Cheap, unpredictable and hard to regulate, synthetic marijuana has emergency responders scrambling to save lives.

By Steve FeatherstonePhotographs by Philip Montgomery

PRE-BEAUTIFIED PROOF 2PRE-BEAUTIFIED PROOF 2

PRE-BEAUTIFIED PROOF 2PRE-BEAUTIFIED PROOF 2

44 7.12.15

One evening in April, Ethan Darbee, a 24-year old paramedic in Syracuse, responded to a call on the city’s south side: unknown man down. Rolling up to the scene, he saw a figure lying motionless on the sidewalk. Darbee raked his knuckles across the man’s sternum to assess his level of consciousness. His eyelids fluttered. Inside the ambulance, Darbee hooked him up to a heart monitor, and he jerked involuntarily. The odd reaction puzzled Darbee. Why would

the guy recoil from an electrode sticker but not a sternal rub? The driver started for the hospital. Darbee sat in the captain’s chair in the back of the rig, typing on a laptop. Then he heard a sound no paramedic ever wants to hear: the click of a patient’s shoulder harness unlatching. Swiveling around, he found himself eyeball to eyeball with his patient, who was now crouched on all fours on top of the stretcher, growling.

That same evening, Heather Drake, a 29-year-old paramedic, responded to a call at an apartment complex on the west side. When she arrived, four firefighters were grappling with a 120-pound woman who was flailing and flinging vomit at anyone who came near her. A bystander shouted that the woman was high on ‘‘spike’’ — the prevailing local term for synthetic marijuana, which is more commonly known around the country as spice. But Drake didn’t believe it. Spike didn’t turn people into violent lunatics. Phencyclidine (PCP) or synthetic cathinones (‘‘bath salts’’) could do that, maybe even a joint soaked in formaldehyde — but not spike. Drake sprayed a sedative up the woman’s nose and loaded her into the ambulance. A may-day call from another crew came over the radio. In the background static of the transmission, Drake could hear Ethan Darbee yelling.

Darbee’s patient had sprung off the stretcher and knocked him to the floor of the ambulance, punching him repeatedly in the face. Darbee grasped the side door handle and tumbled into the street. Within moments, the police arrived and quickly subdued the man. Two days later, 19 more spike overdoses would swamp local emergency rooms, more in one day in Syracuse than the number of overdoses reported statewide in most states for all of April.

Syracuse, where I’ve lived almost my entire life, has struggled with synthetic drugs before. William Harper, a local businessman and two-time Republican candidate for City Council, moonlighted as the kingpin of bath salts in New York for two years before the Drug Enforcement Administration took him down in 2011. Was there a spike kingpin out there now, flooding the street with a bad batch? Perhaps, but similar outbreaks occurred in several states along the Gulf of Mexico in April, and the Amer-ican Association of Poison Control Centers reports that between January and June, the nationwide number of synthetic marijuana ‘‘exposures’’ — that is, reported contact with the substance — had already surpassed totals for 2013 and 2014, and that 15 people died from such exposure. Maybe there was a larger cause.

Every state has banned synthetic cannabinoids, the chemicals in spike that impart the high. Although cannabinoids primarily come from China, where commercial labs manufacture them to order like any other indus-trial ingredient, spike itself is produced domestically. Traffickers spray the chemicals on dried plant material and seal the results in foil pouches; these are then sold on the Internet or distributed to stores across the country, which sell them sometimes under the counter, as in Syracuse, or some-times right by the cash register, depending on local laws. Unlike marijuana, cocaine and other naturally occurring drugs, synthetic cannabinoids can be tweaked on a molecular level to create novel, and arguably legal, drugs.

Since 2008, when authorities first noted the presence of synthetic can-nabinoids in ‘‘legal marijuana’’ products, periodic surges in overdoses have often coincided with new releases, and emergency doctors have had to

learn on the fly how to treat them. This latest surge is notable for the severity of symptoms: seizures, extreme swings in heart rate and blood pressure, kidney and respiratory failure, hallucinations. Many patients require such enormous doses of sedatives that they stop breathing and require intubation, and yet they still continue to struggle. Eric Kehoe, a shift commander at the Rural Metro ambulance company that employs Darbee and Drake, said bath-salts overdoses are easier to deal with. ‘‘You might find them running naked down the middle of the street,’’ he said, but ‘‘you could talk them down. These people here — there’s no point. You can’t even reason with them. They’re just mute. They have this look about them that’s just like a zombie.’’

