The difference between an unpredictable high and a deadly overdose lies in a few grains of powder with a drug new to North Dakota and under investigation by Grand Forks police.
Powdered fentanyl was linked to the recent death of 18-year-old Bailey Henke in Grand Forks, and it's suspected in several other local overdose cases, prompting police to warn the public about the dangerous, unpredictable opiate.
Police in North Dakota's two largest cities are unfamiliar with powdered fentanyl, but they say the drug's presence in Grand Forks is likely part of a recent rise in opiate drug abuse statewide.
Fentanyl is estimated to be 80 times as potent as morphine and hundreds of times more potent than heroin, according to the U.S. Centers for Disease Control.
Experts say powdered fentanyl is much more unpredictable and dangerous than its prescription counterpart, a form of the drug often found in patches for pain relief. One expert said a vial of the drug in its pure, powder form could supply drug users in the Grand Forks area for months.
Prescription fentanyl has been abused in the Grand Forks area in recent years, but use of the drug in powder form is new, said Lt. Bill Macki, of the Grand Forks Police Department.
Police are mainly seeing powdered fentanyl used by people age 18 to mid-20s, Macki said.
While Henke's death Jan. 3 is the only fatal overdose of the drug in Grand Forks, police are investigating drug overdose cases dating back to June 2014 for possible connections.
"The bottom line is getting this out of the hands of our young people," Macki said. "When we're dealing with this powdered fentanyl, there's absolutely no safety involved in this. It's just pure chemical."
In North Dakota
Police officers in both Fargo and Bismarck said they hadn't seen any cases of powdered fentanyl use.
Detective Mike Bolme said the Bismarck Police Department is aware of drug trafficking lines between Bismarck and Williston, Dickinson and Minot, and the department has not run into powdered fentanyl. But that doesn't mean it isn't there, he said.
In Fargo, Sgt. Mike Erbes said if the drug is being used in Grand Forks it's likely also in Fargo, but the Fargo Police Department has not come across it.
While it's new to North Dakota, powdered fentanyl has been circulating in the U.S. since about the mid-2000s, according to a February 2014 Reuters report. The drug caused several deaths on the East Coast in months leading up to the Reuters report.
Both Bolme and Grand Forks police Lt. Dwight Love said the presence of powdered fentanyl in Grand Forks is likely connected to a statewide increase in opiate use in the past year.
Both cities have had more heroin busts the past year, they said.
According to a September report from the state Attorney General's office, the state crime lab analyzed 99 heroin samples in 2013, up from 48 in 2012. The total amount of samples analyzed decreased by about 1,000 between 2012 and 2013.
Police usually see drugs phase in and out of trends, Love said. Opiates, such as heroin and fentanyl, appear to be the new drug of choice, he said.
Up until about a year ago, prescription drugs surged in popularity among drug users statewide, Love said. But it can be easy for an addict to be blacklisted from purchasing prescription drugs, which may have faded that trend, he said.
Manufactured opiates may be easier for addicts to attain because they can be bought online, Love said.
Bolme added that all recent heroin busts in Bismarck have involved people who moved to western North Dakota from out of state. He said police didn't find evidence in those cases of heroin being trafficked from Bismarck to eastern North Dakota.
David Ferguson, a medicinal chemistry professor at University of Minnesota who researches opioids and other drugs, said it's very unlikely the powdered fentanyl being used in North Dakota is made within the state, or even in the U.S., meaning it's probably trafficked from elsewhere.
"It's easy to shutdown labs within the states (because of federal regulations of chemicals)," Ferguson said, "and smart folks know how to make this overseas."
Also, because powdered fentanyl is extremely potent, Ferguson added, someone with a medical vial of it could likely supply the Grand Forks area for months.
"It's a problem," he said. "Fentanyl, it has a high potential for overdose and addiction, especially when it's in its pure form."
The drug is also easily trafficked because its dose is so small, Ferguson said.
Police do not know how powdered fentanyl came to Grand Forks, Macki said, and it is under investigation.
After Henke's death, Grand Forks police warned the public about the dangers of powdered fentanyl through media, the public schools and online at www.grandforksgov.com.
It's unusual for police to draw public attention to an open investigation, Macki said, but in this case the severe potential for danger with this drug outweighs some confidentiality measures.
The story of a teenager's drug-related death prompting deliberate police warnings is familiar to the Grand Forks community.
Police issued similar warnings in 2012 after 18-year-old Christian Bjerk, of East Grand Forks, died of overdosing on synthetic hallucinogens.
But although officers are warning the public in similar ways, Macki said, they're encouraging people to not draw comparisons between the drugs investigated in 2012 and what is under investigation now.
"Both of them involved relatively new substances to the area, but that's the only connection between them," he said.
Macki would not say how many overdose cases police are investigating with possible connections to powdered fentanyl.
He also would not say how police think the drug is being used in Grand Forks.
The police's investigation shows there could still be a lot of powdered fentanyl still "unaccounted for" in Grand Forks, Macki said, which is why police are warning the public.
Macki reiterated that fentanyl is very potent and volatile. Doses of the drug are measured in micrograms -- just a few grains of powder, he said.
And because powdered fentanyl is not a prescription drug, there is no way to properly take it, Macki said.
"The deal with this is it's such a minute amount that'll give you a high, but at the same time, it can kill you," Love said.
Jeffrey Zak, director of pharmacy at Altru Health System, said the highs a drug user experiences from prescribed fentanyl and "street" fentanyl are similar, but whenever someone uses a street drug, the potency and dose are "indeterminable."
Bolme said he considers abuse of fentanyl in its prescribed form to be "easily in the top-three most dangerous" drugs he's seen in Bismarck.
And prescribed fentanyl is less potent than pure, powdered fentanyl, Ferguson said, because the drug is usually diluted for safety in prescribable forms.
Powdered fentanyl is rarely used in the medical field, Zak said.
Police will continue to provide the public with more information on powdered fentanyl as it is learned through investigation, Macki said.
"It's just something that got introduced to the area, and we want to stop it as quickly as we can," he said. "It's a very potentially dangerous substance."
Anyone with information related to a suspected overdose or use of illicit drugs can call police at (701) 787-8000, email firstname.lastname@example.org, or text the word "Tipster" to 84741.
Signs of an overdose
Police say powdered fentanyl is very dangerous and unpredictable. Common signs and symptoms of an overdose of the drug are:
• suicidal tendencies
• chest pain
• inability to speak
• dry mouth
• constricted pupils
• slowed breathing
Source: Grand Forks Police Department