On a single day in March 2021, three New Yorkers ordered cocaine from the same drug delivery service, then died after unknowingly ingesting fatal doses of fentanyl, a potent synthetic opioid.
Warning: This article contains details readers might find distressing.
All three had texted the same drug dispatcher, Billy Ortega, who then coordinated couriers to swiftly deliver the cocaine to three separate locations in Manhattan, according to authorities.
Ortega knew it was tainted, prosecutors later said, but he sold it anyway.
Amanda Scher, a 38-year-old social worker, fatally overdosed in the Greenwich Village apartment she shared with her elderly rescue dog, close to New York University where she had completed her master's degree.
Wall Street trader Ross Mtangi, 40, had farewelled his pregnant girlfriend at their Manhattan penthouse before checking into a nearby hotel room.
He stayed there overnight, then texted her and other family members on the morning of March 17 to say he was OK but needed some space, the Wall Street Journal reported.
Mr Mtangi was found dead the next day by his sister and her partner, along with translucent black baggies containing what police identified as fentanyl-laced cocaine.
In the East Village, 26-year-old Julia Ghahramani, a talented first-year lawyer who had graduated from Columbia Law School in May 2020, died alone in her apartment after consuming the same bad batch of cocaine.
"Julia was amazing. She was brilliant," said her father Sassan Ghahramani, a hedge fund adviser from Greenwich, Connecticut.
He described his eldest daughter as a "warrior for social justice" who wanted to change the world for the better.
"We immediately knew she was poisoned," he said.
The drug fuelling America's deadly overdose crisis
Fentanyl is roughly 50 times more potent than heroin and up to 100 times stronger than morphine.
The pharmaceutical version of the drug is prescribed by doctors to treat severe pain, particularly after surgery or during end-of-life care.
But illicitly manufactured fentanyl, often made overseas, has increasingly spread through the United States' drug supply in recent years, showing up in counterfeit pills, MDMA, and stimulants such as cocaine and methamphetamine.
Amid the opioid epidemic, which began in the late 1990s with the over-prescription of painkillers such as OxyContin, overdose deaths in the US have risen fivefold over two decades, according to the Centers for Disease Control and Prevention (CDC).
But fentanyl has been blamed for a recent deadly surge in unintentional overdoses across the country, which some have called the "third wave" of the evolving health crisis.
The most recent national data paints a grim picture, with more than 106,000 people dying from overdoses in the US in 2021.
Over half of those deaths involved synthetic opioids, such as fentanyl and its chemical analogues.
In New York City, over the same period, 2,668 overdose deaths were recorded by the city's health department.
Of those attributed to cocaine, 85 per cent also involved fentanyl, according to the department.
"Drug dealers don't label their drugs as poison, they just sell them with indifference to the tragedy left in their wake," said Damian Williams, the US attorney for the Southern District of New York, when he announced the conviction of Ortega for supplying the cocaine that killed three people in one day.
"This case exemplifies that the national fentanyl epidemic continues to claim lives and inflict havoc on families from all walks of life."
While some people use fentanyl because of its potency, others are unknowingly exposed to the drug due to the adulteration or cross-contamination of other substances.
Sarah Wakeman, the medical director for substance use disorder at Mass General Brigham in Boston, said this is particularly risky for those who don't generally use opioids or use them infrequently.
"You can imagine if someone is selling both cocaine and opioids out of the same area, a small amount of fentanyl [cross-contamination], because of how highly potent it is, ... could be enough to cause an overdose in someone who has no tolerance to opioids," Dr Wakeman said.
Why fentanyl can be deadly
Fentanyl is a depressant that binds to the body's opioid receptors, found in areas of the brain that control pain and emotions.
Too much can slow a person's heart rate and shut down their breathing, which can lead to hypoxia, a condition caused by decreased oxygen to the brain that may result in coma, permanent brain damage or death.
For someone with low opioid tolerance, "even a tiny bit of fentanyl could be enough to cause an overdose or even a fatal overdose," Dr Wakeman said.
In some cases, an amount the size of a small grain of rice can be deadly.
Ms Wakeman advocates a harm-reduction approach to substance use, including the use of test strips that reveal hidden fentanyl.
But while they are effective at detecting the drug, they don't measure its strength or quantity in a sample.
If an overdose occurs, naloxone, a medication that reverses the effects of opioids, sold under the brand name Narcan, can be lifesaving.
"For a person, particularly someone who uses cocaine or methamphetamine, who doesn't use opioids, to know that there's any amount of fentanyl in the substance you're about to use really is important," Ms Wakeman said.
"Because that could shape your decision about whether or not to use and certainly [your] thinking about precautions, like having naloxone on hand to reverse an overdose."
The small kit that could save a life
Across the East River from the famous skyscrapers of Manhattan, on a recent Tuesday night in Greenpoint, a group of New Yorkers gathered in an upstairs room of their local library.
They were there for a free Narcan and overdose-response training session run by Vocal-NY, a state-wide community organisation, and the volunteer-run Brooklyn Harm Reduction Outreach Cooperative.
