Cause of death: Washington faltered as fentanyl gripped America

Homeland Security Investigations agent Ed Byrne at a fatal overdose in San Diego on Nov. 10. Byrne has responded to nearly 500 such deaths since 2018. (Salwan Georges/The Washington Post)

During the past seven years, as soaring quantities of fentanyl flooded into the United States, strategic blunders and cascading mistakes by successive U.S. administrations allowed the most lethal drug crisis in American history to become significantly worse, a Washington Post investigation has found.

Presidents from both parties failed to take effective action in the face of one of the most urgent threats to the nation’s security, one that claims more lives each year than car accidents, suicides or gun violence. Fentanyl is now the leading cause of death for Americans ages 18 to 49, according to a Post analysis.

The Drug Enforcement Administration, the country’s premier anti-narcotics agency, stumbled through a series of missteps as it confronted the biggest challenge in its 50-year history. The agency was slow to respond as Mexican cartels supplanted Chinese producers, creating a massive illicit pharmaceutical industry that is now producing more fentanyl than ever.

The Department of Homeland Security, whose agencies are responsible for detecting illegal drugs at the nation’s borders, failed to ramp up scanning and inspection technology at official crossings, instead channeling $11 billion toward the construction of a border wall that does little to stop fentanyl traffickers.

The White House Office of National Drug Control Policy, the executive branch office headed by the “drug czar” and tasked with coordinating the government’s response, spent years fending off elimination and struggled to create an effective strategy to combat the scourge. The office lost its seat in the White House Cabinet and remains sidelined.

“Law enforcement did the best it could,” said David King, executive director of a federal drug task force in San Diego. “We can only do so much. But in Washington, they have been very slow to respond to this and now we are at the confluence of paralysis.”

The DEA said it is now taking direct aim at the Mexican cartels and the fentanyl epidemic. DEA Administrator Anne Milgram acknowledged that the government remained too focused on heroin at the onset of the crisis, as Mexican traffickers ramped up production of synthetic opioids.

“It is a new, deeper, more deadly threat than we have ever seen, and I don’t think that the full extent of that harm was immediately seen in 2015,” she said.

Narcotics agents say street-level demand for fentanyl is rising fast because so many new users are getting hooked. More than 9 million Americans “misused opioids” in 2020, according to the latest estimates by the Department of Health and Human Services. But the agency has not tracked the rise of fentanyl and does not know how many Americans are using it.

The Centers for Disease Control and Prevention is unable to track overdose deaths in real-time. Its published data is one year behind, obscuring the picture of what is happening on the ground in 2022. The agency continues to count the death toll for 2021 — in a provisional tally seven months ago, it calculated the overall number of drug overdoses at 107,622. Two-thirds were due to fentanyl.

When President Richard M. Nixon launched America’s first war on drugs 51 years ago, annual overdose deaths stood at 6,771.


The Washington Post followed the fentanyl epidemic from Mexican labs to U.S. streets.

There is one federal system that collects both fatal and nonfatal overdose data in real-time in several regions of the country. But the system, called ODMAP, is kept from public view. A database launched by the drug czar’s office last week maps some nonfatal overdoses, which can highlight regions where deaths are likely to follow.

Without comprehensive data, the federal government is driving blind.

“This is like tracking the epidemic by visiting cemeteries,” said John P. Walters, who served as drug czar during the Clinton and George W. Bush administrations. “We’re not measuring what’s coming into the country in real-time. We’re not measuring what’s happening with the health consequences and where to put resources to buffer those health consequences. Our drug-control strategy is an embarrassment, and it doesn’t begin to propose a way of reversing this problem.”

The American fentanyl crisis deepened during the coronavirus pandemic. From 2019 to 2021, fatal overdoses surged 94 percent, and an estimated 196 Americans are now dying each day from the drug — the equivalent of a fully loaded Boeing 757-200 crashing and killing everyone on board.

Ed Byrne knows better than anyone the cost of fentanyl on U.S. streets. Byrne, 54, a Homeland Security Investigations agent in San Diego, has kept his own count of the nearly 500 fatal overdoses he has witnessed. It was a way to impose some order on the snowballing disaster.

“It is so much useless death,” said Byrne, who began investigating fentanyl cases in 2018.

