DRUG THREAT ASSESSMENT
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- 3. UNCLASSIFIED UNCLASSIFIED 2018NationalDrugThreatAssessment Drug Enforcement Administration This product was prepared by the DEA Strategic Intelligence Section. Comments and questions may be addressed to the Chief, Analysis and Production Section, at DEAIntelPublications@usdoj.gov.
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- 5. i 2018 National Drug Threat Assessment UNCLASSIFIED UNCLASSIFIED TABLE OF CONTENTS Letter from the Acting Administrator ...............................................................................iii Executive Summary .............................................................................................................v Controlled Prescription Drugs ............................................................................................1 Heroin .................................................................................................................................11 Fentanyl and Other Synthetic Opioids .............................................................................21 Cocaine...............................................................................................................................39 Methamphetamine .............................................................................................................59 Marijuana ............................................................................................................................77 NewPsychoactiveSubstances(NPS)...............................................................................89 Transnational Criminal Organizations ..............................................................................97 Gangs ...............................................................................................................................107 Illicit Finance ...................................................................................................................123 Puerto Rico and the U.S. Virgin Islands ...........................................................................131 Guam ................................................................................................................................135 Tribal Lands ......................................................................................................................137 Appendix A: Additional Tables ..........................................................................................140 Appendix B: Twenty-Three DEA Field Divisions ............................................................144 Appendix C: National Drug Threat Assessment Scope and Methodology .......................145 Appendix D: Acronym Glossary ........................................................................................146
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- 7. iii 2018 National Drug Threat Assessment UNCLASSIFIED UNCLASSIFIED LETTER FROM THE ACTING ADMINISTRATOR I am pleased to present the 2018 National Drug Threat Assessment (NDTA), a comprehensive, strategic assessment of the illicit drug threats posed to our communities. The NDTA was produced in partnership with local, state, tribal, and federal agencies. It integrates reporting from law enforcement, intelligence, and public health agencies to provide timely, strategic drug-related intelligence to formulate counterdrug policies. Further, it helps law enforcement personnel, educators, and prevention and treatment specialists establish priorities and allocate resources. The trafficking and abuse of illicit drugs poses a severe danger to our citizens and a significant challenge for our law enforcement and health care systems. Through robust enforcement, public education, prevention, treatment, and collaboration with our partners, we can protect our citizens from dangerous drugs and their dire consequences. Thank you to our partners for their contributions to this report. Your input continues to help us meet the needs of the law enforcement, intelligence, prevention, and treatment provider communities as well as shape counterdrug policies. My colleagues and I at DEA look forward to collaborating on future strategic counterdrug initiatives that impact our national security interests, at home and abroad. Respectfully, Uttam Dhillon Acting Administrator Drug Enforcement Administration
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- 9. v 2018 National Drug Threat Assessment UNCLASSIFIED UNCLASSIFIED EXECUTIVE SUMMARY Figure 1. Number of Injury Deaths by Drug Poisoning, Suicide, Homicide, Firearms, and Motor Vehicle Crashes in the United States, 1999 – 20152 Source: Centers for Disease Control and Prevention 1 Analyst Note: The information in this report is current as of August 2018. 2 Drug overdose deaths are identified using ICD-10 underlying cause-of-death codes X40-X44, X60-X64, X85, and Y10-Y14. Drug overdose deaths involving selected drug categories are identified using ICD-10 multiple cause-of- death codes: heroin, T40.1; natural and semisynthetic opioids, T40.2; methadone, T40.3; synthetic opioids other than methadone, T40.4; cocaine, T40.5; and psychostimulants with abuse potential, T43.6. Categories are not mutually exclusive because deaths may involve more than one drug. Also, not all states report death data the same or at all to the Centers for Disease Control and Prevention (CDC), meaning nationwide counts of drug overdose deaths, especially deaths by a specific drug(s), may vary from statewide counts. As a result, CDC has stated the true number of drug overdose deaths is almost certainly much higher than the numbers officially reported. The 2018 National Drug Threat Assessment (NDTA)1 is a comprehensive strategic assessment of the threat posed to the United States by domestic and international drug trafficking and the abuse of illicit drugs. The report combines federal, state, local, and tribal law enforcement reporting; public health data; open source reporting; and intelligence from other government agencies to determine which substances and criminal organizations represent the greatest threat to the United States. Illicit drugs, as well as the transnational and domestic criminal organizations who traffic them, continue to represent significant threats to public health, law enforcement, and national security in the United States. Drug poisoning deaths are the leading cause of injury death in the United States; they are currently at their highest ever recorded level and, every year since 2011, have outnumbered deaths by firearms, motor vehicle crashes, suicide, and homicide. In 2016, approximately 174 people died every day from drug poisoning (see Figure 1). The opioid threat (controlled prescription drugs, synthetic opioids, and heroin) has reached epidemic levels and currently shows no signs of abating, affecting large portions of the United States. Meanwhile, as the ongoing opioid crisis justly receives national attention, the methamphetamine threat remains prevalent; the cocaine threat has rebounded; new psychoactive substances (NPS) are still challenging; and the domestic marijuana situation continues to evolve.
- 10. 2018 National Drug Threat Assessment vi UNCLASSIFIED UNCLASSIFIED Controlled Prescription Drugs (CPDs): CPDs are still responsible for the most drug-involved overdose deaths and are the second most commonly abused substance in the United States. As CPD abuse has increased significantly, traffickers are now disguising other opioids as CPDs in attempts to gain access to new users. Most individuals who report misuse of prescription pain relievers cite physical pain as the most common reason for abuse; these misused pain relievers are most frequently obtained from a friend or relative. Heroin: Heroin use and availability continue to increase in the United States. The occurrence of heroin mixed with fentanyl is also increasing. Mexico remains the primary source of heroin available in the United States according to all available sources of intelligence, including law enforcement investigations and scientific data. Further, significant increases in opium poppy cultivation and heroin production in Mexico allow Mexican TCOs to supply high-purity, low-cost heroin, even as U.S. demand has continued to increase. Fentanyl and Other Synthetic Opioids: Illicit fentanyl and other synthetic opioids — primarily sourced from China and Mexico—are now the most lethal category of opioids used in the United States. Traffickers— wittingly or unwittingly— are increasingly selling fentanyl to users without mixing it with any other controlled substances and are also increasingly selling fentanyl in the form of counterfeit prescription pills. Fentanyl suppliers will continue to experiment with new fentanyl-related substances and adjust supplies in attempts to circumvent new regulations imposed by the United States, China, and Mexico. Cocaine: Cocaine availability and use in the United States have rebounded, in large part due to the significant increases in coca cultivation and cocaine production in Colombia. As a result, past-year cocaine initiates and cocaine-involved overdose deaths are exceeding 2007 benchmark levels. Simultaneously, the increasing presence of fentanyl in the cocaine supply, likely related to the ongoing opioid crisis, is exacerbating the re-merging cocaine threat. Methamphetamine: Methamphetamine remains prevalent and widely available, with most of the methamphetamine available in the United States being produced in Mexico and smuggled across the Southwest Border (SWB). Domestic production occurs at much lower levels than in Mexico, and seizures of domestic methamphetamine laboratories have declined steadily for many years. Marijuana: Marijuana remains the most commonly used illicit drug in the United States. The overall landscape continues to evolve; although still illegal under Federal law, more states have passed legislation regarding the possession, use, and cultivation of marijuana and its associated products. Although seizure amounts coming across the SWB have decreased in recent years, Mexico remains the most significant foreign source for marijuana available in the United States. Domestic marijuana production continues to increase, as does the availability and production of marijuana-related products. New Psychoactive Substances (NPS): The number of new NPS continues to increase worldwide, but remains a limited threat in the United States compared to other widely available illicit drugs. China remains the primary source for the synthetic cannabinoids and synthetic cathinones that are trafficked into the United States. The availability and popularity of specific NPS in the United States continues to change every year, as traffickers experiment with new and unregulated substances. Mexican Transnational Criminal Organizations (TCOs): Mexican TCOs remain the greatest criminal drug threat to the United States; no other group is currently positioned to challenge them. The Sinaloa Cartel maintains the most expansive footprint in the United States, while Cartel Jalisco Nueva Generacion’s (CJNG) domestic presence has significantly expanded in the past few years. Although 2017 drug-related murders in Mexico surpassed previous levels of violence, U.S.-based Mexican TCO members generally refrain from extending inter-cartel conflicts domestically.
- 11. vii 2018 National Drug Threat Assessment UNCLASSIFIED UNCLASSIFIED Colombian TCOs: Colombian TCOs’ majority control over the production and supply of cocaine to Mexican TCOs allows Colombian TCOs to maintain an indirect influence on U.S. drug markets. Smaller Colombian TCOs still directly supply wholesale quantities of cocaine and heroin to Northeast and East Coast drug markets. Dominican TCOs: Dominican TCOs dominate the mid-level distribution of cocaine and white powder heroin in major drug markets throughout the Northeast, and predominate at the highest levels of the heroin and fentanyl trade in certain areas of the region. They also engage in some street-level sales. Dominican TCOs work in collaboration with foreign suppliers to have cocaine and heroin shipped directly to the continental United States and its territories from Mexico, Colombia, Venezuela, and the Dominican Republic. Family members and friends of Dominican nationality or American citizens of Dominican descent comprise the majority of Dominican TCOs, insulating them from outside threats. Asian TCOs: Asian TCOs specialize in international money laundering by transferring funds to and from China and Hong Kong through the use of front companies and other money laundering methods. Asian TCOs continue to operate indoor marijuana grow houses in states with legal personal-use marijuana laws and also remain the 3,4-Methylenedioxymethamphetamine (MDMA, commonly known as Ecstasy) source of supply in U.S. markets by trafficking MDMA from clandestine laboratories in Canada into the United States. Gangs: National and neighborhood-based street gangs and prison gangs continue to dominate the market for the street-sales and distribution of illicit drugs in their respective territories throughout the country. Struggle for control of these lucrative drug trafficking territories continues to be the largest factor fueling the street-gang violence facing local communities. Meanwhile, some street gangs are working in conjunction with rival gangs in order to increase their drug revenues, while individual members of assorted street gangs have profited by forming relationships with friends and family associated with Mexican cartels. Illicit Finance: TCOs’ primary methods for laundering illicit proceeds have largely remained the same over the past several years. However, the amount of bulk cash seized has been steadily decreasing. This is a possible indication of TCOs’ increasing reliance on innovative money laundering methods. Virtual currencies, such as Bitcoin, are becoming increasingly mainstream and offer traffickers a relatively secure method for moving illicit proceeds around the world with much less risk compared to traditional methods.
