Drugs, Overdose, Hope - North Carolina and Nevada

27:21But you have to address demand, because as long as there are people who are addicted to the drugs, there will be somebody to sell them those drugs. And there is life after addiction. So much life. Remember Jenny, whose law enforcement dad witnessed her distress when she was trying to stop her opioid use? So I am working. I have a corporate job. I'm in a good, healthy relationship with my boyfriend. no children we have a dog she's our baby but yeah life is good for the first time and I don't know how long I just feel peace. Back in Dr Dasgupta's office there's a shelf displaying a handful of the thousands of small white boxes that have arrived at the lab containing street drugs for testing.

28:10They're covered in scribbled messages. People write us notes and draw pictures, put stickers. And they say things like, thank you. Thank you for keeping us alive and educated about what we put in our bodies. Thank you for all of y 'all's hard work. Thank you. Thank you. Thank you, it says. And when you get a note like that on one of the boxes that's coming to your lab? It makes you want to come back to work tomorrow. Thanks for staying with us in North Carolina. Next, we're off to the desert state of Nevada. This is the documentary from the BBC World Service.

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30:20We've been in North Carolina. Now we're in Nevada.

30:29This is the documentary from the BBC World Service. I'm Linda Presley with Assignment and the second of a two-part series from the United States, Drugs, Overdose, Hope. China Light is an organisation supporting drug users living in the underground storm drains of Las Vegas. We walk uncertainly, not sure what we'll find. It's dark and it's filthy. We're wearing head torches as we follow Rob Banghart and his volunteers bringing supplies. Water, snacks and packs of the life-saving antidote for an opioid overdose, naloxone. OK, we're coming back. The United States has seen a dramatic drop in drug-related deaths, especially from fentanyl.

31:12Last year, the number of people who died fell by more than 25%, down from a 2023 high of over 110 ,000 deaths. Last week, an assignment we reported from North Carolina, where far fewer people are dying. This week, we're in Nevada to find out why this is a state that's bucked the national trend. Fatalities last year continued to tick up. There's probably been six or seven deaths in this tunnel alone in the last year or two. Six or seven? Oh, yeah. Shine a Light encourages drug users to start a new life, treatment, stability, a home above ground. We head further in. Above us is the iconic glitzy Caesar's Palace, the casino destination for the world's high rollers.

31:59Down here, we pass one skinny shaft of brilliant sunlight until we reach a man sitting in the dark on a grubby mattress surrounded by his worldly goods. This is Jay. I've been out here for a while. I've seen plenty of drugs and overdoses. The fentanyl thing is terrible. I've seen people overdose on fentanyl and I've seen people die on fentanyl. Jay's known opioid users who've overdosed multiple times, believing the closer they come to death, the better that mind-altering high will be. They're chasing something they can't catch. People brag about that. that they've OD'd 27 times, 15 times. And I try to tell them, you know, at some point when you OD, there's not going to be somebody there to make a phone call or somebody to administer a drug.

32:41That's a wrap. You bet. They don't see it that way. This is how addiction messes with a human brain. There's nothing here that is good. In these tunnels, there's nothing good. Well, I hope you manage to stay connective with Rob and his team. They're always here. They don't let us go far. Yeah, that's where we're at. Yeah. I just have no interest in anything. Where do you go from there? I guess I've seen so much that it just doesn't matter. But there's always hope, isn't there, somewhere? Yeah, I'm sure. Somewhere there's hope? Yeah. Do you have a brother named Scott? Oh, yeah. Rob's trying to get Jay interested in making a change.

33:24He says he has a message from Jay's brother. But for now, Jay's not ready to leave his old mattress in the damp and the dirt to begin the arduous process of getting clean. Jay doesn't use fentanyl, but he knows all about it because he was prescribed opioids in hospital. All your opiate-based pills are all evil because of the fact that if you take them for a couple of days, then your body has to have them, or else you're sick. And when I say sick, like, you're beyond sick. I mean, you'll sneeze, you'll scratch, a diarrhoea. You won't be able to sleep by any means. You'll feel your hair. It's horrific.

34:04Above ground, Las Vegas is one great homage to the seductive power of gambling. In this city, you're never far from the bells and ka-ching of slot machines. In 2024, the number of overdose fatalities in southern Nevada rose to 1 ,257. Homeless people are the visible end of the crisis. But what we know about America's opioid epidemic is that it's affected every section of society, no matter race or class. On one of his off days, we meet Dr Tom Swoboda in the foyer of a swanky casino. He's an emergency room physician and associate dean at Roseman University College of Medicine. And he tells us about the less obvious opioid user population.