San Diego is ground zero for fentanyl trafficking into the United States. More than half of all the fentanyl seized along the southern border is confiscated there, much of it produced in clandestine drug labs and pressed into tablets by cartel networks in northern Mexico. Drug loads that cross the border undetected go to stash houses in Los Angeles and Phoenix before spreading eastward across the country. In Southern California, the cartels are renting Airbnbs to store drugs before shipping them across the country.

Byrne tracked fentanyl shipments as a key member of Team 10, a multiagency task force specializing in the drug. At death scenes, Byrne tested pills and powder and fingernails, a job that took him to $10 million mansions, rental apartments and homeless camps. Sometimes he went to suburban homes to find teenagers dead in their childhood bedrooms.

For all of Team 10’s success in catching dealers, the drugs and the overdoses kept coming. San Diego County tallied 92 fentanyl-related deaths in 2018, the year the task force was formed. Last year, there were 814.

Byrne and his colleagues printed hats and T-shirts with their own logo for Team 10: a lone wolf, howling into a void.

Fentanyl is the worst drug San Diego police Lt. Ken Impellizeri has seen. (Erin Patrick O'Connor/The Washington Post; Photo: Salwan Georges/The Washington Post)

The roots of the epidemic reach back to the Bush administration, which did little as countless Americans became addicted to oxycodone and other prescription opioids while U.S. drug manufacturers, distributors and chain pharmacies made billions in profits.

During the Obama administration, amid a wider questioning of the U.S. criminal justice system, the government defunded and dismantled key drug-monitoring programs in the years before fentanyl hit. President Barack Obama demoted the White House drug czar position, removing the role from the Cabinet. And when heroin use rose after the government crackdown on prescription opioids, authorities treated fentanyl as an additive, rather than a distinct threat requiring its own specific strategy.

President Donald Trump took office just as the fentanyl epidemic was about to explode. He promised to build a wall along the U.S. southern border that he said would stop drugs. But Mexican traffickers were sneaking fentanyl right through the front door, hidden in passenger vehicles and commercial trucks passing through official ports of entry in California and Arizona. Today, the partisan border debate in Washington remains fixated on a physical structure that is virtually useless for stopping the deadliest drug U.S. agents have ever faced.

Since President Biden took office, his administration has amplified a public messaging campaign to warn about fentanyl’s mortal threat — “One Pill Can Kill.” He has stepped up efforts to improve scanning technology at border crossings and repair a broken counternarcotics partnership with Mexico. But with Republicans blaming Biden’s border policies for record numbers of immigration arrests, the president and many of his top officials have said little about the skyrocketing amount of fentanyl entering the country.

LEFT: Mexican authorities at the site of a tunnel used to smuggle drugs into the United States from Tijuana. (Salwan Georges/The Washington Post) RIGHT: The entrance to the tunnel, which went under the border wall and exited inside a warehouse near San Diego. U.S. authorities suspect the tunnel was in operation for months, perhaps longer. (Salwan Georges/The Washington Post)

When the U.S. government cracked down on the U.S. opioid industry starting in 2005, it choked off street supplies of prescription narcotics but left behind a ravenous market. Mexican cartels filled it, first with crude heroin, then fentanyl. The cartels imported drugs and chemicals from China, hired chemists and purchased pill presses. But at the moment when the federal agencies responsible for preventing the drug from gaining a foothold in America were needed most, they fell short.

The amount of fentanyl seized along the U.S. southern border — the most reliable gauge of supply — has jumped ninefold during the past five years. Since July, border seizures of fentanyl have averaged 2,200 pounds a month, meaning U.S. authorities are confiscating more fentanyl in a single month than they did during all of 2018. Federal officials estimate they are capturing 5 to 10 percent of the fentanyl crossing from Mexico, but they acknowledge it could be less.

The drug is cheaper than ever because supplies are so abundant. On the streets of U.S. cities in the early 2000s, the most popular prescription pain pill was made by Mallinckrodt Pharmaceuticals, one of the nation’s oldest drug manufacturers. The company’s 30-milligram oxycodone tablets, known as “blues” or “M-30s,” sold for roughly $30 apiece on the black market. Today, fake M-30s made by Mexican cartels using fentanyl look identical but sell for $4 or $5 apiece on the streets of San Diego, and can be especially lethal to first-time users.