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- 13. 1 2018 National Drug Threat Assessment UNCLASSIFIED UNCLASSIFIED CONTROLLED PRESCRIPTION DRUGS (CPDS) OVERVIEW Controlled Prescription Drug (CPD)3 abuse, specifically of opioid analgesics4 has been linked to the largest number of overdose deaths in the United States every year since 2001. Deaths related to CPDs, cocaine, psychostimulants with abuse potential,5 and heroin all continue to rise (see Figure 2); however, 2016 was the first year deaths from synthetic opioids (other than methadone), the category that includes fentanyl, has been higher than deaths from other illicit drugs. According to the Centers for Disease Control and Prevention (CDC), opioids — which include prescription opioids and heroin— represented 66 percent of the approximately 64,000 fatal drug overdoses in 2016. This equated to nearly 116 opioid overdose deaths per day. Abuse of CPDs has lessened in some areas, although the number of individuals reporting current use of CPDs is still more than those reporting use of cocaine, heroin, and methamphetamine. AVAILABILITY Drug Enforcement Administration (DEA) reporting shows high CPD availability in cities throughout the United States (see Figure 3). Thirteen of DEA’s Field Divisions (FD) reported that CPD availability was high during 2017. While most FDs reported availability Figure 2. Drug Overdose Deaths Involving Selected Drugs, 2009-2016. Source: National Center for Health Statistics/Centers for Disease Control and Prevention6 3 Controlled prescription drugs (CPDs) includes, but is not limited to narcotics (e.g. Vicodin, OxyContin), depressants (e.g. Valium, Xanax), stimulants (e.g. Adderall, Ritalin), and anabolic steroids (e.g. Anadrol, Oxandrin). 4 Opioid analgesic overdose deaths include deaths from natural and semi-synthetics: codeine, morphine, oxycodone, hydrocodone, and methadone. 5 Psychostimulants with abuse potential: include such drugs as methamphetamine, amphetamine, methylphenidate (Ritalin), and 3, 4-methylenedioxy-methamphetamine (MDMA, ecstasy). 6 The CDC drug poisoning death category “medications” was formerly “prescription drugs” but was changed for two reasons: (1) the category includes Over-The-Counter drugs, and (2) in December 2015 the National Center for Health Statistics changed the definition to include “..other and unspecified narcotics” which slightly increased the numbers.
- 14. UNCLASSIFIED CONTROLLEDPRESCRIPTIONDRUGS(CPDS) UNCLASSIFIED 2 Opioids accounted for four out of the seven top controlled prescription drugs distributed nationwide at the retail level (hospitals, pharmacies, practitioners, treatment programs, and teaching institutions) by number of dosage units from 2009 to 2017 (see Figure 4). Over the past nine years, hydrocodone and oxycodone products were the opioid prescription drugs most widely sold in dosage units at the retail level. In addition, two stimulants, amphetamines and methylphenidate (i.e., Ritalin), have maintained a continued and established presence over the years. Buprenorphine, an addiction therapeutic used to treat opioid dependence, replaced methadone in the top seven in 2017. The amount of prescription opioids available on the legitimate market remains significant. DEA data from the Automation of Reports and Consolidated Orders System (ARCOS) indicates the amount of opioid CPDs legitimately distributed to retail level purchasers peaked in 2011, at 17.2 billion dosage units, and has since remained below that amount, with 12.6 billion dosage units manufactured and distributed in 2017. Of the 12.6 billion prescription opioid dosage units sold to retail level purchasers in 2017, 79 percent were oxycodone and hydrocodone products (see Figure 5). was stable at high levels compared to the previous reporting period, the Miami and San Diego FDs reported more availability than the previous year. The Phoenix FD reported availability as moderate and leveled off as stable. Possible reasons for this include the high availability of heroin and counterfeit prescription pills, as well as Arizona’s proximity to the border, where individuals can drive across and purchase pharmaceuticals from pharmacies in Mexico. Heroin and counterfeit pills made from illicitly manufactured fentanyl and fentanyl-related compounds have entered into the drug supply, attracting unwary CPD users with lethal consequences, as synthetic opioid overdoses significantly increased in 2016. 7 Two new DEA Field Divisions, Louisville and Omaha, were opened in 2018, making 23; however, at the time the Field Divisions were surveyed for availability in 2017, there were 21. Figure 3. DEA Field Division Reporting of CPD Availability in 2017 and Comparison to Previous Period. Field Division Availabillity During First Half of 2017 Availabillity Compared to Second Half of 2016 Atlanta Field Division High Stable Caribbean Field Division Moderate Stable Chicago Field Division High Stable Dallas Field Division High Stable Denver Field Division Moderate Stable Detroit Field Division High Stable El Paso Field Division Moderate Stable Houston Field Division High Stable Los Angeles Field Division High Stable Miami Field Division High More New England Field Division High Stable New Jersey Field Division Moderate Stable New Orleans Field Division High Stable New York Field Division Moderate Stable Philadelphia Field Division High Stable Phoenix Field Division Moderate Stable San Diego Field Division High More San Francisco Field Division High Stable Seattle Field Division High Stable St. Louis Field Division High Stable Washington Field Division High Stable Source: DEA Field Division Reporting7
- 15. UNCLASSIFIED CONTROLLEDPRESCRIPTIONDRUGS(CPDS) UNCLASSIFIED 3 Figure 4. Top Controlled Prescriptions Drugs Sold to Domestic Retail Level Purchasers in Billions of Dosage Units, 2009-2017. Source: Automation of Reports and Consolidated Orders System, DEA Figure 5. All Opioid CPDs Compared to the Number of Hydrocodone and Oxycodone Prescription Drugs Sold to Retail Level Purchasers in Billions of Dosage Units, 2008-2017. Source: DEA
- 16. UNCLASSIFIED CONTROLLEDPRESCRIPTIONDRUGS(CPDS) UNCLASSIFIED 4 PRESCRIPTION DRUG MONITORING PROGRAMS Prescription Drug Monitoring Programs (PDMPs) continue to be among the most promising state- level intervention mechanisms to improve opioid prescribing and dispensing, inform clinical practice, and protect patients at risk. As of April 2018, all 50 states, Washington, DC, and Guam have active PDMPs tracking in-state prescriptions. These programs, designed to track the prescribing and dispensing of controlled prescription drugs to patients, can give a prescriber or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help prescribers and pharmacists identify patients at high-risk who would benefit from early intervention. Additionally, law enforcement officials can utilize PDMPs to identify practitioners and registrants that are prescribing and dispensing illegitimately for no valid medical purpose. The funding and operational oversight varies by state. Some states have measures and specific practices in place to allow interstate sharing of information. DEA’S NATIONAL PRESCRIPTION DRUG TAKE-BACK DAY Held twice each year, collection sites are provided by DEA to offer an anonymous, safe, responsible way to dispose of unneeded prescription medication. In April 2018, DEA conducted its 15th National Prescription Drug Take-Back Day at 5,842 collection sites across the country, collecting 949,046 pounds, almost 475 tons, of unused, expired, or unwanted medication. Since this program began in September 2010, 9.9 million pounds of unwanted prescription and over-the-counter drugs, which could have potentially been diverted on the street, have been removed from medicine cabinets, kitchen drawers, and nightstands voluntarily by citizens around the country. ABUSE Abuse levels of CPDs remains high, as CPDs are the second most commonly abused substance after marijuana (see Figure 6). There were 18.6 million people aged 12 or older who misused prescription psychotherapeutic drugs in 2016. This number included 11.5 million who misused pain relievers8 in the previous year, and 6.2 million past month users (see Figure 6). Due in part to the large number of people who abuse licit CPDs, other opioids are now being disguised and sold as CPDs, as traffickers look to gain access to new users (see Heroin and Fentanyl Sections). • In February 2018, DEA San Diego arrested one individual and seized a pill press machine capable of manufacturing 10,000 counterfeit pharmaceutical pills and MDMA tablets. A search of a gym locker used by the defendant resulted in the seizure of a pistol with a silencer, a loaded magazine, approximately 8,000 Xanax pills and ¼ pound of cocaine. Monitoring the Future (MTF) survey data for 2017 showed a decrease in adolescent trends for past year prescription narcotics9 — or CPD—abuse. MTF reported 11 percent of the 12th grade students surveyed reported misusing prescription drugs, down one percent from the previous year. There was also a 0.5 percent decrease in past month prescription drug use among 12th graders. There is no information available on admissions to privately funded treatment facilities; however, according to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Treatment Episode Data Set (TEDS), there were 8 Pain relievers include hydrocodone, oxycodone, tramadol, fentanyl, oxymorphone, hydromorphone, morphine, meperidine, buprenorphine, and methadone. 9 Prescription narcotics abuse includes use of any of the following: amphetamines, sedatives (barbiturates), narcotics other than heroin, or tranquilizers “…without a doctor telling you to use them.”
- 17. UNCLASSIFIED CONTROLLEDPRESCRIPTIONDRUGS(CPDS) UNCLASSIFIED 5 Figure 6. Number of Past Month, Nonmedical Users of Psychotherapeutic Drugs Compared to Other Select Drugs of Abuse, 2010-2016.10,11,12 Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health Figure 7. Number of Admissions to Publicly Licensed Treatment Facilities, by Primary Substance, 2015. Source: Treatment Episodes Data Set 10 Cocaine includes crack cocaine. 11 Prescription psychotherapeutics includes pain relievers, tranquilizers, stimulants, or sedatives, and does not include over-the-counter drugs. 12 Trend analysis on the National Survey on Drug Use and Health prescription psychotherapeutic drugs and methamphetamine abuse only dates to 2015 due to the redesign of the question in 2015.
- 18. UNCLASSIFIED CONTROLLEDPRESCRIPTIONDRUGS(CPDS) UNCLASSIFIED 6 124,943 treatment admissions to publicly- funded facilities for non-heroin opiates/ synthetic abuse14 in 2015, the latest year for which data is available (see Figure 7). The number of non-heroin opiate treatment admissions peaked in 2011 and has decreased steadily since then. This decline can in part be attributed to some CPD abusers switching to heroin or other illicit opioids. A relatively small percentage of CPD abusers, when unable to obtain or afford CPDs, begin using heroin as a cheaper alternative offering similar opioid- like effects. As the CPD abuser population is approximately seven times larger than the heroin user population, CPD abusers transitioning to heroin or other synthetic opioids represent a significant portion of the people who initiate use of these substances. Other reasons for the decline in admissions could include the success of PDMPs, pill abusers seeking treatment at private facilities, increased efforts from law enforcement and public health entities, and corresponding increases in overdose deaths of non-heroin opioid abusers. The 2016 National Survey on Drug Use and Health (NSDUH) report indicates Figure 8. Workplace Positive Drug Tests for Select Prescription Drugs13 . Source: Office of National Drug Control Policy/Quest Diagnostics Drug Testing Index approximately 1.7 million people aged 12 or older were current misusers of prescription stimulants. Of those, approximately 92,000, or 5.4 percent of this population, were aged 12 to 17. The prescription stimulant category includes amphetamine and methylphenidate products that are prescribed for the treatment of attention deficit hyperactivity disorder (ADHD) among other conditions. These schedule II products are marketed under the brand names Adderall, Dextrostat, Vyvanse, Ritalin and Dexedrine. This survey data coincides with the popular reputation of nonmedical use of amphetamines on campuses as study-aids to improve concentration, rather than something harmful or addictive. The number of hydrocodone and hydromorphone users testing positive in the work place has decreased since 2014. One contributing factor in this trend is the rescheduling of hydrocodone combination products to Schedule II in October 2014. Positive oxycodone and oxymorphone work place test results have remained steady at less than one percent for the past two years (see Figure 8). 13 Data for hydrocodone and hydromorphone were not provided for April 2017. The percentages for March 2017 and May 2017 were averaged and included for April 2017. 14 Non-heroin opiates/synthetics include buprenorphine, codeine, hydrocodone, hydromorphone, meperidine, morphine, opium, oxycodone, pentazocine, propoxyphene, tramadol, and any other drug with morphine-like effects.
