A decade ago, five years ago even, many Mainers struggling with substance use disorder could relapse with far less risk of suffering a fatal overdose.

Those odds have diminished significantly.

Fueled by the powerful synthetic opioid fentanyl, which is showing up in nearly every illegal drug being sold, overdose deaths in 2021 are on pace to shatter the annual record set just one year ago.

From January through September, there were 455 fatal overdoses tracked by the Maine Attorney General’s Office and the Office of Behavioral Health, an average of more than 50 every month. If that pace holds for the final three months of the year, there would be more than 600 deaths, easily eclipsing last year’s total of 502 that was attributed in part to increased isolation, challenges with accessing treatment and a disruption of illegal drug supply during the pandemic.

“I think the stress on people and the isolation from the pandemic are certainly factors, but I think the biggest factor is the lethality of the drugs,” said Leslie Clark, executive director of the Portland Recovery Community Center. “When we think about people who relapse or are at risk of relapse, the consequence is just so much greater. That experience didn’t use to be as likely to kill you.”

Nicole Proctor, who is program director for the recovery hub at the Portland center and in long-term recovery herself, said there is no question drugs are more deadly than ever.

“I’ve been grateful that I’m not living through the lethal drugs that are out on the street,” she said. “And it’s not just opioid users. Fentanyl is showing up in cocaine and methamphetamine, even marijuana. I don’t think there are necessarily more people using, I think there are just more people dying.”

In the last decade, the number of yearly overdose deaths has more than tripled, fueled overwhelmingly by opioids – largely diverted prescriptions like OxyContin at first, then heroin and now fentanyl.

Maine went over 200 deaths in a year for the first time in 2014. In 2017, the total was over 400. Now, eclipsing 600 four years after that seems all but certain.

Three of every four deaths this year have involved fentanyl or an analog. Cocaine and methamphetamine each show up in a quarter of all deaths, often in combination with fentanyl.

“We’re certainly not hiding it. The data is out there. But the reason you’re not hearing about it is because COVID is squeezing out everything else,” Gordon Smith, director of Maine’s opioid response, said in an interview.

Drug deaths outpaced COVID deaths last year, although that’s not likely to be the case this year. In 2020, there were 422 deaths attributed to COVID-19 and so far this year there already have been more than twice that many. More than three times as many people in Maine died by overdose last year as died in motor vehicle crashes.

Drug enforcement officials say drug cartels in Mexico are mass producing fentanyl and methamphetamine with chemicals imported from China. Fentanyl is profitable for drug dealers because it’s so potent that small amounts can be mixed with other substances.

Last week, more than 389 pounds of fentanyl – and 17,500 pounds of methamphetamine – were found hidden inside a tractor-trailer full of auto parts at a port in San Diego. The seizures were the largest for either drug in the U.S. for both 2020 and 2021, according to a statement from the U.S. Attorney’s Office.

Maine is by no means alone in the recent trend. The U.S. Centers for Disease Control and Prevention released estimates last week that more than 100,000 Americans died of drug overdoses from May 2020 to April 2021. That’s the highest 12-month period ever recorded, although it’s not yet an official count.

All but four states saw increases over the previous 12-month period. Nearby New Hampshire was among the states that saw overdose deaths decrease. Vermont, on the other hand, saw the largest increase, 70 percent, although that state started from a much smaller number than most.

Maine’s increase of 24 percent was slightly lower than the overall U.S. increase of 28.5 percent.

So far this year, overdose deaths have been reported in every Maine county, led by 82 deaths in Cumberland County. Of the 455 reported through September, 314 victims have been male (69 percent). Individuals between the ages of 40 and 59 account for just under half of all deaths.

As high as the total has been so far, it could have been higher still without the widespread availability of naloxone, a drug that can save lives by reversing the effects of an opioid overdose. Of the 6,892 overdoses reported from January through September, 7 percent have resulted in fatalities.

“It’s incredibly sad how many people are overdosing,” Smith said. “But it’s remarkable that we’re saving 15 people for every person who dies.”

Still, naloxone only works when it is administered shortly after an overdose. If it’s not on hand or if emergency medical providers can’t respond in time, it doesn’t do any good.

Oliver Bradeen, executive director of Milestone Recovery in Portland, said the increase in overdose deaths has come at a time when people have been desperate for access to limited resources. The detox unit at Milestone, for example, was forced to close for roughly three months this year because of staffing shortages. Another detox facility in Bangor also closed temporarily. That meant people who didn’t have private insurance had nowhere to go outside of a hospital emergency room.

“I think the thing we hear from folks, aside from the added level of isolation brought on by the pandemic, is that everything, when it comes to treatment, takes longer or takes more effort,” Bradeen said.

In recent weeks, members of the Alliance for Addiction and Mental Health Services of Maine have warned that the vaccine mandate for health care workers would exacerbate staffing shortages at agencies that provide crucial treatment, especially in rural areas.

“When I came into recovery, I lived in a rural area and had to move to Portland to find support and resources that I felt I needed,” Proctor said. “A lot of people may not have that option, but people can get resources away from Portland more easily than before and we continue to be more creative with how we deliver those services.”

In many ways, Maine has more tools now to fight substance use disorder, Smith said: Medicaid expansion and increased reimbursement rates for treatment; the introduction of medication-assisted treatment in jails and prisons; the widespread availability of naloxone.

But more work is clearly needed.

“With every overdose, there is something to be learned that might help us prevent them in the future,” he said. “For instance, how many people died while trying to get into treatment? If they aren’t trying, that’s one thing. You focus on harm reduction. But if there are barriers to treatment, that’s something else.”

Smith said he has a recurring nightmare about some college kid trying to buy one pill of Adderall – a prescription stimulant – to help him get through an all-night study session. The pill contains fentanyl, unbeknownst to the student.

“That kid isn’t going to wake up. He’s going to die,” he said.

The unprecedented number of overdose deaths, combined with the hundreds who have died from COVID-19, has been unnerving for behavioral health workers.

“The people dying from overdose, so many are in their 20s and 30s, so when you think of how much of their lives have been lost, it really brings it into perspective,” Bradeen said. “And many of them have kids, so that’s another generation that’s affected by this crisis, too.”

“The loss in our community, and the devastation to families, is just so continual,” added Clark. “But it does give us a stronger sense of purpose to keep doing this work. Because we also do see many people doing well and getting better.”