A view of Washington, Pa. Last week, Washington County recorded 16 overdoses in 24 hours and 25 over two days. Three people died. (Marvin Joseph/The Washington Post) 
 
 The first call came at 7:33 p.m. last Sunday: Two people had overdosed on heroin in a home just a few hundred yards from the station where firefighters were awaiting their nightly round of drug emergencies. 
 
 Six minutes later, there was another. A 50-year-old man had been found in his bedroom, blue from lack of oxygen, empty bags of heroin by his body. 
 
 At 8:11, a third call. Then another, and another, and another and another. 
 
 By 8:42 — 69 minutes after the first report — a county of slightly more than 200,000 people had recorded eight overdoses, all believed to be caused by heroin. There would be a total of 16 overdoses in 24 hours and 25 over two days. Three people died. Many of the others were saved by a recent decision to equip every first responder with the fast-acting antidote naloxone. 
 
 The toll wasn’t from a supply of heroin that had been poisoned on its journey from South America to southwestern Pennsylvania. Nor was there an isolated party where careless junkies miscalculated the amount of heroin they could handle. Last week was simply an extreme example of what communities in parts of the country are enduring as the heroin epidemic rages on. 
 
 Valerie Mack, left, is comforted by family friend Carla Stormy Efaw in Washington, Pa. Mack lost her brother, Sammy Mack, to a heroin overdose. (Marvin Joseph/The Washington Post) 
 
 “It’s absolutely insane. This is nuts,” said District Attorney Eugene A. Vittone, a former paramedic who is trying to hold back the tide of drugs washing across Washington County, a Rust Belt community 30 miles south of Pittsburgh. On any day, Vittone said, the county averages five to eight overdoses, almost all from heroin. More are recorded each day in towns just over the county line. 
 
 “There’s been a progressive increase in overdoses the last two years, and it just went out of control,” added Rick Gluth, supervising detective on Vittone’s drug task force. “I’ve been a police officer for 27 years and worked narcotics for the last 15, and this is the worst. I’d be glad to have the crack epidemic back.” 
 
 [Cheap fix: Heroin’s resurgence. ‘And then he decided not to be’] 
 
 The United States averages 110 overdose deaths from legal and illegal drugs every day. The heroin death toll has quadrupled in the decade that ended in 2013, according to the Centers for Disease Control and Prevention. By all accounts, it has only grown worse since. In Washington County, there have been more than 50 fatal overdoses this year. 
 
 The national drug-death total, larger than that from auto accidents, is disproportionately concentrated in the Rust Belt, the Great Lakes region and the Northeast. 
 
 “There is a growing sense of community outrage that we can’t accept this like we are accepting it,” said David J. Hickton, U.S. attorney for western Pennsylvania and co-chair of the National Heroin Task Force established by the Justice Department in April. “We just can’t go on like this.” 
 
 In this working-class community near the Monongahela River, where drilling for gas deposits has begun to stoke an economic revival, there is little sign that anything will change soon. 
 
 This man who only wishes to be identified as Sonny, learned that his daughter had a heroin overdose at a nearby Walgreens store in Washington, Penn. (Marvin Joseph/The Washington Post) 
 
 “I’m destroyed. I’m totally destroyed,” Valerie Mack said Thursday on the front porch of the home she shared with her brother and several other people on a modest block here. 
 
 Her brother, Sammy Mack, the second overdose victim in the Sunday night skein, was found dead in his bedroom, curled in a fetal position. Near his body were “stamp bags” of heroin — small paper packets that most closely resemble chewing gum wrappers. They bore the supplier’s brand, “MADE IN COLOMBIA.” 
 
 The label is one of two flooding the area, Gluth said. The other is stamped “BLACK JACK.” Authorities are still investigating but believe both types of heroin are laced with fentanyl, a powerful synthetic opiate that increases the drug’s potency and may have contributed to the rash of overdoses. 
 
 Sammy Mack had long had problems with alcohol and was not unknown to law enforcement authorities. But as so many others have, his sister said, he turned to heroin after treatment with narcotic painkillers prescribed for an ankle injury he suffered a few months ago. Mack’s divorce was recently finalized, she said. His four children are living with his ex-wife not far away. 
 
 [When life begins in rehab: A baby heals after a mother’s heroin addiction] 
 
 As he began to use heroin, Mack’s habits and personality changed, she said. He became withdrawn, spending more time in his room. That Sunday, she was fixing him a chef’s salad and became suspicious when he didn’t respond to her calls. She tried to push open his bedroom door but couldn’t. A neighbor finally forced his way in. 
 
 Mack’s prized possession, a Harley-Davidson motorcycle, still sits in the home’s back yard. He had promised it to his 14-year-old son upon his high school graduation. “I’ll just have to follow through,” Valerie Mack said. 
 
 With so much awry in Sammy Mack’s life, his sister said, “Maybe the Lord intervened and decided just to take him.” 
 
 Jessica Neal, 26, another of last week’s overdoses, is still alive after a close call. She was found unconscious in a bathroom at a local Walgreen’s on Monday, her 2-year-old strapped in a stroller in the stall with her. She was revived with naloxone. 
 
 Her father, Sonny, who has a different last name that he requested not be used to protect his privacy, said he threatened to have her committed to the psychiatric unit of the local hospital that same day after Neal spoke of committing suicide. Instead, she agreed to sign herself in. She was released Friday and headed to jail. The child is in her father’s care, he said. 
 
