TALLAHASSEE — Opioids, mostly heroin and fentanyl, killed an average of 14 people a day in Florida during the first half of 2016.
At that rate, based on data released in May by the state's medical examiners, last year's fatal overdoses are on track to rise by a record 36 percent.
It's a cruel reversal of fortunes for Florida, which from 2010 to 2013 witnessed the steady decline of opioid deaths as the state closed "pill mills" — pain clinics that recklessly handed out drug prescriptions.
After the crackdown, those addicted to the shrinking supply of prescription painkillers searched for alternatives. The use of heroin, fentanyl and deadlier synthetic offshoots exploded.
Now, it looks as though Florida may have had more opioid deaths in 2016 than at the height of the pill mill crisis. (Final data from the medical examiners won't be out until later this year.)
State lawmakers have taken some steps toward addressing the deadly upswing. In May, Gov. Rick Scott formally declared a public health crisis.
But drug treatment advocates say much more still must be done to curtail the dramatic rise in deaths.
"It's killing more people a day than traffic accidents and than guns," said Mark Fontaine, executive director of the Florida Alcohol and Drug Abuse Association. "There's a lot more that could be done and needs to be done."
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The crisis sweeping Florida today is rooted in a decade-old problem that officials had promised was getting better.
In 2010, eight people were dying every day in Florida from overdosing on opioids — most of them prescription painkillers.
"We're at a critical point in our state regarding the number of pill mills," Pam Bondi told the Times/Herald late that year, just before taking office as the state's attorney general. "We've got to do something to stop it."
Tampa Bay Times
Tampa Bay Times
Over the three years that followed, Florida cracked down. Law enforcement used drug trafficking laws to jail doctors who over-prescribed. The Legislature required statewide tracking of painkiller prescriptions.
Signs of success came twice a year when the state's medical examiners released data showing that overdose deaths were in decline, which Bondi spotlighted with media releases and news conferences.
By 2013, opioid deaths had dropped more than 20 percent.
"Our relentless efforts are finally starting to pay off," Bondi said at a news conference promoting the 2012 medical examiner report. "We are blessed to finally see a decline in these prescription drug deaths."
But while the source of prescription drugs had been blocked, people were still addicted. Heroin and other illegal opioids flooded the state.
Neither the absence of pill mills nor the risks associated with street drugs quelled addiction, said Dr. Marc Romano, medical director of Delphi Behavioral Health Group, which runs Ocean Breeze Recovery treatment center in Pompano Beach.
He has patients who know they could die, but don't care.
"They're willing to roll the dice and take that risk no matter what," Romano said. "It's a phenomenon that I don't think we've ever really seen."
In 2014, the death toll started to tick higher, even as overdoses from oxycodone, which was responsible for most of the pill mill deaths, stabilized. The reason? Those deaths associated with heroin, fentanyl and carfentanyl rose fast.
Last month, the latest medical examiners' report showed that more people were killed by fentanyl and heroin in the first half of 2016 than in all of 2015.
Bondi speaks often about the dangers of heroin and fentanyl. But unlike those first few years when the medical examiners report provided an opportunity for Bondi to tout success, her office has issued nothing official about the most recent report, which was barely publicized.
The last time her office issued a statement on the report was in May 2014, before the upswing in deaths.
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In the final days of their session earlier this year, lawmakers took action aimed at cutting off the supply of deadly opioids.
Their strategy: Put people caught with four grams of fentanyl or carfentanyl in prison for three years. It was controversial in an era when criminal justice reformers want to eliminate rigid minimum mandatory sentences that tie judges' hands.
It took a personal appeal from Bondi to pass the bill, which Scott signed into law in June.
"Will a three-year minimum mandatory make a difference? Heck yeah, it will," Bondi said later. "It's going to get these monsters off the streets."
Other measures passed this year require doctors to log prescriptions in the statewide painkiller database by the end of the next business day. Supporters hope faster reporting will make it harder for people to get prescriptions from multiple doctors.
Lawmakers set aside $10.5 million for medications that can help reduce opioid dependency, most of which will be spent in the state prison system.
Bondi is also on the executive committee of a multistate investigation into painkiller manufacturers, her office confirmed for the first time this week, though it would not provide details, citing that the matter is ongoing.
And Scott's office is "reviewing ways to work with the Legislature to continue to fight the opioid crisis," spokeswoman Kerri Wyland said in a statement.
Rep. Kathleen Peters, R-Treasure Island, compares that response to how the state treated another health concern.
When the Zika virus spread last summer in South Florida, it drew quick attention from state leaders and a batch of emergency spending.
Special to the Times
Special to the Times
But it took until May — three years after opioid deaths started to rise — for Scott to declare a public health emergency on the drug crisis. That order, which he renewed Thursday, let the state draw down an additional $27 million a year in federal funds for treatment.
An authority on mental health, Peters said there's a fundamental difference between the two crises.
"We didn't lose one life to Zika," she said.
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Beyond the $38.5 million in the budget and emergency order, Florida has done little to expand access to treatment for those already addicted to opioids.
"We need more treatment," Bondi said. "These addicts are victims."
This year, she lobbied for legislation meant to shutter fraudulent "sober homes" that chase profits by exploiting those hoping to overcome addiction.
Making matters worse, Florida's already strained mental health care system has a shortage of treatment centers and professionals who can provide care, said Romano, of Delphi Behavioral Health.
"We could use more education, more resources, more treatment centers," he said. "There are far more individuals with addiction than there are beds available."
For example, few Florida counties have a facility that can take patients under the state's Marchman Act, which allows people to be involuntarily committed for substance abuse treatment.
Peters worked last year to overhaul the state's mental health and substance abuse system by directing people quickly to treatment, no matter how they are first identified as needing help.
Tampa Bay Times
Tampa Bay Times
If that coordinated plan were in place, Peters says, the number of overdose deaths could be lower because more people would have access to treatment.
She said there's one big problem: "Until we fund it, the plan is meaningless."
Fontaine worries that another route to treatment is being left out of the conversation: Emergency rooms.
Hospitals now must come up with a standard for preventing accidental overdoses, but they aren't required to refer patients to long-term treatment.
"A lot of people are overdosing, and they're going through hospitals, but we really haven't done a good job of linking the hospital emergency room to treatment," he said.
Other advocates have pushed for broad policies they say will limit addiction in the first place.
Activists called on lawmakers to let doctors treat chronic pain with medical marijuana, which they say is less addictive than prescribed pills. A 2014 study by professors at the University of Pennsylvania and Johns Hopkins found that states with medical cannabis laws had an average 25 percent drop in opioid deaths.
But Florida lawmakers did not approve pot for chronic pain, in part because the constitutional amendment legalizing medical marijuana did not call for it.
In Ohio, Gov. John Kasich limited opioid prescriptions to a seven-day supply, something Florida has not done.
Fontaine said it's time that the state put more resources into doing something about the skyrocketing of opioid deaths.
"I've been doing this for 40 years and I've never seen anything like we're dealing with now," he said. "This is a public health crisis, and I think it needs the full response of a public health crisis."
Contact Michael Auslen at firstname.lastname@example.org. Follow @MichaelAuslen.