There Are No Labels On Street Drugs

[Jaunty Guitar Music]

Mike: Welcome everyone. This is Avoiding The Addiction Affliction, a series brought to you by Westwords Consulting. I'm your host, Mike McGowan.

Mike: You know, most of us have grown up hearing the phrase "Drugs kill", over and over and over again. And despite that knowledge, some people take dangerous drugs anyway, and unfortunately some of them die. We're gonna talk about those drugs today with our guest, Sarah Schreiber. Sarah is the Forensic Technical Director in the Milwaukee County Medical Examiner's Office in Milwaukee, Wisconsin.

Mike: Welcome, Sarah.

Sara: Thank you.

Mike: I'm glad to be here. Well, that's a fancy title, but I think that means you work with people who aren't breathing when they come into your facility, right?

Sara: Correct. My task is to oversee the operations of the toxicology laboratory. And that laboratory, of course, is responsible for analyzing the biological specimens recovered during autopsy for the unfortunate patients that end up here and need their death investigated by our office.

Mike: Yeah. Well, we wanna specifically talk about overdose deaths today, and let's start with the numbers. How do your 2022 numbers compare with previous years when it comes to overdose? And for that matter, how's 2023 looking? .

Sara: So this is an interesting question, and the timeliness is a little bit unfortunate.

Sara: We don't have 2022 completely captured yet. So we have 579 cases confirmed as drug related deaths from 2022, and we have approximately a hundred more probable cases that could end up in that category.

Mike: Wow.

Sara: That puts us just a little bit over, maybe 5% over the numbers from 2021, which was 644 confirmed cases in 2021.

Sara: I don't have the projected numbers in '23, but I can tell you that we've already signed out 12 cases, from a drug related cause.

Mike: Wow. And that's more than automobile accidents? Where does that, where does that rank in your office?

Sara: So last year, and these numbers are probably complete. They may vary by one or two as we roll out, as we finish up the numbers from 2022.

Sara: But we had 91 motor vehicle accidents, 121 suicides, 236 homicides. So all of those together don't touch what we have with drug related death numbers.

Mike: Man. What combinations are you seeing of, of chemicals when you do the toxicology?

Sara: The most prevalent substances identified in these death investigations are those that would, we would consider an opioid.

Sara: So they're a central nervous system depressant. A wide variety of those, but the vast majority in that category are gonna fall within Fentanyl or the Fentanyl related compounds. And oftentimes that combination speaks to the, you know, the very vast majority of our cases in general, but about 80% of our deaths do involve Fentanyl. Of our drug tests.

Mike: And you know, people always ask me, Sara, I don't know if you get this too, but people say, well, if it can kill you, why do people take it? And you know, when we talk to people taking the drugs, they're like, well, I don't think it's gonna happen to me right. Or if it does, oh well it's sad.

Sara: It's real sad, and I think as we see trends change, there adds a bit of unknown for the user as to what substance they're actually consuming. Right? As we've seen the trend go from prescription medication that are used and abused to things like heroin, to now things containing Fentanyl, the product in the end may not, at least as those transitions happen initially.

Sara: May not be known to the individual who's using the drug, right? They may not know what substance they actually purchased. There may be a request and there may be you know, some confidence in that transaction. But in the end, if it's not tested, you don't know what it is that you're consuming and you don't know how much would be an appropriate amount to be consumed in any possible safe way.

Sara: So that's always a concern as we work into different trends within drug use is just the unknown to the user,

Mike: And that seems like such a huge risk.

Sara: In my opinion. It's an incredible risk. I know individuals struggle with that substance use and being sick with that withdrawal is, is a very real thing for them.

Sara: And so getting to the next source of drug to be able to use it, to fix that feeling of, of being unwell is really important to them, that it sometimes outweighs that risk to them. You know, I, I have to use, I need to feel better. You know, and, and maybe they struggle down that journey again for the next decision to, to choose not to use.

Sara: But unfortunately that is an extremely difficult time for them in their.

Mike: You know, I think by now and we've had a number of different episodes talking about Fentanyl and in fact, one of the ladies who we've had on a couple of times just was on CNN last week with Anderson Cooper, and she wants to change the law so it reads Fentanyl poisoning rather than overdose.

Mike: Because of what you just said, if you're putting it in stuff and you're selling it as something else, you're actually poisoning the person.