 “She doesn’t need jail,” Sonny said outside the home where the two lived with Sonny’s wife, who suffers from amyotrophic lateral sclerosis (ALS), until last week. “She wasn’t out stealing or doing crimes. What she needs is help. She needs to be in rehab. And after rehab, she needs to be in a halfway house.” 
 
 Nationally, there are only a small fraction of the inpatient drug rehab beds needed for addicts, but Hickton, in an increasingly common stance for prosecutors, has agreed that users need help more than they deserve incarceration. Even as he has stepped up prosecution of dealers, he is taking a multifaceted approach to the current problem. 
 
 “If they’re using and trafficking, I prosecute them,” he said. “If they’re just using, they need help.” 
 
 Hickton promises to bring homicide charges against any seller he can link to a death. But that is easier said than done. There are no open-air drug markets in this epidemic like the ones that captured public’s attention during drug outbreaks of past decades. Much of the commerce is conducted on cellphones and by word of mouth. 
 
 With many more middle-class people addicted via prescription opioids this time around, heroin is bought and sold in bars, nightclubs, homes and more unlikely places, said Neil Capretto, an addiction psychiatrist and medical director of Gateway Rehabilitation Center, which has 20 locations in the Pittsburgh area. 
 
 Gluth said he has undercover detectives all over the streets making buys, painstakingly working their way up the chain in search of bigger dealers. 
 
 He believes the latest load of heroin came from New Jersey, but Washington County’s location makes it particularly vulnerable to drug traffic. Not far from the Ohio and West Virginia borders, it sits at the intersection of Interstates 70 and 79, east-west and north-south conduits for drugs and everything else. Vittone said the county receives drugs from New York, Newark, Washington, Chicago, Detroit and elsewhere. 
 
 “We’re kind of like ground zero,” he said. 
 
 On the streets here, prescription drugs are selling for about $1 per milligram, or $20 for a single dose. Heroin is much cheaper, at about $8 a stamp bag, Gluth said. It is also much more potent than the heroin of previous eras, Capretto said. Users often start with a single bag, but as their resistance grows, they need increasing amounts. 
 
 All of which signals more overdoses and deaths, at least until authorities can find ways to stem the demand and the supply. 
 
 “If we had a serial killer killing one-tenth as many [people], we’d have the National Guard here,” Capretto said. “We’d have CNN here every night.” ||||| CEDAR RAPIDS — One narcotics law enforcement officer says taking heroin is similar to grabbing a loaded gun and spinning the chamber. 
 
 Even worse, he added, heroin use is spreading in Iowa, and its deadly reach is likely to continue to grow. 
 
 Heroin overdoses, for example, have surged in Cedar Rapids in the past five years. 
 
 In 2009, authorities responded to nine reported heroin-related deaths and non-fatal overdoses, which represented 45 percent of all overdoses in Cedar Rapids. 
 
 Through June 5 of this year, there have been 52 reported overdoses in the city, 44 of which were heroin-related. Heroin has accounted for 85 percent of all overdose calls this year. 
 
 “It's a serious issue — not just the presence of heroin, but the effects that heroin is having on the users,” Cedar Rapids Police Chief Wayne Jerman said. “The number of overdoses and the number of overdose deaths is very concerning.” 
 
 Cedar Rapids is not alone in facing a growing heroin epidemic. One way to gauge the prevalence of heroin in Iowa and where it is being found is through samples, or exhibits, submitted to the Iowa Division of Criminal Investigation Criminalistics Laboratory. According to statistics provided by the crime lab, 37 of Iowa's 99 counties have submitted suspected heroin to the lab for testing since 2005. 
 
 However, three Eastern Iowa counties make up a majority of the cases sent to the DCI lab. Of the 47 exhibits submitted to the lab in the first third of 2015, seven were from Johnson County and eight were from Linn County. Collectively, they account for nearly a third of all heroin cases submitted to the lab this year. 
 
 Scott County leads the state with 16 submitted cases through the first four months of the year. 
 
 Not only is heroin becoming increasingly common, but authorities warn that it's becoming deadlier, thanks to the presence of a synthetic opioid with 80 times the potency of heroin. 
 
 And one Iowa Division of Narcotics Enforcement agent warns that heroin shows no sign of slowing down in Iowa. 
 
 “I think it's going to be on the upswing,” DNE special agent-in-charge Dan Stepleton said. “I think it's going to get worse and worse.” 
 
 Metro hubs 
 
 Heroin is a highly addictive opioid produced from opium poppy. Usually injected by the user, heroin also can be smoked and is a powerful painkiller. It is similar to fellow opioid morphine, but 10 times as powerful. 
 
 The heroin found in Iowa is produced by Mexican cartels and distributed through metropolitan hubs, such as Chicago, which helps to explain why Scott, Linn and Johnson counties in Eastern Iowa see more heroin cases than the more populous Polk County. 
 
 “Because you have a predominant heroin source of Chicago and those are the closest three counties to Chicago in Iowa and they're metropolitan counties,” Stepleton explained. 
 
 Stepleton said heroin usually is distributed by gang members with Chicago affiliations. Criminal investigations often begin with an overdose death, he explained. 
 
 “Unfortunately it's usually already a done deal when we get involved,” said Stepleton, who covers a 24-county swath of Eastern Iowa. “We are working toward the source of supply and not just waiting for an overdose to happen. We're trying to avert those as much as possible.” 
 