Byrne had been to 486 death scenes by the time his bosses decided he’d seen enough. They sent him this summer on a new assignment in the South Pacific. As he prepared to leave San Diego, the narcotics agents and prosecutors who worked with him threw a farewell party at the Tin Roof, a honky-tonk bar downtown in the city’s renovated Gaslamp Quarter.

“I can’t say we made progress,” said Sherri Walker Hobson, a tough, laser-focused former federal prosecutor who worked closely with Byrne, raising a toast to her best friend as the bar went quiet. “But we put up a good fight. We did the best we could to manage this.”

San Diego’s Gaslamp Quarter is lined with pricey new restaurants and old-style saloons that evoke the city’s history. They share the streets with thousands of people sleeping in tents and alleys, many gripped by addiction.

A few stood outside the Tin Roof, just beyond the sidewalk tables, on the night of Byrne’s farewell. At one point, a grubby, disheveled man with bulging eyes walked into the party and sat down among the cops. He didn’t speak, but he appeared to be under the influence of something powerful.

When one of the bartenders noticed and came onto the floor to confront him, the man ran to the back of the restaurant. Two of the plainclothes narcotics officers from Byrne’s party followed. They shooed the man out of the bar and back onto the street.

‘China, China, China’

By 2017, fentanyl had become the leading cause of overdose deaths in America. For three years, Hobson, then an assistant U.S. attorney in San Diego, had been tracking the steady rise in fentanyl seizures at the busiest land port in the nation — San Ysidro, 20 miles south of downtown San Diego. Fentanyl deaths had quadrupled in San Diego County between 2014 and 2017.

In the spring of 2017, Hobson formed the Fentanyl Working Group, a collection of federal and state drug agents, prosecutors and chemists, along with the medical examiner and other public health officials. It amounted to an emergency summit. Byrne joined the cause. They were hoping for a turnout of 15 people. Forty showed up.

The group began to collect drug overdose and seizure data and quickly realized that the doses of fentanyl that had been causing so many deaths in San Diego and across the country were coming from cartels in Mexico, not from traffickers in China.

“China was in the rearview mirror,” Hobson said.

Hobson and her colleagues tried to spread the word. They launched a local public awareness campaign. They created fact sheets and PowerPoint presentations to alert law enforcement agencies in the region. Hobson traveled the country, speaking at national drug policy conferences, where she sounded the alarm about the flood of fentanyl coming from Mexico.

From 2016 to 2017, fentanyl seizures at California’s ports of entry rose by 266 percent, from 573 pounds to 2,099. Most involved counterfeit M-30 pills. At the time, 2.2 pounds of fentanyl cost about $40,000. That amount could be turned into 1 million pills, netting the cartels millions in profit.

Hobson knew how the cartels operated because she had been prosecuting methamphetamine cases since the 1990s. The San Diego region had been a hub for small-batch, U.S.-made “biker meth.” Then Mexican traffickers figured out how to cook it cheaper, and make it purer. They put competitors north of the border out of business.

“I think a lot of people underestimated the Mexican cartels,” Hobson, who retired in 2020 after 30 years with the U.S. attorney’s office in San Diego, said in a recent interview. “I knew they were very innovative. They weren’t hesitant to adapt and try new things.”

Outside San Diego, Hobson’s warnings went largely unheeded.

The importation of fentanyl from Mexico was not the focus of the Trump administration. In October 2017, a Justice Department official said in an op-ed column that “most illicit fentanyl and fentanyl analogues come from China.”

The department announced an indictment against Chinese nationals, furthering the narrative that China was paramount. Reading through the indictment, Hobson realized that the allegations were old, dating back to 2014 and 2015. By 2017, it was clear to Hobson and members of the Fentanyl Working Group that the supply lines had shifted.

“There was so much focus on China, they didn’t look at where the ball was,” Hobson said. “They weren’t looking at the cartels in a serious way. It was all about China, China, China.”

‘A game changer’

Byrne caught a case in 2017 that confirmed the lightning-fast rise of the Mexican cartels. On Aug. 11, a U.S. Customs and Border Protection officer stationed at Los Angeles International Airport intercepted a package from China containing a chemical called 4-ANPP, a precursor used to make fentanyl. Byrne and Hobson, along with agents from the DEA and the U.S. Postal Inspection Service, devised a plan.

