Credit, Darren Conway/BBC
Important: this report contains descriptions of drug use and discussions of suicide.
A few grains of fentanyl sit on a sheet of aluminum foil, while a straw, held between Mike's lips, hovers above them, with a lighter underneath.
The 48-year-old army veteran is crouched in an alley in the Linden neighborhood in the city of Columbus, Ohio.
"This drug will make you do almost anything, unfortunately," he says. The dose he is smoking costs three or four dollars (about R$15 to 20).
"You can smell too much and you can't go back. It sounds like a gunshot. You can't get the bullet back."
Mike burns the leaf and inhales. When the opioid takes effect, he holds the railing behind him.
He sways and a low moan rises from the back of his throat. He could have been singing a song.
We spent a few days with Mike, who is our guide through the neighborhood's alleys. Everyone seems to know him and treat him with affection.
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He helps out a local pawn shop and a gas station. This is how he sustains his 20-year dependence on opioids.
Synthetic opioids are more powerful and widely available. They transformed the drug scene.
Fentanyl, completely artificial, is 50 to 100 times stronger than heroin, grown from poppies.
Now, it often comes together with synthetic tranquilizers, which makes it difficult for overdose victims to recover.
These are homegrown threats, as synthetic cocktails can be made in basements and bathtubs across the United States.
We have naloxone (brand name Narcan) in our pocket in case anyone on our team comes into contact with fentanyl or finds someone around us overdosing.
It is a nasal spray that instantly combats opioid overdoses. Its widespread adoption has drastically reduced the number of fatal incidences in the United States.
At the peak of cases, in 2022, 110,000 Americans died from overdoses, most of them from opioids. This number has been falling since then, reaching around 70,000 last year, which does not mean that the opioid crisis has been overcome.
It's likely that the medication in my pocket, which has saved the lives of tens of thousands of drug users, didn't work on Mike because he wasn't just smoking fentanyl.
The pupils of his blue eyes contract until they become pinpoints.
“Opioids reduce the size of the pupils, but not that much,” he says, in a sing-song voice. Fentanyl itself, which is dangerous enough on its own, contains other synthetic substances added.
We asked what he thinks his drugs might bring with them. He responds "xylazine is the one we can't pronounce."
He means medetomidine. Like xylazine, it is also considered a tranquilizer.
Both are synthetic animal tranquilizers. "Tranquilizers for large animals," according to a recovery expert.
They help prolong the altered state caused by fentanyl, but they are also sedatives that slow down breathing. And, most importantly, naxolone does not work against them.
Xylazine also causes necrotic skin ulcers. These are wounds so deep that they can even reach the bones and are difficult to treat.
Recovery group offers hope
Across town, at Glenwood Church, members of the Hope Dealer recovery group hold their weekly meeting.
The struggle of many of them is evident on their haggard faces and in the eyes of those who have survived a great trauma.
They take the stage at the front of the church and share their stories with brutal, courageous honesty.
A man tells the story of his overdose in July 2022. Two paramedics tried to save his life.
He was taking naxolone serum in both arms. Doctors tried to reverse the effects of the opioid three times, without success.
"It's over, it's the end," said one of the doctors. But the other insisted on one more attempt and saved his life.
The crowd cheers as Tonya takes the stand. She recalls how her nephew died of an overdose while she suffered her own overdose at the same time on crack, a stimulant spiked with fentanyl, and a synthetic opioid.
"It's not luck. It's my destiny to be here," she says, with tears in her eyes. The audience screams in agreement.
Both in Columbus and, later, in Chicago, Illinois, we learned that crack users died of overdoses after their drugs started to contain fentanyl. On the streets, they are known as "hot shots".
"In the last 12 months in Franklin [Columbus] County, 78% of fatal overdoses are from stimulants," explains Hope Dealers coordinator Scott Sanders, 65.
A burly man with electrifying energy, Sanders has been clean for nearly 10 years. He asks those present to raise their hands if they have ever overdosed and most of them comply with the request.
“The crisis simply changed,” he says, after the meeting.
"The tragedy is that stimulant users who are buying crack think that's what they're getting, but it's not. They buy crack laced with fentanyl or other opioid cocktails and overdose without knowing it."