 According to a study released by the Centers for Disease Control last month, heroin use is rising across all demographics, with women and 18-to-25-year-olds seeing the biggest increases in recent years. Experts point to the rise of prescription drug abuse, especially among young people. 
 
 “What we're seeing is young people — high school and college age — will get addicted to Vicodin, oxycotin,” Stepleton said. “When they run out of the prescriptions, they'll resort to heroin because it's 10 times the potency of that drug. Unfortunately you're already hooked at that point. 
 
 Related story: 
 
 Change in law makes heroin death convictions more difficult to prosecute 
 
 “It doesn't take long to make the switch from oxycotin to heroin, which in essence is going to make you a lifelong addict.” 
 
 Heroin is not a high-volume drug — it lags far behind more common illegal substances in Iowa such as marijuana and methamphetamine — and it's highly expensive. One ounce of heroin is a “huge amount,” Stepleton said, and most dealers work in shipments of 10 to 50 grams. 
 
 Heroin is purchased for about $200 to $250 per gram and is usually sold for about $50 for a 10th of a gram. 
 
 “It's a very expensive habit,” he said. “That's why most of your heroin users have to be dealers. You just can't afford to get the drug.” 
 
 Because of its expensive and addictive nature, heroin abuse often is associated with property crimes such as thefts and burglaries. 
 
 “Addicts will do what they need to do to obtain the next fix,” Jerman said. 
 
 Lethal 
 
 While there is no definitive ranking in Iowa on the most lethal drugs, heroin probably would be near the top of the list in terms of deaths with respect to the number of actual users, according to one state official. 
 
 “It would appear that heroin is more lethal than many other substances,” said Dale Woolery, associate director for the Governor's Office of Drug Control Policy. 
 
 Woolery said it appears that a greater proportion of heroin users experience overdoses than users of more common drugs in Iowa, such as methamphetamine. 
 
 “There are a lot of Iowans that have a strong appetite for methamphetamine,” he said. “But it's rare, if it ever occurs ... that you hear of a methamphetamine-overdose death. I think it does occur, but I'm talking very few.” 
 
 Heroin typically is sold at a purity of three percent to five percent, Stepleton said. 
 
 “After that, it gets very, very lethal,” he said. 
 
 However, it's not an exact science and some dealers might not be as careful about diluting their drugs. 
 
 “There's no FDA involved in this,” Stepleton said. “He might dilute it down to 7 to 8 percent ... Taking it at 3 percent and taking it at 8 percent is a big freaking difference.” 
 
 Heroin is becoming even more lethal with the introduction of a drug called fentanyl. A synthetic opioid painkiller, fentanyl is 80 times as potent as heroin and a single piece of pure fentanyl the size of the grain of salt can kill a fully grown man. 
 
 “Now they're lacing heroin with fentanyl,” Stepleton said. “Now you have two drugs together and one is very much more powerful than the other. If I'm taking the same drug dosage unit and it's laced with fentanyl, now I end up with really severe problems ... You don't have long for this world.” 
 
 Stepleton said fentanyl and fentanyl-laced heroin has hit the East Coast hard in recent years, resulting in 2,500 to 3,500 overdoses in major cities. And it's making its way to Iowa. 
 
 Bruce Reeve, administrator for the DCI crime lab, said technicians have been seeing fentanyl in the form of patches prescribed for chronic pain relief for years. But more recently they are seeing heroin laced with fentanyl. 
 
 In January, the lab examined one case of heroin mixed with fentanyl. In April, there were three more. In May, half of the labs 10 heroin cases had samples cut with fentanyl. 
 
 “I think we're starting to see that a lot more in Iowa,” Reeve said. “It's a trend that's alarming. Fentanyl is a dangerous drug if it's not handled right.” 
 
 Stepleton puts it more bluntly. 
 
 “I think it's going to be an extreme problem,” he said. “I can't stress that enough. There is no FDA in illicit drug distribution. It's a crapshoot on what you're going to be buying and putting in your body. ... It's like putting a loaded gun in your hand and spinning the chamber every time.” 
 
 In July, the Cedar Rapids Police Department announced it had received federal funding that would allow it to hire another officer. Having that additional officer will allow the department to place a seasoned professional with the Eastern Iowa Prevention, Treatment and Prosecution Initiative. The officer will emphasize heroin-prevention efforts while also working on the investigation and prosecution of heroin-related crimes. 
 
 “From decades ago, (heroin) seemed to be confined to different areas,” Jerman said. “Now we see there are no boundaries ... It's making its way into all segments of society. 
 
 “Whether it's lower middle, upper middle or the upper class, that's what we're seeing.” 
 
 Change in law makes heroin death convictions more difficult to prosecute 
 
 A grieving mother displayed a photo of her son in a casket during a February sentencing of a man who had sold her child heroin, saying it's all she has left to remember him. 
 
 Stacy Iberg likely is one of many mothers over the past five years in Eastern Iowa who have either lost a child or had a child overdose on heroin. 
 
 Her son, Dustin Legrand, died from a heroin overdose last year after Ramon Freeman, 35, of Chicago, sold to someone who provided the heroin to Legrand. Freeman is now serving 30 years in federal prison. 
 