The team replaced the precursor with a bag of sand, put a tracking device on the package and followed it to San Diego. It was delivered to a post office box near the border linked to a man named Cesar Daleo. Byrne recognized the name from his days working as a U.S. Border Patrol agent before he joined Homeland Security Investigations. Daleo was once a Border Patrol agent, too.

The team members decided to allow Daleo to pick up the parcel. It would be the 14th time that he had signed for such a package since 2016. They hoped Daleo would take the interstate off-ramp from San Ysidro into Mexico. If he took the bait and drove onto the ramp, he would be making a commitment to entering Mexico. The team could then prove in court that the precursor chemicals were bound for the cartels.

On Aug. 29, 2017, Daleo picked up the parcel and opened the box, severing a hairline surveillance wire and sounding an alarm to the team. He tossed the box containing the bag of sand into his trunk and headed south, taking the off-ramp to Mexico. A Homeland Security tactical team cut him off. One of the agents tossed a stun grenade at Daleo’s car. He crashed into a guardrail. The agents smashed Daleo’s driver’s side window, dragged him through it onto the ramp and carted him off in handcuffs.

Daleo later pleaded guilty to drug conspiracy charges and was sentenced to 30 months in prison. For the first time, Byrne and Hobson had unassailable proof that the cartels were making their own fentanyl and cutting out the middlemen.

“It was a game changer,” Byrne said.

But in Washington, fentanyl was barely registering on the radar screen.

That year, the DEA published a 94-page resource document that devoted four pages to synthetic opioids. It made no mention that Mexican traffickers were producing fentanyl. Under “Drugs of Concern,” fentanyl was not listed. In the DEA’s 2017 National Drug Threat Assessment, the agency devoted 10 of 169 pages to fentanyl and other synthetic opioids. U.S. law enforcement agencies surveyed by the DEA identified heroin as the greatest threat facing the nation, followed by meth and prescription drugs. Fentanyl came in fourth, slightly ahead of marijuana.

A memorial to people who have died from fentanyl lines the walls at the headquarters of the U.S. Drug Enforcement Agency. (Jorge Ribas/The Washington Post)

There were other missteps. In the years before fentanyl hit the streets, crucial programs to monitor drug use were dismantled.

One, the Arrestee Drug Abuse Monitoring Program, gathered urine samples from recent offenders. The program, run by the White House drug czar, was scuttled in 2013 by budget cuts.

The Drug Abuse Warning Network, which collected drug use and overdose data from hospitals and emergency responders, was eliminated in 2011. The government brought back a version of the program in 2018, but by then, the fentanyl crisis was well underway.

“These programs, as imperfect as they were, at least gave us something. And they were defunded,” said Keith Humphreys, who served as a drug policy adviser to the George W. Bush and Obama administrations.

Soon after Trump became president, his administration proposed eliminating the drug czar’s office entirely. It became a backwater for political appointees, many of them with scant or no drug policy expertise. A 23-year-old Trump campaign worker was named deputy chief of staff, but no one had been nominated to head the office. Nearly nine months into his presidency, Trump selected Rep. Tom Marino (R-Pa.) — a former federal prosecutor and one of Trump’s first and most strident supporters in Congress — to be drug czar. But Marino soon withdrew his nomination after it was revealed in a joint Washington Post-“60 Minutes” investigation that he had co-sponsored legislation that made it more difficult for the DEA to hold drug manufacturers, distributors and pharmacies accountable when they violated federal law.

As the Trump administration was preparing to leave the White House in 2021, the drug czar’s office issued its annual National Drug Control Strategy to Congress. The document is supposed to detail the government’s plan to reduce drug demand and disrupt supply chains. But the 2021 strategy document was nearly identical to the one issued in 2020. Many of its sections had simply been copied from the previous year.

‘Hold people accountable’

One name on the medical examiner’s list of 2017 overdose deaths in San Diego is Leo Holz. The cause of death was “fentanyl toxicity.” His age: “zero.”