- 19. UNCLASSIFIED CONTROLLEDPRESCRIPTIONDRUGS(CPDS) UNCLASSIFIED 7 Figure 9. Reasons for Misuse of Prescription Pain Relievers Among Past Year Users Aged 12 or Older; Percentage of Responses. Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health DIVERSION According to the 2016 NSDUH, 62.3 percent of the population aged 12 or older who reported misuse of pain relievers, cited relief of physical pain as the most common reason for that misuse. Misuse of prescribed pain relievers occurs when these substances are used by someone other than for whom they were intended, or else used in a manner other than prescribed. Other popular reasons for misuse included to get high and to relieve tension (see Figure 9). The average age of first misuse of prescription pain relievers among past year initiates was 25.8 years. The majority of survey respondents who reported misusing prescription pain relievers stated a variety of means by which they obtained them. Fifty-three percent said they were “given by, bought from, or took from a friend or relative.” Of these misusers, 40.4 percent got their most recently used prescription pain relievers “from a friend or relative for free” while the remainder either bought or took them from a friend or relative without asking (see Figure 10). Another 37.5 percent said they got them through prescriptions or stole them from a doctor’s office, clinic, hospital, or pharmacy. Of those, 35.4 percent said their prescription came from a single doctor, while 1.4 percent said their prescription came from more than one doctor. Frequent or chronic users were more likely than others to primarily obtain prescription pain relievers from a drug dealer or stranger. The percentage of opioid narcotics unaccounted for is small, although this amount still totaled more than nine million dosage units, or less than one percent of the nearly 13 billion dosage units sold to retailers in 2017 (see Figure 11). The
- 20. UNCLASSIFIED CONTROLLEDPRESCRIPTIONDRUGS(CPDS) UNCLASSIFIED 8 Figure 11. Number of Dosage Units of Opioid Narcotics Lost, 2010 - 2017 In Millions. 2010 2011 2012 2013 2014 2015 2016 2017 Opioids 12.5 19.4 13.1 11.6 12.4 9.8 9.6 9.1 Source: DEA Figure 12. Total Number of Prescription Drug Armed Robberies, 2010 - 2017. 2010 2011 2012 2013 2014 2015 2016 2017 Armed Robbery 771 712 801 738 836 871 833 875 Source: DEA number of opioid narcotics distributed to retail level purchasers, in billions of dosage units, and the number of dosage units of opioid narcotics reported lost from the DEA Drug Theft and Loss Database15 peaked in 2011, and have continued to decrease. 15 The DEA Drug Theft and Loss Database compiles information on armed robberies, customer theft, employee pilferage, CPDs lost in transit, and night break-ins at analytical labs, distributors, exporters, hospitals/clinics, importers, manufacturers, mid-level practitioners, pharmacies, practitioners, researchers, reverse distributors, and teaching institutions. The Drug Theft and Loss Database is a live database, meaning all reported numbers are subject to change. Figure 10. Source Where Pain Relievers Were Obtained for Most Recent Misuse Among Past Year Users Aged 12 or Older, 2016. Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health According to the DEA Drug Theft and Loss Database, the total number of prescription drug armed robberies, which resulted in the loss of a variety of prescription medications, has fluctuated but increased overall since 2010 (see Figure 12).
- 21. UNCLASSIFIED CONTROLLEDPRESCRIPTIONDRUGS(CPDS) UNCLASSIFIED 9 Figure 13. Top Ten States Reported with Increases/Decreases in Armed Robberies, 2014 – 2017. Source: DEA In 2017, Washington state experienced a 200 percent increase in the number of armed robberies from the previous year. The high street price of cough syrup with codeine was a contributing factor. Texas and Wisconsin each experienced 100 percent increases, although at 12 robberies, Wisconsin has seen a significant decrease since 2015. Moreover, Iowa, California, and Ohio all experienced nearly double the number of armed robberies than the previous year. California reported the highest number of armed robberies at 270, a 71 percent increase from the year before. Indiana experienced 168 prescription drug armed robberies in 2015, but saw significant decreases in 2016 and 2017, with 78 and 24 armed robberies respectively (see Figure 13). In addition to armed robberies, loss of CPDs also occurs through customer theft, employee pilferage, and burglary, as well as losses in transit. Between 2016 and 2017, incidents of employee pilferage and nighttime break- ins increased in 25 states, Washington, DC, and Puerto Rico. The greatest percentage of increases in employee pilferage in 2017 occurred in Washington, DC; South Dakota; Delaware; Wyoming; Arkansas; and Puerto Rico. The incidents of customer theft decreased in all but ten states. The overall trend of incidents of CPDs being “lost in transit” decreased in 2017. “Lost in transit” describes controlled substances being misplaced while being moved from one point to another within the supply chain. In 2017, 22 states experienced increases in the number of incidents occurring, with the greatest increases occurring in Wisconsin, Nebraska, Mississippi, Wyoming, Idaho, and New Jersey. Wisconsin experienced a significant increase for the third straight year, accounting for nearly one third of the total 15,882 lost in transit incidents reported nationwide (see Figure 14). It is unclear if these dosage units are being diverted, destroyed, or truly lost. ECONOMIC IMPACT OF PRESCRIPTION DRUG ABUSE The economic impact of prescription drug abuse is significant. These costs are carried by the public sector in increased health care, substance abuse treatment, and criminal justice costs. The costs associated with prescription opioid abuse represent a substantial and growing economic burden for society. The increasing prevalence
- 22. UNCLASSIFIED CONTROLLEDPRESCRIPTIONDRUGS(CPDS) UNCLASSIFIED 10 of abuse suggests an even greater societal burden in the future, manifesting in increases in emergency department admissions and costs associated with first responders in overdose events. In addition to health care costs, the productivity of a worker is greatly reduced when the worker abuses drugs, including CPDs, due to absenteeism and decreased participation in the work force. An employed person who is a current drug user is twice as likely to skip one or more work days a month, and is also more likely to miss two or more days due to illness or injury when compared to non-drug users. Unscrupulous physicians, pharmacists, and doctor shoppers add to the health care burden in the United States. • In July 2017, a Vermont doctor was charged with prescription fraud and Medicaid fraud. The doctor authorized prescriptions for controlled substances utilizing personal information from patient records, and then diverted the substances for personal use. • In March 2018, DEA San Diego arrested a physician and seven co- conspirators who were responsible for distributing hundreds of thousands of hydrocodone tablets to the community. The physician issued at least 16 separate prescriptions for hydrocodone to seven patients who were deceased. • In April 2018, an Indiana medical office assistant was charged with prescription fraud and possession of a controlled substance. In addition to utilizing fraudulent prescriptions, the assistant paid for them utilizing unwitting patient’s insurance information. OUTLOOK CPD availability and abuse will continue to pose a significant drug threat to the United States as demonstrated by the increase in overdose deaths. Diversion will likely become more difficult due to the implementation of legislation and successful law enforcement efforts that have proven effective. Increased awareness in the medical community, restrictions placed on opioid prescriptions, and successful prescription drug monitoring programs and data sharing will be contributing factors. With the successful reduction in availability of controlled prescription drugs, more users may shift to abusing heroin and other cheaper, easier-to- obtain opioids that produce similar effects for users of prescription drugs. Figure 14. Wisconsin Controlled Prescription Drugs Lost in Transit Incidents, 2014-2017. Source: DEA
- 23. 11 2018 National Drug Threat Assessment UNCLASSIFIED UNCLASSIFIED HEROIN OVERVIEW The United States continues to face a crisis involving heroin use. The use of heroin has grown at an alarming rate and the death toll increases each year. According to the most recent overdose death statistics, in 2016 there were 15,469 heroin-related deaths in the United States, a 19 percent increase from 2015. Rates of deaths involving heroin increased in almost all U.S. Census regions from 2006 to 2016. Mortality statistics indicate that individuals from every demographic use heroin, and deaths attributed to heroin have been increasing every year since 2010. The increase from 2015 to 2016 may be driven in part by increases in the heroin supply and by the use of fentanyl related substances as an adulterant to heroin. Mexican TCOs continue to dominate the heroin market in the United States by controlling the supply, trafficking, and wholesale distribution of heroin. They control smuggling routes across the SWB and they arrange the transport and distribution of heroin throughout the United States. Mexican TCOs work with U.S. based gangs and other drug trafficking organizations who distribute the drugs at the regional and local levels. AVAILABILITY Heroin is readily available in the United States and is sold in various forms; fine powder, sticky tar, granular or chunky, gummy/pasty, pills, or a rock-like black substance that shatters like glass. Powder heroin sold in the United States varies in color and can be smoked, snorted or injected. The cutting agents used may contribute to its color and appearance. All of DEA’s Field Divisions reported that heroin is available in their areas of responsibility. Availability ranges from moderately available to highly available (see Figure 15). DEA reporting continues to indicate that there is ample supply to meet the demand of heroin users. Figure 15. DEA Field Division Reporting of Heroin Availability in the First Half of 2017 and Comparison to Previous Period. Field Division Availabillity During First Half of 2017 Availabillity Compared to Second Half of 2016 Atlanta Field Division High Stable Caribbean Field Division Moderate Stable Chicago Field Division High Stable Dallas Field Division Moderate Stable Denver Field Division Moderate More Detroit Field Division High Stable El Paso Field Division Moderate Stable Houston Field Division Moderate More Los Angeles Field Division High Stable Miami Field Division High More New England Field Division High Stable New Jersey Field Division High Stable New Orleans Field Division High More New York Field Division High Stable Philadelphia Field Division High More Phoenix Field Division Moderate Stable San Diego Field Division Moderate Stable San Francisco Field Division Moderate More Seattle Field Division High Stable St. Louis Field Division High More Washington Field Division High More Source: DEA Field Division Reporting16 16 Two new DEA Field Divisions, Louisville and Omaha, were opened in 2018, making 23; however, at the time the Field Divisions were surveyed for availability in 2017, there were 21.
