Fentanyl mixed into heroin and counterfeit pills

Fentanyl mixed into heroin and counterfeit pills marks a dangerous escalation in the opioid crisis described in the book: an illicit synthetic opioid made the existing heroin supply more lethal, while counterfeit pills widened the routes by which people could encounter it. Its arrival in Roanoke, Virginia, is traced through overdose alerts, police seizures, and the death of Bobby Baylis. The response exposes a recurring imbalance: the supply could change quickly, but treatment, public understanding, and local capacity were slower to catch up.

A changing and unpredictable supply

By 2015, fentanyl was appearing in heroin sold in the region. Between May 1 and June 23, a local drug task force investigated eleven overdose calls, four of them fatal; fentanyl was identified as the culprit. The drug had once been diverted from medical use in patch form, including for patients with advanced cancer. In the crisis described here, it was instead illicitly imported, including from China, and mixed with heroin or pressed into counterfeit pills. Some shipments reached American residences directly by mail.

The potency made the change especially consequential. Fentanyl is described as twenty-five to fifty times stronger than heroin. Carfentanil, a separate synthetic opioid encountered in the same broader crisis, was described as one hundred times stronger than fentanyl. The book places these drugs within an increasingly volatile supply: a single batch of heroin was later linked to twenty-six people losing consciousness in Huntington, West Virginia, in one day. The episode shows how a supply shock could become a mass emergency, even far from the local ring whose arrest had disrupted the regional market.

Mail-order fentanyl and pill presses also altered how the drug could be sold. Dealers could use the powder to make pills, while counterfeit tablets were marketed as medications such as Xanax or oxycodone. In 2015, Roanoke Police Department chief Chris Perkins anticipated that these products could draw in teenagers who might snort a drug rather than inject it, avoiding the stigma associated with injection and its visible signs. That route did not make the supply safe: a counterfeit pill could contain fentanyl despite being sold as another medication.

Overdose and the local toll

The shift from earlier adulterants to fentanyl changed the risks embedded in heroin. Chris Perkins recalled that in his first years working undercover in the 1990s, dealers commonly cut heroin with baby powder. By 2015, fentanyl had become the cut. Roanoke police seized 560 grams of heroin that year, an amount estimated in the book as 18,666 doses. Perkins described a market with numerous suppliers, including former crack dealers diversifying their products and subordinate sellers. Removing one source did not end supply; after a short pause, another appeared, while overdoses continued.

The records place the escalation within a wider regional pattern. By early 2017, fentanyl-overdose calls were coming in at twice the rate recorded for the same period the previous year. Across the region, police responded to 334 overdose calls in 2017: 36 were fatal and 298 nonfatal. Those figures describe overdose calls generally, not deaths attributed solely to fentanyl, but they convey the scale of the emergency in which fentanyl was circulating. An October 2016 fentanyl-laced batch also prompted a regional increase in overdoses and naloxone use.

For families, the danger was not an abstraction about potency or supply. In June 2015, Bobby Baylis was among four people who died from fentanyl-laced heroin. He had first become addicted to OxyContin after receiving it following surgery for an ACL injury sustained in a snowboarding accident. After years moving between rehabilitation and jail, he had completed a three-year prison sentence that included drug treatment and vocational training. On probation, he was working, living in his mother Janine Underwood’s basement, and, in her account, seemed to have regained his energy. Three months after leaving prison, a visit with old friends led to a single dose of fentanyl-laced heroin. Janine found him dead in the basement; the people who had been with him had left.

Enforcement meets a moving target

Fentanyl’s circulation made enforcement difficult not only because the supply was abundant, but because its sources and forms could change. In 2015 and again in 2017, China began banning the manufacture of several fentanyl analogs at the request of the Drug Enforcement Administration. Yet each time a derivative was banned, new versions emerged from underground laboratories, sometimes more potent than the drugs they replaced. Packages labeled as research chemicals and bearing false return addresses could be difficult for law enforcement to distinguish from legitimate shipments of research chemicals.

At the local level, police saw the same pattern of substitution. Taking one supplier out of circulation produced, at most, a short interval before another source appeared. That churn complicates any account that treats arrests or seizures as an endpoint: the book describes a market capable of reorganizing faster than a single investigation could suppress it. Fentanyl also linked local street sales to distant manufacturing and shipping, making the origin and contents of a drug less visible to the people who bought it and to officials attempting to intercept it.

Treatment, stigma, and public response

Fentanyl-related deaths also brought the weakness of the treatment system into view. Underwood joined the first Hope Initiative meeting in the fall of 2015, six months after her son’s death. As executive director of the Bradley Free Clinic, she could map practical gaps in care, from privacy barriers and difficulties securing treatment to the lack of guidance families faced when they discovered that a young relative was injecting heroin. She had also found needles hidden among Bobby’s childhood keepsakes. His death joined personal grief to the work of building a local response.

The Hope Initiative sought to connect people with treatment through trained volunteer mentors and referrals. In early 2017, its volunteers assembled a five-page list of thirty-six rehabilitation and aftercare providers across the southeastern United States, with options dependent on a patient’s finances and the availability of beds. People could visit the Bradley Free Clinic on the second Monday of each month and, if they had no outstanding warrants, be paired with volunteers to navigate care. The program offered a practical bridge, but access still depended on eligibility, money, and openings; some volunteers were also divided over medication-assisted treatment despite evidence supporting it.

The surrounding culture could create another barrier. In the Appalachian communities shaped by the painkiller epidemic, some people in recovery regarded buprenorphine as incompatible with being clean, even though official Narcotics Anonymous policy accepted medication-assisted treatment. People taking the medication could consequently find it harder to secure peer support. Underwood, meanwhile, described a different form of silence when she told local school and county officials what was happening in Hidden Valley and asked them to take notice: no one asked a question, and the school board declined to support the prevention program.

Research and clinical initiatives offered a contrasting approach. Warren Bickel received a $1 million grant for a Virginia Tech Carilion Research Institute pilot intended to streamline transfers from emergency care to outpatient buprenorphine treatment. The plan would connect patients who had overdosed with outpatient treatment using Sublocade, a once-monthly injection. The proposal addressed a break in the path from survival to ongoing care, but local capacity remained limited: the Roanoke Community Services Board had added treatment for twenty-one patients, contingent on counseling, while Carilion Clinic had a three-week wait for outpatient medication-assisted treatment. Fentanyl’s significance in the narrative lies not only in its potency, but in how it exposed the distance between a fast-changing illicit supply and the slower work of keeping people alive and connected to care.