In early 2010, teenagers began overdosing on “bath salts.” The substance looked innocent -- white powder or crystals that were sold freely in gas stations, convenience stores and tobacco shops. But bath salts had nothing to do with bathing. They were snorted, producing a euphoric high that’s been described as “excited delirium.” They could also bring on intense hallucinations, paranoia, heart attack, kidney failure and death. Unlike heroin or cocaine, which come directly from the poppy flower and coca plants, respectively, bath salts came from cathinones that were synthesized in labs.

Bath salts weren’t the only new synthetic drugs appearing on retail shelves. So was another product, often described as “synthetic marijuana,” “K2” or “Spice.” The product consisted of dried plant leaves, suitable for smoking, that were sprayed with a synthetic cannabinoid similar to THC, the primary psychoactive ingredient in marijuana. It was sold in a variety of forms. Some retailers packaged them to appeal to kids under names such as Scooby Snax or Blueberry Haze. Others described them as “herbal incense” or plant fertilizer. The implication was that these substances were marijuana-lite. In fact, like bath salts, the chemically treated plant material in these packets offered heady highs and dangerous downsides -- abnormally high heart rates, lethargy, vomiting, hallucinations, kidney failure and seizures. Worse, the drugs were also connected with violent behavior by users.

Synthetic marijuana, or synthetic cannabinoids, as law enforcement prefers to call them, caught on quickly. A 2012 survey of high school seniors found that 11 percent had tried them -- far fewer than the 36 percent of seniors who had smoked actual marijuana, but far more than those who had tried any other type of illicit drug.

Between 2010 and 2011, calls to poison control centers related to synthetic drug overdoses surged, rising to a peak of 15,000 calls in 2011. At the same time, the number of emergency room visits involving synthetic cannabinoids nearly tripled, leaping from roughly 11,500 to more than 28,500 in 2012. More than half of those visits involved people who were under 21 years old.  

Faced with the dangers of synthetic drugs, states and localities promulgated emergency orders that outlawed specific compounds used to make the drugs. Legislatures passed laws that added problem compounds to state schedules of restricted drugs. They also enacted so-called “analogue laws” to restrict the sale of look-alike drugs. Law enforcement, often working with the federal Drug Enforcement Administration (DEA), targeted retail sales. 

These approaches seemed to work. Synthetic cannabinoids disappeared from the counters of retail stores. Visits to the ER for overdoses declined, as did calls to poison control.

Last year that all changed.

In 2015, calls to the nation’s 55 poison control centers regarding synthetic drug overdoses doubled, rising from 3,700 in 2014 to roughly 7,800 in 2015. Many of the largest increases were in the East and Southeast. New York City reported a nearly fivefold jump; Alabama saw a tripling of overdoses. The largest percentage increase in the country occurred in Mississippi, where the poison control center reported a leap of 3,000 percent -- from 40 calls about synthetic drugs in 2014 to 1,350 in 2015. 

Compared to the nation’s opioid epidemic, synthetic drug overdoses are currently a small-scale problem, even after accounting for last year’s doubling in calls. Crime labs nationwide report that only about 5 percent of the substances they seize and analyze turn out to be synthetic drugs, a number that has remained constant since 2012. However, policymakers say that several attributes of these drugs justify a high level of concern and a need to take action. The first is that they target children and young adults -- teenagers and college students are the heart of the market. The second is that their side effects can be unsuspectingly severe and dangerous both for users and those around them. “These are the worst drugs I have ever seen,” says Dr. Mark Ryan, director of the Louisiana Poison Control Center. “Take the bad attributes of PCP, cocaine, meth and Ecstasy, lump all the bad things into one drug, and that is what you sometimes get with these.”

The violent hallucinations are particularly disturbing. In Elkhart, Ind., Prosecuting  Attorney Curtis Hill recalls an unusually grisly case that his office was involved with this spring. A couple had taken a bad batch of synthetic drugs. She zoned out. He got delusional and killed her with a knife, which he then used to remove some of her organs.