 Federal prosecutors say Freeman is only one of 75 people charged in U.S. District Court in the past five years for distribution of heroin, and 38 of those have been in Linn County. From 2011 to 2015, 14 defendants in the Northern District have been charged in cases involving heroin deaths and six have been charged with bodily injury that resulted from heroin overdoses. 
 
 But prosecuting these dealers has become more difficult after a 2014 U.S. Supreme Court decision involving an Iowa case in the Southern District, he said. 
 
 That case set a higher standard for prosecutors to meet in distribution cases involving death, Assistant U.S. Attorney Dan Chatham said. There must be sufficient evidence the heroin is what caused the death, according to the law. 
 
 Prosecutors previously only had to prove the heroin was a “contributing cause.” In many of these cases, users may take other drugs along with the heroin. 
 
 In an overdose causing bodily injury, Chatham said, there has to be evidence that the user was at high risk to die without medical intervention. 
 
 Some cases haven't been able to meet that standard to convict for a heroin death, but Chatham and Patrick Reinert, also an assistant U.S. attorney, said they can argue in sentencing for more time based on other factors, such as previous convictions, purity of heroin or how close the dealer is to the main source. 
 
 In the sentencing for Freeman in February, Chatham argued for more prison time based on the purity — in that case, 68 to 73 percent — of heroin he was selling, and Freeman's position in the chain of distribution. Dealers with higher purity levels typically are closer to the main source, he said. 
 
 Chatham said the overdoses usually occur because the purity is so much higher than what the user is used to. In the past, the heroin might have been cut with another substance, so the dealers could have more product and make more money. 
 
 Chatham said there also are cases in the district where users have overdosed because it's mixed with another drug such as fentanyl, used to treat severe pain and often used after surgery. 
 
 There were two defendants indicted in June from Cedar Rapids for distribution of heroin/fentanyl and conspiracy to distribute heroin/fentanyl that resulted in bodily injury. ||||| Law enforcement agencies nationwide are struggling to stop a growing heroin epidemic from spreading across the United States. (McKenna Ewen, Whitney Shefte/The Washington Post) 
 
 Midwest health officials worried this would happen. 
 
 It’s why they brought together a tri-state coalition — Ohio, Indiana and Kentucky — to talk about the dangers, and it’s why they issued a stern, desperate warning last month to first responders and addiction counselors who patrol the front lines of the opioid war every day. 
 
 They said the situation was “dire.” One Ohio coroner told users they were “literally gambling” with their lives. 
 
 But their public plea could not prevent the heroin on their streets from being cut and sold with a new opioid analog 100 times more potent than fentanyl and 10,000 stronger than morphine. 
 
 In chemical terms, it’s called carfentanil. Colloquially, it’s an elephant tranquilizer. 
 
 It’s the most potent opioid used commercially, strong enough to knock out — or even kill — a 15,000-pound pachyderm, and used primarily to sedate other large animals, like ox, moose and buffalo. 
 
 [A new front in the opioid war: Elephant tranquilizer] 
 
 Now drug dealers, in an attempt to stretch their supply and deliver a stronger, longer high, are cutting their heroin with carfentanil — which is far more dangerous than its already troublesome but less potent cousin, fentanyl. 
 
 And in a 48-hour window this week, two counties near the Ohio-Indiana border may have been hit with a dangerous wave of it. 
 
 On Tuesday night, officers responded to at least 11 overdose cases in Jennings County, Ind. That same day and into Wednesday evening, authorities in Hamilton County, Ohio — home to Cincinnati — received more than 50 heroin overdose calls, reported TV station WCPO. 
 
 In Ohio, the calls took first responders all over the city: a United Dairy Farmers bathroom, a McDonald’s, the scene of a car crash and a Rally’s parking lot. 
 
 The man at Rally’s died, according to WCPO. 
 
 Just last weekend, only days before the 48-hour frenzy of calls, about 30 other overdoses were reported in Hamilton County, Newtown Police Chief Tom Synan told Fox 19. 
 
 Officers responding to numerous overdoses this evening in Jennings Co. 11 patients so far. #Narcan in high demand. pic.twitter.com/LMwhWPAaOo — Sgt. Stephen Wheeles (@ISPVersailles) August 24, 2016 
 
 Authorities have been careful not to speculate whether the overdoses across the two states are connected, or whether they all came from one particularly potent batch of heroin, but police told WCPO that is likely the case. It may have been mixed with fentanyl, carfentanil or even rat poison — making it that much harder to treat overdose patients. 
 
 That was a crucial part of the public health warning Hamilton County released last month. 
 
 “Take this as a dire warning to all, if you choose to purchase and use any forms of heroin,” Hamilton County Coroner Lakshmi K. Sammarco said. “No one knows what other drugs may be mixed in or substituted and you may be literally gambling with your life. 
 
 “Don’t count on Narcan to be able to reverse the effects of carfentanil.” 
 
 
 
 A box of the opioid antidote Naxolone, also known as Narcan, sits on display during a family addiction support group on March 23 in Groton, Conn. (John Moore/Getty Images) 
 
 Narcan is an FDA-approved nasal spray version of naloxone, a life-saving medication that can reverse the lethal effects of an opioid overdose. It was approved in November 2015 and has been credited with saving countless lives. Across the country, first responders are stocking up on Narcan and some agencies have even started training civilians on how to use it on each other. 
 
 Usually, one, maybe two, doses of Narcan will sufficiently help someone overdosing on pure heroin. 
 
