COLUMBUS, Ohio – For the first time in a decade, the number of deaths caused by fentanyl and synthetic opioids is declining. Residents and law enforcement in the struggling Hilltop neighborhood attribute this positive trend to a lifesaving drug: naloxone.

James “Sleaze” Morgan shares that naloxone has revived him from an overdose as many as 20 times over recent years.

This essential nasal-spray antidote is readily available in the numerous Hilltop “trap” houses where users purchase and consume fentanyl. Local authorities distribute it for free, ensuring that supplies are plentiful at the residence where Sleaze smokes fentanyl and provides security in exchange for drugs.

On one occasion, a customer inhaled smoke from heated fentanyl powder and immediately stopped breathing. Sleaze responded quickly, administering naloxone by spraying three doses into the unconscious man’s nose, successfully reviving him.

“It’s become second nature to me,” Sleaze explains, with his nickname tattooed above his left eye. “I sprayed him three times, and he woke up.”

Researchers focused on narcotics believe that the broad availability of naloxone has significantly contributed to the notable drop in synthetic overdose deaths over the past year. From July 2023 to July 2024, such deaths decreased by 22% nationally and by 34% in Ohio compared to the previous year, according to the latest statistics from the U.S. Centers for Disease Control and Prevention. This translates to about 17,500 fewer lives lost nationwide.

This decline aligns with the FDA’s decision in March 2023 to permit the sale of naloxone without a prescription. Various brands are now available at pharmacies and online, priced between $30 and $45 per kit. Additionally, Ohio and several other states have implemented giveaway programs for this crucial drug. The Columbus Police Department credits naloxone as a key reason for the decrease in 911 calls related to overdoses in the area.

Dr. Rahul Gupta, who heads the White House Office of National Drug Control Policy, cites a federal initiative to distribute naloxone and other addiction treatments in communities, playing a significant role in the ongoing decrease in overdose deaths. He also notes that legal actions against suppliers and manufacturers of fentanyl have disrupted the supply chain, leading to a less potent form of fentanyl available on the streets.

However, the overall death toll due to fentanyl remains alarming. Reports highlight that illicit fentanyl, made from chemical ingredients sourced from China and smuggled into the U.S. and Mexico, continues to be affordable and widely available. For instance, in Columbus, a dose costs just $10.

To understand the complex global supply chain of this drug and its implications for users, journalists have visited Ohio, which was among the first states severely affected by fentanyl fatalities. While it is now seeing a decline in such deaths, the experiences of Sleaze and others in Columbus illustrate that breaking fentanyl’s hold on America is an ongoing challenge, even with the antidote readily available.

READ MORE from Fentanyl express: Behind America’s opioid crisis

• Part 1: With $3,600 and Wi-Fi, we bought everything needed to make fentanyl
• Part 2: How fentanyl traffickers are exploiting a U.S. trade law to kill Americans
• Part 3: Trump camp says China is ‘attacking’ U.S. with fentanyl. They aim to fight back
• Part 4: The shadowy ‘brokers’ helping Mexico’s cartels smuggle fentanyl chemicals from China

Forecasts indicate that between 50,000 and 60,000 Americans might succumb to synthetic opioid overdoses this year, predominantly involving fentanyl or similar drugs. This marks a staggering sixfold increase since 2015, right before the fentanyl crisis escalated. The cumulative number of deaths from synthetic opioids in the U.S. has approached 450,000 since that time.

Scott Sanders, the executive director of the Hope Resource Center, provides support and refuge for Sleaze and others in the Hilltop community. He distributes about 1,000 naloxone kits monthly.

There are two nasal-spray canisters of naloxone available. Although naloxone is effectively saving lives, Sanders points out that the number of people struggling with substance abuse on Hilltop’s streets continues to increase.

Visits to Hope’s drop-in center have surged by nearly a third this year, reaching around 18,300 in the twelve months leading to November 2024, compared to about 13,400 in the previous year.

“That genuinely terrifies me,” Sanders expresses. “Because those in power will celebrate and say, ‘Look, it’s no longer an issue,’ based on decreasing fatality statistics. But our workload is heavier than ever.”

In addition to naloxone, researchers point out two other potential explanations for the decline in overdose deaths. Some illicit drug suppliers are increasingly mixing a veterinary tranquilizer known as “tranq” with fentanyl. The reasons behind this trend are still uncertain, but tranq is deemed less lethal than fentanyl. It also creates a prolonged high, which may postpone the onset of fentanyl withdrawal, reducing some users’ urge to seek more. Less frequent use of fentanyl can lead to fewer overdose incidents. Some researchers suggest that tranq could be just as significant a factor as naloxone in the reduction of overdose deaths.