Overdose deaths among black men in Ohio have been rising, according to Sanders.
His organization works with the US Centers for Disease Control and Prevention (CDC) on a drug sampling program. Participants bring their needles or pipes to collect samples, which are sent to the CDC laboratory in the US state of North Carolina.
That's how we knew Mike's impression was correct. He was probably not just smoking fentanyl, as one of the drug kits he brought with him tested positive for medetomidine.
“The drug trade in 2026 works like this: we think we are buying crack, but no, we are buying several different substances,” explains Sanders.
"Today, it's mixed, not just cut, but mixed with other drugs like fentanyl or methamphetamine and other adulterating substances, produced in basements."
And it was these synthetic drugs produced in basements that caused the dramatic increase in overdose deaths in the State of Illinois.
I found a supplier in Chicago who sells fentanyl to the Mexican cartels. He only spoke to the reporter because we agreed to hide his identity.
Asked about his role in the deaths of 50,000 people every year due to the opioid crisis, he responds that he knows he is wrong. But when we ask why he continues in activity, his answer is that the end justifies the means.
He claims that despite the US government's recent efforts to classify cartels as terrorist groups and fentanyl as a weapon of mass destruction, its supply chain is stronger than ever.
I ask whether the attacks on ships containing people suspected of drug trafficking by the Donald Trump administration made any difference. He responds that his product continues to leave Mexico.
"If it doesn't go over the wall, it goes under," he says. "If you don't leave through the border, you arrive through the border above. This game is about adaptability."
And when I ask what has changed in his business, his answer is clear.
"Synthetics. We haven't seen yet... what synthetics can do. This isn't even the tip of the iceberg."
Innovative technique
Cook County is the largest jail in Chicago and one of the largest in the United States.
Traditional drugs were typically brought into the jail in body cavities. Therefore, the prison now has the same body scanners that we find in airports to prevent this from happening.
“In 2023, we suddenly saw a spike in overdose deaths,” says prison administrator, Sheriff Tom Dart. "But in parallel, next to the people who had died or who we had helped, there was paper everywhere."
"We were watching paper being burned and this was all completely new," he explains.
The prison has, on average, one or two overdose deaths per year. But in 2023, eight prisoners suffered fatal seizures.
Security footage showed prisoners having spasms and fainting. They also showed them lighting papers in the microwaves in the blocks' kitchens.
It was, indeed, an innovative technique, as Dart said. Drugs were being mailed to the prison, embedded in the pages of books and letters.
“Cannabinoids are being impregnated into a series of other objects, which are later lit on fire and inhaled to cause intoxication,” explained the sheriff.
Also known as K2, cannabinoids are a fully synthetic version of a cannabis plant extract. They are extremely dangerous and cause fatal seizures.
In August, I met Dart staff at the prison as they prepared for an early morning inspection of the prison's high-security D block.
Just over 20 employees walked lightly and whispered as they gathered outside the block's door.
"Don't let them hear you. Silence, silence", advises one of the employees who coordinated the search.
When the police invaded the place, I smelled burning paper in the air and heard the sound of toilets flushing, supposedly hastily disposing of the material.
The search continues and its focus is any type of paper found in the cells, such as books and letters belonging to inmates.
Inmates are escorted to a holding area while their cells are searched. Every piece of paper is scrutinized by police officers.
There are burn marks on the ventilations of many cells. There, inmates place slow-burning candles, which allow them to light the drug-impregnated paper.
Now, all objects that arrive in the mail at the prison are examined to determine their moisture content. Between 20 and 25% of packages and letters test positive and are rejected.
Outside the prison walls, it is not difficult to find the effects of the wave of synthetic drugs on the streets of Chicago.
On the west side of the city, day and night, men and women are found bent over, swaying like Mike, with spikes of fentanyl and other synthetic substances throughout their bodies.
In the upscale Oak Park neighborhood, the local subway station has a vending machine that dispenses free naloxone. Nearby, there is a skeletal-looking man in a wheelchair, with deep wounds on his legs, probably caused by the use of xylazine.
He is being cared for by Karen Bell, 40, a recovery worker with the Liv4Lali group. A former heroin user, she has been free from hard drugs for 17 years.