34:49We have a lot of patients who are on opiate pain medication here, Oxycodone, Oxycontin, for chronic pain. And these type of pain medications develop tolerance over time. What it means is you need more of these opiate pain medications to get the same pain effect. So they start looking for other things to help with their pain. And they know fentanyl is the same type of medication. So they go out onto the street to find it? Or they know people who know people. So we've come to Nevada because your figures in terms of the numbers of people who are dying from overdose, and especially at the south here in Las Vegas, they don't really seem to be going in the right direction so far.

35:34What's your analysis of what's going on with overdose deaths here? Part of it is the fact that here in Nevada, we've had a really strong population growth, and the health care infrastructure really hasn't caught up with that quite large growth. When I first came to Las Vegas in 1996, we were anticipating one million people living in the Las Vegas area. We thought that was a lot. Now the population's close to two and a half million. And when you look at the difference in the 25 years, the number of facilities that we have, the number of physicians that we have, including mental health providers, including substance abuse counsellors and stuff, we are lacking the coordination of care that is needed.

36:16In terms of the numbers of people who are appearing with some kind of drug problem, what do you see on your average week? So there are certain sections in the city where we see it more often, mainly in the area of downtown Las Vegas and the Las Vegas Strip area. When I'm working in facilities near there, we see it fairly frequently, like one or two per day. One or two per day? Yeah. In the case of fentanyl, they would be too sleepy, maybe not breathing. And we have a lot of stimulant use of methamphetamine here, and it's the exact opposite. They're too crazy and wired. Methamphetamine, known as crystal meth or just meth, is a highly addictive synthetic stimulant.

36:57The days of Breaking Bad, American home-cooked meth, have pretty much gone. These days, industrial quantities of the drug is trafficked into the US from Mexico. In Nevada, we hear often about the crazy wired behaviour Dr Swoboda talks about. And methamphetamine can kill. It increases heart rate and may lead to fatal cardiac arrhythmia. But it's fentanyl that's changing the game for meth users. Come on, guys. China light! China light! China light! Tony, it's you! Underground again with Rob Banghart, we get a lesson in Nevada's perilous drug supply. Tim emerges from the darkness. He uses meth. But when one of the volunteers offers him a pouch of naloxone, the nasal spray antidote for an opioid overdose, he takes it.

37:53It saved my life once. Did it? Yeah. I was handed a foil that I thought was crystal meth and it actually ended up being fat and all that. It was kind of ironic. The guy that saved me was kind of an enemy at the time. Me and him weren't getting along whatsoever. And he seen me in distress and came to the call. It's actually saved my life. I've saved a few people's lives with this stuff, actually. Have you? How many times have you used it? I've used it myself five different times on five different people. Wow, down here? Not down here, just all over. Yeah. Yep. I've done it with homeless people.

38:26I've done it with people there that work very well high-paying jobs. It affects all forms of life, not just one particular class. Luckily, Tim was on a hand to assist. But you have few chances if you overdose alone. In Nevada, more than half the state's drug deaths are unobserved. There's no one there to help. I asked Tim if he uses drug testing kits to check for the presence of fentanyl. I have, yes. I'm testing, usually methamphetamines is where you normally would test, and everything's come up positive for fentanyl. Everything's come up positive for fentanyl? I would say out of, I don't know, we'll say 10 bags at least, maybe three of them will come up negative for fentanyl.

39:07So what do you do if it comes up positive for fentanyl? Do you still take it? Do you take the chance? No, I don't usually take a chance, but I usually just don't accept it. Right. You know, some people, they're too impatient, they just want to get to it now, get to it now, and that can be fatal. Because we're hearing that a lot of meth users are overdosing because they don't realise that fentanyl's there. Yeah, that's exactly right, absolutely. It's happened to me. In Nevada, fentanyl and methamphetamine have become a lethal cocktail. An hour's flight north of Las Vegas, crossing some of Nevada's breathtaking mountain scenery, we arrive in Reno for a meeting with Dr Laura Knight, the chief medical examiner and coroner for the city, Washoe County and its surrounding rural region, a population of nearly a million people.