Other experts are considering the drop in the number of individuals likely to become addicted—suggesting that the large number of overdose deaths in recent years (around 280,000 since 2021) has significantly reduced the pool of potential fentanyl users, thereby resulting in fewer overdoses.

However, during a November visit by Reuters to Ohio, naloxone was a frequent topic of discussion. Users in the area refer to the overdose-reversal medication as Narcan, which was the first brand introduced in a nasal spray format.

Sleaze is among ten users in Ohio who shared with Reuters their experiences of being revived multiple times with naloxone. Although their individual accounts could not be verified, Sanders from the Hope center confirmed that he knows of several individuals who have been brought back from overdose numerous times.

Those like Sleaze, who have been repeatedly saved by naloxone, also highlight a troubling aspect of this life-saving drug. Its effect causes a swift and intense withdrawal from fentanyl, which is 50 times more potent than heroin, creating an immediate craving for another dose.

The argument for naloxone

Ohio has been a focal point in the fentanyl crisis since the drug surfaced in Dayton in 2017. In the first ten months of this year, state and local officials distributed nearly 320,000 two-dose naloxone kits, which is an increase of 20,000 from all of 2023 and 110,000 from 2022. According to CDC data, synthetic overdose deaths in Ohio decreased by about a third, totaling 2,676 in the year ending July, marking the lowest figures since 2016.

In Columbus, Sanders actively encourages visitors to the Hope center to take as many naloxone kits as they wish. On a cold, misty day in mid-November, Ryan Hall stopped by Sanders’ office to say hello. Hall, who claims he has 13 children by “six different mothers,” visited to celebrate his 41st birthday. He has struggled with addiction and has been in and out of treatment numerous times, also having been revived with naloxone multiple times, according to Sanders.

Hall asserts that he is currently sober, but Sanders remains skeptical. Sanders, who overcame his own crack addiction in 2017, encourages Hall to reach out to him later, promising to assist him in return to treatment whenever he feels ready. (On December 9, Sanders would take Hall to a rehabilitation facility.) Much of Sanders’ work involves helping individuals secure treatment and sober living arrangements.

A little while later, Sleaze, who is 40 years old, arrives in Sanders’ office and takes a seat.

“I enjoy getting high,” he admits.

However, he dislikes the experience of being revived with Narcan. A fentanyl overdose can be deadly as it leads to respiratory failure. Naloxone, known as Narcan, works by displacing fentanyl molecules from opioid receptors in the brain and preventing any more fentanyl from binding.

The effect is instant: The individual begins to breathe again and regains consciousness. But there’s a catch: Those addicted to opioids often find themselves craving the drug even more. Law enforcement reports that revived overdose victims can react violently, thrashing their limbs. Some may vomit uncontrollably.

Sleaze describes feeling intense pain whenever he is administered naloxone, prompting him to flee in panic afterward. Just a few weeks prior, someone revived him with Narcan.

His initial encounter with naloxone occurred in 2022, coinciding with his first experience with fentanyl. He had recently been released from prison after serving a seven-year sentence for burglarizing Walmart stores to steal TVs. Even while incarcerated, he claims he managed to continue using opioids, a habit he developed in young adulthood.

Despite his extensive experience with opioids, he had always avoided fentanyl; he lost too many friends to overdoses. At the time, he was homeless, living in his girlfriend’s vehicle, and dealing with the emotional turmoil of his mother being imprisoned for drug trafficking.

“My entire world just fell apart,” he shares. That day, someone handed Sleaze a small bag that contained fentanyl powder. He injected the remaining residue and lost consciousness instantly. “I didn’t even have time to pull the needle from my arm.”

He was revived when his girlfriend sprayed naloxone into his nostrils. Once he regained consciousness, the withdrawal was so intense that he had never felt such extreme “dope sickness” before.

“I was in excruciating pain,” he describes.

Attempts to reach Sleaze’s former girlfriend and mother for comment were unsuccessful. His mother is currently serving a minimum of nine years in Dayton Correctional Institution on drug-related charges.

Not long after conversing with Reuters, Sleaze steps outside.

In a narrow passage close to the Hope center, he glances back nervously. After being released from prison this summer, he removed his ankle monitor and ceased his visits to his probation officer. He lowers his knit hat over his eyes and takes a hit of powdered substance.

A man riding a red bicycle is trailing him by about fifty yards. Sleaze casts a quick look in his direction. The man does not appear to be a police officer.

Just two weeks later, two police officers in Columbus would arrest Sleaze for violating the terms of his felony probation.