- 24. UNCLASSIFIED HEROIN UNCLASSIFIED 12 Figure 16. Domestic Heroin Purchases, January 2013 - December 2016. Source: DEA According to the analysis of price and purity information derived from drug undercover purchased exhibits sent to the DEA laboratories, from January 2016 through December 2016, the price per pure gram (PPG) for heroin increased 5.5 percent, from $855 to $902 while the purity level averaged 33 percent, a slight dip from the prior years (see Figure 16). For the past several years, there has been a steady fluctuation in PPG until October 2015, when the PPG dropped substantially to $667 from $820 while purity levels remained about the same. In 2016, prices began an upward trend, while purity levels remained relatively stable. Heroin PPG data, unlike cocaine PPG and methamphetamine PPG, show a different pattern related to the price and purity of the drug. For both cocaine and methamphetamine, the PPG decreased as purity levels increased (see Cocaine and Methamphetamine sections). The reasons for this anomaly may be due to demand. Heroin is a highly addictive drug, which contributes to enabling suppliers to keep their prices at a steady level while meeting demand. The DEA Special Testing and Research Laboratory classify seized exhibits of heroin based upon the source area of the world where the heroin originates, the method of production and type of heroin. The source of origin classifications are: MEX/T (Mexican tar), MEX/BP (Mexican brown powder), MEX- SA (Mexican white powder), SA (Colombian white powder), SWA (Southwest Asia), SEA (Southeast Asia) and Inconclusive South American (INC-SA). INC-SA is white powder heroin processed using the South American method but unable to be sourced to Mexico or Colombia. The 2016 Heroin Signature Program (HSP) reports findings from the analysis of 744 samples, representing 1,632 kilograms of heroin. Heroin from Mexico accounted for 86 percent of the heroin by weight analyzed through the HSP in 2016. Heroin classified as INC-SA accounted for ten percent; SA heroin accounted for four percent; and SWA heroin accounted for less than one percent (see Figure 17). The HSP also identifies purity levels for heroin sold at the wholesale level. White powder heroin from Mexico had average purity levels as high as 82 percent through
- 25. UNCLASSIFIED HEROIN UNCLASSIFIED 13 Figure 17. Source of Origin for the United States Wholesale-Level Heroin Seizures, 2000-2016. Source: DEA 2016. MEX/T ranged from 34 percent to 43 percent. White powder heroin purity at the wholesale level exceeded purity at the retail level where the highest average purity level observed did not exceed 34.1 percent in 2016. Purity levels for the other classifications ranged from 26 percent to 47 percent. The DEA Heroin Domestic Monitor Program (HDMP) collects and analyzes price and purity data of heroin sold at the retail level. The HDMP collects data on the geographic origin, price, purity, adulterants, and diluents of heroin sold at the street-level in major metropolitan areas of the United States. The source origin and type purchased under the HDMP provide a snapshot of the heroin sold in these cities to identify local user preference and availability. HDMP purchases in 2016 revealed that MEX-SA and MEX/T were the most prominent types of heroin in the U.S. retail markets. Of the heroin exhibits analyzed under the HDMP, the overall average purity of Mexican heroin was 31 percent (see Figure 18). The source of origin for retail level purchases in the eastern part of the United States remained consistent with prior years. In the eastern HDMP cities, white powder heroin was sold in all cities along with MEX/BP (see Figure 19). Black tar heroin (MEX/T) was sold in the 12 western cities that participated in the HDMP, and there was little to no white powder heroin (see Figure 20). INC-SA, white powder where the origin cannot be determined was sold in all HDMP cities. Four (4) exhibits of SWA heroin purchased on the East Coast under the HDMP; however, the presence of this form is rare. From the late 1990’s until 2014, Colombian sourced heroin was the most prominent form of heroin available in the U.S. Since 2015 most of the heroin sold in the U.S. is from Mexico. The form of heroin purchased is generally due to user preference, with all forms available in the western cities: brown powder, white powder and tar, and only the powder form (no tar) in the east.
- 26. UNCLASSIFIED HEROIN UNCLASSIFIED 14 Figure 18. Source of Origin and Purity for Retail-level Heroin Purchases in U.S. Cities, 2016. Source: DEA Figure 19. Source of Origin for Retail-level Heroin Purchased in Eastern U.S. Cities, 2006-2016. Source: DEA
- 27. UNCLASSIFIED HEROIN UNCLASSIFIED 15 Figure 20. Source of Origin for Retail-level Heroin Purchased in Western U.S. Cities, 2006 - 2016. Source: DEA Sixty-one percent of those admitted for treatment reported that they used additional substances. CDC drug overdose data for 2016 indicates that there were 15,469 drug poisoning deaths involving heroin,17 a 21 percent increase over the 12,989 heroin-involved overdose deaths in 2015 (see Figure 23). The states that lead the nation for heroin- related deaths (approximately 1,000 or more) were Ohio, New York, Illinois, and Pennsylvania. Almost all jurisdictions that reported heroin-related deaths showed an increase, with the highest rates of increase occurring in Washington D.C., West Virginia, and Ohio. All states and jurisdictions— with the exception of Wyoming, Montana, South Dakota, and Nebraska— reported age- adjusted overdose death rates18 (see Figure 24). In 2016, Washington, DC experienced the highest age-adjusted rate of heroin- related deaths at 17.3 per 100,000, followed by West Virginia (14.9) and Ohio (13.5). Further analysis of 2016 HDMP exhibits indicate that out of 667 heroin exhibits analyzed, 158 (11%) were found to contain fentanyl and/or fentanyl-related substances, which is an increase from 2015 (see Figure 21). The increase in the exhibits that contain fentanyl and/or fentanyl- related substances coincides with DEA reporting that indicates that the popularity of fentanyl-related substances as an adulterant is expanding. USE The heroin user population in the United States continues to grow and results from national-level treatment data and statistical death data indicate heroin availability is increasing. TEDS reporting indicates that, between 2005 and 2015, the number of admissions to publicly funded facilities for primary heroin abuse increased by 54 percent, from 260,902 to 401,743 admissions (see Figure 22). Heroin admissions in 2015 increased 26 percent over the prior year. Young adults (aged 20-34) comprised the largest group admitted for heroin treatment. 17 No overdose deaths were reported in Wyoming, Montana, South Dakota or Nebraska. 18 CDC excluded overdose death reporting for these states.
- 28. UNCLASSIFIED HEROIN UNCLASSIFIED 16 Figure 22. Heroin Admissions by Year and Age, 2005 - 2015.19 Source: Treatment Episode Data Set 19 Census population estimate data on age, gender, and race/ethnicity are currently not available for Puerto Rico; therefore, the totals reflected in Figure 22 exclude primary heroin admissions in Puerto Rico. Figure 21. Cities with Heroin Exhibits that Contained Fentanyl or Fentanyl-Related Substances, 2016 Heroin Domestic Monitor Program. Source: DEA
- 29. UNCLASSIFIED HEROIN UNCLASSIFIED 17 Figure 23. Heroin Deaths in the United States, 2006 –2016. Source: Office of National Drug Control Policy/Centers for Disease Control and Prevention Nationwide the rates of drug overdose deaths involving heroin increased to 4.9 per 100,000 population from 4.1 in 2015. Heroin-involved overdose deaths increased across all Census regions from 2015 to 2016, with some of the largest increases occurring in the Northeast and the South (see Figure 25). The Northeast reported a 24.84 percent increase in heroin-related deaths and the South showed a 22.06 percent increase over the prior year. In 2016, the Census regions reported heroin-related deaths per 100,000 population: Northeast (7.9), Midwest (7.1), South (3.8) and West (2.7). The West reported a 10.45 percent increase and the Midwest reported a 15.36 percent increase over the prior year. In 2014, the gap in heroin-related overdoses occurring in the Northeast and Midwest began to close when both regions reported similar death rates. The South and the West had less than half the number of deaths in 2014 and deaths continue to trend upwards at the same pace. National-level survey data results indicate that use remains high and stable. According to NSDUH, in 2016 an estimated 948,000 people aged 12 or older used heroin in the past year. The estimate of past year heroin users in 2016 was similar to the estimates in 2014 and 2015. About 475,000, approximately 0.2 percent of the population aged 12 or older, were current heroin users in 2016, also similar to the 2015 estimates. In 2016, less than 0.1 percent (3,000) of adolescents aged 12 to 17 were current heroin users, approximately the same rate since 2007. Among young adults aged 18 to 25 in 2016, 0.3 percent (88,000) were current heroin users. In 2016, 0.2 percent (383,000) of adults aged 26 or older were current heroin users. The percentage of young adults in 2016 who were current heroin users was similar to the percentages in 2015. The percentage of adults aged 26 or older in 2016 was also similar to the percentages in 2014 and 2015. In 2016, 0.1 percent (13,000) of adolescents aged 12 to 17 were past year users. This percentage was slightly lower than the percentages in 2015. Among young adults aged 18 to 25 in 2016, 0.7 percent (227,000) were past year heroin users. This percentage was similar to the percentages in 2015. In 2016, 0.3 percent (708,000) of adults aged 26 or older were past year heroin users. This percentage was similar to the percentages in 2015. According to the 2017 MTF, the prevalence of reported heroin use among 8th, 10th and 12th graders has been declining since 2009. Survey respondents view heroin as one of the most dangerous drugs. In 2016, prevalence of reported use reached its lowest levels in all three grades (0.3%) with little change in 2017. There has been
- 30. UNCLASSIFIED HEROIN UNCLASSIFIED 18 Figure 24. Age Adjusted Heroin Deaths in the U.S. by Census Region, 2016. Source: Office of National Drug Control Policy/Centers for Disease Control and Prevention little fluctuation in the very high levels of disapproval of heroin use over the years, though it did rise gradually between 2000 and 2010. Perceived availability of heroin among 8th, 10th, and 12th graders has declined since the 1990s, and has been level since 2014. The percentage of 12th grade students who stated that heroin is “fairly easy” or “very easy” to obtain has remained at approximately 20 percent since 2009. PRODUCTION Four geographic source areas produce the world’s heroin supply: South America, Mexico, Southwest Asia, and Southeast Asia. Southwest Asia, while the dominant producer represents a very small portion of the U.S. heroin market. Southeast Asian heroin is rarely encountered in U.S. markets. In 2017, heroin from Mexico accounted for 91 percent (by weight) of the heroin analyzed through the DEA’s HSP. Heroin from South America accounted for most of the remainder with less than one percent by weight from Southwest Asia. The annual United States Government estimate of Mexican Poppy Cultivation and Heroin Production found poppy cultivation reached a record high in 2017. Poppy cultivation in Mexico rose 38 percent, from 32,000 hectares in 2016 to 44,100 hectares in 2017. Similarly, potential pure heroin production increased by 37 percent, from 81 metric tons in 2016 to 111 metric tons in 2017. TRANSPORTATION AND DISTRIBUTION The SWB remains the primary entry point for heroin into the United States. Most of the heroin seized by CBP occurs along the U.S.- Mexico border near San Diego, California. In 2017, approximately 1,073 kilograms of