Controlling these substances is by no means straightforward. For policymakers, synthetic drugs pose confounding choices. The early attempts -- outlawing the compounds used in making the drugs and banning look-alikes -- gave prosecutors and law enforcement the tools they needed to remove synthetic cannabinoids from gas station and convenience store shelves. Since then, however, matters have gotten more complex. Overseas chemists continue to create new synthetic cannabinoids designed to evade state and federal restrictions. Identifying these substances is time-consuming for drug labs. Meanwhile, more compounds are constantly appearing. “We are entering new frontiers every day with this stuff,” says DEA spokesperson Rusty Payne. “With the advances in chemistry and science, things that used to take years to develop and synthesize now take months, maybe even weeks.” 

Faced with this emerging and ill-defined problem, state and local governments are not sure what to do. With the heroin crisis raging, there is a reluctance to put too great a focus on synthetic drugs. But a few states are beginning to address the issue before it blows up into a major crisis. 

Synthetic drugs began with the best of intentions, as an attempt to create a safe, medicinal and legal form of marijuana. While non-medicinal users may indulge themselves in the drug for the sensory experiences it provides, people with medical conditions that cause loss of appetite, nausea, chronic pain, sleeping disorders or intense anxiety report that consuming cannabis brings relief. As a result, researchers had long been interested in developing synthetic forms of THC in the hope of developing a licensed drug that could relieve these symptoms.

One of the most committed researchers was a chemist at Clemson University, John W. Huffman. During the 1990s, with funding from the National Institute on Drug Abuse, Huffman created hundreds of synthetic cannabinoids that he named after himself, starting with JWH-007. Then he did what researchers do: He published his results. A series of papers and journal articles included the formula of one of his creations, JWH-018.

In 2008, Huffman got a call from the DEA. Authorities in Germany had recently come across a new drug, a chemical being sprayed onto plant leaves so that it could be smoked and consumed. The resulting substance was being sold as synthetic marijuana. A forensic lab had identified the chemical in question as JWH-018. The drug’s street name was Spice. Today, Spencer Collier, who served as Alabama’s Secretary of Law Enforcement until he was fired in late March, calls Spice “the No. 1 narcotics-related issue in Alabama.” 

Alabama’s experiences with Spice show just how challenging crafting an effective response to synthetic drugs can be. In 2011, Gov. Robert Bentley issued an executive order that temporarily outlawed five chemicals used to make bath salts and other synthetic drugs. Agents from the state Alcohol Beverage Control Board visited gas stations, tobacco shops and convenience stores across the state to let the retailers know that products such as Spice could no longer be stocked. 

In some ways, these efforts worked. Synthetic drug sales that once took place openly in retail outlets were pushed into the shadows. Yet far from diminishing, the severity of the problem seems to be increasing. The drugs themselves continue to mutate, making law enforcement trickier. As Alabama’s chief law enforcement officer, Collier had called on lawmakers to stiffen penalties for dealers while the agents working under his direction spent more time on educating teenagers about the risks of synthetics, particularly their devastating side effects. 

In 2012, for example, young adults were transferred from a smaller facility in the northeast part of Alabama to the emergency room at the University of Alabama-Birmingham (UAB) Medical Center. The teens had been smoking a synthetic cannabinoid they had ordered on the Internet called “blueberry spice.” After dealing with bouts of nausea and vomiting, they became much sicker. Their kidneys started to fail. At UAB, three of the four kids had to be hooked up to dialysis machines. 

The cases were nothing new for Dr. Erica Liebelt, a pediatrician and toxicologist who serves as the co-director of Alabama’s Regional Poison Control Center. Patients with cannabinoid toxicity usually present with central nervous system effects, says Liebelt. Common manifestations include “agitation, delirium, anxiety, seizures,” she begins, listing the variety of symptoms her patients have had. “Extreme paranoia, psychosis.” She also mentions a cardiac effect, in which the heart muscle itself starts breaking down. 

For a clinician, these cases are frustrating. The patients rarely know what they’ve consumed. Unlike heroin and other drugs in the opioid family whose bad effects can be interrupted by specific medications, there are no antidotes for these overdoses. Doctors can only be aggressive in providing support care and hoping the patient pulls through.