 But when the drug is cut with other substances, especially carfentanil, it can take as much as a half dozen doses, maybe more. Complicating matters is that law enforcement officers have no way of knowing on scene what kind of heroin cocktail the user has injected. Fentanyl and carfentanil are mixed into the heroin in nearly untraceable doses. Both are colorless and odorless. 
 
 Often, users don’t even know until it’s too late. 
 
 “It’s not like they hand you your dope and say, ‘Here’s the carfentanil dope,’” Jessica Sageser, a former heroin user, told WCPO. “You don’t know. The seriousness of it has escalated so much more because this drug is, like, indescribable. It’s a snap of the fingers and the blink of an eye, and you are done.” 
 
 [‘To my daughter’s drug dealer’: A distraught mother’s viral Facebook post] 
 
 Carfentanil is not just dangerous to users, according to an Aug. 12 Washington Post story: 
 
 Veterinarians who handle the drug wear protective gloves, aprons and masks, treating it “almost like uranium,” in the words of one zoo veterinarian who spoke to Fusion. A dose the size of a grain of salt could kill a person, and carfentanil can even be lethal when absorbed through the skin, according to the Drug Enforcement Administration. 
 
 The DEA has warned narcotics officers, reported the Cincinnati Enquirer, and Ohio Attorney General Mike DeWine has urged police in his state to stop field testing for fear that handling the substances without proper precautions could be too dangerous. 
 
 “It’s just too high of a risk,” DeWine said, according to the Columbus Dispatch. “This stuff is just now hitting. You’re really not seeing [police] departments with any experience with it at all.” 
 
 
 
 A man injects himself with heroin using a needle obtained from the People’s Harm Reduction Alliance, the nation’s largest needle-exchange program, in Seattle in April 2015. (David Ryder/Reuters) 
 
 Earlier this month, prosecutors in Pennsylvania issued a warning on carfentanil, which may be responsible for some of the 200 recent overdoses in the area — 20 of them fatal. 
 
 It also has been linked to overdoses this year in Kentucky and Florida. 
 
 Last week, police in Huntington, W. Va., responded to 26 heroin overdoses in a span of four hours. 
 
 [The latest overdose outbreak shows just how dangerous the heroin epidemic has gotten] 
 
 The Hamilton County Heroin Coalition, which works with law enforcement officials in southeast Indiana and northern Kentucky, is still investigating the widespread spat of overdoses this week. 
 
 “I’ve got to say to whoever pushed this out on the street,” Synan told WCPO, “this was the wrong thing to do.” 
 
 More from Morning Mix: 
 
 Texas law now permits guns in college classrooms. Protesters came armed with sex toys instead. 
 
 World’s largest aircraft takes world’s slowest nosedive during second test flight 
 
 Federal judge: Starbucks is not ripping you off when it puts lots of ice in your iced tea ||||| AKRON, Ohio — Drug overdose deaths in 2016 most likely exceeded 59,000, the largest annual jump ever recorded in the United States, according to preliminary data compiled by The New York Times. 
 
 The death count is the latest consequence of an escalating public health crisis: opioid addiction, now made more deadly by an influx of illicitly manufactured fentanyl and similar drugs. Drug overdoses are now the leading cause of death among Americans under 50. 
 
 Although the data is preliminary, the Times’s best estimate is that deaths rose 19 percent over the 52,404 recorded in 2015. And all evidence suggests the problem has continued to worsen in 2017. 
 
 Drug overdose deaths, 1980 to 2016 *Estimate based on preliminary data 
 
 Because drug deaths take a long time to certify, the Centers for Disease Control and Prevention will not be able to calculate final numbers until December. The Times compiled estimates for 2016 from hundreds of state health departments and county coroners and medical examiners. Together they represent data from states and counties that accounted for 76 percent of overdose deaths in 2015. They are a first look at the extent of the drug overdose epidemic last year, a detailed accounting of a modern plague. 
 
 The initial data points to large increases in drug overdose deaths in states along the East Coast, particularly Maryland, Florida, Pennsylvania and Maine. In Ohio, which filed a lawsuit last week accusing five drug companies of abetting the opioid epidemic, we estimate overdose deaths increased by more than 25 percent in 2016. 
 
 “Heroin is the devil’s drug, man. It is,” Cliff Parker said, sitting on a bench in Grace Park in Akron. Mr. Parker, 24, graduated from high school not too far from here, in nearby Copley, where he was a multisport athlete. In his senior year, he was a varsity wrestler and earned a scholarship to the University of Akron. Like his friends and teammates, he started using prescription painkillers at parties. It was fun, he said. By the time it stopped being fun, it was too late. Pills soon turned to heroin, and his life began slipping away from him. 
 
 Mr. Parker’s story is familiar in the Akron area. From a distance, it would be easy to paint Akron — “Rubber Capital of the World” — as a stereotypical example of Rust Belt decay. But that’s far from a complete picture. While manufacturing jobs have declined and the recovery from the 2008 recession has been slow, unemployment in Summit County, where Akron sits, is roughly in line with the United States as a whole. The Goodyear factories have been retooled into technology centers for research and polymer science. The city has begun to rebuild. But deaths from drug overdose here have skyrocketed. 
 
 In 2016, Summit County had 312 drug deaths, according to Gary Guenther, the county medical examiner’s chief investigator — a 46 percent increase from 2015 and more than triple the 99 cases that went through the medical examiner’s office just two years before. There were so many last year, Mr. Guenther said, that on three separate occasions the county had to request refrigerated trailers to store the bodies because they’d run out of space in the morgue. 
 