- 31. UNCLASSIFIED HEROIN UNCLASSIFIED 19 Figure 25. Heroin-Related Deaths by U.S. Census Region, 1999 - 2016 Age Adjusted Rates. Source: DEA Figure 26. Customs and Border Protection Heroin Seizures by Southwest Border Corridor in CY 2017, with Percent Change from CY 2016. Source: U.S. Customs and Border Protection heroin were seized in the San Diego corridor, a 59 percent increase over the total seized in 2016 (see Figure 26). A small percentage of all heroin seized by CBP along the land border was between Ports of Entry (POEs). The CBP San Diego sector reported the greatest amount of heroin seized of all non- POE land border seizures, followed by the Tucson sector. Mexican TCOs control the movement of heroin that enters the United States across the SWB, until it reaches its destination in cities all over the United States. The majority of the flow is through POVs entering the United States at legal ports of entry, followed by tractor-trailers, where the heroin is co-mingled with legal goods (see Figure 27). Body carriers represent a smaller percentage of heroin movement
- 32. UNCLASSIFIED HEROIN UNCLASSIFIED 20 Figure 27. Heroin Concealed in Privately Owned Vehicles, 2018. Source: U.S. Customs and Border Protection across the SWB and they typically smuggle amounts ranging from three to six pounds taped to their torso, or in shoes and backpacks. A very small percentage of the heroin seized by law enforcement enters through the Northern Border between the United States and Canada. Heroin is also seized on the ferry from the Dominican Republic to Puerto Rico. Heroin dealers in the United States vary from city to city, ranging from gang members to independent groups of every nationality. In the Northeast, street gangs and Dominican Drug Trafficking Organizations (DTOs) with direct ties to Mexican TCOs dominate the heroin trade. On the West Coast, Mexican TCOs and their gang affiliates dominate the heroin trade, and in Florida, Puerto Rican traffickers and Dominican DTOs are the largest heroin sources of supply. Heroin sourced to Mexico and Colombia is trafficked in New York predominately by Dominican DTOs. In Tennessee, African- American street gangs with ties to major cities like Atlanta or Chicago are responsible for heroin distribution in both urban areas and residential suburbs. In Philadelphia, Dominican DTOs with ties to Mexico have a strong presence. In Washington state, Mexican TCOs transport heroin into the area. OUTLOOK Heroin will remain a serious drug threat in the United States as heroin use and heroin availability increases. The flow of heroin into the United States from Mexico will easily meet the demands of an expanding heroin user population. Heroin-related overdose deaths will continue, partially due to the growing trend at the retail level of traffickers mixing fentanyl with heroin, which creates a higher risk of overdose to even the most experienced opioid users.
- 33. 21 2018 National Drug Threat Assessment UNCLASSIFIED UNCLASSIFIED FENTANYL AND OTHER SYNTHETIC OPIOIDS OVERVIEW Fentanyl is a Schedule II synthetic opioid20 approved for legitimate use as a painkiller and anesthetic. However, the drug’s extremely strong opioid properties make it an attractive drug of abuse for both heroin and prescription opioid users. Clandestinely produced fentanyl is trafficked into the United States primarily from China and Mexico, and is responsible for the ongoing fentanyl epidemic. In contrast, the diversion of pharmaceutical fentanyl in the United States occurs on a small scale, with the diverted fentanyl products being intended for personal use and street sales. Fentanyl continues to be smuggled into the United States primarily in powder or counterfeit pill form, indicating illicitly produced fentanyl as opposed to pharmaceutical fentanyl from the countries of origin. Fentanyl-containing counterfeit pills, along with other new preparations of the drug, demonstrate fentanyl continues to be marketed to new user markets. AVAILABILITY Fentanyl is widely available throughout the United States, with all DEA FDs reporting accessibility. Fentanyl is available in both its legitimate and illicit forms. Physicians prescribe legitimate fentanyl in the form of transdermal patches or lozenges. Fentanyl in these forms is diverted from the legitimate market, although on a smaller scale compared to clandestinely produced fentanyl. Illicitly produced fentanyl is synthesized in clandestine laboratories and typically distributed in a white powder form, to be mixed into heroin or pressed into counterfeit opioid prescription pills. Fentanyl’s availability is widespread and increasing, while also becoming more geographically diverse. Eleven out of 21 DEA FDs surveyed indicated fentanyl availability was “High” during the first half of 2017, meaning fentanyl was easily obtained at any time (see Figure 28). The other ten FDs were Figure 28. DEA Field Division Reporting of Fentanyl Availability in the First Half of 2017 and Comparison to Previous Period. Field Division Availabillity During First Half of 2017 Availabillity Compared to Second Half of 2016 Atlanta Field Division Moderate More Caribbean Field Division Low Stable Chicago Field Division High More Dallas Field Division Low More Denver Field Division Low Stable Detroit Field Division High More El Paso Field Division Low Stable Houston Field Division Low More Los Angeles Field Division High More Miami Field Division High More New England Field Division High More New Jersey Field Division Moderate More New Orleans Field Division High Stable New York Field Division Moderate More Philadelphia Field Division High More Phoenix Field Division High More San Diego Field Division Moderate More San Francisco Field Division Moderate More Seattle Field Division High More St. Louis Field Division High More Washington Field Division High More Source: DEA Field Division Reporting21 20 In this document, the phrase “synthetic opioid” refers to only those substances which are classified as opioids and have no plant-based material in their production (i.e. fentanyl, fentanyl-related substances, and other novel opioids) and therefore does not include heroin. 21 Two new DEA Field Divisions, Louisville and Omaha, were opened in 2018, making 23; however, at the time the Field Divisions were surveyed for availability in 2017, there were 21.
- 34. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 22 split evenly between reporting fentanyl as having either “moderate” or “low” availability. In addition, 17 out of the 21 FDs indicated fentanyl was “more” available compared to the second half of 2016, demonstrating fentanyl use is increasing across all parts of the United States. The other four FDs indicated fentanyl availability was “stable” compared to the second half of 2016, meaning no FD reported fentanyl availability as “less” in comparison to 2016. Fentanyl-related substances (FRS) are also increasingly becoming available throughout the United States. These substances are in the fentanyl chemical family, but have minor variations in chemical structure. These substances are typically sold as alternatives to, or substitutes for, fentanyl, but may also be sold as heroin or pressed into counterfeit prescription medications. Most of these substances are not approved for use in humans, so information about potency and lethal dosage are frequently unknown. Fentanyl continues to be the primary synthetic opioid available in the United States, while more FRS and other new opioids continue to be identified, according to DEA’s Emerging Trends Program. In CY 2017, there were 2,825 identifications of fentanyl, FRS, fentanyl precursors, and other new opioids based on exhibits seized and analyzed by DEA. Fentanyl accounted for approximately 66 percent, or 1,873 of the identifications (see Figure 29). Further, of the 1,873 fentanyl identifications, fentanyl was found as the only controlled substance in approximately 43 percent of the identifications and was found in combination with heroin in approximately 47 percent of the identifications. This indicates fentanyl at the retail level is still primarily tied to the opioid market as opposed to the markets for other common controlled substances, such as cocaine or methamphetamine. The overwhelming majority of fentanyl exhibits analyzed in the United States have been fentanyl in powder form, but fentanyl in counterfeit pill form still represents a significant public health risk and law enforcement challenge in the near term. As of September 2017, DEA had analyzed 583 kilograms of fentanyl powder compared to 17 kilograms of fentanyl in tablet form for CY 2017. However, simply comparing the total weights of each form of fentanyl seized does not provide an accurate representation of the threat posed by fentanyl in counterfeit pills. Figure 29. Identifications of Fentanyl, Fentanyl Related Substances, Fentanyl Precursors, and Other Synthetic Opioids, CY 2017. Source: DEA
- 35. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 23 According to the 2016 NSDUH, there were approximately 3.4 million current misusers of prescription pain relievers compared to 475,000 current heroin users. Traditionally, fentanyl was mixed with or sold as white powder heroin, which potentially limited the overall scope of the fentanyl user market. However, as traffickers have expanded into the sale of fentanyl-containing counterfeit pills, the scope of users who were exposed to fentanyl increased significantly; the prescription pain reliever misuser population is almost ten times that of the heroin user population. According to national estimates from the National Forensic Laboratory Information System (NFLIS), fentanyl represented approximately the same percentage of all reports of fentanyl and FRS reported between 2015 and 2016. In 2015, fentanyl represented 14,440 reports (84.59%) of the total 17,071 reports of fentanyl and FRS identified in NFLIS. For comparison, in 2016, fentanyl represented 34,204 reports (85.33%) of the total 40,083 reports of fentanyl and FRS identified. This demonstrates that fentanyl continues to be the most popular synthetic opioid available Figure 30. National Annual Estimates of Fentanyl and Fentanyl-Related Substances Reported in NFLIS, 2015-2016.22 Fentanyl and Fentanyl- Related Substances 2015 2016 Number Percent Number Percent Fentanyl 14,440 84.59% 34,204 85.33% Acetyl fentanyl 2,412 14.13% 1,669 4.16% Furanyl fentanyl 0 0.00% 2,273 5.67% Carfentanil 0 0.00% 1,100 2.74% 3-Methylfentanil 1 0.01% 427 1.07% Butyryl fentanyl 205 1.20% 93 0.23% Fluoroisobutyryl fentanyl 0 0.00% 82 0.20% p-Fluoroisobutyryl fentanyl 0 0.00% 76 0.19% p-Fluorobutyryl fentanyl 2 0.01% 72 0.18% Valeryl fentanyl 0 0.00% 52 1.13% Acryl fentanyl 0 0.00% 26 0.06% p-Fluorofentanyl 8 0.05% 5 0.01% o-Fluorofentanyl 0 0.00% 3 0.01% Beta-hydroxythiofentanyl 3 0.02% 0 0.00% ANPP 0 0.00% 1 0.00% Acetyl-alpha- methylfentanyl 1 0.01% 0 0.00% Alpha-methylfentanyl 0 0.00% 1 0.00% 4-Methoxy-butyryl fentanyl23 0 0.00% * * Source: DEA National Forensic Laboratory Information System 22 This table includes drugs submitted to laboratories from January 1, 2015 through December 31, 2016 that were analyzed within three months of the calendar year reporting period. 23 Estimates that do not meet NFLIS standards of precision and reliability are denoted with “*”.
