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March 23rd, 2019

Revealed; In-Depth

The shocking manner in which Obama officials failed to focus as fentanyl burned its way across America

Scott Higham, Sari Horwitz & Katie Zezima

By Scott Higham, Sari Horwitz & Katie Zezima The Washington Post

Published March 14, 2019

The shocking manner in which Obama officials failed to focus as fentanyl burned its way across America Firefighter helps addict at Manchester's Safe Station program. Salwan Georges for The Washington Post
In May 2016, a group of national health experts issued an urgent plea in a private letter to high-level officials in the Obama administration. Thousands of people were dying from overdoses of fentanyl - the deadliest drug to ever hit U.S. streets - and the administration needed to take immediate action. The epidemic had been escalating for three years.

The 11 experts pressed the officials to declare fentanyl a national "public health emergency" that would put a laserlike focus on combating the emerging epidemic and warn the country about the threat, according to a copy of the letter.

"The fentanyl crisis represents an extraordinary public health challenge - and requires an extraordinary public health response," the experts wrote to six administration officials, including the nation's "drug czar" and the chief of the Centers for Disease Control and Prevention.

The administration considered the request but did not act on it.

The decision was one in a series of missed opportunities, oversights and half-measures by federal officials who failed to grasp how quickly fentanyl was creating another - and far more fatal - wave of the opioid epidemic.

In the span of a few short years, fentanyl, a synthetic painkiller 50 times more powerful than heroin, became the drug scourge of our time. Fentanyl has played a key role in reducing the overall life expectancy for Americans.

If current trends continue, the annual death toll from fentanyl will soon approach those from guns or traffic accidents. Among the dead are the anonymous and the famous, including musicians Prince and Tom Petty. It is so powerful that just a few flecks the size of grains of salt can cause rapid death.

Between 2013 and 2017, more than 67,000 people died of synthetic-opioid-related overdoses - exceeding the number of U.S. military personnel killed during the Vietnam, Iraq and Afghanistan wars combined. The number of deaths, the vast majority from fentanyl, has risen sharply each year. In 2017, synthetic opioids were to blame for 28,869 out of the overall 47,600 opioid overdoses, a 46.4 percent increase over the previous year, when fentanyl became the leading cause of overdose deaths in America for the first time.

"This is a massive institutional failure, and I don't think people have come to grips with it," said John Walters, chief of the White House Office of National Drug Control Policy between 2001 and 2009. "This is like an absurd bad dream and we don't know how to intervene or how to save lives."

Federal officials saw fentanyl as an appendage to the overall opioid crisis rather than a unique threat that required its own targeted strategy. As law enforcement began cracking down in 2005 on prescription opioids such as OxyContin and Vicodin, addicts turned to heroin, which was cheaper and more available. Then, in 2013, fentanyl arrived, and overdoses and deaths soared.

"Fentanyl was killing people like we'd never seen before," said Derek Maltz, the former agent in charge of the Drug Enforcement Administration's Special Operations Division in Washington. "A red light was going off, ding, ding, ding. This is something brand new. What the hell is going on? We needed a serious sense of urgency."

But for years, Congress didn't provide significant funding to combat fentanyl or the larger opioid epidemic. U.S. Customs and Border Protection didn't have enough officers, properly trained dogs or sophisticated equipment to curb illegal fentanyl shipments entering the country from China and Mexico. The U.S. Postal Service didn't require electronic monitoring of international packages, making it difficult to detect parcels containing fentanyl ordered over the internet from China. CDC data documenting fentanyl overdoses lagged events on the ground by as much as a year, obscuring the real-time picture of what was happening.

Facing hotly contested midterm elections in 2018, Congress finally passed legislation aimed at addressing the increasingly politicized opioid crisis, including a measure to force the Postal Service to start tracking international packages.

"How many people had to die before Congress stood up and did the right thing with regard to telling our own Post Office you have to provide better screening?" Sen. Rob Portman, R-Ohio, sponsor of the legislation, asked on the Senate floor last fall.