 It’s not unique to Akron. Coroners’ offices throughout the state are being overwhelmed. 
 
 Drug overdose deaths in six Ohio counties, 2010 to 2017 Totals for 2017 assume that overdose deaths continue at the same rate through the remainder of the year. Source: Butler County Coroner’s Office; Cuyahoga County Medical Examiner’s Office; Hamilton County Coroner; Montgomery County Alcohol, Drug Addiction & Mental Health Service; Montgomery County Sheriff’s Office; Summit County Department of the Medical Examiner 
 
 In some Ohio counties, deaths from heroin have virtually disappeared. Instead, the culprit is fentanyl or one of its many analogues. In Montgomery County, home to Dayton, of the 100 drug overdose deaths recorded in January and February, only three people tested positive for heroin; 99 tested positive for fentanyl or an analogue. 
 
 Fentanyl isn’t new. But over the past three years, it has been popping up in drug seizures across the country. 
 
 Drug seizures containing fentanyl Source: D.E.A. National Forensic Laboratory Information System 
 
 Most of the time, it’s sold on the street as heroin, or drug traffickers use it to make cheap counterfeit prescription opioids. Fentanyls are showing up in cocaine as well, contributing to an increase in cocaine-related overdoses. 
 
 The most deadly of the fentanyl analogues is carfentanil, an elephant tranquilizer 5,000 times stronger than heroin. An amount smaller than a few grains of salt can be a lethal dose. 
 
 “July 5th, 2016 — that’s the day carfentanil hit the streets of Akron,” said Capt. Michael Shearer, the commander of the Narcotics Unit for the Akron Police Department. On that day, 17 people overdosed and one person died in a span of nine hours. Over the next six months, the county medical examiner recorded 140 overdose deaths of people testing positive for carfentanil. Just three years earlier, there were fewer than a hundred drug overdose deaths of any kind for the entire year. 
 
 This exponential growth in overdose deaths in 2016 didn't extend to all parts of the country. In some states in the western half of the U.S., our data suggests deaths may have leveled off or even declined. According to Dr. Dan Ciccarone, a professor of family and community medicine at the University of California, San Francisco, and an expert in heroin use in the United States, this geographic variation may reflect a historical divide in the nation’s heroin market between the powdered heroin generally found east of the Mississippi River and the Mexican black tar heroin found to the west. 
 
 This divide may have kept deaths down in the West for now, but according to Dr. Ciccarone, there is little evidence of differences in the severity of opioid addiction or heroin use. If drug traffickers begin to shift production and distribution in the West from black tar to powdered heroin in large quantities, fentanyl will most likely come along with it, and deaths will rise. 
 
 Drug overdose deaths in Philadelphia and San Francisco Drug overdose deaths since 1980 have surged in Philadelphia despite a shrinking population; most heroin there is powdered. They have remained relatively flat in San Francisco, where most heroin is black tar. Source: C.D.C. WONDER 
 
 First responders are finding that, with fentanyl and carfentanil, the overdoses can be so severe that multiple doses of naloxone — the anti-overdose medication that often goes by the brand name Narcan — are needed to pull people out. In Warren County in Ohio, Doyle Burke, the chief investigator at the county coroner’s office, has been watching the number of drug deaths rise as the effectiveness of Narcan falls. “E.M.S. crews are hitting them with 12, 13, 14 hits of Narcan with no effect,” said Mr. Burke, likening a shot of Narcan to “a squirt gun in a house fire.” 
 
 Early data from 2017 suggests that drug overdose deaths will continue to rise this year. It’s the only aspect of American health, said Dr. Tom Frieden, the former director of the C.D.C., that is getting significantly worse. Over two million Americans are estimated to be dependent on opioids, and an additional 95 million used prescription painkillers in the past year — more than used tobacco. “This epidemic, it’s got no face,” said Chris Eisele, the president of the Warren County Fire Chiefs’ Association and fire chief of Deerfield Township. The Narcotics Anonymous meetings here are populated by lawyers, accountants, young adults and teenagers who described comfortable middle-class upbringings. 
 
 Back in Akron, Mr. Parker has been clean for seven months, though he is still living on the streets. The ground of the park is littered with discarded needles, and many among the homeless here are current or former heroin users. Like most recovering from addiction, Mr. Parker needed several tries to get clean — six, by his count. The severity of opioid withdrawal means users rarely get clean unless they are determined and have treatment readily available. “No one wants their family to find them face down with a needle in their arm,” Mr. Parker said. “But no one stops until they’re ready.” 
 
 About the data 
 
 Our count of drug overdoses for 2016 is an estimate. A precise number of drug overdose deaths will not be available until December. 
 
 As the chief of the Mortality Statistics Branch of the National Center for Health Statistics at the C.D.C., Robert Anderson oversees the collection and codification of the nation’s mortality data. He noted that toxicology results, which are necessary to assign a cause of death, can take three to six months or longer. “It’s frustrating, because we really do want to track this stuff,” he said, describing how timely data on cause of death would let public health workers allocate resources in the right places. 
 
 To come up with our count, we contacted state health departments in all 50 states, in addition to the District of Columbia, asking for their statistics on drug overdose deaths among residents. In states that didn't have numbers available, we turned to county medical examiners and coroners’ offices. In some cases, partial results were extrapolated through the end of the year to get estimates for 2016. 
 
