Near Aaron Arnold’s office, a whiteboard hangs on the wall. It tells you where fentanyl, a powerful synthetic opioid, and other dangerous heroin additives are popping up around the city of Pittsburgh. It’s a useful display for drug users who visit Prevention Point for health services.

They know signs of fentanyl. When they notice a crystalline — an iridescent substance in their usually opaque, off-white heroin — they know it must be cut with fentanyl. They make note of it on the board, where they bought it and if there was any kind of insignia on the stamp bag.

“Others say, ‘It looked no different but my buddy dropped like a rock after he used it, so I’m glad I waited,’” said Arnold, executive director of Prevention Point, a nonprofit.

While the information on the board is typically anecdotal, Arnold said it does show that synthetic opioids, sometimes added to heroin, are on the rise in Pittsburgh. The statistics on overdose deaths confirm the upward trend. Law enforcement officials see it, too.

Over the past year, they’ve become more aware of the synthetic substances and say the worst of the bunch — carfentanil — could crop up sooner rather than later. Carfentanil has not been detected yet in Pittsburgh, but officials are especially cautious because the drug can be up to 10,000 times stronger than morphine and powerful enough to sedate an elephant. In Ohio, the drug has taken at least eight lives.

“It seems like it’s not popping up here, but if you went out and grabbed a bunch of bags of heroin you might find it,” Arnold said.

Data from the Allegheny County Medical Examiner’s office shows opioid deaths involving fentanyl first spiked in 2014, when 63 people who overdosed had the drug in their system. As of July this year, fentanyl had turned up in 108 cases so far. Before 2014, fentanyl was sparse, and fewer than 20 people per year since 2008 were found to have had it in their systems when they died.

Could carfentanil be next? In September, the Drug Enforcement Agency issued a national warning about the “crazy dangerous” synthetic drug. The DEA doesn’t know what the lethal dose range of carfentanil is, only that it’s 100 times stronger than fentanyl, which can be deadly if a person ingests even 2 milligrams.

According to the U.S. Attorney’s office, Cincinnati is the closest carfentanil has made it to Pittsburgh. In late September, the office reported that two people were indicted in the Ohio city for distributing the drug.

Because synthetic opioids are so powerful, one dose of naloxone, the emergency medication that can reverse the effects of opioids, is sometimes not enough.

Two or three doses are sometimes needed to cancel out the drugs in the body, said Elizabeth Van Nostrand, a law professor at Pitt who has studied the opioid epidemic. Prevention Point has even provided several naloxone kits to the County Medical Examiner’s office just in case staff members accidentally come into contact with the substances.

For emergency responders, the drugs pose a challenge because the window of time they have before a person dies is much smaller. A person overdosing on heroin may survive for about an hour. Fentanyl or carfentanil can shut a person’s heart and lungs down in minutes.

To combat the problem, Van Nostrand and Arnold said more naloxone in the hands of users is an effective way to limit overdoses.

Last month, Van Nostrand and a group of her students at Pitt presented a report at a public health conference in Denver that outlined how training veterans and inmates on how to use naloxone can help decrease the number of opioid overdoses. As for long-term solutions, researchers and other experts aren’t sure where to turn yet.

Legislators in Pennsylvania recently passed a package of bills that restrict doctors in the state from prescribing opioids like Xanax (alprazolam) and Percocet (oxycodone) to patients. But according to Van Nostrand, no one bill can stop the epidemic.

“This problem is systemic,” she said. “This situation is a moving target.”

Reach J. Dale Shoemaker at 814-215-0509 or at Follow him on Twitter @JDale_Shoemaker.

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J. Dale Shoemaker was a reporter for PublicSource between 2017 and 2019.