Local and state leaders in hard-hit communities say the federal government wasted too much time at a cost of far too many lives.

"Everybody was slow to recognize the severity of the problem, even though a lot of the warning signs were there," said Republican Gov. Chris Sununu of New Hampshire, which has one of the highest fentanyl overdose rates in the United States.

In Sununu's state, Narcan, which delivers an opioid-overdose antidote, has become standard issue for some school districts. Addicts overdose on the sidewalks and in public parks of Manchester and are found slumped over the steering wheels of cars in traffic. Firefighters and paramedics are called nearly every day to fentanyl overdoses and have opened their station houses to addicts seeking treatment.

"In the city of Manchester, we saw 20 overdoses to 80 overdoses a month. We were like, 'What the heck is happening with these overdoses?' " said Manchester Fire Chief Dan Goonan.

He said politicians and policymakers held numerous roundtable discussions to talk about solutions, but there was little action.

"I said, 'If I had to go to another roundtable, I'm going to jump out the window myself because we're going nowhere with these roundtables,' " he said.

Drug treatment experts compared the government's slow response to an earlier failure to face the AIDS epidemic.

"There was a stigma about being gay," said Luke Nasta, executive director of the largest drug treatment facility on Staten Island, New York. "There is also a stigma about being addicted to drugs. The entire society is suffering and the government can't seem to get their arms around this epidemic.

"If it's an epidemic, then treat it like an epidemic."

The first wave of the opioid epidemic began in 1996 after drug manufacturer Purdue Pharma introduced what it claimed to be a wonder drug for pain - OxyContin, a powerful opioid that was aggressively marketed to physicians as less addictive than other prescription narcotics. As the medical community embraced the new drug, it became a blockbuster for Purdue, generating billions in sales.

Over the next decade, doctors and corrupt pain management clinics prescribed massive amounts of opioids. To meet the demand, drug manufacturers and distributors flooded communities across the country with opioid pills, including oxycodone and hydrocodone. Drug users and dealers diverted hundreds of millions of doses to the streets.

The DEA started to crack down on the illegal trade in 2005. Two years later, Purdue paid $600 million in fines and its executives pleaded guilty to federal criminal charges for claiming the product was less addictive than other painkillers. The company agreed to make its marketing conform to federal rules and has launched programs to combat opioid abuse.

"It is deeply flawed to suggest that activities that last occurred 18 years ago are responsible for today's complex and multi-faceted opioid addiction crisis," the company said in a recent statement.

The federal government also fined the largest drug distributors and pharmacies tens of millions of dollars over allegations that they failed to report suspicious orders of pain pills.

As the supply of prescription opioids began to tighten, America's pill addicts became desperate. Street prices soared. Mexican drug cartels saw an opening to sell more heroin, a cheaper, more potent way to get high. That set off the second wave of the epidemic by 2010 and a rise in overdose deaths.

Then fentanyl hit the streets. A synthetic opioid developed in 1960 by a Belgian physician, fentanyl is normally reserved for surgery and cancer patients. It is up to 100 times more powerful than morphine, its chemical cousin.

For traffickers, illicit fentanyl produced in labs was the most lucrative opportunity yet, a chance to bypass the unpredictability of the poppy fields that produced their heroin. The traffickers could order one of the cheapest and most powerful opioids on the planet directly from Chinese labs over the internet.

It was 20 times more profitable than heroin by weight. By lacing a little of the white powdery drug into their heroin, the dealers could make their product more potent and more compelling to users. They called it China White, China Girl, Apache, Dance Fever, Goodfella, Murder 8 or Tango & Cash.

The third wave of the opioid epidemic was about to begin. Ground zero was Rhode Island, already reeling from a crippling prescription pill and heroin problem.

The first signs were detected in the spring of 2013 when overdose deaths spiked at the state morgue in Providence. Then-Rhode Island Health Director Michael Fine wondered: What was killing so many so quickly?

Fine was surprised to learn when the toxicology reports came back that 12 people who overdosed between March and May had died from fentanyl. They ranged in age from 19 to 57, and most were from the northern part of the state.

