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The counterfeit pain pills that killed Prince in April of 2016 held a drug far deadlier than heroin: fentanyl.

Fentanyl, a synthetic opioid, arrived on the US illegal drug market at just the right time, in 2012, to set off a wave of fatal overdoses like a match dropped into a gasoline tank. After a decade of free-wheeling painkiller prescribing and cut-rate prices for illegal drugs, more people than ever were addicted to heroin. And thanks to a hollowed-out economy in Appalachia and New England, where disability and lack of jobs has played into an epidemic of drug addiction, people were looking for the cheapest possible fix.

“It’s our deadliest concern,” Russ Baer of the Drug Enforcement Agency (DEA) told BuzzFeed News.

The agency is now routinely seeing deadly cocktails of heroin, fentanyl, and fentanyl-related compounds turning up with US seizures of cocaine and methamphetamines. Of about 33,000 overdose deaths nationwide tied to opioids in 2015, 9,000 — or about 27% — were blamed on fentanyl.

For 2016, inquiries by BuzzFeed News to the public health agencies of all 50 states found that only 30 have so far tallied a total number of opioid deaths. But even this preliminary data shows that in 13 states — Delaware, Florida, Iowa, Kentucky, Maine, Massachusetts, Montana, New Hampshire, New York, North Carolina, Pennsylvania, Rhode Island, Virginia, West Virginia, and the District of Columbia — there were more overdose deaths from fentanyl and other synthetic opioids than heroin.

That’s all up from hardly any fentanyl deaths in 2012. The spike is caused by many related factors, but basically boils down to one thing: money.

“Everything with fentanyl comes back to economics,” Baer said, echoing experts who spoke at the April Rx Drug Abuse & Heroin Summit in Atlanta.

Here are the shocking stats you need to know.

1. Heroin addiction rates have risen roughly 90% in the past decade, to about 1 in every 500 people.

US Heroin addiction rates have doubled since 2002.

Peter Aldhous for BuzzFeed News / Via drugabuse.gov

Starting around 2007, heroin addiction rates began to climb nationwide. The timing coincides with an increase in the price of cocaine from Colombia and a crackdown in Mexico on marijuana, which might have led dealers to turn to heroin as a money maker.

Whatever the cause, a recent JAMA Psychiatry report found a roughly 90% increase in heroin use from 2001 to 2013. That’s about 1,127,000 more people trying the drug.

That’s a lot of extra customers for heroin dealers. There are now about 467,000 heroin addicts nationwide, according to NIDA. And another 2.1 million people are addicted to prescription painkillers like oxycodone, chemical cousins to heroin.

Many people take painkillers responsibly, whether dealing with debilitating chronic pain or with cancer. But others develop a physical dependency, taking them long after their pain is gone. Some painkiller users switch to cheaper heroin: About 31% of new heroin users reported being dependent on painkillers, according to a 2013 survey.

2. About 80% of US heroin now comes from six Mexican cartels, and is winding up in rural regions that never had it before.

Origin of heroin sold in US cities.

DEA

The Mississippi River used to divide the heroin market, with Mexican heroin predominating in the West and Colombian heroin to the east. But that’s changed in the last decade or so, with about 80% of US heroin now coming from Mexico, trafficked largely by six cartels. The best known is the Sinaloa Cartel, which was headed by Joaquín “El Chapo” Guzmán Loera, extradited to the US in January.

Although the Sinaloa Cartel reportedly controls where much of the opium is grown, refining it into heroin is more decentralized. Many cartels have started selling “Mexican White” powdered heroin, replacing the older black tar and brown powder versions they used to sell.

Once a trademark of East Coast Colombian criminal networks, this white powder heroin is more potent (it has a higher drug “purity”) and cheaper than older varieties, according to DEA lab results, which means it can be snorted just like a crushed pain pill. Counterfeit pain pills made with white heroin have also started to turn up in drug seizures since 2015, aimed at addicts who don’t like needles.

Mexican heroin is now routinely sold in many parts of rural America where it used to be absent, powered by networks that essentially deliver drugs like pizza. Dealers drove into rural states where disability payments and pain prescriptions had massively spiked — West Virginia alone received 780 million oxycodone and hydrocodone pills from 2007 to 2012 — just as legal officials were clamping down on pill mill pharmacies.

“Dealers head east of the Mississippi River — primarily in Appalachia and Ohio and Indiana and Kentucky and those areas — where this massive marketing of pills has taken hold,” crime reporter Sam Quinones, author of Dreamland: The True Tale of America’s Opiate Epidemic, said in a 2015 interview. “Their system takes off hugely because they stumble upon an enormous new population of addicts.”

3. US heroin is cheaper than ever, as low as $5 per hit.

The US street price of a single gram of heroin since 1980.

Peter Aldhous for BuzzFeed News / Via IDSA

The bottom really began to fall out of the street price of US heroin starting in 1997, according to a 2016 study led by Travis Wendel of St. Ann’s Corner of Harm Reduction in the Bronx, when Colombian drug cartels cut the price by more than than a half, from $175,000 to $75,000 a kilo. Soon supply outstripped demand.

“Used to be the custies [customers] fiending for the product, now it’s the dealers fiending for a custy,” a drug dealer was quoted as saying in a related study from 2003.

The drop in price may have contributed to reduced crime rates in major cities, according to Wendel and his colleagues, because people had to steal less to pay for their habit.