Is fentanyl changing?

Scott Oulton, the head of forensic sciences at the U.S. Drug Enforcement Administration, reports that testing of seized fentanyl powder and tablets since late summer 2023 has revealed a steady decline in purity.

In the past two years, the DEA analyzed approximately 9,200 samples from throughout the United States. The average purity of fentanyl powder has dropped from 19.5% in 2023 to 15.2% in 2024. Additionally, the typical fentanyl tablet now contains an average of 2 milligrams of the drug, down from 2.3 milligrams. Oulton notes that this decrease in purity aligns with a recent decline in synthetic opioid-related deaths.

However, some scientists who are aware of the DEA study are doubtful that the findings accurately represent street-level substances. Their own analyses reveal that the drugs available for consumption still contain high levels of fentanyl.

Alex J. Krotulski, who operates the toxicology and chemistry lab at the Center for Forensic Science Research & Education in Horsham, Pennsylvania, provides analysis for law enforcement and other clients. He asserts that the fentanyl and related substances he measures have consistently shown a purity level around 10% over the last three years. Similarly, Nabarun Dasgupta, a senior scientist affiliated with the University of North Carolina’s Injury Prevention Research Center, claims his lab has not identified any reduction in fentanyl strength.

Nonetheless, both Krotulski and Dasgupta highlight another noteworthy transformation.

They have observed a rise in a significant category of adulterant drugs being mixed with fentanyl: veterinary tranquilizers, often called “tranq,” which are used to sedate dogs, horses, and other animals. Notable examples include xylazine, the most recognized tranquilizer, and a newer one named medetomidine, which is used for both animals and humans. Krotulski mentions that medetomidine has now surpassed xylazine in prevalence in samples from Philadelphia during the third quarter of this year.

Xylazine shocked health authorities when it first appeared in fentanyl in cities like Philadelphia back in 2021. Users reported horrifying necrotic wounds that damage their skin and underlying tissue—complications associated with the use of this veterinary drug. If these wounds are not treated, they may require amputation.

Currently, some health experts speculate that there might be a positive aspect to the introduction of these perilous tranquilizers. They may help in reducing the number of opioid overdoses.

Fentanyl is highly addictive, often requiring users to seek multiple doses daily compared to heroin or other opioids. The euphoria it provides is short-lived, usually lasting just one or two hours for habitual users, leading to a strong desire for another high. In contrast, xylazine and similar drugs act as longer-lasting sedatives that can prolong the effects of opioids, allowing users to space out their doses—potentially lowering their risk of fatal overdose.

Unlike fentanyl, xylazine and medetomidine do not cause respiratory failure, which is the primary cause of death in fentanyl overdoses. They are also significantly less addictive. When these tranquilizers are mixed with street fentanyl, they may ease withdrawal symptoms, contributing to a reduction in overdose deaths.

In jurisdictions like New York City, Ohio, and Philadelphia, which were initially hit hard by fentanyl, medetomidine was detected within the local drug supply as of June.

Sam Rivera, who is the executive director of OnPoint NYC, which provides support to those with substance use issues, mentions that long-time opioid users have created strategies to prevent withdrawal symptoms. This practice, known as “speedballing,” involves mixing a stimulant like methamphetamine or cocaine with an opioid to create a balance, allowing them to postpone their urge for another dose.

For example, Sleaze states that after smoking fentanyl, he prefers to inject meth followed by cocaine.

Dasgupta, a researcher at the University of North Carolina, notes that the precise impact of xylazine and similar substances on overdose rates is still unclear. However, if these drugs lead to longer intervals between doses for users, it could reduce their risk of overdose.

Some experts are skeptical that the presence of tranquilizers is contributing to the decline in overdose deaths.

Dr. Bonnie Milas, an anesthesiologist at the University of Pennsylvania, utilizes fentanyl along with a medication similar to medetomidine for surgical patients with heart and lung issues. She believes these combinations found in illicit drugs are less likely to save users’ lives because the dosages in street drugs are not regulated. According to her, such mixtures may be even more hazardous than fentanyl by itself.

Milas recalls a warning issued by the Philadelphia health department on December 10 regarding the fentanyl-medetomidine combination, which can result in severe withdrawal symptoms for some users that require emergency care.

“I understand this from a clinical perspective,” Milas states. “On a personal level, I recognize the signs of an overdose.”

Dr. Milas tragically lost both of her sons to fentanyl. She managed to revive her younger son from overdoses on two occasions using naloxone. Unfortunately, she was not present during the last incident.