Leo was 10 months old. He was crawling around on the bed between his sleeping parents. Leo picked up a bright blue pill and put it in his mouth. When his parents woke up, their baby was cold and unresponsive.

Leo was the youngest person in San Diego to die because of fentanyl. Since then, the drug has killed two other children there before their first birthdays.

Byrne and Hobson investigated the Holz case, tracing the pills to a drug ring that included a U.S. citizen in Tijuana named April Spring Kelly. She told prosecutors she used heavyset women as “body carriers,” because they were less likely to be patted down, and sent them through Arizona and California crossings.

Couriers were smuggling packages taped to their thighs and abdomens, or in body cavities. “Stuffers,” as the agents called them, could sneak a pound of pills or powder through a port of entry. Kelly admitted in a plea agreement to smuggling nearly half a million fentanyl pills across the border. She was sentenced to 14 years.

The Trump administration was less focused on drugs than immigration. Trump officials were preparing to award contracts worth billions of dollars for the president’s border wall, and they invited construction firms to set up side-by-side prototype designs on a dusty lot near the Otay Mesa crossing, 27 miles south of downtown San Diego. The region was a natural choice. The fencing CBP had installed along the border there over the previous two decades was more formidable than anywhere else.

What Trump officials didn’t acknowledge was that the barriers made little difference to the cartels: The place with the mightiest fence was also the traffickers’ primary gateway for hard drugs.

“The cartels saw the void left by the U.S. pharmaceutical industry,” said John Callery, a 30-year veteran of the DEA who retired after running the San Diego field office. “Nature abhors a vacuum and they said, ‘Holy crap. We only have to get five pounds of fentanyl across the border instead of 7,000 pounds of meth. Perfect. And we can make 10 times as much money.’”

In the summer of 2018, a hard-charging local prosecutor in San Diego named Terri Perez proposed setting up Team 10 to investigate every fentanyl death and trace the drugs to the dealers. The team was headquartered at the DEA’s San Diego field office, and staffed by federal and local law enforcement officers from across the region.

“I had never seen anything like this. It’s impacting people from their early teens to their 40s and 50s, families being destroyed, parents losing their kids, schools losing their students,” Perez said. “We needed to hold people accountable.”

Perez turned to Byrne. He started to investigate dozens of overdose deaths, comforting family members while trying to gain access to the cellphones of the dead for leads.

Byrne and Hobson knew they were seeing only a small fraction of the drugs pouring across the border. And what they were hearing from DEA agents was not encouraging. Mexican President Andrés Manuel López Obrador was critical of his country’s drug war partnership with the United States and argued that it burdened Mexico unfairly and fueled violence.

Once López Obrador took office in December 2018, security and counternarcotics relationships with the United States had gone cold. He was distrustful of the DEA and the access U.S. agents had cultivated across the Mexican government.

In Washington, Trump had declared the opioid epidemic “a national health emergency” and pressured China to crack down on fentanyl shipments to the United States. But his administration’s focus at the border was to stop immigration. Trump, who falsely said Mexico would pay for the border wall, wanted the Democrats to provide $5 billion for the project. He shut down the government toward the end of 2018 when they wouldn’t give it to him.

The impasse ended after 35 days and led to a compromise on border security. Democrats agreed to furnish $1.4 billion for the wall. Republicans agreed to provide $564 million to add more-advanced “non-intrusive inspection” technology, known as NII, at the ports of entry.

“We asked: What would it take to stop the flow of drugs? Could we do a Manhattan Project for NII?” said a congressional staffer who worked closely on the funding plan but wasn’t authorized to speak publicly.

More than 228,000 cars and trucks were entering the United States each day from Mexico, but CBP officers were scanning only about 6 percent of commercial trucks and 1 percent of passenger vehicles.

Mexican traffickers were playing those odds, and winning. They could send the stuffers through the crossings, or just load the drugs into cars and trucks, and shrug off whatever losses they incurred as the price of doing business.

The border security plan that emerged in 2019 after the shutdown promised to change that calculus. Congressional appropriators set a goal for CBP to scan 72 percent of commercial trucks and 40 percent of passenger vehicles entering from Mexico.

Fentanyl’s deadly surge
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To reach that objective, CBP needed software systems capable of processing the millions of images from the state-of-the-art scanning equipment. That required artificial intelligence to help agents quickly detect hidden compartments, altered engine parts and other anomalies.