Fine notified the CDC about the cluster. On Aug. 30, 2013, the CDC in its Morbidity and Mortality Weekly Report highlighted the unusual spike in Rhode Island. It didn't attract much national attention.

Eighteen days before the CDC issued its "Notes from the Field," then-Attorney General Eric Holder traveled to the other side of the country to issue one of the biggest policy proclamations of his career.

Standing before hundreds of lawyers gathered for the American Bar Association's annual conference in San Francisco, Holder announced that he was rolling back the aggressive prosecution strategy that had been launched to target the crack cocaine crisis of the 1980s and 1990s.

Calling the new policy "Smart on Crime," Holder said he was directing federal prosecutors to stop bringing low-level, nonviolent drug charges that would trigger mandatory-minimum sentences. The charges had resulted in harsh sentences for first-time offenders, many of them young black men. Holder told his prosecutors to focus on large drug-trafficking organizations.

He wanted a major reduction in the burgeoning federal prison population, but his initiative also was part of the Obama administration's strategy to favor drug treatment over incarceration.

"Our system is, in too many ways, broken," Holder said that day. "A vicious cycle of poverty, criminality and incarceration traps too many Americans and weakens too many communities."

Prison reform activists, civil rights groups and some federal prosecutors hailed the new policy, laid out in a three-page Department of Justice memorandum that became known as the "Holder Memo."

Tim Pifer and his team at the state crime lab in Concord, New Hampshire, started to see the same pattern in 2014 that Fine had noticed in Rhode Island the previous year.

"We were thinking, why would anyone inject something that's so potentially deadly?" Pifer, the veteran chief of the lab, said in a recent interview. "We saw this huge spike in drug deaths."

To get the word out, state health and law enforcement officials in New Hampshire and Rhode Island joined with the DEA, which had been seeing the same pattern across New England.

In January 2014, the DEA issued a bulletin warning local authorities nationwide about "killer heroin" cut with fentanyl. First responders needed to "exercise extreme caution" because fentanyl could be absorbed through the skin. The bulletin resulted in a few local news stories. But, once again, there was little national attention.

In March, a month after actor Philip Seymour Hoffman's heroin overdose generated national headlines, Holder released a video to notify the public of the rising number of heroin deaths across the country. He called heroin an "urgent and growing public health crisis." Between 2006 and 2010, heroin overdose deaths had increased by 45 percent.

"Confronting this crisis will require a combination of enforcement and treatment," Holder said in the video. "The Justice Department is committed to both."

Holder made no mention of fentanyl; top officials in Washington were still focused on heroin and prescription pain pills.

Former DEA agents said they provided Holder with a personal briefing that included a 30-slide PowerPoint presentation about the dangers of fentanyl in June 2014, three months after Holder's video. Several DEA officials were present, including then-DEA administrator Michele Leonhart.

The PowerPoint, which The Washington Post reviewed, warned that heroin was being laced with fentanyl and there had been an "outbreak" of fentanyl overdoses in the Northeast. It also noted that the drug was being ordered over the internet. The agency had traced the source to Chinese drug-trafficking organizations.

While raising red flags, the PowerPoint presentation itself did not request any particular action.

"We were hoping and expecting a briefing to the nation's number one law enforcement official would not only raise the level of awareness, but would cause him to take action within the department to direct people to make this matter a high priority since people were dying," Maltz, the DEA's former agent in charge of the Special Operations Division, later told The Post.

Maltz's division prepared and delivered the PowerPoint. He said he and his agents believed that a national problem like fentanyl was "way bigger than the DEA," and the attorney general could have taken a leadership role, urging other agencies to focus on the emerging threat.

Leonhart did not respond to requests for comment. Holder declined an interview request. His former spokesman said it was up to the DEA to ask the attorney general for specific action.

"It says something that the people pointing fingers at the attorney general can't point to a single action they recommended that he declined to take," said Matthew Miller, Holder's former spokesman at DOJ. "Eric Holder made fighting the opioid crisis a major focus, he strongly supported the DEA's work in this area, and if the officials trying to now lay the blame at someone else's feet had asked for more assistance, he would have given it, as he did in nearly every instance a law enforcement agency made such a request."