39:57The vast majority of the overdose numbers that we're seeing here in the north of the state are due to fentanyl and methamphetamine. We're seeing quite a lot of cases where those two drugs are present in combination in the person's blood when we test it after their death. But we're also seeing quite a lot of cases where methamphetamine alone is present. But fentanyl has really driven the increase and fentanyl has driven the small decrease that we're seeing as well. In contrast to Las Vegas and the south of the state of Nevada, Dr Knight's talking about a drop in the number of overdose fatalities in her jurisdiction between 2023 and 2024.

40:3590 fewer deaths year on year. I ask her what she thinks made the difference locally. I think it's hard to say because there's really a combination of factors. The drug supply in the community, the efforts that are going on to reduce harm in our community as well, and just awareness of the population about the fact that fentanyl is in our drug supply and we need to be cautious of that. Some folks, unfortunately, are still looking for fentanyl or abusing fentanyl, but I think there are others probably who are still trying to avoid it because they know the risk of dying. But even so, I think in 2024, 395 people died from an overdose.

41:14That's still over seven people a week in your area. Yes, I mean, it's still a staggering number. I can tell you that in our peak year in 2023, about a third of the cases that had meth or fentanyl present had both. To understand more about methamphetamine use in Nevada, we call on Dr. Carla Wagner at the University of Nevada in Reno. I am a professor in the School of Public Health. I do research on harm reduction and overdose prevention. If you look at the drug use trends and overdose trends in the state, you'll see that methamphetamine has always been contributing to a large share of drug-related harm in Nevada.

41:54It's not a new phenomenon. Methamphetamine has been prevalent in the western United States for many, many years. And I think since 2015 that the deaths associated with meth and opioid use together have increased dramatically. What's going on there? There's a lot of theories about what's going on. There's a lot of reasons that people use methamphetamine and opioids together. Sometimes it's deliberate. People like the way it feels. So some people combine them simultaneously into what's called a goofball because people like the experience of having both the upper and the downer together. It's also possible that people are being inadvertently exposed.

42:31This is what we heard in the Las Vegas storm drains. Some commentators have suggested mixing the two drugs together is a deliberate move by Mexico's cartels to get stimulant users hooked on opioids. But this isn't what Dr Wagner found in a study. The prevalence estimates were about 9 % of the methamphetamine samples had fentanyl in them. So it is possible that some of those stimulant samples accidentally or inadvertently had fentanyl in them through the manufacturing process, through the packaging process, through the trafficking process. But that's the cross-contamination you're talking about.

43:07I think that our data suggests that a large proportion of the fentanyl in the stimulant samples is through cross-contamination. Remember that these are not trained, certified chemists operating in Mexico. Brian Clark, one of the US Drug Enforcement Administration's special agents in charge, doesn't discount either the casual or intentional mixing of methamphetamine with fentanyl. We commonly refer to them as cartel chemists. So sometimes it is a cross-contamination. Sometimes it could also be your local level dealers basically mixing fentanyl with methamphetamine in order to, again, drive addiction and make more profits off of their product.

43:50OK, so that is not necessarily being done by the cartels in Mexico. It could be done once the drugs reach the United States. Correct. The DEA is a federal law enforcement agency responsible for coordinating drug investigations at home and internationally. Brian Clark's impressed by initiatives taken by President Trump's administration to stem the flow of drugs into the US. I believe we've seen an increase of cooperation from our foreign counterparts in Mexico. The DEA and the Department of Justice have had significant indictments on Chinese chemical companies within the recent six months as well.

44:27The ingredients used to make illicit narcotics in Mexico are often imported from China. And then the administration is also taking a lot stronger stance on our borders, increasing the pressure to seize narcotics and stop the flow of fentanyl and others coming into the United States. So what about recent drug seizures? Fentanyl seizures have dropped slightly over these past seven months, but we are seeing an uptick in methamphetamine. Does that indicate that cartels are producing more methamphetamine? Possibly. As we have continued to put more pressure on China to restrict those precursor chemicals, if the cartels are not getting those chemicals to synthesize fentanyl, they may start increasing the methamphetamine production.

