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July 2018 in This Issue Volume 66 Number 4 Introduction………….…………..……… Fentanyl and Related Threats July 2018 In This Issue Volume 66 Number 4 Introduction………….…………..………...............................................................3 By James A. Crowell IV, Director, EOUSA United States Department of Justice Executive Office for Danger in Milligrams and Micrograms: United States Attorneys’ United States Attorneys Offices Confront Illicit Fentanyls……………………………..………………….5 Washington, DC 20530 By Seth Adam Meinero James A. Crowell IV Director A Primer on Investigating Doctors Who Illegally Prescribe Opioids……..……………………………………………...…..………19 Contributors’ opinions and statements should not be considered an By K. Tate Chambers endorsement by EOUSA for any policy, program, or service. Investigating and Prosecuting “Pill Press” Manufacturing The United States Attorneys’ Bulletin Schemes……………………………………………………………….…………..33 is published pursuant to By Benjamin R. Barron and Michael G. Freedman 28 C.F.R. § 0.22(b). The United States Attorneys’ Bulletin New Amendments to the U.S. Sentencing Guidelines Concerning is published by the Fentanyl and Fentanyl Analogues………………………………..……………..41 Executive Office for United States Attorneys By Joseph S. Gerbasi Office of Legal Education 1620 Pendleton Street Columbia, South Carolina 29201 The Medical Examiner’s Role in Addressing the Opioid Crisis.……………...47 By Thomas P. Gilson, M.D. Editor in Chief K. Tate Chambers Fentanyl Trafficking Trends in the United States……………………………..55 Lead Editor By Kirsten Walters Nikki Piquette Homeland Security Investigations, Border Search Authority, Law Clerks Joseph Garfunkel and Investigative Approaches to Fentanyl Smuggling……………………...…57 Aimee Intagliata By Gregory C. Nevano Internet Address https://www justice gov/usao/resources Hunting in the Dark: A Prosecutor’s Guide to the /united-states-attorneys-bulletins Dark Net and Cryptocurrencies…………………………………….…….…….65 By Matthew J. Cronin Send article submissions to Editor, United States Attorneys’ Bulletin The Role of Community Outreach in the Opioid Crisis: National Advocacy Center Office of Legal Education Maintaining Hope in the Face of Rising Overdose Deaths……….…………...79 1620 Pendleton Street Columbia, SC 29201 By Joseph M. Pinjuh Cite as: Prescription Drug Abuse and Illicit Substance Use: 66 U.S. ATT’Y BULL. (July 2018) A Crisis in Indian Country.…………………………………………...….……..83 By Leslie A. Hagen Public Safety and Public Health Efforts to Combat the Opioid Epidemic……………..………………………………………….……...103 By Naomi Adaniya Book Review of Dreamland: The True Tale of America’s Opiate Epidemic……………….………………………………………...………109 By Mary Beth Pfister Note from the Editor in Chief………………………………….........................111 By K. Tate Chambers Page Intentionally Left Blank 2 United States Attorneys’ Bulletin July 2018 Introduction James A. Crowell IV Director Executive Office for United States Attorneys We are facing the deadliest drug crisis in American history. Confronting the nation’s opioid epidemic is one of the Department of Justice’s highest and most pressing priorities. Fentanyl—a synthetic opioid much stronger than heroin—and related threats are fueling this lethal crisis. Fentanyl is sold in many forms in the United States—such as powder, crystals, or liquid—and only a couple milligrams can kill. Fentanyl can be mixed into other drugs, such as heroin and cocaine, or pressed into pills and sold as counterfeit prescription drugs. Users who seek to obtain these other drugs often have no idea they are actually putting something much deadlier into their bodies. Even worse, fentanyl analogues, like carfentanil, are even more potent than fentanyl and are being trafficked to users with increasing frequency, further threatening the lives of countless Americans. In addition to the overdose user deaths, fentanyls pose enormous risks to the safety of law enforcement, first-responders, and postal and package handlers. Police officers, agents, emergency medical personnel, and canine units can accidentally inhale or ingest microscopic yet highly lethal amounts of the substances during calls for emergency services. Because fentanyls are often shipped surreptitiously from China into the United States, package carriers and mail handlers can be exposed if these substances escape their packaging. The proliferation of fentanyls has resulted in breathtaking increases in fatal drug overdoses. Approximately 64,000 Americans lost their lives to drug overdoses in 2016—the highest drug death toll in American history—with at least 20,000 of those deaths attributable to fentanyls. Crime rates are not like the tides. We must break out of the vicious cycle of drug abuse, addiction, and overdose that has devastated countless American families. We can and must take action that makes a