The three-dimensional scans couldn’t find fentanyl buried deep in an engine block, but they could detect suspicious changes in densities. The drug loads show up as glowing bright spots because the X-rays pass through them so easily. CBP officers could route those vehicles to additional inspection.

“We gave them a huge pot of money,” the congressional staffer said. “We thought we had a good plan.”

The rising toll

After Byrne had responded to 100 fatal overdoses in San Diego, the pace suddenly picked up. Less than a year later, he was at his 200th death scene. Fentanyl was killing people in the most private and intimate of places — in their bedrooms, their bathrooms, in the hallways of their homes.

One of Byrne’s problems was that no one else wanted to test for fentanyl at crime scenes. In the early stages of the crisis, much of the DEA messaging had been geared toward alerting first responders to the dangers of fentanyl. They became so terrified that they would call in hazmat crews if they thought fentanyl was present.

But Byrne saw the downside to the scary messaging. Fentanyl is only a significant threat if the powder is dispersed into the air and inhaled. Touching the pills or handling bags of powder is not a mortal risk because the drug isn’t easily absorbed through the skin. Pharmaceutical fentanyl “patches” prescribed to manage intense pain use a chemical agent to allow the drug to be absorbed.

Fentanyl’s reputation made it hard for Byrne to get fellow officers and agents to do their own testing. So, they would call him, and he’d arrive in his Ford Explorer. In the back, he kept two MX908 mass spectrometers. He once found the crumbs of a pill under a dead teenager’s keyboard. The boy’s father hit the space bar, and when the monitor lit up, the boy’s message exchanges with the dealer popped up on the screen.

Sending samples to a lab that took weeks to process the results meant the loss of crucial time for investigative leads. And when a “hot,” or super-potent, supply was ravaging users in rapid succession, it was important to know right away that an especially lethal batch of fentanyl had hit the streets.

By 2019, fentanyl deaths in San Diego had risen 787 percent in five years.

“Just when we think it can’t get any worse, the latest numbers prove us wrong,” U.S. Attorney Robert Brewer said at a news conference that July.

That summer, Byrne responded to a call at an extended-stay motel in San Diego’s Clairemont Mesa district. A 30-year-old parolee named Major Williams, whom police had identified as a gang member, was found dead in his room. The cause of death: “fentanyl, cocaine and alcohol.”

Less than two years later, Byrne was back at the same motel to investigate another fentanyl death.

“It was the exact same room,” he said.

Glory days

During the 1980s and 1990s, DEA agents were seen as the rock stars of the law enforcement world, making major busts in the United States and helping to capture Latin American drug lords like Joaquín “El Chapo” Guzmán and Pablo Escobar.

The DEA has struggled during the past decade, losing nearly 1,300 staffers, 700 of them agents. Many agents retired early to take lucrative private-sector jobs. Today, the agency has more than 800 vacancies.

For six years, the DEA went without a Senate-confirmed administrator. Michele Leonhart, a 35-year veteran, announced her retirement in 2015 following revelations that DEA agents were attending sex parties with prostitutes hired by Colombian drug cartels.

Leonhart’s departure marked the beginning of a tumultuous time at the DEA. The agency went through five acting administrators, three of them during Trump’s tenure.

In 2018, DEA agent Fernando Gomez was charged with participating in a decade-long conspiracy to smuggle thousands of pounds of cocaine from Puerto Rico to New York. He was sentenced to four years in prison.

In 2020, DEA agent Jose Irizarry was accused of conspiring to launder money for a Colombian drug cartel while living a lavish lifestyle replete with wild yacht parties, bikini-clad prostitutes and homes in Cartagena, Colombia; Puerto Rico; and South Florida. He was sentenced to 12 years in prison.

More recently, a former agent, Manuel Recio, was accused of making payments to current agent John Costanzo Jr. in return for inside information about pending DEA cases. That information was then allegedly peddled to criminal defense attorneys hoping to recruit new clients. Recio and Costanzo could face more than 20 years in prison if convicted. They have denied the allegations.

