Illicit fentanyl spread first through the midwestern and eastern states. By 2018 it was all over the West as well. Overdose deaths shot farther north; more Americans died yearly than in the entire Vietnam War. Cuyahoga County, where Cleveland is located, saw overdoses double from 2014 to 2017—from 353 to 727, with almost 500 deaths involving fentanyl. San Francisco saw a similar increase between 2018 and 2020, when three times as many people died of overdoses as of COVID-19. Philadelphia had long been a heroin town, but by 2019 90 percent of 1,150 fatal overdoses were due to fentanyl.
