Overdose deaths tied to potent new drug

Opioids

An opioid is one of a variety of substances similar to natural opium alkaloids. The drug dulls the senses and relieves pain. Heroin, morphine and fentanyl are all opioids. Other examples include pharmaceuticals like OxyContin, Vicodin, codeine and methadone. Heroin is an illicit drug with no legitimate medical use in the United States. Morphine and fentanyl are both licit opioids used during medical procedures and often prescribed by doctors to control pain. Fentanyl, however, is increasingly being manufactured clandestinely and mixed with heroin or sold alone as a heroin substitute.

Opioids can be swallowed, smoked, sniffed, or injected. Users are prone to become psychologically and physically dependent on opioids.

Morphine

Morphine is a naturally occurring substance extracted from the seedpod of the Asian opium poppy plant, Papavar somniferum. The principal constituent of opium, it is one of the most effective drugs at relieving severe pain.

Opium is made by drying the milky resin that seeps from incisions made in unripe seedpods. An alternate method of harvesting morphine is to extract alkaloids from the mature dried plant stalks, to produce a fine brownish powder.

Street names: Dreamer, Emsel, First Line, God’s Drug, Hows, M.S., Mister Blue, Morf, Morpho, and Unkie

Heroin

Heroin is a highly addictive drug and the most rapidly acting opiate.

Heroin is synthesized from morphine, the naturally occurring substance extracted from the seed pod of the poppy plant. Heroin usually appears as a white or brown powder or as a black sticky substance, known as “black tar heroin.”

Heroin works much faster because it’s less soluble in water than morphine and more soluble in oils and fats. Once in the bloodstream it can pass rapidly through the blood-brain barrier which normally prevents the passage of water-soluble and large molecules. As a result it is much more potent than morphine, but its effect does not last as long.

The majority of heroin sold in the U. S. originates from Southeast Asia, South America and Mexico. Low purity Mexican black tar heroin is most common on the West Coast, while high purity Colombian heroin dominates in the East and most Midwestern states.

Street names: Big H, Black Tar, Chiva, Hell Dust, Horse, Negra, Smack, and Thunder

Fentanyl

Fentanyl is a synthetic opioid 100 times more powerful than morphine and many times more powerful than heroin. It was first introduced as an intravenous anesthetic under the trade name Sublimaze in the 1960s.

Licit pharmaceutical products include lozenges, tablets and transdermal patches as well as injectable forms. Fentanyl is often used for pain management in cancer patients as well as analgesic and anesthetic for patients undergoing surgery.

Street names: Apache, China Girl, China White, Dance Fever, Friend, Goodfella, Jackpot, Murder 8, TNT, as well as Tango and Cash

Sources: Drug Enforcement Administration, National Institute on Drug Abuse

Covering the Heroin Crisis

The Dayton Daily News continues its unmatched reporting of the heroin epidemic to provide the latest insight into the many public health issues touched by the crisis.

Watch a video at MyDaytonDailyNews.com of Brooke Ehlers, a technical leader at the Miami Valley Regional Crime Laboratory, discuss the surge of fentanyl cases investigated by the lab’s Chemistry Section.

A synthetic opioid as much as 50 times more potent than heroin has flooded the streets of Dayton and its suburbs with deadly consequences, leading to a surge in deaths of people who think they are buying straight heroin.

What they’re more often buying is illicit fentanyl, which was responsible for at least 43 overdose deaths in Montgomery County alone in 2014.

Addicts say taking an unknown amount of fentanyl is like playing Russian roulette with a needle.

“You say a little prayer before and do what you got to do,” said Tyler Walters, 38, of Dayton, who is in treatment. “It crossed my mind every time before I’d use. I just wondered if that was going to be it.”

Walters, who shot his last capsule of heroin on July 24, said a lot of his friends are now dead. “A few months ago I went to three funerals in a week,” he said.

Credit: Chris Stewart

Credit: Chris Stewart

Fentanyl, rarely cited as a factor in local overdose deaths just 14 months ago, is nearly overtaking heroin in causing death. Through August of this year, 54 deaths in Montgomery County were tied to heroin, 43 to fentanyl and 31 to both drugs, meaning the victims had heroin and fentanyl in their system.

Fentanyl, in other words, was a primary or secondary factor in 74 of the 175 total overdose deaths, or about 44 percent.

“The bottom line is fentanyl is so much more powerful and the user doesn’t know it,” said Dr. Kent Harshbarger, the Montgomery County coroner. “That’s why it’s dangerous.”