A recent audit by the Justice Department’s Office of the Inspector General found that the DEA failed to effectively monitor its foreign offices and agents overseas. The DEA has ordered an outside review of the agency’s 92 foreign offices in 69 countries “to ensure integrity and accountability.”

Mark Coast, a retired DEA agent in San Diego who also spent 30 years as a Marine Corps reservist, said he saw the agency lose its operational muscle and strategic focus. “Everything is whack-a-mole,” he said in an interview. “A dealer pops up, they take that dealer out, and another one pops up.”

“There is no strategic plan,” he said.

Eighteen months ago, Milgram, a former New Jersey attorney general, became the first Senate-confirmed DEA administrator since 2015. She inherited the fentanyl crisis and has been scrambling to marshal a more robust response.

“This is not a war on drugs, this is a war to save lives,” she said in a recent interview at DEA headquarters in Northern Virginia, where the lobby walls are covered with more than 4,000 portraits of fentanyl overdose victims sent in by their families. They are almost entirely young faces, many of them in their teens and 20s.

“When you look at the faces, you have a sense of the enormity of what we’re losing,” Milgram said.

Since taking office, she has promoted the One Pill Can Kill campaign and begun targeting the two top Mexican cartels behind the flood of fentanyl — Sinaloa and Jalisco New Generation — going after their financial networks and global supply chains.

Between May and September, the DEA and other law enforcement agencies seized nearly 980 pounds of fentanyl powder and 10.2 million pills, and they investigated 380 fentanyl-related cases, connecting 35 directly to the two cartels. The DEA also investigated 129 cases of fentanyl ordered via social media platforms, including Snapchat, Facebook Messenger, Instagram and TikTok.

Milgram described the cartels’ push to expand markets by addicting more people as “deliberate, calculated treachery.”

Rahul Gupta, Biden’s drug czar and the first trained physician to hold that job, said in a recent interview that he is focused on flattening fentanyl’s death curve. He said he does not need the president to return his role to the Cabinet.

“The goal is really to address the crisis of today, not yesterday,” he said.

Gupta said the Biden administration is implementing a “harm reduction” approach that seeks to reduce deaths by supporting safe-use policies and expanding access to counseling and treatment. “Only 1 in 20 people who need the help are able to get it today in the United States of America,” he said.

LEFT: Families of fentanyl overdose victims held a rally on the Mall in September to raise awareness about the epidemic. (Eric Lee for The Washington Post) RIGHT: Brandi Hickman holds a photo of her late son, Andron Petteway II, at the rally. (Eric Lee for The Washington Post)

Along the border, the administration is struggling to deploy the sophisticated scanning systems. Nearly four years after Congress gave the CBP money to expand inspections, new systems have been installed in Brownsville and Laredo, Tex., and at other border crossings. But they require officers to conduct labor-intensive reviews because the CBP lacks the ability to automate the process with artificial intelligence software and centralized command centers.

A House Appropriations Committee report published in June chastised the agency for its failures, saying it had a “paradigm-shifting opportunity” to “revolutionize” the inspection process. Instead, the strategy “continues to depend on CBP Officers to review thousands of images manually,” the report stated, calling it a shortsighted “failure to innovate” that is “inexcusable and must be immediately addressed by current DHS leadership.”

‘Just heartbreaking’

During a visit this fall to the medical examiner’s office in San Diego, 261 corpses in body bags were laid out on metal trays and stacked up on carts in the refrigerated morgue. Thirty-seven of the people had died of fentanyl overdoses. Fentanyl is now responsible for 1 in every 5 deaths handled by the San Diego County Medical Examiner’s Office. So many people are dying, it takes nearly four months to complete toxicology reports.

“It’s just heartbreaking,” said Medical Examiner Steven D. Campman, who reviewed 1,672 fentanyl-related deaths from 2014 through 2021.

“A fair number of families ask: ‘Shouldn’t I have done something? Couldn’t I have seen something?’ I tell them it shouldn’t be on them, and I can’t offer them much more.”

In October, after three months in the South Pacific, Byrne returned to San Diego. The city’s Deputy District Attorneys Association had named Byrne “Law Enforcement Officer of the Year” and invited him to pick up the award. Byrne looked 10 years younger, his face thinner and more tanned than when he had left San Diego.

After the awards ceremony, he went back to work. An old case among his 486 came to court for a sentencing hearing.