Ten months after the briefing, Holder left the administration.

By then, fentanyl was spreading across the country. Large increases in fentanyl seizures were being reported in Massachusetts, New Jersey, Ohio, Pennsylvania, Florida, Kentucky, Maryland and Virginia.

At the same time, in the wake of Holder's memo, federal drug cases were dropping. In a year, the number of people charged with federal drug crimes fell by more than 4,700 - from 27,106 in 2013 to 22,387 in 2014.

"There was a dramatic decline in drug prosecutions," Rod Rosenstein, who served as the U.S. attorney in Baltimore during the Obama administration and is now the deputy attorney general, recently told The Post. "That was a reflection of administration policy to de-emphasize imprisonment and to shift focus away from prosecution into treatment."

Then-Deputy Attorney General Sally Yates said in 2016 that U.S. Sentencing Commission data showed that the number of serious drug prosecutions - such as those involving firearms - increased.

But a report by Justice Department Inspector General Michael Horowitz found that the sentencing data Yates used had "significant limitations" because it did not count the number of cases from drug agents that assistant U.S. attorneys turned down for prosecution. Horowitz concluded that there was no way to gauge the precise impact Holder's memo had on drug prosecutions.

Holder's former spokesman said the memo did not take away tools from prosecutors.

"It gave them discretion," Miller said in a written statement. "They have the same ability to charge cases they have always had, they are just supposed to use discretion and not automatically trigger mandatory minimums when they aren't appropriate. There are many reasons for the increase in fentanyl abuse, but there is no evidence that the Smart on Crime initiative is one of them."

But out in the field, some drug agents and prosecutors said they noticed an immediate difference, just as fentanyl started to show up on the streets.

Dominick Capuano, a former veteran New York City narcotics supervisor who worked with federal task forces on Staten Island, said his agents traditionally launched their cases by arresting low-level dealers. Prosecutors would then offer plea deals for information about bigger traffickers. Law enforcement would work its way up to the kingpins. Federal laws carry long prison sentences and provide powerful incentives for people to talk.

After the Holder memo, Capuano said federal prosecutors would no longer take the lower-level cases and morale among his drug agents plummeted as heroin and fentanyl overdoses soared.

"The low-lying fish is where you start the cases," said Capuano, who recently retired after 21 years on the job. "Those are the people who flip, who give information, and that's what leads to these bigger cases."

Utah U.S. Attorney John Huber, an Obama appointee who was renamed to the position by the Trump administration, said in a recent interview that the change in policy "took the edge off" drug prosecutions.

The message, he said: "This isn't so important anymore."

On March 18, 2015, nine months after its presentation to Holder, the DEA put out its strongest warning yet to law enforcement agencies and the public about the mounting threat, issuing a "Nationwide Alert on Fentanyl."

The alert was a distillation of what the agency had learned about the drug in the previous two years. It was intended to sound the alarm, not only to the agency's field offices, but also to federal and state officials, and to the public. The DEA warned that fentanyl was increasingly showing up in heroin.

DEA agents said fentanyl was being ordered by traffickers and users over the internet and the dark web. They paid for the drug with bitcoin and other forms of cryptocurrency. The agency noted that Mexican cartels were smuggling fentanyl through ports of entry along the Southwest border, hiding it in wheel wells and secret compartments in cars and trucks.

State and local labs reported that seizures had risen from 942 in 2013 to 3,344 in 2014.

The rise in deaths was disturbing: 80 fentanyl deaths in the first six months of 2014 in New Jersey and 200 deaths in Pennsylvania over 15 months.

The same month that the DEA issued its alert, Congress directed the Justice Department and the White House drug czar to convene a National Heroin Task Force to develop strategies to confront the "heroin problem" and "curtail the escalating overdose epidemic and death rates."

This was meant to be the administration's big effort, bringing together 25 agencies to develop a "comprehensive" national response to the crisis.