Cheaper heroin also leads to more overdoses. A 2014 study of 3,400 hospitals nationwide, for example, found that for every $100 decrease in the price of a gram of heroin, the number of overdose hospitalizations goes up by 2.9%, around 10,000 more nationwide.

In studies over the last decade, Daniel Ciccarone of the University of California, San Francisco, and his colleagues have shown that marketing, branding, and economics create unique heroin markets in different cities. Philadelphia users, for example, tend to buy powdered heroin in open-air markets filled with competing brands, whereas people in San Francisco mostly buy black tar heroin from dealer acquaintances. Every market, Ciccarone wrote, is driven by a “connoisseurship of potency," where users seek out the strongest possible dose.

4. Fentanyl is 30 to 50 times more potent than heroin: Just 2 or 3 milligrams can kill.

US opioid overdose deaths 1999-2015, by drug.

Peter Aldhous for BuzzFeed News / Via drugabuse.gov

Around 2011, into that market for stronger heroin came the new users from pain pills, who added to those larger number of heroin users. Within a couple of years, this combined market began to see heroin tainted with fentanyl, a surgical painkiller that can be 50 times more potent than heroin, on the black market.

A fatal dose of fentanyl next to a penny.

DEA

Fentanyl’s chemistry makes it far riskier than heroin. A typical dose of heroin might require 15 to 30 milligrams for a fix, and an overdose might take 3 to 10 times more than that. In contrast, just 1 milligram of fentanyl could get someone high and 2 or 3 milligrams could kill. This leaves little room for error, Baer noted. “These are not professional chemists.”

Fentanyl-laced heroin sold with names like “King of Death,” which killed three people this year in Atlantic City, or “Grey Death,” which killed four people in two states this month, plays right into the demand among heroin users for the most potent drug possible.

5. Fentanyl, a completely synthetic drug, is 20 times more profitable than heroin, which is made from harvested poppy plants.

Number of law enforcement reports of samples that tested positive for fentanyl ("fentanyl encounters") from 2014 to 2015.

CDC/DEA / Via cdc.gov

Fentanyl is not only more deadly than heroin, but can be far more lucrative.

“A kilo of fentanyl can be split up many more times than a kilo of heroin, to make more money.”

In the US, Baer said, a kilogram of heroin that costs about $4,000 dollars might be made into enough does (typically cut with milk sugar) to garner the dealer around $60,000. A kilogram of fentanyl might also cost a dealer $4,000 wholesale, according to the DEA, but it can be split into 20 times more doses, garnering $1.2 million or more.

Carfentanil, a related tranquilizer 100 times more powerful than heroin (even skin contact can trigger an overdose), pushes the economics even farther, turning up in overdoses across the Midwest, and up and down the East Coast. The first human poisoning with carfentanil was only reported in 2010 — a veterinarian was splashed with a dose from a dart intended to sedate an elk so not a lot is known about human use of the drug. So far, it appears to be a “boutique” occurrence in illegal drugs, Baer said, albeit one turning up with increasing frequency.

Unlike such synthetic opioids, heroin requires a lot of hassle for the cartels: planting poppies in fields in Mexico (or Afghanistan or elsewhere), harvesting, and processing them to collect raw opium, which in turn needs chemical processing to make into morphine and then heroin, all the while dodging law enforcement and eradication efforts.

Fentanyl only takes a small lab, with raw materials typically imported from China. In 2015, China started cracking down on exports of the drug and its chemical cousins to Mexico, the US, and Canada. As each synthetic opioid is banned, another still-legal variation on fentanyl pops up for sale. That has led to a game of outlawing new variants as soon as they appear on the market.

“It’s whack-a-mole but we have to do it,” Ambassador William Brownfield of the US State Department’s International Narcotics and Law Enforcement Affairs office told BuzzFeed News.

6. Fentanyl is now routinely showing up in counterfeit painkiller pills: DEA seizures of these drugs have increased 2,019% in the last five years.

Counterfeit pain pills with fentanyl.

DEA

Prince’s death illustrates the latest chapter in the fentanyl saga, with the drug turning up in counterfeit pain pills. Money again explains its appearance: a $20 fake pain pill might contain much less fentanyl than a $10 baggie of fentanyl-laced heroin, letting the dealer split the dose even more and rake in more money.

One kilo of heroin can make about 20,000 dime bags. One kilo of fentanyl might make 666,666 counterfeit pills, according to the DEA. The profits for these tainted pills can range from $10 to $20 million. Each pill contains 1.5 milligrams. That means two pills could be deadly.

“Cartels are predatory, they don’t care about killing people,” Baer said. “If for every person who dies another one to three are addicted, they are fine with that.”

The “Watson 385” pills reportedly found at Prince’s estate after his death have led to suspicions the singer may not have known he was taking fentanyl when he died. Real Watson 385 pills contain acetaminophen and hydrocodone, a less potent opioid painkiller, frequently given for back pain.

Some news reports suggest the counterfeit pills that killed Prince also contained UL-47700, a different opioid increasingly turning up in drug cocktails, as well as in cocaine and methamphetamines.

The surge in fentanyl deaths and opioid addiction defies any simple solution. The problem is rooted more in economics, a failed revolution in pain treatment, and the neurobiology of addiction than the tired stereotypes of the “War on Drugs.”

“We cannot arrest our way out of this,” Baer said. “The solution has to come from the demand side, the people taking this, and from community awareness where they live.”

LINK: The Addicts Who Forgot

LINK: On The Front Lines Of The Overdose Epidemic In Baltimore

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