On Nov. 3, 2020, Sarah Elizabeth Fuzzell, 24, had been found dead in her apartment in Vista, Calif., 40 miles north of downtown San Diego. Byrne gained access to her phone. The drug dealer was unaware that one of his customers had just died. A Team 10 member texted the dealer, posing as Fuzzell on her phone. The man who had sold Fuzzell the fentanyl, Cole Salazar, fell for the ruse. Salazar was charged with selling the lethal dose.

The case took two years to wend its way through the courts. On Oct. 15, Byrne drove to the federal courthouse in downtown San Diego for Salazar’s sentencing. Fuzzell’s older sister, Megan, along with her mother, Mindy, had made the trip from their home in Oklahoma City. Megan, 30, was a medical researcher who had graduated magna cum laude from the University of Oklahoma and been a high school valedictorian and National Merit scholar. She volunteered at medical clinics to raise awareness about the dangers of drug overdoses.

Megan testified about the loss of her little sister.

“Since her death, I’m left with a hole in my heart that is irreparable and constantly present,” she told the judge. “I’m lost without her. My family feels incomplete and broken.”

That Wednesday evening, Byrne met Megan and Mindy for dinner in San Diego’s Little Italy. Even though the judge had sentenced Salazar to 10 years in prison, the mood was muted. The next night, the Fuzzells returned home to Oklahoma.

The following day, Byrne received a text message from Megan’s father.

“Mindy and I found Megan dead in her bed about 630 last night,” David Fuzzell wrote.

David and Mindy had lost their only remaining child. The autopsy results were still pending, but Byrne already knew. Megan was 487.

Six days later, he wrote to a Post reporter:

“I have been lucky to not have lost someone close to me in this battle, but I can sadly say I know all too well the heartbreaking sorrow of those who have. I accept Megan as 487. It impacted all of us from Sarah’s case like a knife in the gut. I still cannot speak with her mother. I know it’s not true but I somehow feel like I’ve failed the Fuzzells. How did we sit with her at dinner less than 48 hours before and not see or sense anything?

“In 2021, 107,000 souls were snuffed out from fentanyl in America. That number will be eclipsed this year. All the futures that have been lost, those still to be lost.

“Where’s the outrage?”

About this story

Reporting by Nick Miroff, Scott Higham and Steven Rich. Alice Crites also contributed to this report. Photography by Salwan Georges. Videos by Erin Patrick O’Connor and Jorge Ribas.

Design and development by Allison Mann and Tyler Remmel. Additional design and development by Laura Padilla Castellanos and Rekha Tenjarla. Data analysis by Steven Rich. Video graphics by Sarah Hashemi.

Jeff Leen, Trish Wilson and Courtney Kan were the lead editors. Additional editing by Sarah Childress, Christian Font, Meghan Hoyer, Jai-Leen James, Jessica Koscielniak, Robert Miller, Frances Moody and Martha Murdock.

Additional support from Steven Bohner, Matthew Callahan, Sarah Dunton, Jenna Lief, Osman Malik, Monika Mathur, Jordan Melendrez, Angel Mendoza, Sarah Murray, Ben Pillow, Sarah Pineda, Andrea Platten, Kyley Schultz, Casey Silvestri, John Taylor and Mael Vallejo.

Cartel RX

In a seven-part investigation, The Washington Post followed the fentanyl epidemic from Mexican labs to U.S. streets.


The Post analyzed data from a range of sources to measure the rise of fentanyl in the United States and Mexico. Among other topics, reporters compiled data on drug seizures, overdose deaths and reversals, border crossings and fentanyl potency.

The data was collected from more than three dozen federal, state and local sources across the United States and Mexico. For example, for the count of overdose deaths in the United States, The Post used mortality data from the Centers for Disease Control and Prevention. To measure data seizures along Route 15 in Mexico, reporters standardized multiple datasets from agencies including the Secretaría de la Defensa Nacional, Fiscalía General de la República, Secretaría de Marina and the Guardia Nacional.

Reporters made open records requests in both countries, retrieved data from government websites to create data sets and obtained and analyzed seizure data from High Intensity Drug Trafficking Areas, run by the White House’s drug czar, by submitting a detailed research proposal to gain access.