Harshbarger said what’s sold on the street as heroin can be nearly all fentanyl, which was first introduced in the 1960s as an intravenous anesthetic and pain killer.

“They are taking the same dose thinking they bought heroin,” said Harshbarger, who’s also the Ohio State Coroners Association chief forensic officer and chair of Ohio’s Overdose Prevention Task Force. “In the user’s mind, it’s heroin.”

Skyrocketing numbers

Little if any illicit fentanyl made its way to the Dayton area before last fall, said Brooke Ehlers, technical leader of the Miami Valley Regional Crime Laboratory’s Chemistry Section, which serves eight area counties. In the past five years, the lab has tested nearly 36,000 substances sent by the region’s law enforcement agencies to build drug cases.

Ehlers knew a new drug had hit area streets when she tested a batch on Oct. 28, 2013. About the same time the coroner’s office next-door saw an unusually high number of overdose deaths. She took her suspicions straight to the coroner.

“When I analyzed the case and realized I had powder fentanyl, which was extremely unusual for us, I immediately notified our toxicology section,” Ehlers said. “That’s not something they would normally look for on a death, just because the heroin had been so prevalent.”

After the coroner started testing for fentanyl, “our numbers just skyrocketed,” Ehlers said.

In the span of just two months at the end of 2013, fentanyl was tied to 20 deaths in Montgomery County.

The samples tested by Ehlers’ lab are dropped off by law officers after undercover drug buys and busts, the follow up on search warrants, confiscations during traffic stops — and sometimes from syringes pulled from corpses.

Since that October 2013 drug case, Ehlers said, 708 samples tested at the crime lab contained fentanyl, including 615 this year.

Ehlers said she attended a meeting this September with forensic scientists from across the country and heard of no other region as awash in fentanyl as Dayton.

“If a lab gets a case, it may be a case or two but it’s nothing like on a daily basis like we see it,” Ehlers said. “When we say we’re seeing 3-4 fentanyl cases a day, they are just flabbergasted.”

“Dayton, Ohio, is running the fentanyl market right now.”

‘Dayton bubble’

Fentanyl is a synthetic opioid, similar to morphine but 80-100 times more powerful, said Robert Lubran, director Division of Pharmacologic Therapies, at the federal government’s Substance Abuse and Mental Health Services Administration.

Fentanyl is used to treat pain and, in combination with other drugs, as an anesthetic during surgery. It was introduced under the trade name Sublimaze in the 1960s. Pharmaceutical versions include lozenges, tablets, transdermal patches as well as injectable forms.

Like heroin and morphine, fentanyl binds to opiate receptors in the brain and causes relaxation and euphoria. Along with its pain-relieving benefits, it causes respiratory repression. Taking too much can stop a person’s breathing, resulting in an overdose death.

Before last fall, every case of fentanyl tested by the crime lab dating back to a 2006 involved abuse of pharmaceuticals – mainly from people scraping fentanyl from transdermal patches, Ehlers said.

But the fentanyl on the street today is far different, Ehlers and other officials say. It’s not being scraped from patches and it’s typically not stolen from drug stores or hospitals and later resold.

Rather, it originates south of America’s border and is landing here in what Ehlers calls a “Dayton bubble.”

A similar rash of fentanyl deaths began nearly 10 years ago in the Midwest and along the East Coast, according to Lubran.

“I was around in 2005 when that outbreak took place in Chicago, Philadelphia and other areas and swept through the country killing people left and right,” he said.

That outbreak lasted through 2007 and claimed 1,013 lives in six states, including Ohio.

Investigations by the Drug Enforcement Agency (DEA) and other law enforcement led to the arrest of fentanyl sellers and the closure of a lab in Toluca, Mexico, according to a 2013 study of the outbreak published in the Journal of Medical Toxicology.

The DEA also took steps following the deaths to domestically restrict certain precursor materials needed to manufacture fentanyl.

Those efforts seemed to quell large-scale supplies for a time, but local law enforcement says “superlabs” are back up and running south of America’s border.

Dayton may be a landing place for the drug because of its location and distribution network.

“We have that (interstates) 70-75 connection,” said Capt. Mike Brem, commander of the Regional Agencies Narcotics & Gun Enforcement Task Force. “We’re a source city. Five or six years ago you had to go to Columbus or Cincinnati, or even Chicago, Atlanta, to really get a good discount on your bulk quantity of drugs. Now it’s Dayton. It comes from the border to here. There’s no taxing it along the way.”