For toxicologists like Dr. Erica Liebelt, synthetic overdose cases are becoming all too familiar. (David Kidd)

While Alabama and other states were just beginning four or five years ago to see an upsurge in poisonings from synthetic cannabinoids, the DEA was already working on the problem. In March 2011, the federal agency had issued an emergency rule that made JWH-018 and four closely related compounds subject to the same restrictions as cocaine, heroin and marijuana. Six months later it added the chemicals used to make bath salts to the list. Suppliers -- primarily located in China, according to the DEA -- responded by tweaking the molecular structure of these substances in ways that would allow the drugs to stay off the restricted list. To control these copycat drugs, the DEA turned to a 1982 law that provided penalties for look-alike or analogue drugs. 

Several states, including Alabama, quickly followed suit. However, applying the law to these new substances was problematic. In addition to establishing whether the chemical composition of new substances was similar to that of scheduled substances, the law also required that they have similar effects. Yet no one really knew what the effects of these new substances would be. 

In an effort to overcome this hurdle, states undertook some unusual initiatives. For instance, the Missouri Safety Center in 2010 designed a protocol to test the effects of synthetic cannabinoids under the close supervision of specialists. The results were then shared with law enforcement, toxicologists and crime labs across the nation.

Because of the complexity of establishing substantial similarity, many prosecutors were reluctant to use analogue laws. Instead, most states developed systems whereby state health departments or pharmacy boards could quickly outlaw -- on a temporary basis -- new substances as soon as they appeared. The state legislature would then come in later to add these chemicals or class of chemicals to the section of the statute governing synthetic drugs. 

Local authorities also looked for innovative ways to reduce the sales of synthetic drugs. In DeKalb, Ill., City Attorney Dean Frieders was one of the first to use retailers’ alcohol and tobacco licenses to pressure them to stop selling synthetic drugs. The law he drafted has been widely disseminated by the National Alliance for Model State Drug Laws. The threat of loss of license, Frieders says, has been a powerful spur to cooperation on the issue of synthetic drugs.

Alabama tried these measures and more. In 2012, the state legislature followed up on a tragedy -- a child committed suicide after smoking a synthetic cannabinoid -- by outlawing a variety of chemicals. Two years later after the death of another child, the legislature added language outlawing look-alike drugs as well. That same year, in 2014, state and local law enforcement agencies, in conjunction with the DEA, launched Operation Red Tide. More than 4,000 packets of synthetic cannabinoids were seized -- some 200 pounds -- along with 19 guns and $500,000 in cash. In all, 38 people were arrested. 

Red Tide and other enforcement actions produced some real wins. But synthetic cannabinoids didn’t go away. Instead, they went underground. Some store clerks would sell to trusted buyers or their friends. 

Law enforcement had ways to target these types of operations. Confidential informants could do buys or relay passwords to undercover agents. But the work was tedious. Establishing operator culpability was challenging. Convenience stores in many states are controlled by byzantine webs of holding companies. Ownership changed frequently. As a result, law enforcement agencies were wary of asking judges to seize private property and risk getting sued. 

Ultimately, these approaches proved faulty. Cases were hard to take to court. Investigations were costly and time-consuming. The laws passed by states were untested. In Indiana, plaintiffs challenged a state law that sought to schedule categories of synthetics as overly broad. The statute was upheld by the state Supreme Court. Many prosecutors shied away from using analogue drug laws. The cost and difficulty of establishing that these drugs truly were analogous to existing scheduled drugs was simply too much.

It’s easier for those selling synthetic drugs. Take the cost-benefit calculation. An investment of $3,000 is easy to parlay into $100,000 from Internet and street sales. Entering the market is effortless. Would-be narcotics entrepreneurs don’t even have to know the names of the chemicals they need, says Heather Gray, the legislative director for the National Alliance for Model State Drug Laws. She recently spent a few hours Googling the street names of synthetic marijuana. When she arrived at work the next morning, she found two emails from distributors in China offering to send her the chemicals to make synthetic cannabinoids. “That’s how easy it is,” she says. “You literally do not have to leave your desk.” 