Trainer Laura Levine asked the group if anyone knew how to recognise an opioid overdose.
She then explained what to look for — signs of drowsiness, slowed or stopped breathing, pale skin and blue lips — and how to administer a single-dose Narcan nasal spray if a person is unresponsive.
Ms Levine, who is Vocal-NY's education coordinator, also laid out the protections of New York state's "Good Samaritan" law, which is designed to allow people to call emergency services for medical support without fear of arrest if they or someone else are experiencing a drug or alcohol overdose.
Each attendee left with informational flyers and a zipped blue pouch containing two doses of Narcan, provided by the city's health department.
"The more that we're able to educate drug users and not only drug users but family and friends of drug users … the more lives can be saved," Ms Levine later told the ABC.
"What we're doing is just giving them the education and the information to make a safer decision.
"It's not to scare people."
Ms Levine was also quick to bust what she called "the biggest myths around fentanyl", including that it's possible to overdose from brief skin contact with the drug, as a bizarre spate of US media reports has suggested.
"In order to experience a fentanyl overdose, it needs to be absorbed into your body," she said.
"So either absorbed into the mucous membranes by sniffing or [by] injecting right into the bloodstream."
How New York's night spots can help prevent overdoses
Training sessions like those run by Vocal-NY are becoming commonplace across New York City, where around every four hours someone dies from an overdose, with Black and Latino communities and poorer neighbourhoods worst affected.
Authorities, local organisations and grassroots groups alike are grappling with how to curb the problem and empower residents to protect themselves and others.
Health officials have announced a plan to install 10 "public health vending machines" in the city, stocked with free supplies including naloxone, sterile syringes, safe-sex kits and more.
Naloxone is already available over the counter at pharmacies across the state, and the FDA is expected to soon approve its sale without a prescription nationwide.
But for those without health insurance, the cost can be prohibitive.
New York City's Office of Nightlife has partnered with its Department of Health to equip venues and hospitality workers with overdose-prevention tools through a program called Narcan Behind Every Bar, which includes training for the nightlife community and the distribution of free naloxone kits.
In 2018, Ariel Palitz, a former club owner, was appointed to lead the agency, which acts as a liaison between the mayor's office and the hospitality industry.
She said harm reduction, which includes moving away from a "strictly [law] enforcement approach" to drug use, is at the centre of her work.
"We see [stocking naloxone] now as benign and yet as important as having a CPR kit behind a bar, or a first aid kit," Ms Palitz said.
"It doesn't necessarily mean people are having heart attacks all over New York City bars. But if you are having one, it's nice to know you have a CPR kit."
Ms Palitz said it is important to acknowledge that recreational drug use is often a reality in bars and clubs but nightlife itself is not the issue.
"It's not a nightlife problem, it's a drug use and contamination problem," she said.
"Nightlife just happens to be a location where people socialise, gather, and happen to use drugs. And therefore it is an opportunity, rather than a liability, to help people learn about how to prevent an overdose.
"And if [one] happens, how to bring somebody back."
The 'fourth wave' of the opioid epidemic
Daniel Ciccarone is a professor of family and community medicine at the University of California in San Francisco, who has spent more than two decades as a public health researcher, studying what he calls "drug use in the real world".
Mr Ciccarone explained the triple-wave opioid epidemic can be traced from the rise of opioid pills through the 2000s, which led to some people seeking out heroin in the early 2010s, to heroin increasingly being replaced and adulterated with synthetic opioids from around 2014.
This created a "huge spike in overdose deaths due to fentanyl," he said.
While the epidemic presents differently coast to coast, both prescription opioid and heroin deaths peaked nationally in 2017, whereas the fentanyl crisis continues, exacerbated by the pandemic and racial and economic inequalities.
Mr Ciccarone said stimulant-related deaths have become more common and increasingly entwined with opioids, particularly fentanyl, leading to what he has dubbed the "fourth wave" of the evolving epidemic.
"It's important to understand that co-use can have an accidental form where the end user is not aware of the substance they're using," he said.
But, he added, people who are opioid dependent may also seek out stimulants to boost the effects of other drugs, for example co-using heroin and cocaine.
"The interesting thing post-COVID is that methamphetamine plus fentanyl use is up," he said.
"That is very unusual. And just to see people combining that brings us into a whole new realm, a whole new phase of drug use, at least in the United States."
Mr Ciccarone said as different drugs move into and out of popular use there are often spill-over effects, such as shifts in user demographics or spates of overdoses.
"Once the supply recognises that, 'Oh, cocaine is going up in demand. Oh, methamphetamine is going up in demand. We're going to supply more of it. Why? Because we're capitalists.'
"The illicit drug markets are as capitalistic as any legitimate industry you can think of, maybe even more so."
But while supply-side interventions are often touted as the solution, Mr Ciccarone warned they can also have unintended consequences.
"Supply-side interventions, always run into what we call the balloon effect in drug policy, and that is you squeeze the balloon at one end and it pops out and the other end," Mr Ciccarone said.