Syracuse is one of the poorest cities in America — more than a third of the people here live below the poverty line. After I made a few visits to Upstate University Hospital’s emergency department, where most spike cases in the area end up, it became clear to me that the vast majority of serious users here don’t resemble the victims typically featured in reef-er-madness-inspired stories about the dangers of ‘‘designer drugs.’’ They aren’t curious teenagers dabbling in what they thought was a legal high dispensed from a head shop. They’re broke, often homeless. Many have psychiatric problems. They’ve smoked spike for months, if not years. They buy it from rundown convenience stores and corner dealers in the city’s worst neighborhoods, fully aware that it’s an illegal drug with potentially severe side effects. Doctors could tell me what happened when people overdosed on spike, but they couldn’t tell me why anyone would smoke it in the first place, given the possible consequences.

‘‘It’s crazy,’’ was all that one overdose patient could tell me. ‘‘Syracuse is Spike Nation, man. I don’t know who called it that, but that’s what they’re saying.’’

The visible center of Syracuse’s spike epidemic is the Mission District, a three-block wedge bounded by treeless boulevards and a red railroad trestle with the pronouncement LIVES CHANGE HERE painted on it in huge white letters. Before urban renewal gutted the neighborhood in the 1960s, it was home to a typewriter factory and a rail yard surrounded by blue-collar homes and fringed by mansions that have long since been bulldozed or carved up into boardinghouses. The sprawling Rescue Mission campus, which includes a men’s shelter and a soup kitchen, lends the district its name. The shelter explicitly forbids spike, along with alcohol and other drugs. But at any time during the day, a knot of people can be found under

the trestle, dealing and smoking spike, and some-times passing out from it. One unseasonably hot May afternoon, while I was combing a creek bank for discarded spike packets, a man shouted at me from a bridge: ‘‘That’s a lot of spike down there!’’

He introduced himself as Kenneth, a 44-year-old barber and spike addict with fingertips stained highlighter-yellow by spike resin. He had thin, expressive lips, and when he spoke, his words flowed in multiple stanzas. We sat in the shade under the trestle to talk. Kenneth was in prison when he first smoked spike, which he praised as a ‘‘miracle drug’’ because it didn’t show up on a drug test. ‘‘An addict is always trying to get slick, always trying to get over, always trying to beat a urine, always trying to beat a parole officer, always trying to get high without getting in trouble,’’ he said. ‘‘So I’m loving this drug! I come home, and it’s all over the place.’’

That was a year ago, after Kenneth got out of prison. For a time, he said, he considered dealing

‘The first week or so of smoking spike, there’s no control over it. I’d smoke it and black out and come to three hours later, hugging a pole.’

Drop

PRE-BEAUTIFIED PROOF 2

45Photograph by Philip Montgomery for The New York Times

spike but decided that smoking it was all the trouble he could afford. Now he hated the stuff. Nobody he knew would choose it over real weed — if real weed were legal. In this way, spike was less a drug of choice than one of necessity. Now he was hooked, he said, and trying to quit. ‘‘It’s an annoying drug,’’ he said, comparing it to crack. ‘‘It’s great in the first two minutes. But then you got to keep lighting up, and lighting up, and lighting up. It’s not like marijuana, smoking a blunt and you’re high for two or three hours.’’

I asked him if he was afraid of landing in the hospital with a tube in his throat, or even dying. The risk of death isn’t a deterrent to an addict, he explained — it’s a selling point. Take Mr. Big Shot, for example, a brand of spike that had a reputation on the street for knocking people unconscious. That’s the one everybody wanted, including Kenneth: ‘‘One joint lasted me six hours! I would light it up, take about three lungs, and turn it off. It was that strong. Even the guy in the store where I bought it from said, ‘Listen, smoke this in your house, don’t go into the street with this.’ ’’ If there was a spike dealer in the city selling bad stuff, Kenneth wasn’t aware of it, or he wouldn’t say. In his opinion, people were losing control on spike because they were smoking way too much of it. It was that simple.

‘‘That’s what all these guys do all day long,’’ he said, pointing to a group of loud-talking men hanging out at the other end of the trestle. ‘‘That’s what they’re doing right now.’’ (Kenneth later told me that he had kicked his spike habit.)