Record year possible

Several states, including Pennsylvania, have sounded the alarm this year over fentanyl-laced heroin overdose deaths. Other Ohio regions and cities are not immune. Just last month officials in Cuyahoga County called a news conference to warn about fentanyl on the streets there after two deaths in one weekend.

Brem, whose task force coordinates with local, state and federal authorities, said undercover officers have purchased gel caps of pure fentanyl from area dealers. Little of it, he said, is produced locally.

“The majority of (fentanyl) comes across our borders, mainly from Mexico and the cartels,” Brem said. “It’s pushed across our borders just like the heroin is.”

“We see a lot of (heroin) shipments coming into the Dayton area already cut with fentanyl. So that means it’s either coming across the border that way or the source of supply just across the border has cut it and brought it up here.”

The bulk of the product here is from large, underground suppliers, said Rich Isaacson, a DEA special agent and spokesman whose Detroit office covers Ohio.

“Certainly when you talk about the number of cases (in Montgomery County), we’re talking about clandestinely-produced fentanyl. We’re not talking about the pharmaceutical-grade fentanyl,” Isaacson said. “That’s a safe assumption.”

Harshbarger said unintentional overdose deaths are expected to reach if not exceed the record 226 recorded last year — this despite the implementation of drug task forces, prevention campaigns, Scared-Straight-type billboards, religious revivals, support groups, and free distributions of naloxone or Narcan, an overdose reversal drug now widely in use.

Natural evolution

Credit: Linda Scott

Credit: Linda Scott

The epidemic of heroin — and now fentanyl — is fed by those initially addicted to pain killers.

Walters said he got hooked on heroin after being cut off from prescription pain medications. He said a doctor prescribed fentanyl patches and Percocet after he suffered three broken vertebra, three cracks to his pelvis, and a broken wrist in a fall. His body revolted after he could no longer get the drugs.

“I had no idea about the effects of opiate withdrawal,” Walters said. “The effects are serious. It’s like having the worse flu you’ve ever had in your life. Then you can take this one cap and it all goes away.”

Many heroin users — half of all young people, according to recent studies — reported first abusing prescription pain killers.

Walters found cheap relief in heroin. But after a while, even that didn’t work, he said.

“There was a time when I was trying to find the strongest stuff. I was using like a gram at a time,” Walters said. “I was using every bit I could possibly get ahold of.”

As even stronger batches hit the market this year laced with fentanyl, Walters decided to stop using.

There is “almost a natural evolution” from pain medications to heroin to fentanyl, said Andrea Hoff, director of community engagement and special Initiatives at Montgomery County Alcohol, Drug Addiction & Mental Health Services.

“The heroin is not doing as much as they’d like it to feed their addiction so the next best high, the next best thing to feed their addiction, is something more potent and that’s fentanyl,” she said.

That next-best high can exact a permanent price even if one survives an overdose, said Dr. Dennis Mann, an emergency physician who treats two or three overdose patients a shift at Miami Valley Hospital.

“The usual heroin overdose — and I hate to say this — is pretty simple to deal with,” Mann said. “You give them an injection of Narcan and you watch them for an hour or so.”

Although doctors initially can’t tell what opiate or combination is causing a patient to overdose, the more Narcan a patient needs, the more liable it’s fentanyl working away on the patient’s brain, Mann said.

“With fentanyl it’s a little longer lasting,” he said. Physicians make sure patients likely on fentanyl don’t leave the hospital until they are completely oriented because they can “cycle down again and go back into respiratory depression.”

Mann said permanent brain damage can result, even when Narcan is administered in time to prevent death. “Every now and then we will reverse one who does not recover their brain function completely,” he said. “They’ve been down too long.”

Hoff said detailed toxicology reports made by the Montgomery County coroner’s office during autopsies may make the area appear to have a far greater opiate problem than other communities that don’t track overdose deaths as rigorously.

“When you are an outsider looking in it really does make it look like Dayton has a disproportionate problem than other communities. And I think in some cases that is probably true. But in some cases it’s not. We have to just realize the data have limitations.”

Hoff said the fentanyl problem compounds what is already a devastating public health epidemic. The question is whether the strategy for dealing with this new, potent alternative should be separate from what is already being tried with heroin.

“I don’t know that we have an answer yet,” she said.