"But the even more finesse part of the balloon metaphor is that it pops out in an unknown direction."
Mr Ciccarone said the Biden administration had made "bold leaps in the direction of demand reduction", including by increasing access to Buprenorphine, which is used to treat opioid use disorder.
The first National Drug Control Strategy under the leadership of a medical doctor, Raol Gupta, promised a "new era of drug policy" led by "compassion" — a stark departure from the harsh rhetoric and draconian laws that stemmed from former president Richard Nixon's "war on drugs".
The strategy includes plans to expand access to prevention and harm-reduction programs and treatment and recovery support services, while pledging to disrupt drug trafficking into the US by targeting criminal organisations.
But not everyone has welcomed the new approach, particularly members of the Republican Party who have sought to tie the fentanyl crisis to border security, given most of the illicitly manufactured fentanyl in the US is synthesised in China and Mexico.
In a recent poll, Republicans said fentanyl and other opioids represented the biggest threats to Americans' public health, which for Democrats was guns.
During President Joe Biden's recent State of the Union speech, he promised a "major surge to stop fentanyl production, sale, and trafficking", including stronger penalties for traffickers.
The moment was met with outrage from Republican members of Congress, including one who yelled, "It's your fault!" from the floor of the House.
Victim's father calls for action
For those affected personally by the overdose crisis, the seeming lack of action and political point-scoring can feel exhausting.
Mr Ghahramani, who lost his daughter nearly two years ago, said Mr Biden's words at the State of the Union felt like "lip service".
In the past couple of years, Mr Ghahramani said he has "learned more than I ever would have imagined about fentanyl", connecting with other grieving families and various advocates through social media.
"I stopped because I couldn't take it anymore," he said.
"It was just too hard for me. But I heard so many stories of so many people whose children had died and been poisoned with fentanyl."
Mr Ghahramani described the drug as the "most deadly poison ever to hit our streets".
He also said failures of the "war on drugs" shouldn't prevent law enforcement from acting against drug dealers, such as Ortega, who knowingly put people at risk.
While Mr Ghahramani agreed Narcan could be "a lifesaver", he said it was "not going to solve everything".
"You can't fight with one hand," he said.
"You have to root out the supply. You can't roll over and imagine that it will just go away."
Ortega was unanimously convicted by a jury on five charges in January following a trial.
He is scheduled to be sentenced in June and faces 25 years to life in prison.
Mr Ghahramani said he believes the onus should not be on victims to mitigate risks, while acknowledging the importance of education.
"When Julia died, there was no awareness," Mr Ghahramani said.
"They were just starting to put fentanyl in cocaine. She would have never in a million years have come close to it if she knew this was possible. People need to be warned."
Could Australia face its own fentanyl crisis?
Australia has so far avoided an opioid epidemic on the same scale as the US and Canada, in part due to laws restricting the direct marketing of pharmaceuticals to consumers.
But overdose deaths are rising, exceeding the road toll each year since 2014 when the country first breached 2000 annual drug-related fatalities, according to the Penington Institute.
Its most recent annual overdose report, based on data from 2020, warns Australia could slide into a US-style fentanyl crisis if common-sense steps aren't taken to prevent that from happening.
"It's still the case that in the US, it's a much worse situation. But the problem is, we often follow the US in terms of drug-use patterns," said John Ryan, Penington Institute's CEO.
"And if we get the same scale of problem that's been happening in the US now for a number of years, we're very unprepared for it."
Mr Ryan said Australia's overdose crisis is "incredibly diverse", but worse per capita in regional and rural parts of the country, and among Aboriginal and Torres Strait Islander communities.
He said stigma around drug use and dependence means the issue is often hidden from public view.
Overdose deaths involving fentanyl and other synthetic opioids have increased by 1,275 per cent since 2006, but most involved pharmaceutical fentanyl, which is commonly diverted from healthcare settings.
Illicitly manufactured fentanyl is not widespread in Australia, although in August 2022, the Australian Federal Police (AFP) announced a record bust of around 11 kilograms in Melbourne.
Mr Ryan said it could be a sign that more is on the way.
"Drugs in Australia are often described as readily available and easy to access," Mr Ryan said.
"And so even though [the AFP] did well … it's a real sign, I think, that there are people out there contemplating the opportunity. And the opportunity is obviously big profits."
While Australia may be downstream from the US in terms of drug-use trends, Mr Ryan said following "the American approach to drugs, which is to try and arrest our way out of these problems," had proven unsuccessful.
The Australian government has announced an investment of $19.6 million over four years to make naloxone available for free nationally without a prescription.
Mr Ryan is also pushing for a national overdose prevention strategy, which would bring together the federal and state governments, law enforcement and health services.
"I think we've got to really improve access to drug treatment, but also access to harm reduction services," he said.
"And that includes, most importantly, [ensuring] better understanding in the community about drug-use issues, and not relying on the police to get us out of what's basically a health problem."
