DALLAS — If someone had come into his facility five years ago seeking treatment for a fentanyl addiction, Aaron Bitter said his staff would not have known what to do.
"Five years ago, we would be unlikely to encounter it," Bitter said. "It would be something, realistically, we'd make a phone call to consult someone else about."
Bitter is the program director for the Symetria Rehab clinic in Lewisville. He has worked in the drug rehabilitation industry for about five years, and he's in long-term recovery from his own addiction.
Even so, he did not expect what's he's seen over the past year in his clinic.
"We ask [patients] questions about what they're using," Bitter said. "They say percocets, oxy, perc 30s, M30s. Part of our process is we have to drug test them. By and large, they test negative for every substance other than fentanyl. Their minds are blown.”
In 2021, Bitter said more than 99 percent of the patients who came to the facility seeking treatment for opioid addiction tested positive for fentanyl, with more than half of them not knowing they were taking fentanyl.
“At this point, essentially, anyone walking in here that’s using pills they acquired on they street, they test positive for fentanyl. Period,” Bitter said.
It’s an epidemic he admits he didn’t fully understand the scope when he started, but one he fears people still don’t understand now.
But as overdose numbers continue to rise sharply and illicit fentanyl continues to flood communities, often in bright colored pills marketed to kids and teens, Bitter said no can afford to not understand.
“We are absolutely in a crisis,” Bitter said.
What is fentanyl?
Fentanyl was not created to be used recreationally or bought and sold on the street.
In the early 1960s the synthetic opioid was manufactured and approved by the FDA a few years later, for a specific purpose: to treat pain.
"I've used it for five decades in anesthesia," Dr. C.M. Schade, a North Texas pain doctor of more than 50 years, said. "It has a very rapid onset, but it lasts an hour and half."
According to the National Institute of Health and the Drug Enforcement Agency (DEA), fentanyl’s two main purposes were to be prescribed to chronic pain patients as well as for anesthesia during surgery.”
“It was available only in powder and liquid," Schade said. "It was only manufactured and used in anesthesia because it’s so short-acting."
From dosed to deadly
Schade is also an emeritus board member of the Texas Pain Society and is the elected presiding officer of the Prescription Monitoring Program Advisory Committee.
He said the path fentanyl took from being a useful, effective tool for doctors to claiming the lives thousands weaves through history. Schade describes trends in prescribing opioids as a pendulum swing, with doctors alternating between years of under-prescribing chronic pain patients to over-prescribing based on what regulations existed at the time.
In both instances, patients were left to hang in the balance.
Schade said he believes the current demand for illicit opioids is rooted in a generation of chronic pain patients and addicts who were left out to dry following a crack down to address opioid abuse in the early 2000s.
“The time period of 2000 to 2010 was one of a mass escalation of prescribing opioids, pushed heavily by the pharmaceutical companies,” Schade said.
Schade called the information doctors were given about the risks associated with the drugs they were prescribing “improper”.
“It was just rogue,” Schade said. “I mean, it was so bad. That was not evidence-based medicine. That was not the practice of medicine. That was selling drugs.”
Schade said he worked with federal and state agencies and law makers to develop systems and legislation to help monitor pain management clinics and protect patients from over-prescribing.
In 2016, the federal government released new, more stringent, guidelines on prescribing opioids to non-cancer patients. Schade said many doctors had watched peers in their field go to prison for so-called “pill mill” operations.
“We’re already six years in to this, and it was totally misrepresented, and doctors basically thought they could not prescribe so they abandoned patients,” Schade said.
Schade said he believes that pushed a lot of people who had developed dependencies and addiction to the streets to avoid withdrawals.
“Didn’t taper them. Didn’t offer them any other treatment. It was horrible,” Schade said.
According to data from the Texas Board of Pharmacy, there were 157,947 prescriptions written for fentanyl, hydrocodone or oxycodone in Dallas, Tarrant, Denton and Collin Counties in February 2016.
The CDC guidelines were released in March 2016.
Six months later, in September 2016, the total number of prescriptions for those three opioids in North Texas’ four largest counties was down to 153,608.
People who developed addiction and dependencies on the opioids they were prescribed went to the streets.
Fewer prescriptions meant fewer opportunities for dealers to get their hands on legitimate prescription opioids.
A North Texas man agreed to tell his story of fentanyl addiction to WFAA but asked to not be identified to protect his family.
“We wouldn’t be where we’re at if they hadn’t ripped the carpet from underneath us like they did,” he said. “That’s some stuff that happened overnight. I went in one day, and I was basically told that the government had new guidelines.”
He described it as having the "door slammed" in his face.
This man started taking fentanyl in patches for back pain after multiple back surgeries.
"I had some pain doctors tell me that fentanyl was a great, wonderful drug and then I had others that were completely against it," he said.
The more he used it, the more he needed it.
When filling his prescription didn't feed his body's dependency, he looked elsewhere.
"I was abusing it," he said. "I got to the point where I was having to turn to the streets when I ran out early to get me through for when I went to the doctor."
In 2014, he started buying fentanyl patches off of the dark web.