The focus was still on heroin and prescription pills.

The task force's 23-page report was delivered to Congress by the new attorney general, Loretta Lynch. Five sentences were devoted to fentanyl.

The report said the surge in opioid deaths "may be related" to a rise in heroin being laced with fentanyl. It called for the creation of response teams to warn police and the public about overdoses, some of which may involve fentanyl, and said there should be more research into "opioid use disorder," including the use of fentanyl.

No mention was made of the role of China and orders of fentanyl over the internet, the smuggling of fentanyl through the U.S. mail or the lack of resources devoted to fighting fentanyl trafficking at the border and ports of entry.

"In retrospect, it should have been a focus of the report," Michael Botticelli, the White House drug czar at the time, said in a recent interview.

A task force leader saw fentanyl as an extension of the prescription pill and heroin crisis, not as the beginning of a new and far deadlier drug epidemic.

"It was not ignored and it was on the radar and we did talk about it, but it was sort of like another problem on top of everything else," said David Hickton, former U.S. attorney of the Western District of Pennsylvania, who co-chaired the task force. "The big problem at the time was opioids in pill form. Fentanyl was episodic at that time. It looks so different to me today than it did then. Now, it looks like its own problem. At the time, it looked like a spike problem."

Hickton said he was frustrated that the report didn't fault Congress for failing to provide funding to fight the epidemic. He said the task force believed that at least $1 billion was needed immediately for law enforcement efforts and treatment programs.

"We were very clear about what we needed," said Hickton, who later created his own state task force to focus on heroin and fentanyl traffickers. "We didn't get half. We got zero."

At the same time, the state of Rhode Island launched its own task force after newly elected Democratic Gov. Gina Raimondo declared opioid overdoses to be a "public health crisis" in 2015.

Two experts advising the task force visited the state morgue in Providence. Josiah Rich and Traci Green, epidemiologists from Brown University, pored over the autopsy reports that had so alarmed Michael Fine two years earlier.

"There's a fentanyl, there's another fentanyl," Rich recalled in a recent interview.

As they sifted through the reports and the photographs of the dead, one stood out: a pregnant woman, slumped over, surrounded by the presents she had recently received for her baby shower.

"It hits you in the heart," Rich said. "You read through a two-foot stack of those and you're a different person."

Rich and Green began to contact their colleagues around the country and discovered that others had also seen troubling spikes of fentanyl deaths.

"We said, 'Oh my goodness, this fentanyl is really starting to take off,' " Rich said. "Nobody's doing anything about it. Nobody's saying anything about it."

Lynch, the attorney general, did mention fentanyl in one sentence during a keynote address she delivered at the Opioid Misuse and Addiction Summit in Massachusetts that fall. Lynch said the DEA had recently taken "several major actions" against drug traffickers and was "raising awareness about the growing presence of fentanyl in heroin sold on the streets, which substantially and tragically increases the risk of overdose."

In Washington, Tom Frieden, the CDC chief during the Obama administration, notified several senior administration health officials about the increasing fentanyl overdoses, including a doubling of deaths in New Hampshire in one year.

Frieden believed one of his roles was to alert government officials to dangerous trends in the field. In October 2015, the CDC issued a nationwide health advisory about the increasing dangers of fentanyl. It was up to the various agencies to take action, he said.

"I felt like I was a bit of a voice in the wilderness," Frieden recalled in a recent interview. "I didn't have the sense that people got this as a really serious problem."

One of the people Frieden contacted was Botticelli, the drug czar.

"I had many conversations with him, encouraging law enforcement to take rigorous action," Frieden said. "He assured me they were."

The drug czar's office depended on overdose data from the CDC. But data from the field was sometimes a year behind, and local coroners and medical examiners were not always testing for fentanyl.

"It's incredibly frustrating when you feel like, given the resources of the United States, that we can't harness those resources in ways that help us see around the corner," Botticelli said.

He said he pressed for faster overdose reporting from medical examiners. He also worked to increase funding for drug task forces around the country.