Other spike users I spoke to in the Mission District made the same argument. One of them was Tyson, a 27-year-old drifter with shaggy brown hair who affected an air of party-dude bonhomie. He’d shot up, smoked, swallowed or snorted just about every drug there is, he said. Last fall, he

started using spike for the same reason Kenneth did — to foil mandatory drug tests. Now he was living on the street, waiting for a bed to open up in a rehab facility. I bought him an iced coffee and a wedge of poundcake at the Starbucks in Armory Square, an upscale neighborhood of shops and restaurants three blocks from the Mission Dis-trict. We sat on a sun-dappled bench, watching lawyers and insurance executives come and go. When I asked him why so many people were overdosing on spike in Syracuse, Tyson blamed novice smokers.

‘‘The first week or so of smoking spike, there’s no control over it,’’ he said. ‘‘I’d smoke it and black out and come to three hours later, hugging a pole.’’

They can’t all be novices, I pointed out. Many of the spike users I talked to at Upstate University Hospital were plenty experienced, and they’d ended up in the emergency room nonetheless. Tyson slurped a blob of whipped cream from his coffee cup and reconsidered the question. His answer was rambling and profane, but it gave me deeper insight into how the spike economy works in Syracuse.

Spike, Tyson said, is a ‘‘poverty drug.’’ A five-gram bag goes for $10 in the store, but it is often subdivided and resold on the street as $1 ‘‘sticks,’’ or joints, and $2 ‘‘freestyle’’ portions — spike poured directly from the bag into the hand of the buyer. Many of the users I spoke to claimed that, in addi-tion to being dirt cheap, spike was addictive. There are no studies to back

The New York Times Magazine

Above: Kenneth, 44, is a barber who first tried spike in prison. The drug can’t be seen by drug tests.

Previous pages: A man in a Syracuse emergency room after a spike overdose. Such patients are restrained: They can suddenly become violent.

PRE-BEAUTIFIED PROOF 2

46 7.12.15

up this claim. Toxicologists know only that synthetic cannabinoids bind to certain receptors in the brain, and they understand nothing about the drug’s long-term health effects. Scientific proof aside, Tyson said he knew spike users who performed sex acts for a few dollars. ‘‘That’s how you know that spike is definitely addictive,’’ he said. ‘‘People are out tricking for it.’’

Tyson also explained how easy spike is to get in Syracuse. He ticked off the names of corner stores that sold it from behind the counter. Some required users to know code words — ‘‘Skittles,’’ for example — while others sold spike to anybody who asked for it, including children. Along with the stores, and the entrepreneurs peddling sticks to subsidize their own habits, street dealers offered bags of spike purchased in bulk from distributors in New York City.

‘‘That dude over there, with the headphones on?’’ Tyson said. ‘‘He does it.’’ He pointed his chin toward a young man in a leather coat crossing the street. ‘‘He’s got bags on him right now, but he does that pop-top.’’

‘‘Pop-top’’ is slang for the local spike that is sold in resealable pouches, the cheapest of the cheap. ‘‘You don’t know where it’s been, who did what with it,’’ Tyson said. No brand of spike is tested for its pharmacological effects, but pop-top spike doesn’t even have the benefit of a street rep. It’s the ditch weed of Spike Nation: rank, wet and worst of all, weak — unless you get a ‘‘hotspot,’’ an unpredictably powerful batch. ‘‘Seventeen joints, you might be fine. Eighteenth joint might put you down for six hours.’’ Tyson said. ‘‘That’s probably going to be what’s going to give somebody a heart attack.’’

Tyson said he’d seen a pop-top operation once, in a dingy basement on Syracuse’s north side. Potpourri was spread atop silk screens on Ping-Pong tables, then doused with chemicals from a spray bottle. What was in the bot-tle, he couldn’t say. What pop-top manufacturers lacked in quality control, they made up for in marketing talent. Their spike was even cheaper than the store-bought variety, and new brands hit the street every month. They also produced clever knockoffs, stuffing their inferior spike into pouches identical to popular store brands. ‘‘That’s the name of the game right now, dude,’’ Tyson said. ‘‘Who can have the best-looking bag.’’