45:14In northern Nevada, we're told about a local shortage of fentanyl, although this may predate President Trump taking office. The point is, it could be contributing to the local decline in fatal overdoses. Heather, to the charge desk, please. In the emergency room of the renowned regional medical centre in Reno, Dr John Hardwick says he's treating fewer people who've taken fentanyl. For opioid overdoses, now I see about one per week maybe, and it was about, you know, one per shift. With methamphetamine, I mean, I see it every shift, multiple patients a day, every single shift. I think there is at least some scarcity of fentanyl.

45:52So you're seeing more people switch their behaviour from using fentanyl to methamphetamine, and now we've seen a surge in methamphetamine use. And these are very different drugs. Meth is a stimulant, an upper, and fentanyl is an opioid, a downer, that slows brain activity. But both help satisfy the reward pathway. Both result in a tremendous amount of dopamine surge and can kind of satisfy at least those parts of the reward pathway. And are you seeing the same people over and over again here in the emergency room? Absolutely, especially with methamphetamine. And methamphetamine results in this very cyclical pattern where someone is high on methamphetamine, they come in for acute psychosis.

46:33We treat their acute psychosis and then they leave. And we try to give them wraparound psychiatric services. And then if they don't seek those and they're not using, the come down from methamphetamine results in severe depression and suicidal behavior. And so we see them on both ends where they're either acutely psychotic or acutely suicidal.

46:58So this is 4th. Stephen Markley shows us around Reno. He's someone with a history of drug use. 4th Street is kind of the central hub for a lot of folks who are unhoused. Just because there's a lot of services here, this is where the shelter is. So we're under one of the big concrete flyovers here in Reno. There's somebody sleeping there on the street.

47:24and there's also a man striding uncertainly up the street in raggedy clothes talking to himself he's agitated and upset one of reno's methamphetamine users when you stay up for a few days if you haven't been drinking water eating food getting proper rest that's what causes people to talk to themselves more than like just the meth it's the lack of self-care i never quite It got to that point, but I did have some moments of psychosis when I was using meth on the street. When we talk about the drug crisis in the US, often we're so transfixed by the numbers, the thousands who've died, that the ongoing and life-changing harm done by narcotics is obscured.

48:06Stephen's old life was drug-filled and precarious. He survived six years living in the underground drainage tunnels we visited in Las Vegas. So I ended up going to prison. After I got out of prison, I paroled to Reno because I just needed a change of pace. It took me a long time to really get back into the swing of even wanting to be a part of society again. Stephen went to rehab and he's in recovery now. He has his own apartment and a job at the University of Nevada in Reno. We do various studies. We also help conduct surveys to help us guide how the funding from the opioid settlement gets spent in the community.

48:45The opioid settlement is the cash secured by the state's attorney generals from companies that promoted the use of addictive medication and kick-started America's overdose epidemic back in the late 1990s. As we heard from North Carolina in last week's assignment, a whopping US$60 billion from those out-of-court settlements are being divided between American states.

49:10Around 200 kilometres south-east of Reno on the main highway, connection to Las Vegas is the town of Hawthorne, population 3 ,000. It's a dramatic drive past towering rugged peaks and then a skirt round the vast glassy surface of Walker Lake. In Hawthorne, some of those opioid settlement dollars have been used to buy new police vehicles to support efforts to stop drug running in this part of Nevada.

49:46And we've got somebody else on board. Who's behind you?

49:59In terms of the drugs that are passing through your territory, what kind of drugs are we talking about? Mainly meth. Meth is the biggest drug that we see across the board. And now fentanyl. At a junkyard in Hawthorne, the undersheriff demonstrates how quickly Nora can find the methamphetamine he's hidden on an old car. She's on drive, right? She can smell the odour right now. She's working it. It takes the dog seconds. OK, let her go. So she's working the odour. Boom. Right on it. So she's sitting right next to where the meth was hidden. She's staring at it, so she's waiting for the reward now.

50:38Nora's reward is a well-chewed tennis ball. Good morning, Sheriff. Good, how are you? In his office, we meet the man in charge, Sheriff Bill Ferguson. He sits behind his desk with an antique rifle mounted on the wall behind him. We view footage of the large halls of fentanyl and meth made by his team, and I ask the sheriff if he's noticed any difference since President Trump assumed power. So far, obviously, it's been short, not even a year yet, but we have yet, this year, since the new administration, taken over to have a large fine. So at this time, it appears to be working. But drugs, especially meth, are still very much on the sheriff's radar.