In 2016, he started seeing the drug pressed into pill form on the street.
“They were scarce," he said. "When [his dealer] had them, he had them and you’d better hurry up and get them cause if you didn’t, you’d have to wait a month or so."
But, with time, things started to change.
“When it started getting harder to get it on the street, people started putting other stuff in the pills,” he said. “When you got the pills and they told you it was hydrocodone, it wasn’t hydrocodone. Maybe it was hydrocodone with some other stuff in. You just never knew.”
It was a risk addiction made him, and so many others, willing to take.
“You don’t have a choice,” he said. “Do you go through withdrawal and deal with it? Or do you take the pill? You take the pill.”
The man who shared his story with WFAA said he could tell when the pills he bought were laced with fentanyl, but only because of his experience with illicit drugs.
“If you know your narcotics, your pharmaceuticals, you know you’re getting a pressed pill,” he said. “It looks fake. It’s got little brown specks. But most people don’t know. They have no idea. They just look at it and say, ‘Oh, a pill. Cool.’ They are clueless. They have no idea, so they’re not going to know. They’re not going to know that there’s fentanyl in it.
According to the DEA, the powder form of fentanyl can be made to look like many other drugs, including other pills once it’s pressed.
The man in this story said he’s seen fentanyl pills that mimicked hydrocodone, oxycodone and Xanax.
“I’ve seen it in everything,” he said.
Fentanyl, being a full synthetic opioid, is easy and cheap to make. Federal law enforcement reported that drug cartels are smuggling illicitly manufactured fentanyl (IMF) from Mexico after receiving the chemicals to create it from China.
As WFAA reported last week, Law enforcement in North Texas has seized a number of the pressing machines used to press fentanyl into pills.
“The fake pills is what changed everything,” Schade said. “That’s what moved the dial.”
Schade said that people who struggle with substance abuse have been overdosing on fentanyl, both prescribed and illicitly manufactured, for years. He said the reason fentanyl has become the source of so many headlines recently is because IMF has infiltrated the supply of recreational drugs.
“There’s a demand side and a supply side,” Schade said. “The only thing on the supply side to speak of is the illegal pills that are laced with fentanyl.”
The demand can look like someone feeding their addiction, a chronic pain patient who is desperate but can’t get the medicine they need from their doctor, a person looking for a pill to party or even a teen who took a pill from a friend to help ease anxiety or study.
Unless the medicine is prescribed by a doctor, experts say the supply that all of those people would be sourcing from is likely laced with fentanyl.
“Those pills they were getting on the streets are now fentanyl, and their lives are unraveled,” Bitter said.
Bitter said fentanyl is more addictive than other opioids, and the addiction itself is harder to treat.
“The addiction gets completely out of control,” Bitter said. “They went from five pills a day to, say, 20 pills a day. We see people with numbers you wouldn’t believe. 30…40 pills a day where you wonder how the person is even functioning.”
Bitter said an added problem is that the cartels that are creating illicit fentanyl pills aren’t abiding by any sort of dosage, making every pill potentially deadly and making it almost impossible for people who survive to have a good grasp of how much they’re taking.
“It is going to be an addiction that is harder to break the cycle with because it is more profound,” Bitter said.
The man who shared his addiction story with WFAA is preparing to celebrate two years of sobriety at the end of the summer. Looking back, he said he wouldn’t with the withdrawals on anyone.
“It was more violent,” he said. “They were way more violent than withdrawals to, say hydrocodone.”
Before he decided to get clean, he overdosed in 2020.
He’d taken eight pills from his dealer and got in the car. The next thing he remembered was waking up in a hospital surrounded by police and hospital staff.
The first call he made when he got out of the hospital was to his dealer.
“I said, ‘Hey, dude, I need meds’”, he said. “I went and picked up meds and went home and figured I’d take four instead of eight to see how that worked.”
Overdosing didn’t make him stop.
Neither did losing his sister to a fentanyl overdose a few years prior.
It wasn’t until he fell in love with a woman who’d won her battle with addiction that he was inspired to get clean.
“I never saw myself as an addict, even though I am. I just never saw myself as that,” he said.
He said is grateful to be alive.
Is there a fix?
Schade said he believes under-prescribing pain medications to chronic pain patients has pushed many of them to purchase illicit opioids to treat pain.
This legislative session, he’s testified in favor or adjusting laws to allow doctors more leeway for prescribing pain medications responsibly.
“They need to let us get back to practicing medicine,” Schade said.
Both he and Bitter said the rate of fentanyl-related overdoses in Texas makes it clear it’s too late to simply be talking about fentanyl.
“We needed to do that maybe two years ago,” Bitter said. “When it’s getting this deep, there needs to be more of a focus on recovery. What does that look like? What does recovery look like for adolescents? What does it look like for adults?”
If you or a loved one is struggling with addiction, use this map of substance abuse service locations to find help.
The U.S. Drug Enforcement Administration's fentanyl website has information and resources for parents to use to talk to their kids about the dangers of the drug.
Helpful phone numbers:
National Rehab Hotline (866) 210-1303
Texas Substance Abuse Helpline (866) 971-2658