- 36. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 24 in the United States, even as the total reports of fentanyl and FRS increase each year. Nevertheless, the number of fentanyl- related substance reports increased significantly between 2015 and 2016, as both more total exhibits of FRS were analyzed and more FRS were analyzed and confirmed for the first time. In 2015, seven FRS contributed to the 2,631 total FRS reports identified in NFLIS. However, in 2016, 12 total FRS combined for 5,879 reports identified, marking a 123 percent increase in total reports in one year (see Figure 30). In 2016, the most commonly identified FRS was furanyl fentanyl, with 2,273 identifications; previously, acetyl fentanyl was the most commonly identified FRS with 2,412 identifications. The most widely available FRS can vary from year to year depending on a combination of user feedback and international control efforts. According to DEA’s Fentanyl Signature Profiling Program24 (FSPP), in CY 2017, fentanyl seized and analyzed in the United States averaged 5.1 percent pure, based on analysis of approximately 520 fentanyl powder exhibits representing 960 kilograms. FSPP analysis indicated fentanyl available in the United States can range from 0.1 percent to 97.8 percent pure, depending on the source of the fentanyl. DEA and CBP reporting indicate the fentanyl shipped directly from China is typically seized in smaller quantities but with purities commonly testing above 90 percent. By comparison, fentanyl trafficked overland into the United States from Mexico is typically seized in larger, bulk quantities but with much lower purity, with exhibits on average testing at less than ten percent pure. As fentanyl has become more available in the United States, it has increasingly been seen in new and unique mixtures/cocktails. In 2017, one of the most widely reported and most dangerous of these mixtures was “gray death.” This drug cocktail reportedly contained different drugs depending on where in the country it was reported. Across all references to “gray death,”25 the cocktail is described as a mixture of illicit opioids with the appearance of concrete mix and gray in color. The consistency of the substance described varied, and ranged from a hard and chunky material to a finer powder used for snorting and inhaling smoke. According to the Southeast Florida Fusion Center, “gray death” was comprised of heroin, fentanyl, carfentanil, and U-47700. The “gray death” mixture has been reported in multiple states, to include: Alabama, Indiana, Georgia, Ohio, Pennsylvania, and possibly New York (see Figure 31). In powder form, “gray death” can go airborne, which could be harmful, or even fatal, to law enforcement officers; as such, police are cautioned to avoid field- testing suspected “gray death” and wear appropriate personal protective equipment (PPE). • Between February 2017 and May 2017, the Georgia Bureau of Investigation had received 50 overdose cases involving “gray death,” mostly from the Atlanta area. Samples of reported “gray death” seized from Georgia were a match to a sample submitted from Alabama. However, the amount of each ingredient present differed between the two cases. Additionally, some Georgia samples contained butyrylfentanyl and acrylfentanyl, while others had a completely different composition. • In May 2017, the Stuart Police Department in Stuart, Florida published an Officer Safety Alert about the possible appearance of “grey death.” During that month, officers received reports of a possible overdose in Jensen Beach. Two, possibly three, people took a drug they believed to be “grey death.” Two of the subjects suffered overdose effects and were hospitalized. No drugs were recovered. • In early March 2017, the DEA Buffalo Resident Office (RO) obtained 48 grams of suspected fentanyl, which appeared cement-gray in color (see Figure 32). This gray-colored fentanyl was linked to multiple drug overdose deaths in various states. As such, it is suspected, though unconfirmed, the gray fentanyl may be linked to 24 DEA’s FSPP performs in-depth chemical analyses on fentanyl and fentanyl-related exhibits obtained from seizures made throughout the United States. Analytical methodologies developed by DEA give in-depth reporting on seizures and also link seizures for intelligence purposes. FSPP data is not intended to reflect U.S. market share, but is rather a snapshot of current trends. 25 The spellings “gray death” and “grey death” are used interchangeably in this report to refer to the same ‘brand’ of illicit drug cocktail. Reporting from across the law enforcement community contains both spellings.
- 37. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 25 Figure 31. “Grey Death” in Chunky Rock Form. Source: Gulf Coast High Intensity Drug Trafficking Area Figure 32. Gray-Colored Fentanyl Obtained by DEA Buffalo. Source: DEA DEA EMERGENCY SCHEDULES FENTANYL- RELATED SUBSTANCES On November 9, 2017, the U.S. Department of Justice (DOJ) announced it was temporarily emergency scheduling all substances chemically related to fentanyl as Schedule I drugs under the Controlled Substances Act (CSA). This order, effective February 2018, signifies criminals who possess, import, distribute, or manufacture any FRS is subject to criminal prosecution in the same manner as for fentanyl and other controlled substances. Overseas chemical manufacturers, aided by illicit domestic distributors, currently attempt to evade regulatory controls by creating structural variants of fentanyl that are not directly listed under the CSA. This action will make it easier for law enforcement officers and federal prosecutors to arrest and prosecute traffickers of all forms of FRS without having to rely on the Analogue Act. “gray death.” The seized fentanyl was powdery in texture as opposed to the chunky texture described by other law enforcement agencies. Fentanyl available in the United States is often sold under the same or similar “brands” as heroin, which can lead to confusion and wariness among customers depending on what the customer is seeking. For example, one of the most popular “names” associated with high quality heroin is “China White,” but distributors across the United States all use “China White” to mean different products. Moreover, it is highly likely many distributors do not know what exactly they are selling when it comes to differentiating between heroin, fentanyl, and fentanyl-laced heroin, as well as differentiating between diverted pills and fentanyl-containing counterfeit pills. This probably means many distributors are not intentionally deceiving customers; instead, suppliers do not always inform distributors specifically what substances or combinations of substances they are selling. Still, other distributors actively cut heroin with fentanyl to extend their heroin supply; however, it is often unclear whether customers in these cases are aware of how/if their heroin has been cut. • In October 2017, a Boston, Massachusetts-area illicit drug distributor was actively involved in selling heroin and fentanyl in the Boston, Massachusetts and Lynn, Massachusetts areas. This distributor was also reportedly specifically involved in the distribution of kilogram quantities of “China White,” described as fentanyl-laced heroin. • In October 2017, a Phoenix, Arizona-area illicit drug distributor offered to sell pills to multiple customers. Based on the response
- 38. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 26 DOJ AND TREASURY DEPARTMENT ANNOUNCE FIRST EVER INDICTMENTS, SANCTIONS AGAINST CHINESE FENTANYL MANUFACTURES In October 2017, the DOJ announced federal grand juries in the Southern District of Mississippi and the District of North Dakota returned indictments against two Chinese nationals and their North American based traffickers and distributors for separate conspiracies to distribute large quantities of fentanyl and fentanyl analogues and other opiate substances in the United States. The Chinese nationals are the first manufacturers and distributors of fentanyl and other opiate substances to be designated as Consolidated Priority Organization Targets (CPOTs). Both CPOTs sold/distributed fentanyl and other illegal drugs over the Internet, sometimes operating across multiple websites in order to sell fentanyl and fentanyl analogues directly to customers in the United States. One of the suspects was charged with operating at least two chemical plants capable of producing ton quantities of fentanyl and fentanyl analogues. The suspect monitored legislation and law enforcement activities in the United States and China, modifying the chemical structure of fentanyl analogues produced to evade prosecution in the United States. Another suspect was charged with sending pill presses, stamps, and dies used to shape fentanyl into pills in addition to trafficking in fentanyl and fentanyl analogues. Pill presses were shipped to customers in the United States through the mail or international parcel delivery services. In April 2018, the U.S. Department of Treasury’s Office of Foreign Assets Control (OFAC) identified one of the CPOTs as a Significant Foreign Narcotics Trafficker pursuant to the Kingpin Act. OFAC also designated the CPOT’s Hong Kong registered chemical company as being used to facilitate the unlawful importation of fentanyl and other controlled substances into the United States. As a result, any assets in which the CPOT has an interest which are located in the United States or in the possession or control of U.S. persons must be blocked and reported to OFAC. OFAC’s regulations generally prohibit all dealings by U.S. persons within (or transiting) the United States that involve any property or interests in property of blocked persons. This represents significant action on behalf of the United States Government to target fentanyl traffickers and chemical companies alleged to have shipped fentanyl from China to the United States. from one of the customers, the referenced pills were blue fentanyl pills marked with “M 30”, made to resemble oxycodone pills. The customer was hesitant when offered the pills and indicated customers are afraid of the pills from Mexico because “they have poison in them.” Another customer explained nobody wanted to buy these pills because they had fentanyl, which was killing people, and individuals selling these pills were being charged for the deaths of persons who died from consuming them. • In July 2017, a Philadelphia, Pennsylvania-area heroin and fentanyl distributor sold what was claimed to be brown/beige colored heroin which was later determined to contain both fentanyl and heroin, according to DEA lab analysis. During this same time period, the distributor discussed being able to obtain “China White,” described as high quality fentanyl. Later, in August 2017, the same distributor sold what he/she claimed to be “white” heroin, which was later determined to contain fentanyl and acetyl fentanyl with no heroin.