 While noting the difficulty of making predictions, Mr. Anderson reviewed The Times’s estimates and said they seemed reasonable. The overdose death rate reported by the N.C.H.S. provisional estimates for the first half of 2016 would imply a total of 59,779 overdose deaths, if the death rate remains flat through the second half of the year. Based on our reporting, we believe this rate increased. 
 
 While the process in each state varies slightly, death certificates are usually first filled out by a coroner, medical examiner or attending physician. These death certificates are then collected by state health departments and sent to the N.C.H.S., which assigns what’s called an ICD-10 code to each death. This code specifies the underlying cause of death, and it’s what determines whether a death is classified as a drug overdose. 
 
 Sometimes, the cases are straightforward; other times, it’s not so easy. The people in charge of coding each death — called nosologists — have to differentiate between deaths due to drug overdose and those due to the long-term effects of drug abuse, which get a different code. (There were 2,573 such deaths in 2015.) When alcohol and drugs are both present, they must specify which of the two was the underlying cause. If it’s alcohol, it’s not a “drug overdose” under the commonly used definition. Ideally, every medical examiner, coroner and attending physician would fill out death certificates with perfect consistency, but there are often variations from jurisdiction to jurisdiction that can introduce inconsistencies to the data. 
 
 These inconsistencies are part of the reason there is a delay in drug death reporting, and among the reasons we can still only estimate the number of drug overdoses in 2016. Since we compiled our data from state health departments and county coroners and medical examiners directly, the deaths have not yet been assigned ICD-10 codes by the N.C.H.S. — that is, the official underlying cause of death has not yet been categorized. In addition, the mortality data in official statistics focuses on deaths among residents. But county coroners typically count up whichever deaths come through their office, regardless of residency. When there were large discrepancies between the 2015 counts from the C.D.C. and the state or county, we used the percent change from 2015 to calculate our 2016 estimate. 
 
 We can say with confidence that drug deaths rose a great deal in 2016, but it is hard to say precisely how many died or in which places drug deaths rose most steeply. Because of the delay associated with toxicology reports and inconsistencies in the reported data, our exact estimate — 62,497 total drug overdose deaths — could vary from the true number by several thousand. ||||| Police and social service workers search under an Everett overpass while administering a Point in Time survey of the homeless in Everett. The city of Everett is considering a lawsuit against Purdue Pharma, arguing the manufacturer of OxyContin is responsible for the community’s surge in overdose deaths, homelessness and street crime. (Herald file) 
 
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 EVERETT — The mayor in Snohomish County’s largest city, a place where addiction to heroin and other opioids is officially considered an epidemic, wants the manufacturer of the powerful painkiller OxyContin to start paying to repair the damage done to the community. 
 
 Everett Mayor Ray Stephanson said he plans to ask the City Council on Wednesday to support a civil lawsuit by the city against Purdue Pharma. 
 
 The case would allege the drug manufacturer was negligent when it aggressively marketed OxyContin as a supposedly less-addictive alternative to other pain medication while simultaneously ignoring evidence that substantial quantities were diverted through “pill mills” to illegal drug traffickers. 
 
 OxyContin has addictive qualities on a par with morphine. The demand it created among people who became addicted planted the seeds here for what has become rampant use of heroin and other opioids, the city hopes to argue. 
 
 Everett has been studying for months how to make a case that Purdue is responsible for the community’s surge in overdose deaths, homelessness and street crime, Stephanson said. 
 
 The more the city and its attorneys have learned, the more convinced the mayor has become that the drug manufacturer needs to be held accountable. 
 
 “We are going to go at them, and we are going to go at them hard,” Stephanson said. 
 
 The family-owned pharmaceutical company is worth billions, according to a 2015 Forbes story. Purdue has racked up more than $35 billion in sales since launching OxyContin, with annual sales at $3 billion, according to the Forbes story. 
 
 It also has faced criminal prosecution and civil lawsuits across the country. In 2007, company executives pleaded guilty to criminal charges related to deceitful marketing practices and the company agreed to pay hundreds of millions of dollars in penalties and other costs. 
 
 Everett alleges that diversion and harm continued. 
 
 Some key evidence surfaced because of the federal prosecution of Jevon Lawson, formerly of Mill Creek, and people associated with a California-based clinic that illegally diverted OxyContin to drug traffickers. 
 
 Lawson was a California gang member who six years ago was making a name for himself in the rap world under the stage name Swag. The Daily Herald published a front-page story about him in 2011 after he was indicted for peddling large amounts of drugs in Snohomish County. 
 
 Lawson and his connection to Everett’s heroin problem was featured in an Los Angeles Times series in July. The Everett City Council began talking about Purdue’s possible involvement a few days later. 
 
 Lawson had caught the attention of local law enforcement as early as 2007, when a confidential informant reported buying crack from him. Cops were told that Lawson was getting out of the crack business. He’d found a more profitable product: OxyContin. 
 
 Federal agents raided his Mill Creek area home in 2008, seizing marijuana, a large amount of money and financial documents. It’s unclear why Lawson wasn’t prosecuted at the time. 
 
 As part of his 2011 plea agreement, Lawson admitted to selling large amounts of Oxy between 2008 and 2010, well after he was on law enforcement’s radar. 
 