Since the attack on Ethan Darbee, the number of spike overdoses in Syracuse has fallen by half, just as mysteriously as it rose. Maybe spike smokers are being more careful, or doctors are reporting overdoses less frequently. Maybe a bad batch of spike finally ran its course. The answer doesn’t really matter. In a year, or a month, or perhaps tomorrow, the chemicals will be completely different, and we’ll be talking about another epidemic.

The problem is resistant to criminal prosecution, or even basic police work. The Syracuse Police Department has a cellphone video of a spike overdose that they use for training purposes. It was taken in the first week of the outbreak, when the police were responding to as many as 20 overdoses a day. A lieutenant played the video for me one afternoon on a computer at the police station. It starts with a man writhing on the floor in a corridor of an apartment building. The man isn’t under arrest, but his hands are cuffed behind his back, for his own safety, until an ambulance can get there. The man screams the same unintelligible words over and over in a hysterical falsetto. He bangs the back of his head against the wall and hammers his bare heels against the floor. Ragged flaps of pink skin hang off his kneecaps. His bottom lip is literally chewed away. The video ends abruptly with the man in midscream. The lieutenant jerked his thumb toward the computer screen. ‘‘Now,’’ he said to me, ‘‘try to get his name and phone number.’’

When the bath-salts outbreak peaked in 2012, the city passed an ordi-nance equating possession of synthetic drugs with minor infractions like loitering. It also gives the police the authority to confiscate spike from users and, with probable cause, from stores as well. But the ordinance,

which pushed spike sales onto the street, did little to prevent the surge of overdoses that hit the city in April. Bill Fitzpatrick, the Onondaga County dis-trict attorney, responded to the recent ‘‘crisis,’’ as he put it, by notifying store owners in May that he would charge them with reckless endangerment if they were caught selling spike, a misdemeanor punishable by up to a year in prison. That was the extent of his authority. ‘‘What I would ask from the federal government is some sort of sanction against China,’’ a frustrated Fitzpatrick told me. ‘‘Forget about the doctrines of Mao Zedong or Karl Marx — what better way to subvert American society than by shipping this garbage over here and making it attractive to our future generations?’’

In March, the D.E.A. did arrest one Chinese national, a suspected manufacturer who made the mistake of traveling to the United States on busi-ness. For the most part, though, federal prosecutors have focused on arresting United States distributors under the controlled-substance-analogue statute,

which was designed specifically to target synthetics. According to the statute, prosecutors must prove that the cannabinoids are ‘‘substantially similar’’ to previously banned cannabinoids both chemically and pharmacologically, and that they’re meant for human consumption. That’s why every bag of spike carries the disclaimer ‘‘Not for Human Consumption’’ as a legal fig leaf.

Carla Freedman, assistant United States attorney for the Northern Dis-trict of New York, has successfully prosecuted many synthetic-drug cases under the statute. She won convictions against not just Syracuse’s bath-salts kingpin but also the owner of a chain of upstate head shops and the members of a Syracuse family who cranked out 200 pounds of spike a month in a rented house with the aid of a cement mixer. ‘‘If you keep taking out smoke shop after smoke shop, you’re putting your finger in the dike,’’ Freedman said. ‘‘If you take out the manufacturer and shut his business down, you stop production for a while.’’

Her current case concerns three associates of a Los Angeles-based orga-nization called Real Feel Products Inc., who are charged with conspiring ‘‘to distribute one or more controlled substance analogues.’’ Real Feel has done its business in the open, and indeed claims on its website to rank as ‘‘the Top 5 counter culture distribution company in North America.’’ Since Freedman charged the defendants under the analogue statute, their most likely defense will be to argue that they have changed their products fre-quently enough to keep them within the realm of legality. It’s Freedman’s job to prove that they didn’t. If they had sold heroin instead of spike, they’d already be in jail, and none of this would be an issue. As if more evidence were necessary to prove that synthetic drugs are the new frontier, Real Feel was also at one point developing a reality television show about growing its business.

Neither Fitzpatrick nor Freedman nor Syracuse’s mayor, Stephanie Miner, had any idea who, or what, was causing the overdoses. In Miner’s view, spike was just the drug of the moment, as heroin was last year and bath salts the year before that. She said she believes the real problem is centered on ‘‘undiagnosed trauma’’ that drives people to use drugs — any drugs — in the first place.