Bell exudes kindness. I ask her about the drugs she currently uses and she responds:
"A lot of things are being mixed up these days. And they're affecting our bodies, whether it's the wounds or the withdrawal. And sometimes the wounds can reach permanent levels."
His organization, like Hope Dealers in Columbus, distributes test strips for drugs such as fentanyl, medetomidine, xylazine and other adulterants.
Drugs are now "much more dangerous", according to Bell.
"Before, in my time, I stopped using heroin 17 years ago and that was fine. That was still heroin. When you bought it, you knew it was heroin."
"But now, when you buy it, you don't actually know what it is," she explains.
Dart has been the Cook County sheriff for 20 years. I ask him about the progress of the war on drugs.
"I don't think anyone involved with it would sit down and say it's a smashing success," he responds. "It is not."
The new problem, according to him, is synthetics, reiterating what the Chicago drug supplier said.
"Traditionally, the police have always played a fundamental role, as everything that was powerful came across the border, whether it was coming from Colombia, Mexico, China or the poppy fields of Afghanistan," he explains.
"Now, with the explosion of synthetic drugs, people can do this in their own home, in their sink, in their bathtub, wherever you want."
Victory in the war on drugs won't come from focusing just on the supply side, according to Dart. "First of all, there needs to be strong substance abuse treatment."
The sheriff mentions several active recovery programs at his jail.
"You can reduce the market if you address people's substance abuse issues," he explains. "And I know a lot of people who, after long battles, came out of the situation very well."
'A lot of people are struggling'
Bell knows how difficult it is to give up drugs. She was still using heroin when she became pregnant with her daughter, Abby, now 17.
We met on the subway and later I meet the two of them in a country park in a suburb of Chicago. And, with typical caution, Bell tells me to pay attention to the poison ivy as we walk along a muddy path.
Not far away, about 17 years ago, she was at her deepest abyss.
The wind blows the leaves of an oak tree next to us as she remembers that time.
"The day I found out I was pregnant, I was on the verge of committing suicide. I was tired of trying to quit. I was tired of living in a tent in the woods, using a bucket. I was tired of losing my friends and family because I felt so ashamed."
But the pregnancy test changed her mind.
She spent time in Cook County Jail for robbery. Her parents saw an opportunity for her to get clean and refused to pay the bail money. With that, Bell was clean and Abby was born inside the prison.
Abby wants to be a tattoo artist. I ask if she has ever been tempted to try drugs.
"No, I saw how they really harmed my family, my father, my mother, they killed my aunt, my uncles", she replies. "You know, it's not worth it for maybe two hours of ecstasy."
"There are a lot of people struggling, especially with our country raising our prices, raising food prices and causing this," she continues.
"Taking care of mental health is now very expensive and people can't get help. And one way they can turn to is drugs."
Generations of Americans have faced the drug crisis, but it is never the same crisis. It has moved from heroin to prescription opioids, then to fentanyl, and now to a whole new range of synthetic substances.
Successive governments have fought and lost the war on drugs. Suppliers, traders, cartels and users adapt and stay a few steps ahead of efforts to stop them.
In collaboration with Darren Conway.
Watch the documentary (in English) that gave rise to this report on the BBC News YouTube channel.
If you are or know someone who is showing warning signs related to suicide, or has lost a loved one to suicide, check out some places to ask for help:
- The Life Valorization Center (CVV), via telephone 188, offers free service 24 hours a day; there is also the option to chat, email and search for service stations throughout Brazil;
- For young people aged 13 to 24, Unicef also offers the Pode Falar chat;
- In cases of emergency, another recommendation from experts is to call the Fire Department (phone 193) or the Military Police (phone 190);
- Another option is to call SAMU, by calling 192;
- In the local public network, it is also possible to seek help at the Psychosocial Care Centers (CAPS), in Basic Health Units (UBS) and 24-hour Emergency Care Units (UPA);
- Also check out the Mental Health Map, which helps you find free mental health care throughout Brazil.
- For those who have lost someone to suicide, the Brazilian Association of Survivors Bereaved by Suicide (Abrases) offers assistance and support groups.
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