Not surprisingly, the market has attracted a wide variety of criminals. In Birmingham, a student at UAB built a mail-order synthetic drug empire in the bathroom of his apartment. He ordered chemicals, herbal leaves and packaging from an overseas producer. Then he dissolved the chemical powder into a liquid and sprayed it onto the leaves in his bathtub before packaging the product and mailing it to customers around the country. The day state police raided his apartment, they were startled to discover the dealer was in Las Vegas playing poker at a high-roller table with poker legend Doyle Brunson. 

Other actors have entered the market as well, including people with close ties to fighting in the Middle East. In Northern Alabama alone, the DEA and state law enforcement agency identified three stores operated by Yemenis who authorities believed were selling synthetic cannabinoids and who were sending millions of dollars a year back to Yemen. 

Thanks to constantly changing ownership, even pursuing these targets has been challenging. The result has been a game of cat and mouse -- a game where the authorities always seem to be one or two steps behind as variations of the compounds have escalated from an original five to more than 400. While the rate of innovation has slowed somewhat in recent years, crime lab scientists say that new compounds continue to emerge every couple of months. 

It can take even the most qualified lab technicians a full month to identify and validate an unknown substance -- if everything goes well. Sometimes states can’t identify the compounds at all. Last spring, Mississippi’s Poison Control Center went from receiving two to four calls a month about synthetic drug overdoses to receiving over 700 in April and more than 500 in May. In two months’ time, synthetic drug overdoses contributed to the deaths of 17 people. The outbreak was traced back to two distributors who were importing synthetic cannabinoids from China. “You had people literally mixing it up in a cement mixer,” says Dr. Robert Cox, the head of Mississippi’s Poison Control Center. “They had no concept of how much they were giving people.”

“This is not like a lot of other drugs where you can do a test and say, ‘Yes, this is X drug,’” says Mississippi Poison Control chief Robert Cox. “There is literally no test for this.” (David Kidd)

Faced with these challenges, some agents on the front line of the fight against synthetics say a different approach is necessary. “We’re not going to arrest our way out of this,” says Paul Hayes of the Alabama Law Enforcement Agency. “We’ve tried.” 

What approach authorities should pursue, though, is unclear. In Alabama, narcotics agents now spend a significant amount of time focusing on education. But alerting teenagers to the dangers of drug use is problematic. When kids take the drugs, says Deb Sims, the medical director of the Beacon Addiction Treatment Center, which is affiliated with UAB, “they’re trying something new, taking it to the edge a lot of times. It’s the lure of something that might give them a different bump.” Education campaigns that focus on the danger of substances, she suggests, could serve only to heighten their appeal.

Some law enforcement officials question the extent to which they should focus on synthetics at all. Last year, two people in Alabama died from synthetic drug overdoses, notes Nicholas Derzis, the police chief of Hoover, a town outside of Birmingham. In contrast, Jefferson County alone had more than 100 deaths from heroin. “You talk about the issues of synthetic drugs in the community,” he continues. “Even though there have been some, it’s nothing like the last few years of heroin.” 

It’s a legitimate point. Opioids like heroin are clearly the more serious threat. But most of the officials who have seen the effects of synthetics firsthand say it would be a mistake to minimize the dangers they pose. “Sometimes we get so mired down in what is staring at us in the face -- heroin, prescription drugs -- that we don’t look outside to see what is coming next,” says Clay Morris, who heads the DEA’s Birmingham office. “If we pay attention to the youth, they will tell us by their actions what they are using and trying and what could be the next big thing.” 

*This story has been updated from the version that ran in the April print magazine to correct an error. Governing misrepresented Missouri's efforts to understand the effect of synthetic cannabinoids. The Missouri State Highway Patrol did not ask officers to ingest these substances as originally stated. Rather, the Missouri Safety Center recruited paid volunteers and no participants in the study overdosed. This story has also been updated to reflect the fact that Alabama Secretary of Law Enforcement Spencer Collier was fired in late March amid a personal scandal involving the governor.

*Photos without credit are courtesy of Shutterstock.