- 39. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 27 • In March 2017, a Cincinnati, Ohio- area illicit drug distributor sold heroin, fentanyl, and fentanyl-laced heroin to various customers. The same distributor would often alter the quality of the substance being provided based on the number of customers and how much product the customers were seeking to purchase. Whenever several customers were seeking to purchase one to two ounces of heroin, the distributor would cut the heroin more to stretch supplies. The distributor also sold retail quantities of fentanyl-laced heroin and fentanyl with other cuts. LARGEST FENTANYL SEIZURE OCCURRED IN QUEENS, NEW YORK APARTMENT In August 2017, DEA seized 66 kilograms of fentanyl, the largest seizure of fentanyl in United States history (see Figure 33). The shipment was located in an apartment in Queens, New York and was linked to the Sinaloa Cartel. Previously, the largest recorded single seizure of fentanyl was 40 kilograms seized from a pickup truck in Bartow County, Georgia. use continues to be most prevalent in areas of the country with high rates of heroin and prescription opioid deaths and availability, indicating fentanyl use still presents the greatest threat among the opioid user population. In addition, the increasing availability and use of fentanyl-containing counterfeit pills demonstrate a relationship with sudden outbreaks of overdose deaths. The CDC reported a 103 percent increase in synthetic opioid deaths from 2015 to 2016, from 9,580 deaths to 19,413 deaths. Synthetic opioids are now involved in more deaths than any other illicit drug. While the synthetic opioid category does include other substances such as tramadol, fentanyl largely dominates the category. There is a strong relationship between the number of synthetic opioid deaths and the number of fentanyl reports encountered by forensic labs (see Figure 34). When the number of fentanyl reports in NFLIS increase, so too does the number of synthetic opioid deaths recorded by the CDC. Death certificates continue to report the presence of fentanyl with other substances of abuse, indicating the increased availability of fentanyl. According to highlights from the 2016 mortality data, the annual percentage of fentanyl reported in death certificates reporting heroin, cocaine, psychostimulants, and semi-synthetic opioids has increased significantly since 2014. Moreover, the removal of fentanyl from cocaine-, heroin-, or prescription pain medication-involved overdose data can change the respective trends. The removal of fentanyl-involved deaths from other categories between 2013 and 2016 has these effects: cocaine-involved deaths increased 32 percent versus 110 percent, heroin-involved deaths increased 20 percent versus 87 percent, and semi- synthetic prescription pain medication- involved deaths increased seven percent versus 32 percent. The increased presence of fentanyl in multiple different drug categories has important public health implications. Tolerances for one class of drugs do not prepare a user for a different class of drugs. As such, individuals who are primarily stimulant users (i.e. cocaine and/or methamphetamine users) are at a significantly increased risk of a fatal overdose if they inadvertently use fentanyl, because of their inexperience with opioids. Additionally, this means messaging directed Figure 33. Fentanyl Seized from Queens, New York Apartment. Source: High Intensity Drug Trafficking Area/Domestic Highway Enforcement USE Fentanyl use continues its prevalence in the United States and is a major contributor to the continuing epidemic of drug overdose deaths. Fentanyl’s high potency and powerful effects continue to lead to users overdosing and dying in record high numbers. Fentanyl
- 40. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 28 at opioid users (e.g. a warning of a ‘bad batch’ of heroin) and programs designed to help opioid users (e.g. needle exchanges) may be ineffective at reaching non-opioid users, for whom these treatments and messages are not intended. The areas of the United States most heavily affected by illicit fentanyl continue to be those parts of the country with high rates of white powder heroin use. In CY 2016, states with the highest rates of synthetic opioid-involved overdose deaths per 100,000 population and the largest number of fentanyl reports contained in NFLIS are correlated with those same metrics for heroin and semi-synthetic prescription pain medications. West Virginia experienced the second highest age-adjusted totals for both heroin- and fentanyl-involved overdose deaths in addition to the highest total of semi-synthetic prescription pain medication-involved overdose deaths per 100,000 population: 14.9 heroin overdoses, 26.3 fentanyl-involved overdose deaths, and 18.5 semi-synthetic prescription pain medication-involved overdose deaths (see Figure 35). Ohio reported the most heroin, fentanyl, and combined hydrocodone and oxycodone reports: 20,964 heroin reports; Figure 34. Number of Synthetic Opioid26 -Involved Deaths and Fentanyl Reports in NFLIS by Year, 2004-2016. Source: Centers for Disease Control and Prevention and DEA National Forensic Laboratory Information System 9,244 fentanyl reports; 5,702 combined oxycodone and hydrocodone reports (see Figure 36). Fentanyl’s top ten list for overdoses shares three states—Ohio, Connecticut, and Massachusetts— in common with heroin’s top ten list for overdoses, and shares two states—Rhode Island and Maine— in common with semi-synthetic prescription pain medications’ top ten overdose list (see Figure 37). The top ten lists for NFLIS reports among all three drugs shared three states: Ohio, Pennsylvania, and New York. In addition, NFLIS reports demonstrate a strong link between the top states for heroin and fentanyl reports. These two substances share four states in common on their respective top ten NFLIS reports list: Illinois, Massachusetts, Maryland, and Virginia (see Figure 38). In comparison, only one state—Florida—was linked between fentanyl and semi-synthetic prescription pain medication lab reports, possibly because of Florida’s history as a state with high levels of prescription drug abuse. It is increasingly more common for fentanyl to be mixed with adulterants and diluents and sold as heroin, with no heroin present in the 26 In 2014, 76 percent of all synthetic opioid-involved deaths specifically mentioned fentanyl.
- 41. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 29 Figure 35. Top Ten States by Age-Adjusted Rate of Drug-Involved Overdose Deaths Each for Heroin, Fentanyl, and Semi-Synthetic Prescription Pain Medications, CY 2016. Heroin Fentanyl Semi-Synthetic Prescription Plan Medication States Death Rate States Death Rate States Death Rate District of Columbia 17.3 New Hampshire 30.3 West Virginia 18.5 West Virginia 14.9 West Virginia 26.3 Utah 11.5 Ohio 13.5 Massachusetts 23.5 Maine 10.8 Connecticut 13.1 Ohio 21.1 Maryland 10.7 Maryland 10.7 District of Columbia 19.2 Tennessee 10.2 New Jersey 9.7 Maryland 17.8 Kentucky 9.3 Massachusetts 9.5 Rhode Island 17.8 Rhode Island 8.1 Vermont 8.7 Maine 17.3 Nevada 7.6 Illinois 8.2 Connecticut 14.8 New Mexico 7.5 New Mexico 8.2 Kentucky 11.5 District of Columbia 7.4 Source: DEA and Centers for Disease Control and Prevention Figure 36. Top Ten States by Number of NFLIS Reports Each for Heroin, Fentanyl, and Combined Hydrocodone and Oxycodone, CY 2016. Heroin Fentanyl Hydrocodone and Oxycodone States Reports States Reports States Reports Ohio 20,964 Ohio 9,224 Ohio 5,702 Pennsylvania 17,222 Massachusetts 6,028 Arkansas 3,533 New Jersey 14,970 Pennsylvania 3,173 Tennessee 3,478 California 12,837 New York 2,365 Virginia 3,331 Illinois 11,240 New Jersey 1,770 Georgia 3,237 New York 10,597 Maryland 1,587 Louisiana 2,709 Massachusetts 9,461 Illinois 1,582 Florida 2,695 Maryland 7,933 New Hampshire 1,524 Kentucky 2,655 Virginia 6,584 Virginia 1,450 Pennsylvania 2,537 Texas 5,212 Florida 1,137 New York 2,403 Source: DEA
- 42. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 30 Figure 37. Top Ten States with Most Drug Poisoning Deaths Per 100,000 Population Each for Heroin, Fentanyl, and Prescription Opioids, CY 2016. Source: DEA and Centers for Disease Control and Prevention Figure 38. Top Ten States with Most NFLIS Submissions Each for Heroin, Fentanyl, and Prescription Opioids, CY 2016. Source: DEA
- 43. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 31 Figure 39. Fentanyl Combination Reports in NFLIS, 2014 - 2016. Source: DEA National Forensic Laboratory Information System, August 2017 product. In 2016, an overwhelming majority of fentanyl exhibits in NFLIS were fentanyl alone, without heroin, at 22,278 reports (see Figure 39). DEA reporting reveals fentanyl in these forms possesses the following qualities: looks like heroin, presents in the same packaging as heroin, and displays similar stamps or brands as heroin. While many heroin users have no desire to use fentanyl, some do seek it out because of its potency. This can cause public health warnings to have unintended consequences; notifying the community that a particular heroin stamp is known to contain fentanyl or cause overdoses may cause some users to go in search of it. The presence of fentanyl-containing counterfeit pills in an area is increasingly associated with spikes in overdose deaths. Fentanyl traffickers use fentanyl powder and pill presses to produce pills that resemble popular prescription opioids such as oxycodone and hydrocodone. As the popularity of fentanyl-containing pills increases, fentanyl has been observed in non-opioid prescription drugs, such as alprazolam. According to research from The Partnership for Safe Medicines (PSM), as of September 2017, 40 states had encountered fentanyl-containing counterfeit pills. PSM reported confirmed overdose deaths from fentanyl-containing pills in at least 16 of those states. The other 24 states probably had deaths attributable to fentanyl-containing pills; however, because awareness of fentanyl- containing pills was limited when research started in 2015, those deaths may not have been investigated for counterfeit drugs. In many cases, the colorings, markings, and shape of the counterfeit CPDs were consistent with authentic prescription medications, meaning users would not necessarily be able to identify fentanyl- containing pills from authentic prescription medications. CPD users may be unaware of the strength of fentanyl-containing pills compared to authentic diverted prescription medications and as such are more susceptible to overdosing. • In November 2017, the Mississippi State Crime Lab found fentanyl in the system of a recently deceased person who overdosed by taking an unknown amount of pills. This death was the fifth overdose in Madison County, Mississippi for 2017. The lab reported seeing an increase in fentanyl disguised as oxycodone. • In June 2017, more than two dozen patients were admitted to an emergency room in Macon, Georgia over a two-day-span after ingesting counterfeit Percocet pills. The patients all admitted to having taken the pills but did not initially suspect them to be counterfeit. Analysis later revealed the pills contained a
- 44. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 32 mix of various substances including cyclopropyl fentanyl and U-47700. • In March 2017, the Medical Examiner’s Office in Maricopa County, Arizona reported 32 confirmed overdose deaths from counterfeit pills containing fentanyl between May 2015 and February 2017. The DEA Heroin Enforcement Action Team attributed the fatalities to fentanyl-containing counterfeit oxycodone pills smuggled into the United States by Mexican DTOs. In addition to fentanyl, nearly 75 percent of the overdoses contained dipyrone, a painkiller banned for use in the United States since 1977. The variable amount of fentanyl present in fentanyl-containing pills is another major contributor to pills’ lethality. According to DEA’s FSPP, in CY 2017, the average fentanyl-laced tablet contained 1.1 milligrams of fentanyl with a range of 0.03 to 1.99 milligrams per tablet, based on an analysis of 26 tablet exhibits representing nine kilograms. This range of purities represents a large degree of variability in the amount of active substance in each fentanyl-laced pill and/or in each batch of fentanyl-laced pills (see Figure 40). Clandestine pill mill operators create hot spots, or areas of higher concentration, of fentanyl in batches of pills due to improper mixing. This means even fentanyl-containing counterfeit pills from the same batch and appearing simultaneously in a market could be very different in terms of their potential lethality due to variations in milling operations. PRODUCTION Illicitly-produced fentanyl and FRS are manufactured in China and Mexico. Fentanyl is synthesized in laboratories entirely from chemicals and requires no plant material to produce, unlike heroin. There are two primary methods to synthesize fentanyl: the Janssen method and the Siegfried method. Clandestinely-produced fentanyl is synthesized using the Siegfried method, as it is simpler for DTO cooks to follow the steps involved. This method can use N-phenethyl- 4-piperidone (NPP) as its starting point and synthesizes 4-anilino-N-phenethyl-4- piperidone (ANPP), an immediate precursor to fentanyl. DEA has regulated both NPP and 4-ANPP as these substances have no legitimate purpose other than as precursors to synthesize fentanyl. In 2018, China’s Ministry of Public Security announced scheduling controls on both NPP and 4-ANPP; the controls took effect February 1, 2018. In total, China has domestically controlled 138 NPS, to include Figure 40. Variable Dose of Active Substance in Clandestinely Manufactured Pills. Source: United Nations Office on Drugs and Crime
