudden surge in overdoses.
In 2016, pure cocaine killed 85 people, 49 of whom were African Americans. Heroin killed 72 people, six of whom were black.
"According to our latest data, cocaine deaths by themselves are the only deaths where we have a majority of African Americans. All of the other deaths that we're seeing, the majority is white," Gilson said. "I think it's very reasonable for drug dealers to say, 'We have this untapped market that is something we could reach out into with fentanyl as well.' "
Mixing an opioid with cocaine isn't new, said Ted Parran, an addiction expert and the co-medical director of Rosary Hall, one of the county's oldest inpatient facilities for substance abusers. He noted the cocaine and heroin combination known as "speed balls" that gained popularity in the 1990s.
"During previous opiate epidemics, dealers began to tell people to use cocaine with your opiates, and that way, you'll get the opiate high, but the cocaine will kick in and you'll get the euphoria of the stimulant," Parran said.
Authorities believe dealers are adding fentanyl to cocaine for that very reason, because it makes the drug's effects stronger and addicts want the strongest version they can buy. Imprecision in the mix — or a user being unfamiliar with the new version of the drug — can be fatal.
The new cocaine-fentanyl mix is inherently deadlier than the cocaine-heroin mix from decades past because fentanyl is 50 to 100 times more potent than heroin, and carfentanil is 100 times more potent than fentanyl, according to the National Institute on Drug Abuse and the Drug Enforcement Administration. And just a tiny amount of the powerful opioids can be catastrophic.
"If a person is buying $10 worth of heroin, and there are the equivalent of 10 grains of salt worth of carfentanil, there's a good chance that the user is going to have an overdose," Parran said.
Parran said it makes sense that the medical examiner was the first to notice how cocaine and fentanyl were being combined because recovering cocaine addicts usually submit to a toxicology screen that would overlook fentanyl.
"The patient who thinks they just have cocaine problem, they get a tox screen that shows cocaine, but is negative for opiates," he said. "Heroin shows up, but fentanyl, you have to check for because it disappears so fast."
He and others fear overdose rates will skyrocket while the county tries to get its arms around this new aspect of its addiction crisis.
"We're losing the game. We're not winning this war," Denihan said. "We have to stop and look at everything we're doing and try to make it significantly different."