difference by using every tool at our disposal to end this drug crisis. Despite the bleak outlook, there is new cause for optimism. The President, the Attorney General, and the Deputy Attorney General have made clear that we will defeat the opioid crisis. The articles that follow demonstrate that federal prosecutors and civil practitioners, brave agents and officers, public health officials, regulators, and other talented women and men are working tirelessly to fulfill that pledge. U.S. Attorneys’ Offices (USAOs)—which I am honored to serve and support—are working with the Drug Enforcement Administration, Homeland Security Investigations, the Organized Crime Drug Enforcement Task Forces (OCDETF), and other law enforcement agencies to disrupt fentanyl chains of supply from China into the United States and prosecute the peddlers of this poison in our communities. The Department of Justice is better aligning its training and resources and using sophisticated data to better target opioid- and fentanyl-related crime. Prosecutors and agents are making progress in disrupting dark web fentanyl trafficking. USAOs are engaging their communities with opioid-prevention efforts, working closely with medical examiners to obtain key evidence for trials, and promoting appropriate treatment to quell the ravages of addiction. We are pleased to address such an important, timely topic in this issue of the USABulletin. My gratitude to the Executive Office for U.S. Attorneys’ Office of Legal Education and Office of Legal and Victim Programs and the Executive Office for OCDETF for compiling this compelling issue. I also thank all the authors, reviewers, and editors for their skill and hard work. July 2018 United States Attorneys’ Bulletin 3 Page Intentionally Left Blank 4 United States Attorneys’ Bulletin July 2018 Danger in Milligrams and Micrograms: United States Attorneys’ Offices Confront Illicit Fentanyls Seth Adam Meinero National Violent-Crime and Narcotics Coordinator Executive Office for United States Attorneys From Appalachian hamlets to inner-city streets, from struggling Rust Belt towns to tony suburbs, skyrocketing overdose deaths have cast a pall across the country. The primary drivers of this alarming trend are fentanyls: the synthetic opioid fentanyl itself and its synthetic derivatives, or analogues.1 According to estimates from the National Institute on Drug Abuse, over 63,000 Americans died of drug overdoses in 2016. Approximately two-thirds of these deaths involved an opioid, with over 20,000 of the deaths related to fentanyls.2 The precipitous rise in drug deaths in recent years—fueled by fentanyls—has been so momentous, it has pulled down many Americans’ average life expectancy by about two months.3 Each United States Attorney’s Office (USAO) is confronting this deadly dilemma, implementing a comprehensive strategy to tackle illicit fentanyl trafficking. This article discusses the origins of this grave epidemic and the USAOs’ relentless efforts to end it. I. A Crisis “Impossible to Overstate” When Belgian physician Paul Janssen developed fentanyl as an analgesic to treat severe pain in 1960,4 he could have scarcely imagined planting the seeds of a 21st century public health flashpoint. Fentanyl is a Schedule II controlled substance under the Controlled Substances Act.5 It has an “accepted medical use,” but also a “high potential for abuse” with potential for “severe psychological or physical dependence.”6 Its strong opioid properties—producing both insensitivity to pain and a euphoric high—make it a particularly attractive drug of abuse for opioid users.7 Medical doses of fentanyl—which can be inhaled, injected, or absorbed through skin—are typically administered in micrograms, usually 1 For efficiency, this article uses the term “fentanyls” as an aggregation of fentanyl itself and analogues such as acetylfentanyl, carfentanil, alfentanil, and sufentanil. However, “due to variations in the legal and scientific definitions of analog[ue]s, it may be inaccurate to call all fentanyl varieties a fentanyl analog[ue].” Counterfeit Prescription Pills Containing Fentanyls: A Global Threat, DEA INTELLIGENCE BRIEF 2 (July 2016). 2 Overdose Death Rates, NAT’L INST. ON DRUG ABUSE (Sept. 2017). 3 Deborah Dowell, MD, MPH, Elizabeth Arias, PhD, & Kenneth Kochanek, MA, et al, Contribution of Opioid-Involved Poisoning to the Change in Life Expectancy in the United States, 2000-2015, 11 J. AM. MED. ASS’N NETWORK 1065 (2017). While overall life expectancy rose about two years from 2000 to 2015, opioid overdose deaths pulled down that gain by about two months for non-Hispanic White Americans. 4 Theodore H. Stanley, The Fentanyl Story, 15 AM. J. PAIN 1215 (2014). 5 21 U.S.C. § 812(c)(Schedule II)(b)(6) (2012); 21 C.F.R. § 1308.12(c)(9). 6 § 812(b)(2). 7 2017 National
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