Since then, she has been an advocate for widespread distribution of naloxone, urging it to be included in every household’s first-aid kit. She insists this is the best method to save lives until individuals choose to seek treatment.

The ‘Susceptibles’

Charles Fain Lehman, a researcher focused on policing and public safety at the Manhattan Institute, provides another insight into the decrease in fatalities: the concept of a “depletion of susceptibles.”

High school seniors are increasingly avoiding hard drugs, with narcotic use now only a quarter of its highest levels from the 2000s. Experts cite the rising number of synthetic opioid overdoses in recent years as a strong indication that the population of those at risk is significantly decreasing.

According to Lehman, “Only a limited number of individuals ever use narcotics, which means there’s a stable group of people who are at risk for overdosing.” He makes a morbid point, stating, “If someone dies young, they can’t die again later.” The recent high rate of fatalities among drug users suggests, he argues, that the overall number of susceptible individuals in the U.S. is on the decline.

The Hilltop area of Columbus is still heavily affected by fentanyl, and the population there remains vulnerable. On Sullivant Avenue, the main street, women struggling with addiction resort to selling sex at many intersections. Individuals experiencing homelessness and drug dependency are often found camping in wooded spots along nearby train tracks, in deserted buildings, and doorways.

Many individuals visiting the Hope center attribute their addictions to family members who also abused drugs. According to Sanders, this often leads to a predictable pattern: beginning with prescription painkillers, then proceeding to heroin, and ultimately, fentanyl.

Angel Mccallister enters the office clad in a black hoodie and torn black leggings, her curly auburn hair spilling over her shoulder. Having not yet consumed fentanyl that day, she is feeling restless from withdrawal. It’s lunchtime, but food is far from her thoughts.

Now 32, Angel has battled addiction for two decades. With her mother addicted to prescription pills like oxycodone, Angel found herself trapped in the cycle of dependency by age 12, consuming illicit prescription medications and snorting powdered heroin. One day, while babysitting for a friend, feeling sick from withdrawal, she was injected with heroin by the wife of the couple she was with.

This first experience with intravenous opioids changed everything. “That was all I wanted,” she recalls. “It became my constant companion, always there when I needed it.”

Eleven years ago, Angel became a mother. After fentanyl appeared on the streets a few years later, she switched from heroin to fentanyl injections, but now she smokes the substance.

Her son lives with Angel’s grandmother, while Angel mentions her mother remains an addict and that her aunt has died from a fentanyl overdose. Attempts to contact both her mother and grandmother were unsuccessful.

Angel admits to engaging in sex work several times a week to fund her drug habit, and she has experienced rape more times than she can count.

In a moment of vulnerability, she turns away and covers her eyes with her hair, tears streaming down her face. Sanders places a comforting hand on Angel’s shoulder.

Taking a long breath, Angel brushes her hair back. She estimates she has been revived with Narcan countless times. On at least one occasion, she survived an intentional overdose attempt.

How to save a life

Naloxone is a nasal spray medication available over-the-counter that can save someone from an overdose by quickly reversing the impacts of opioids like fentanyl and heroin.

Doctors recommend that everyone, especially those with prescription opioids at home or who have a substance user in their household, keep naloxone in their first aid kits or bags. Opioid emergencies can affect anyone, including young children who might accidentally ingest these drugs.

Naloxone is found under brand names like Narcan and RiVive and can be purchased online or at major pharmacies ranging from $30 to $45 per kit. Each kit typically includes two nasal spray applicators, and sometimes more than one dose is necessary.

Many local health departments and community organizations distribute these kits freely, no questions asked. A quick online search for “free naloxone” reveals hundreds of possibilities.

Milas, an intensivist at the University of Pennsylvania, utilizes fentanyl together with other medications for patients in critical condition. Tragically, she has buried two sons due to accidental fentanyl overdoses. She represents the American Society of Anesthesiologists’ REVIVEme.com initiative, which provides instructional materials on naloxone usage for reviving individuals who have overdosed.

Milas shares her story with various groups mourning loved ones lost to fentanyl, comforting them with the words, “You should never feel guilty or responsible. You tried, they tried, and ultimately, the outcome was beyond your control … But know that you did your best, and you should take solace in that.”

READ MORE from Fentanyl express: Behind America’s opioid crisis

• Part 1: With $3,600 and Wi-Fi, we bought everything needed to make fentanyl
• Part 2: How fentanyl traffickers are exploiting a U.S. trade law to kill Americans
• Part 3: Trump camp says China is ‘attacking’ U.S. with fentanyl. They aim to fight back
• Part 4: The shadowy ‘brokers’ helping Mexico’s cartels smuggle fentanyl chemicals from China