- 45. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 33 23 synthetic opioids. Notable synthetic opioids controlled by China include, but are not limited to, carfentanil, furanyl fentanyl, valeryl fentanyl, and acryl fentanyl. In October 2017, ANPP and NPP were included in Table I of the Convention against Drugs and Psychotropic Substances of 1988, which placed them under international control. These new restrictions will likely make synthesizing fentanyl more difficult in the near term for DTOs currently reliant on receiving already synthesized NPP. However, DTOs with trained chemists will likely be able to either synthesize NPP or else switch to another method of fentanyl synthesis. DTOs have consistently demonstrated the ability to adapt to precursor chemical restrictions, such as with methamphetamine, all while maintaining a consistent supply of product to the United States. FENTANYL PRODUCTION LABORATORY SEIZED IN MEXICO FOR THE FIRST TIME SINCE 2016 In November 2017, a Mexican Army patrol deployed to a remote part of Sinaloa state discovered what was later confirmed as a fentanyl production laboratory, the first such discovery in Mexico since 2006. Mexican authorities seized 809 grams of NPP; 1,442 grams of ANPP; 80 liters and 789 grams of noscapine; and 66 grams of fentanyl at the site, in addition to laboratory equipment. The discovery suggests lab operators were using the Siegfried method to synthesize fentanyl at this location, supporting previous United States Government (USG) assessments that Mexico was likely a source, alongside China, for illicitly-produced fentanyl in the United States. Neither NPP nor ANPP have any legitimate uses outside of being precursors used to synthesize fentanyl, according to DEA laboratory information. TRANSPORTATION AND DISTRIBUTION Fentanyl is transported into the United States in parcel packages directly from China or from China through Canada, and is also smuggled across the SWB from Mexico. Large volumes of fentanyl are seized at the SWB, although these seizures are typically low in purity, less than ten percent on average. Conversely, the smaller volumes seized after arriving in the mail directly from China can have purities over 90 percent. Because of the differences in both seizure size and average purity, it is currently not possible to determine which source, Mexico or China, is the greater direct threat as a supplier of fentanyl to the United States. While seizures likely originating in Mexico represent the largest total gross weight of fentanyl seized in the United States, the overall low purity of this fentanyl means a relatively small portion of a given fentanyl seizure is actually fentanyl. Fentanyl sourced from China arrives in significantly smaller quantities than fentanyl sourced from Mexico, but due to its exceptionally high purity, it both poses a greater risk to the purchaser/user and can be adulterated many more times. DEA reporting also indicates Mexican traffickers order fentanyl from China, adulterate it, and smuggle it into the United States themselves, meaning an unknown amount of seized Mexican parcels containing fentanyl are ultimately of Chinese origin. In addition, Mexican traffickers’ primary source of supply for fentanyl precursor chemicals is also China. MEXICO-SOURCED FENTANYL Fentanyl trafficked by Mexican TCOs is typically in multi-kilogram quantities and is combined with adulterants in clandestine facilities in Mexico prior to it moving into the SWB region. Mexican TCOs most commonly smuggle the multi-kilogram loads of fentanyl concealed in POVs before trafficking the drugs through SWB POEs. According to CBP and DEA reporting, although fentanyl is often seized as a part of poly drug loads (generally cocaine, heroin, and methamphetamine), fentanyl mixtures with other illicit drugs are very uncommon at the wholesale level. This
- 46. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 34 indicates the mixing of fentanyl with other illicit drugs is most frequently done inside the United States and is not representative of any definitive Mexican TCO strategy. Fentanyl seizures27 at SWB POEs increased by 135 percent— from 223 kilograms to 524 kilograms— between CY 2016 and CY 2017. The CBP San Diego Field Office AOR remains the primary entry region for fentanyl entering the United States via the SWB (see Figure 41). Approximately 85 percent of the fentanyl seized— 447 kilograms of 524 kilograms— entering the United States via the SWB flowed through the San Diego POE in CY 2017. During this timeframe, personally operated vehicles were the conveyance for 74 percent of the fentanyl seized, by weight, at SWB POEs. The second largest volume of flow— 14 percent of all the fentanyl seized along the SWB— was seized in the CBP Tucson Field Office AOR in CY 2017. In comparison, during CY 2016, the CBP San Diego Field Office AOR accounted for 91 percent of all the fentanyl seized along the SWB and the CBP Tucson Field Office AOR accounted for nine percent. For both the San Diego and Tucson Field Office AORs, the number of fentanyl seizures at the POEs increased between CY 2016 and CY 2017. The San Diego Field Office reported 68 fentanyl seizures— compared to 23 in CY 2016— and the Tucson Field Office reported 31 fentanyl seizures— compared to five in CY 2016. These two offices accounted for 99 of the 109 fentanyl seizures at SWB POEs reported in CY 2017. DEA investigative reporting indicates, the Sinaloa and CJNG Cartels are likely the primary groups trafficking fentanyl into the United States via the SWB. Most CBP fentanyl seizures occur at POEs in Southern California. These POEs are directly adjacent to areas in Mexico with a strong Sinaloa and CJNG presence and both of these cartels are known to smuggle multi-kilogram drug loads through California POEs. The presence of fentanyl comingled with other poly drug loads typical of Sinaloa and CJNG suggests strong links between these TCOs and fentanyl trafficking into the United States. Figure 41. Custom Border and Protection Fentanyl Seizures by Southwest Border Corridor in CY 2017, with Percent Change from CY 2016. Source: DEA 27 These data include only seizures vetted by CBP’s Office of Field Operations.
- 47. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 35 CHINA-SOURCED FENTANYL Fentanyl and FRS are also being imported in low weight, high concentration shipments via mail and express consignment from China. These shipments are likely being imported by small criminal networks because of the potential for fentanyl and FRS to generate high revenue without the need for allegiance to a larger DTO or Mexican TCO. According to CBP data, nearly all fentanyl seized from international mail and express consignment operations28 (ECO) originated in China29 and averaged less than 700 grams in weight. CBP laboratory analysis of similar seizures indicated international mail and ECO seizures are typically over 50 percent pure. DEA ARRESTS ONE OF THE MOST PROLIFIC DARK WEB FENTANYL DISTRIBUTORS IN THE UNITED STATES In November 2016, DEA officials executed a search on a residence in Cottonwood Heights, Utah after investigating what was believed to be a fentanyl distribution operation manufacturing counterfeit fentanyl pills and other counterfeit medications. The search led to the seizure of $1.2 million United States Currency (USC); $2 million virtual currency (VC); 750 grams of fentanyl powder; 400 grams of alprazolam; approximately 200,000 counterfeit oxycodone pills containing fentanyl; approximately 100,000 counterfeit alprazolam pills; and four commercial-grade pill presses (see Figures 42 & 43). The distribution network operated by purchasing fentanyl and pill presses over the dark web from China and subsequently selling counterfeit pills containing fentanyl over the dark web. The sales were conducted over AlphaBay, which at the time was the largest dark web market. During this time, the suspect was widely considered by customers to be the number one seller of fentanyl- containing pills on AlphaBay due to overwhelmingly positive customer feedback and the ability to ship drugs in bulk quantities. Customers would purchase fentanyl and other counterfeit pills using Bitcoin. The suspect used a close network of friends and associates in and around Salt Lake City to package and mail thousands of orders for customers across all 50 states. Fentanyl sourced from China accounted for 97 percent of fentanyl seized from the international mail and ECO environments in both CY 2017 and CY 2016. China- sourced fentanyl, by weight, accounted for 165 kilograms of the total 171 kilograms seized from the international mail and ECO environment during CY 2017. This represents a 140 percent increase in the amount of fentanyl sourced from China seized in the mail and ECO environments between CY 2016 and CY 2017— from 69 kilograms to 165 kilograms. To help distinguish between the mail/ECO product line of fentanyl and the SWB product line of fentanyl, CBP’s Laboratory and Scientific Services Directorate tested 63 fentanyl samples—nearly all of which were mail/ Figure 42. Counterfeit Pills Containing Fentanyl. Figure 43. U.S. Currency Found at Suspect’s Residence. Source: DEA 28 Express consignment operations refer to operations involving parcel courier companies. 29 Use of the term “China” includes both China and Hong Kong for the purposes of this data set.
- 48. UNCLASSIFIED FENTANYLANDOTHERSYNTHETICOPIOIDS UNCLASSIFIED 36 ECO seizures— and determined 51 percent of the samples tested between 90 and 100 percent purity. Moreover, 79 percent of the samples analyzed were over 50 percent pure, further distinguishing the two product lines. Criminal indictments relating to fentanyl smuggling in the mail/ECO environment further suggest individuals involved in U.S.-based fentanyl smuggling act alone or as part of relatively small, independent criminal networks. These networks typically distribute fentanyl locally or sell it to others via the Internet. Further, the increasing use of relatively anonymous “dark web”30 purchases, paid using money service business (MSB) transfers or virtual currency, facilitates fentanyl trafficking in the mail and ECO environments. For instance, AlphaBay, a dark web marketplace shut down by the Federal Bureau of Investigation (FBI) in July 2017, reportedly had over 200,000 users; 40,000 vendors; 21,000 opioid listings; and 4,100 fentanyl listings. Despite this success, the popularity of fentanyl listings on the dark web indicates it is highly likely dark web fentanyl transactions are extensive and are likely to persist. The National Cyber-Forensics and Training Alliance estimates there are between 100-150 fentanyl vendors currently operating on the dark web. Moreover, as of January 2018, FBI analysis identified approximately 700 fentanyl-related sales listings on the current top six English-language dark web marketplaces. Clandestine fentanyl pill press operations are becoming increasingly popular in the United States due to the profitability of fentanyl pills and the large potential user market. Traffickers typically purchase already synthesized fentanyl and fentanyl- related compounds in powder form, in addition to pill presses available from China, to create counterfeit pills intended for street sales. Under U.S. law, DEA must be notified when a pill press is imported into the country. However, foreign pill press vendors circumvent this requirement by mislabeling equipment or sending equipment disassembled to avoid detection by port authorities or law enforcement. These laboratories are often found in residential areas and can present challenges for local police departments responding to requests for assistance or executing search warrants. Figure 44. Pill Press Equipment Seized in Richmond, Texas. Source: DEA Figure 45. Fraudulent Oxycodone Tablets Containing Fentanyl Seized in Richmond, Texas. Source: DEA 30 The dark web refers to the portion of the Internet that is intentionally hidden and is only accessible through encrypted applications, such as TOR.