That same year, Kemp Chester was named the associate director of the National Heroin Coordination Group in Botticelli's office. Chester said the government was focused on pain pill and heroin overdoses; fentanyl was still seen as an outlier.

"There was not an interagency understanding of what this drug is, where it's coming from and how it's getting into the country," Chester recalled.

Chuck Rosenberg, the DEA administrator at the time, declined a request for an interview.

That November - eight months after the DEA issued its national fentanyl alert - the Obama administration sent its annual National Drug Control Strategy to Congress. The 107-page report devoted one sentence to fentanyl, noting that it was showing up in heroin.

"It caught a lot of people by surprise," said Jon DeLena, the associate special agent in charge of the DEA's New England Field Division. "People didn't understand until it was really put in their face. People weren't paying attention to how rapidly this evolved and they weren't prepared for it."

On March 29, 2016, Sen. Edward Markey, D-Mass., joined President Barack Obama on Air Force One for a trip to Atlanta, where both were scheduled to speak at the National Rx Drug Abuse & Heroin Summit.

By then, Markey said, the "fentanyl story was still masked in the prescription drug and heroin epidemic" and he felt like "Paul Revere, warning that even greater danger was coming." He and Senate Majority Leader Mitch McConnell, R-Ky., had requested the previous year that the U.S. surgeon general provide Congress with a report to highlight the seriousness of the overall opioid epidemic.

The senator used the rare one-on-one time to tell the president about fentanyl.

"I mentioned to him how this was morphing into increasingly a fentanyl epidemic and that's what was hitting Massachusetts and we were the canaries in a mine shaft," Markey recalled. "He was very concerned about it."

During Obama's hour-long appearance as part of a panel, the president discussed pills, heroin and efforts to provide treatment to opioid addicts. He made an oblique reference to fentanyl without mentioning the drug by name.

"We are now seeing synthetic opioids that are oftentimes coming in from China through Mexico into the United States," Obama said. "We're having to move very aggressively there, as well."

The situation had become so desperate that health experts from around the country banded together to make an impassioned plea to the highest levels of the Obama administration.

On May 4, 2016, a month after Obama's Atlanta appearance, the 11 public health experts wrote to the six administration officials, requesting the emergency declaration. Among the experts were Rich and Green, the two Rhode Island epidemiologists who had seen the devastation firsthand.

"What was happening was not enough given the scale of the challenge," said another of the authors of the letter, Joshua Sharfstein, vice dean at the Johns Hopkins Bloomberg School of Public Health.

In their 14-page letter, the experts pointed out that the fentanyl epidemic appeared "to be intensifying after two years."

It was far more dangerous than an earlier fentanyl outbreak in several states between 2005 and 2007, when nearly 1,000 people died. In that case, quick action had saved lives: The DEA had traced the fentanyl to a clandestine lab in Toluca, Mexico, and shut it down immediately.

Now, fentanyl deaths were spreading across the nation. In Maryland, the toll had jumped by more than 800 percent from 2013 to 2015.

"Like a light switch turning on," they wrote, referring to Maryland.

Traffickers were now buying pill presses from China and lacing fentanyl into counterfeit pain pills such as Vicodin, Xanax and oxycodone.

The experts asked the administration to take several steps to immediately address the crisis.

To start, they requested an emergency public health declaration from the Department of Health and Human Services that would sound the alarm. "An emergency declaration would clarify the public health nature of the crisis and bring needed focus to a new threat that is claiming thousands of lives," the experts wrote.

But an administration official who spoke on the condition of anonymity to discuss the matter dismissed the idea of a declaration, saying it would have been "largely symbolic" and required emergency funds from Congress.

Sylvia Mathews Burwell was then the HHS secretary who would have had to approve the declaration. She declined an interview request.

Two months after the emergency request, Burwell spoke at the National Governors Association's summer meeting on opioid addiction in Des Moines, Iowa. She said she had put together a "working group" at HHS and asked the audience for help.

