Until 2007, the most common way to die accidentally in Ohio was in a car crash. That was the year drug overdoses took over.

By today’s standards, it was a safer, saner time.

Ohio went from 411 deaths by drug overdose in 2000 to more than 3,000 in 2014, according to the state’s Department of Health. Nearly all of the deaths are due to overdoses on opiates.

In one place—Stark County, home to Canton and the Pro Football Hall of Fame—the opiate-related death toll grew so quickly, nearly doubling from 75 in 2015 to 118 last year, that the county morgue ran out of room. 

In March, the Stark County coroner was forced to rent a cold-storage trailer—normally intended for use at the scene of natural disasters or during the outbreak of a deadly, infections disease—to store all the bodies.

What happened? What changed for a bad epidemic to become so much worse, so quickly?

Most people know the trajectory of the country’s ongoing opiate crisis. Beginning around 2000, prescription painkillers became plentiful, people complaining of pain prescribed them became addicted—then, when either the pills or the money ran out, newfound addicts switched to cheaper or more readily available heroin.

This later, deadlier stage comes as synthetic opiates and ersatz pharmaceuticals cobbled together from mystery ingredients proliferate.

Now, it’s come to this: Compared to synthetic opiates, heroin is safer.

Not that heroin is safe, but in the days when powder distilled from poppies was the opiate of choice, rather than synthetic opiates cooked up in a lab, fewer people died.

Here’s the Canton Repository, trying for an explanation:

Fatal overdoses in Stark County jumped from 75 in 2015 to 118 last year, driven by a rise in fentanyl cases, according to the Stark County Coroner’s Office…

Fentanyl, an opioid 50 times stronger than heroin and 100 times more powerful than morphine, was linked to 64 deaths, the most of any opioid.

Heroin was linked to 26 deaths, and 13 overdose victims tested positive for carfentanil…

The lab found fentanyl, carfentanil and related substances in 367 samples [of seized drugs], up from zero in 2013.

By now, most the world is familiar with fentanyl, the synthetic opiate many factors stronger than heroin found in the black-market pills which killed Prince. If fentanyl is evil, at least it’s intended for human consumption. 

A similar drug, carfentanil, is 10,000 times stronger than heroin. Intended as an elephant tranquilizer, according to experts, the slightest scrap can overwhelm a human being.

As DEA spokesman Ross Baer told the Milwaukee-Journal Sentinel: “A lethal dose of carfentanil is not visible to the human eye.”

Carfentanil first appeared in the United States last summer. Nobody can explain why, but it appeared in Ohio. According to the DEA, more than 230 drug overdoses—14 of them fatal—in Akron, Ohio, in July 2016 were traced to carfentanil.

Since that time, the drug has appeared across the Midwest and South, with the first case of a fatal carfentanil overdose in Wisconsin recorded last week.

As NPR reported last month, most of the country’s synthetic opiate supply appears to originate in China, from where it is shipped overseas into the country via the U.S. mail.

In a brutally ironic twist, successes in stemming the supply of poppy-derived heroin, the traditional sources for which are Mexico and Southeast Asia, appear to have been rewarded with the demand fulfilled by far deadlier synthetics.

Concoctions based on synthetic opiates—and passed off as heroin—are dropping unsuspecting people all over the world.

In Northern Ireland, the threat of synthetic drugs is so acutely felt that there’s now a cautionary saying, with its own hashtag: #onepillwillkill. According to his family, 23-year-old Jamie Burns took a single pill of what was alleged to have been ecstasy before collapsing and dying later that night at a hospital.

Not that any sane person would argue heroin is safe, or a good lifestyle choice.

In Milwaukee County, 132 of the 299 drug-related deaths in 2016 were traced back to heroin. By comparison, fentanyl “only” killed 80. This, of course, was before carfentanil arrived.

The problem is, even if an addict or curious drug user wanted to try straight-up, old-school, unadulterated heroin, they might not be able to. As with any black market, drug users buy what’s available. And what’s available now has elephant tranquilizers in it.

“We see [carfentanil] on the streets, often disguised as heroin,” Acting DEA Chief Chuck Rosenberg said last year. “I hope our first responders—and the public—will read and heed our health and safety warning.”

On March 1, China added carfentanil to its list of controlled substances. Any manufacturer can now be raided and is subject to the strict punishment reserved for drug traffickers in that country. As NPR reported, a similar ban is credited with ending the country’s brief-but-furious flirtation with bath salts and flakka

At the same time, an enterprising chemist can keep making subtle changes to the formula and, in theory, evade detection.

The same month China’s ban went into effect, federal drug agents in Ohio discovered 100 grams of a synthetic opiate. This one, “fluoroisobutyryl fentanyl,” was purchased for $800 and shipped via the mails from Hong Kong, and it was the first time the agents had seen it.

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