America is grappling with one of the largest social challenges in its recent history: how to stop people dying from fentanyl overdoses.
The cheaply manufactured synthetic opioid is highly addictive and, if taken in the wrong amount, deadly. Most disturbingly, it is finding its way into other substances and people often have no idea they are taking it.
Last year, more than 109,000 people in the US died due to drug overdoses, a national record. Three quarters of these deaths were linked to fentanyl, with many of the victims unaware they were ingesting the potent drug.
This national crisis has started to seep overseas, with authorities in other countries seeing fentanyl use and overdoses rise. The issue has become a major political talking point in the run-up to the 2024 presidential elections, with politicians blaming China and Mexican cartels for a surge in the drug's distribution.
Nowhere is the drug's impact more visible than in Philadelphia, the largest city in the state of Pennsylvania.
In the city's rundown Kensington area, it is common to see fentanyl users on the streets, completely unaware of their surroundings, often with infected injection wounds on their arms and legs.
“Fentanyl is 50 to 100 times more potent than other recreational drugs. It's no game,” said Jeremy Montgomery, President and CEO of Philly House, which has for 144 years been helping people struggling with addiction, by offering food, housing and recovery programmes.
Mr Montgomery predicts that fentanyl use will continue to spread.
“It will hit every little and big city which allows and condones open and public drug consumption with no preventive efforts,” he told The National.
Mr Montgomery and his wife Erin save lives daily thanks to Naloxone, a medicine that quickly reverses an opioid overdose. They keep the medication with them at all times.
“We have to use it every single day” said Ms Montgomery.
Produced chemically and often manufactured illegally, just 2mg of fentanyl is considered a lethal dose.
The Food and Drug Administration (FDA) has approved fentanyl as a pain reliever, but drug traffickers often lace other narcotics with it. Sometimes, unscrupulous drug makers put fentanyl in products that are then marketed as harmless medicines for colds and minor ailments, such as Fenex, a cough suppressant.
Dr Rahul Gupta, Director of the White House Office of National Drug Control Policy, told The National that Fenex buyers, especially when purchasing online, often end up with fentanyl-laced fake pills.
He said the chances of getting those rogue pills when ordering online was “in six out of 10 they might be deadly doses of fentanyl”.
“That number is worse than playing Russian roulette with your life,” he said.
Dr Gupta described fentanyl as “a public health crisis, and also a national security crisis” that prompted the White House to recently announce a global coalition against synthetic drugs.
More than 120 countries have signed on, including the UAE, Saudi Arabia, Israel and India.
“Today, no country is immune to the threat of synthetic drugs. We see this is a clear threat, not only to the United States but to all countries across the world, and that is why we can work together to address it,” Mr Gupta said.
The White House has pushed for greater access to Naloxone, and the medicine is now widely carried across the US by first responders.
Slowing the fentanyl crisis is akin to turning a container ship around, Dr Gupta said.
“If you want to turn it around, you have to slow it down, stop it and then turn it around. This is exactly what we want to do,” he said, pointing to the ability to reverse overdoses as a good sign.
Frederick County, in the state of Maryland, is one of the East Coast's most affected areas. Its location positions it as a hub for drug traffickers bringing fentanyl up from the southern border and shipping it further north or to the west.
“We respond everyday to overdoses. In the past decade, we have had 237 lives that we have saved by administering Narcan,” Sheriff Chuck Jenkins told The National, using Naloxone's brand name.
“We as a country failed to see the problem coming 10 years ago, and we are now trying to catch up.”
Law enforcement officials like Sheriff Jenkins see a direct link from fentanyl to street crime.
“Probably 70 per cent of the property crimes are directly related to the drug market, and fentanyl has become a huge part of that, especially in the last two or three years,” he said.
The sheriff converted part of the local work-release centre into Frederick County's first detox centre. It opened in May as a drug rehabilitation centre for 128 people.
A huge sign outside counts local overdoses to raise awareness. On a recent September day, the tally was 115 overdoses, 20 of them fatal.
Jessica, who lives nearby, has been clean for nine years. She works at the Phoenix Recovery Academy to help teenagers and their families struggling with addiction.
She started using drugs at the age of 14 when experimenting with other substances such as alcohol and marijuana.
At 19, she started using opioids including OxyContin and fentanyl patches, under medical prescription. She abused the prescribed medication and eventually turned to heroin use.
“I did it to feel numb,” Jessica said. “Your whole body starts to feel warm, sleepy, and you feel nothing. You really just don’t care about anything. It is a very isolated feeling as well.”
She eventually “needed more of a high to feel the effect” and started using fentanyl from the Baltimore area.
Her family was “extremely supportive” when she quit drugs, but it took her several attempts.
“It just got me to a place where I felt so tired of doing the same thing over and over again, and hurting my loved ones, especially my daughter,” she said.
“I just surrendered myself with other people in recovery. Being in a community has helped me extremely.”
The crisis is already inside schools and “has only gotten worse”, Jessica told The National shortly after receiving a call from a mother worried about her 16-year-old daughter who is abusing fentanyl.
“I can’t tell you the number of calls I receive about kids overdosing in schools, two of them from the same school in a matter of three weeks, one fatal. She was only 15 years old.”
Nearby, Edward and Karen Schildt endured the same situation in 2016 when their son Chris died of an overdose, aged 25.
“We never thought our son would be addicted,” Mr Schildt said.
Chris started taking painkillers after breaking his arm playing baseball, but within weeks was using heroin and fentanyl.
“It is definitely getting to the younger crowd now and we are finding that fentanyl is laced and put in all sorts of substances,” Jessica said.
In a bid to quell the crisis, the White House is trying to find policies to save more lives and is talking to families across the country.
“From Connecticut to California, from Texas to Wisconsin. Not only to have conversations with them, because we believe it is important to share their suffering, but also to learn from them,” Dr Gupta said.
“This particular epidemic does not care for who you are. It cuts across all communities, no matter if you are black or white, rich or poor, urban or rural.”