LOUISVILLE, KENTUCKY - Within seconds of pulling out of the station parking lot, Major Mike Will gets his first call to respond to a crisis. Wills switches on his lights and siren and picks up the pace.
A thirty-year veteran of the Louisville's emergency medical services, he has witnessed the explosion in opioid overdoses that have ravaged the city over the past two-years.
"The information we have right now is a 52-year old adult male who is unconscious, CPR in progress. And it look like an overdose," he tells us.
The epidemic is taking a toll on Louisville's first responders who field an average of over 20 overdose calls a day.
"When I first started, we could anticipate making narcotic or opioid overdose calls maybe five times a year," he says. "And in the past year or two we have several of our crews that are making five in a 12 or 16 hour shift."
As overdoses have steadily risen in cities and small towns across the country, officials have been searching for answers. Louisville reached a crisis point last August, with 151 overdoses over a span of four days.
Doctor on the front lines
Dr. Robert Couch, an emergency room physician and medical director at Louisville's Norton Audubon Hospital, was on call at that time. He saw nine overdoses in five hours.
"We have been seeing heroin overdoses for a long time. But what was unusual about this overdose experience was it was taking larger and larger doses of the antidote Naloxone to reverse the effects of it," he says. "So we knew that it wasn't just heroin."
Couch had learned of a similar spike in overdose cases in Ohio and West Virginia several weeks earlier. According to toxicology reports, those cases were caused by heroin mixed with Carfentanil, an opioid derivative often known as "the elephant tranquilizer," that is 5,000 times more powerful than heroin.
"It is toxic in microgram quantities," says Couch. "And so I suspected what other communities had seen was moving into Louisville at that time."
According to the U.S. Drug Enforcement Administration, Fentanyl and Carfentanil are synthetic opioids predominantly manufactured in underground laboratories in China. Often sold as research chemicals, they can be bought on the dark web.
Cheaper to produce than heroin, they are often delivered to the U.S. through the mail. Dealers then mix the synthetics with their heroin to boost profits. The results are often deadly.
"Unfortunately, users don't know what they are getting," says Couch. "Heroin is toxic enough as it is. These other derivatives can cause death almost immediately through respiratory depression."
Fentanyl and its derivatives have forced emergency rooms across the country to change their protocols for overdose patients.
"A couple of years ago we would start with a very small dose, say 0.4 milligrams of Naloxone and that would be effective," Couch tells us. "That dose has increased to about 2 milligrams and now we are using 4 milligrams of Naloxone just to restore breathing initially."
Naloxone can suppress opioids in the body for about 30 minutes, which is long enough to treat a typical heroin overdose. The Fentanyl derivatives are so potent emergency rooms are having to re-dose patients as the Naloxone wears off.
"People can re-sedate and be right back in the throes of their overdose even though they have been administered the reversal agent," Couch says.
Fear on the streets
As overdoses have risen, so has fear on the street among drug users.
"To find a bag of heroin is pretty rare – that is just heroin," says Mathew LaRocco, who runs the Louisville Metro Needle Exchange out of the first floor of a city government building. The exchange provides clean needles and other supplies to 400 drug users a week.
Studies have shown that drug users who frequent needle exchanges are 5 times more likely to seek treatment and less likely to contract HIV, hepatitis, and other health problems associated with intravenous drug use.
LaRocco works closely with the drug-using community in metro Louisville and says people are legitimately scared.
"There is a lot more respect for the product that is on the street," he says. "People are realizing just how dangerous this is."
LaRocco says several years ago when Fentanyl first came on the scene there was a small subset of users – usually young male users – who had the attitude that it would never happen to them.
"You don't see that anymore," he says. "You are seeing a volatility to the drug where people who used to inject five times a day are now injecting 15 times a day. They are still using the same amount of drug throughout the day, they are just breaking it up into smaller doses because they don't want to die."
He says Fentanyl and its derivatives are also showing up in other street drugs like methamphetamine.
"I have a client that only shoots methamphetamine," says LaRocco. "He doesn't shoot anything else. He was drug-screened and there was Fentanyl in his screen."
LaRocco says even with the fear on the streets it is still difficult for an addict to overcome their irrational cravings.
"That still doesn't change the fact that when someone overdoses on a bag of dope, everybody want to figure out where they got that bag of dope from. Because they know it is going to get them high," he told us.
Major Mike Will arrives on the scene and pulls up behind a fire truck parked in a middle-class, suburban neighborhood lined with sidewalks. Two police officers are standing in the yard of a modest house with a brick front porch. Inside, paramedics are administering Naloxone, the opioid antidote, and the patient begins to regain consciousness.
"The transport unit was right on top of the run," says Will. "So that gives this individual a much better chance because the first responders were so close. Apparently we had a two minute response time."
A few minutes later, a white man with graying hair walks out under his own power and lays on a gurney waiting for him in the front yard – cheating certain death. Major Wills says he's one of the lucky ones.
"You know these people we are bringing back with Naloxone, it's giving them a second chance," he says. "And it is frustrating to see these folks doing it over and over again. But I mean, you know, addiction is a sickness. And these people are addicted."