 While Lawson was under investigation, local leaders already were discussing the surge of prescription pain medication abuse. The Daily Herald published a story in 2008 about a conference in Everett for health care workers about the effect of the abuse. 
 
 At the time, prosecutors told the crowd there was a spike in pharmacy robberies and other crimes tied to black market prescription drugs. They also were already seeing people switching to heroin, a cheaper alternative. 
 
 Lawson wasn’t the only illicit OxyContin supplier in Snohomish County. Federal agents cracked down on an Everett osteopath who operated a pain management clinic on Evergreen Way. Delbert Whetstone’s prescribing practices came under scrutiny after several drug dealers were arrested with prescription medication bottles bearing his name. 
 
 Investigators alleged that Whetstone had prescribed nearly 88,000 of 80 mg OxyContin in a 10-month period in 2009. In comparison, Providence Regional Medical Center Everett had ordered 13,400 of the tablets during the same time frame, according to court papers. Whetstone was sentenced in 2012 to three years in federal prison. 
 
 In 2010, under pressure, Purdue changed the formula of its product, making it more difficult to smoke. People addicted to the powerful prescription pain killer turned to heroin. 
 
 Heroin deaths rates have quadrupled over the past decade, according to the Centers for Disease Control and Prevention. In Snohomish County, heroin and prescription opioids were responsible for two-thirds of the 130 accidental overdose deaths in 2013. 
 
 Snohomish County Human Services Division and the county’s Health District compiled a report about heroin, overdose deaths and treatment trends. The report was released in 2015. 
 
 It showed that fatal heroin overdoses were happening most frequently in north Everett and the Tulalip Indian Reservation. 
 
 The spike in heroin use has taxed resources in Snohomish County. Law enforcement, the courts, health care and treatment providers, social service agencies and others have struggled to respond. 
 
 As heroin use has increased, so has the homeless population in the county. Business owners and neighbors are demanding solutions to an increase in panhandling, encampments and property crimes. 
 
 The Everett Police Department and Snohomish County Sheriff’s Office have teamed up officers with social workers in an effort to get people help, including treatment and housing. In the jail, staff is helping enroll inmates into Washington Apple Health, the state’s Medicaid program. That means once people are released they can access medical services, such as chemical dependency treatment or mental health resources. 
 
 Everett also is working to build a housing project that will offer 70 apartments for the chronically homeless. 
 
 Those are all costly programs that are being shouldered by taxpayers. Stephanson said Purdue has a responsibility to help bear the costs, particularly in the years ahead. 
 
 The lawsuit would be “an action we can take as a community to say ‘Enough is enough,’ ” the mayor said. 
 
 The drug company has been accused before of selling OxyContin in Washington without regard to its role in fueling addiction. 
 
 In May 2007, Rob McKenna, then state attorney general, announced a legal settlement to end litigation over how Purdue had marketed the powerful painkiller. At the time, Washington was one of roughly two dozen states around the country alleging the company had for years been attempting to increase the market for OxyContin while deliberately downplaying the risk of addiction and other harm. 
 
 Purdue’s salespeople at the time were compensated based in part on how much of the drug they sold, the complaint alleged. State attorneys accused the drug manufacturer of ignoring prescribing data that could have identified “pill mills” and other sources of abuse. The company also was accused of not sharing suspicions with law enforcement. 
 
 “Purdue sales representatives instead targeted the highest prescribers and encouraged them to prescribe more OxyContin, in larger doses, to more patients,” the 2007 complaint said. “Purdue’s marketing practices thus exacerbated the abuse and diversion risks.” 
 
 In exchange for an end to the pending lawsuits, the drug company agreed to pay the states $19.5 million. Washington’s share was $719,500. Under terms of the 2007 consent decree, Purdue admitted no wrongdoing. 
 
 Diana Hefley: 425-339-3463; hefley@heraldnet.com.
– The Washington Post takes a look at the country's surging heroin epidemic by zeroing in on Pennsylvania’s Washington County, a place one local detective refers to as "ground zero" for heroin in the area. Last Sunday, in less than 70 minutes, eight heroin overdoses were recorded in the county of about 200,000 people. By a day later, that number had jumped to 16; by two days later, 25—three of which were fatal. As the Post notes, this period of time wasn't an isolated case but rather "an extreme example of what communities in parts of the country are enduring." In a Florida community earlier this month, 11 people overdosed on heroin in a 24-hour span, WKMG reported; this year, Cedar Rapids, Iowa, had seen 44 heroin overdoses by June 5, the Gazette reported; New Jersey saw 781 overdose deaths related to heroin last year, 101.5 reported. Just yesterday, NPR ran a story on Marion, Ohio, a small town whose police chief says that his team sometimes responds to as many as three overdoses in just one hour. One of the reasons heroin is booming: It's cheap—cheaper than the prescription drugs that, for some, start them down the road of addiction. And one of the reasons there are so many overdoses? Nowadays, the drug is even more potent. The US attorney for western Pennsylvania is one of a growing number of prosecutors who aren't interested in jailing users, the Post reports: "If they're using and trafficking, I prosecute them. If they’re just using, they need help," he says. But finding dealers—including any linked to fatal overdoses, who will be charged with homicide—is no easy task, as these days drugs are sold via cellphone or even, with more middle-class people addicted now, in unlikely locations like homes. The county's supervising detective sums up the "out of control" heroin problem: "I'd be glad to have the crack epidemic back." Click for the full Post article.