‘‘You can’t arrest your way out of these problems,’’ Miner said. ‘‘If some-body thinks that you can use the law to correct behavior that results from mental health issues? Not gonna happen.’’

The next day I went for a ride along with Police Officer Jacob Breen. Just four years out of the academy, Breen still enjoyed patrolling a beat and

‘If you keep taking out smoke shop after smoke shop, you’re putting your finger in the dike.’

Drop

Syracuse’s Spike Epidemic: More photos are online at nytimes.com/magazine.

PRE-BEAUTIFIED PROOF 2

Photograph by Philip Montgomery for The New York Times

showed a keen interest in the social fabric of the city’s tough south- and west-side neighborhoods. After decades of economic decline, Syracuse has become one of the most segregated cities in the country, with a predomi-nantly black underclass trapped in the urban core and middle-class whites living in the suburbs. Onondaga County, where Syracuse is the largest city, also has the third-highest rate of ‘‘zombie homes’’ — abandoned by their owners but not yet reclaimed by the banks — in the state. Cruising from block to block, Breen glanced back and forth between the road and a lap-top wedged between our seats that displayed mug shots of felons on open warrants, the majority of them young black men. We passed a dilapidated two-story house, its boarded-up windows tagged with graffiti. The front door was ajar. ‘‘Open for business,’’ Breen said, craning his head around to get a glimpse through the door.

What bothered Breen most about the spike problem was how little he could do about it. Dealers, he knew, didn’t care about being hit with an appearance ticket for violating the city ordinance. He had to spend much of his time running around the city to protect ambulance crews from being attacked by freaked-out spike heads — ‘‘a waste of police resources.’’ Sure enough, around 5 p.m., dispatch put out a call regarding a spike overdose. Four policemen were already on the scene when we arrived. They stood in the yard of a tidy white house, trying to coax a man down from a set of stairs. The man was in his 40s, with a shaved head and a scraggly beard. Oblivious to the policemen, who seemed to know him, he stared at the sky, rolling his eyes.

‘‘Hey Will, c’mon,’’ one officer said. ‘‘You want to crawl down?’’ Paramedics wheeled a gurney to the stairs, and the situation escalated quickly. When the police laid hands on him, Will began jerking spastically and didn’t stop, even after he was strapped to the gurney and loaded into the ambulance.

Nurses at the hospital discovered three bags of spike on Will. But there was also a sandwich bag filled with what appeared to be small stones. Breen took the spike and the ‘‘moon rocks,’’ as he called them, to the Public Safety Building downtown. While he went to fetch a drug-test field kit, the supervising officer, Sergeant Novitsky, examined the haul. The bag of moon rocks baffled him. ‘‘I just don’t want to touch it,’’ he said.

Whatever it was, it certainly wasn’t spike. The kit returned negative results for amphetamines, cocaine, LSD, marijuana, MDMA, methadone, methamphetamine and PCP as well. Stumped, Breen and Novitsky weren’t sure what to do next. Toss the moon rocks into an evidence locker? Send them to the crime lab? Neither possibility appealed to Breen. ‘‘The lab’s not testing any-thing we’re sending,’’ he complained. ‘‘They won’t unless it’s a criminal case,’’ Novitsky shrugged. Overdoses weren’t criminal cases. At my suggestion, Breen decided to take it to Ross Sullivan, an emergency-room doctor at Upstate who has been investigating the toxicology of synthetic drugs.

We parked outside the entrance of Upstate’s

emergency department and waited in the dark for the handoff. This was how knowledge of synthetic drugs was being advanced — an ersatz drug

deal between a rookie cop and a toxicologist, with a reporter acting as middleman. It was absurd, but somehow fitting. The synthetic-drug industry, and the response to it, are based on improvisation. A molecule is tweaked in a Chinese lab, triggering a chain reaction that goes all the way down the line from dealers and users to paramedics and the police to doctors and lawyers. Just when every-body seems to have a handle on it, the molecule gets tweaked again, and the cycle begins anew. Whatever these rocks were, Upstate’s doctors might very well see a flood of people overdosing on it next year./•/

A Syracuse police officer holds a packet of a synthetic cannabinoid. In Syracuse, local shops sell it under the counter; elsewhere, it is sometimes sold openly.

PRE-BEAUTIFIED PROOF 2