51:27Methamphetamine has been around the 21 years of my career I've been around. We deal with it on a daily basis, whether it's somebody under the influence, somebody stealing something, somebody having a mental health breakdown. So you're seeing this because people are talking about seeing far more cases of psychosis now with the meth that's coming from Mexico. We do, I would say absolutely. The amount of mental health cases that I have in my jail compared to five years ago have quadrupled. At any given time, I would say there's at least 100 different subjects known to us to use illegal narcotics, whether it's heroin, fentanyl or methamphetamine.

52:14Wow, that's quite a large number of people in a small community. It absolutely is. There are moments in Nevada when the scale of the drug epidemic really hits home. This is one of them. Hawthorne's population is just 3 ,000 people. That's one in 30 people in the community taking highly addictive substances. And there have been fatal overdoses here too. The town spent some of the money it received from the opioid settlement on outreach about naloxone, or Narcan, its trade name, the nasal spray that can reverse an opioid overdose. but Sheriff Ferguson struggled with the idea of distributing Narcan.

52:54At first I was hesitant to just provide it to individuals. In my jail I wasn't for just giving it out. To me that's telling people go ahead and continue to do what you want to do which is break the law and use illicit drugs. Now we actually have held opioid awareness programs. May of this year we did a big rodeo and opioid awareness event for the whole community explaining where they can get help for it and passing out Narcan. And so your views changed on that a bit has it? It has I'm still on the fence with it I'm okay with providing that but I think the biggest thing we can do is supply the information on where to get help.

53:41But naloxone saves lives. It's saved thousands of lives probably. It absolutely does but how many times do we have to give the same individual naloxone because they choose to just continue to use? Many would take issue with the sheriff's view that drug use is a choice. I was in Kandahar, Afghanistan in Korongal Valley in 2009 and 10. Jordan's downward spiral with narcotics began in the Marine Corps. They fell. They fell off the top of the vehicle and I ended up sustaining a severe jaw fracture. I shattered my lower jaw into five pieces. And your opioid use disorder started after that? Yes, because they had me on all the opiate medications after the surgeries.

54:26We meet Jordan on 4th Street, where he's staying in one of Reno's sober living facilities. Chatting to him about his history, what strikes me is how terrifying and stressful life is for drug users. The insidious presence of fentanyl means the idea of death isn't abstract. It's pervasive and real. I've had so many people overdose in front of me that I've had to intervene. Fortunately, Jordan was there with know-how and Narcan. I can't count them all in one hand. So how many times do you think you've used it on Friends? Narcan? Probably somewhere in the range of like 20 times, 15 or 20 times, and a combination of CPR and Narcan.

55:09Every time I would resuscitate somebody, even when the medics showed up, I don't know if they died after the paramedics got there. Does that stay with you, that thought, you wonder? I process it a little better after the fact, but most of the times that I ended up successfully resuscitating somebody, afterwards I have an adrenaline dump. I go into a mildly catatonic state. I shake real bad. It's just, it's the same kind of thing as like the fog of war. When things are crazy, things are going wrong, because there's a lot of pressure, because we're, as human beings, we're not supposed to have the power of life and death in our hands.

55:50Jordan's in recovery now. He doesn't use opioids. His story is a potent reminder of the fallout from America's opioid crisis. The lives lost, the trauma born, the immense harm done over decades. Nationally, the trend in overdose deaths is down in the US. But more than 800 ,000 people perished in the years from 1999 to 2023. It's an immense death toll and it's brought profound change. As one of Nevada's medical examiners, Dr. Laura Knight, reminds us. Even on elderly folks who die, we always look to see if they are prescribed opioids. We look at their medical records to see if they have a history of drug abuse.

56:33There's no longer anyone that we would consider safe from a drug-related death. Thanks for listening to this double edition of Assignment for the documentary podcast on the BBC World Service. I'm Linda Presley. The producer was Tim Mansell. The programs were expertly mixed by Hal Haynes. Gemma Ashman is the production coordinator, and Penny Murphy is the editor of Assignment. If you'd like to hear our earlier investigation into fentanyl in both Mexico and the US, you can search Killer Drug where you found this podcast.

57:13We focus on the part of the internet that most people don't know about. It's called the dark web. Undercover in the furthest corners of the dark web, US special agents are on a mission to locate and rescue children from abuse. Move in now. Police! From the BBC World Service, World of Secrets, the darkest web follows their shocking investigations. Search for World of Secrets wherever you get your BBC podcasts.