"I'm sure you all know better than I do, fentanyl is the problem on steroids," she said. "If you're seeing things that are working in your states, please let us know."

Botticelli, the drug czar and another recipient of the request, said the Obama administration's priority was getting more money from Congress for treatment.

"Quite honestly, I think our focus at that point was not just to declare a public health emergency, but really to get additional resources out to states," he said.

But many leading voices in the field feel an emergency declaration could have saved lives by shining a bright spotlight that would have galvanized the administration, awakened the public and warned users of the danger they faced.

"A great deal would have been done by the White House simply saying we have this horrible danger out there," said Walters, the earlier drug czar. "We saw more action by the White House over an outbreak of tainted food, giving out news releases telling people what to look for, telling people to protect their friends and family, than you did for fentanyl. It's a little ridiculous that we don't use the bully pulpit to at least provide a national warning."

In the summer of 2016, a few months after the fentanyl letter, the Obama administration declared the Zika virus to be a public health emergency and had already requested $1.9 billion from Congress to address it. Two people in the United States died of Zika-related illnesses.

At the same time, the DEA warned, counterfeit pain pills laced with fentanyl were posing a "global threat."

That fall, with the presidential campaign in full swing, the White House proclaimed "Prescription Opioid and Heroin Epidemic Awareness Week." It had been three years since the CDC issued the first fentanyl warning in its morbidity report.

The administration announced several fentanyl initiatives. It would continue to work with China and Mexico to stem the flow into the United States, make the anti-overdose medication naloxone more widely available and give additional money to drug task forces. The administration said it was adding money to accelerate data collection on overdoses. Finally, it planned to hold a "roundtable" with grieving parents.

As part of the "awareness week," Attorney General Lynch traveled to the University of Kentucky, where she highlighted the rise of opioid overdoses and said "more than a third were caused by fentanyl."

Lynch said the Justice Department would fund research into fentanyl, and she directed her prosecutors to focus on "the greatest threats, including but not limited to individuals and institutions responsible for the trafficking of heroin and fentanyl." A report issued much later highlighted five fentanyl cases federal prosecutors had brought across the country under Lynch.

Lynch declined a request for an interview.

Obama also declined to be interviewed.

Katie Hill, Obama's communications director, said any story about "our administration's fentanyl response" should be put in the context of "our comprehensive approach to the opioid crisis," which included passage of the Affordable Care Act, a push for funding to expand treatment and the updating of guidelines for prescribing opioids.

"It's impossible to divorce fentanyl from the broader opioid use epidemic and how we responded," Hill said.

After the 2016 election, at the urging of Obama, Congress approved nearly $1 billion for opioid treatment programs. Drug policy experts called that figure "a drop in the bucket."

On Nov. 17, the surgeon general released the opioid report Markey and McConnell had requested the previous year. "As the nation struggles with an unprecedented opioid epidemic, this report is a missed opportunity," Markey said in a statement at the time. "The deaths caused by prescription drug, heroin and fentanyl overdoses are growing exponentially every year, yet this report fails to provide any detailed roadmap for how best to curb opioid addiction."

On Jan. 11, 2017, in the waning days of the administration, Obama delivered his annual National Drug Control Strategy to Congress. Four years after the epidemic began in Rhode Island, the White House called fentanyl a national crisis.

The report said fentanyl overdoses and seizures were soaring. Members of the outgoing administration said they had been meeting with Chinese and Mexican officials to stop the flow. The administration was also working to break up drug trafficking rings and trying to improve communication between agencies to fight the spread of heroin and fentanyl.

On page 73 of the 76-page report, the drug czar's office issued one of its strongest statements yet: "The dramatic increase in the availability and use of heroin and fentanyl is a national security, law enforcement, and public health issue, and it has become the highest priority illicit drug threat to the Nation."

There were no news conferences or releases to announce the report's findings. There were no news stories written about the report. No one in Congress issued public statements or calls for action. Nine days later, Donald Trump was inaugurated as the 45th president and Obama officials stepped down from their posts, leaving the next administration to confront the deadliest drug crisis in American history.

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