Sara: It's very true, and I think that terminology can be used even in signing death certificates and things. It ends up being more of a regional decision as to how to sign those.

Sara: We, we tend to list them as intoxications. Some will say toxicity from a combination of things, but there is a variety of terminology that can be used. But in the end, you know, the goofy phrase [chuckle] that toxicologists rely on all the time is that anything can be a poison. It's the dose that makes it a poison.

Sara: So even things that seem incidental or, or commonly used over the counter, you know, or other substances like that that you might not wanna qualify as a poison can be toxic, if not, you know, fatal to an individual depending upon that dose.

Mike: One of the reasons I wanted to have you on is I think people. By now if they haven't heard of Fentanyl, that group is probably not listening to this podcast, but I understand there's something new, right? I was on the street, they call it dope or trank, but it's something called Xylazine.

Sara: That's correct. We have seen, about 10% of our Fentanyl cases containing Xylazine.

Sara: And that number is increasing over the last couple of years. So its prevalence is becoming more concerning within our casework.

Mike: And what is it?

Sara: Xylazine is used as a veterinary medication. It's used for sedation and anesthesia for your pet, for an animal. So it's not meant for human consumption.

Sara: It's not meant for human, treatment in any way. So that's where it would need to be recovered from, or obtained from.

Mike: Is that ketamine was used with animals too, right?

Sara: Correct. Ketamine had some human use. And, and it still does, but it is a veterinary drug as well. So it is very similar to that in that capacity that it's used for sedation in anesthesia.

Sara: What's concerning about this substance is that it doesn't respond to Narcan.

Mike: Yeah.

Sara: It causes central nervous system depression and respiratory depression in an individual, but it doesn't respond to Narcan the same way that other opioids do. It just, it doesn't bind to the same receptor.

Mike: Which, which means if you're an EMT and you come across somebody who's out and you give them Narcan, so then what, there's a timeline then, right?

Sara: There is a timeline there. Fortunately, I would still recommend that you administered because we are seeing it, you know, 99% of the time when we see Xylazine, it is with Fentanyl.

Mike: Yep.

Sara: So the administration of the Narcan will help with the Fentanyl presence. It just won't help with the Xylazine. So you are gonna be benefiting the patient by helping in that capacity.

Sara: But you'll, you will still need to have some additional, you know, treatment in order to save their life if they've been exposed to the Xylazine in addition.

Mike: You know, maybe it's cuz we're in the Midwest, but I, I just read an article that in Philadelphia, for instance, Xylazine is in 90% of the Fentanyl, and that it's now you said 10% I think? They're, they're saying it's about 38% in Philadelphia.

Sara: So you gave two numbers there 99% and 30 something percent.

Mike: Yeah, like they're finding that their overdose deaths are, is like 38% now contain Xylazine, so.

Sara: Oh, of the deaths. Okay. Sorry.

Mike: So what is, why, why is that deadly? So will it just keep you from breathing?

Sara: Correct. It does cause respiratory depression, just like the opioids do. So that that on top of the opioid that's already causing respiratory depression causes a synergistic effect that becomes more toxic, if not fatal to the individual that consumed both.

Mike: Does it matter how it's taken, whether it's snorted, needle?

Sara: No, the route of administration doesn't seem to matter. Literature points to many different routes of administration for folks that have been exposed to it. But it again, points to that unknown. Don't know when that's a part of the combination of things that you're consuming.

Sara: So therein lies another risk to that unknown combination.

Mike: You know, we did an episode a long time ago about the receptors, but that's been a while, and you just referenced it a minute ago about how Narcan works. Can you walk us through that for just a second?

Sara: Sure I'll go on a real high level here, but opioids bind to the mu opioid receptor in the body.

Sara: That's the one that's responsible for that respiratory depression. And it is dose dependent. So when Narcan is administered that Naloxone binds to that receptor preferentially and blocks the opioid from being able to bind there. So that leaves the opioid free in the system to be metabolized and eliminated from the body, but it's not acting upon that receptor to cause the respiratory depression.

Sara: So sometimes there's a misnomer that that removes the opioid from your system and it does not. That still takes time for your body to get rid of it, but it blocks that receptor so that it cannot bind there and it cannot cause the respiratory depression. And that binding happens very quickly with the Naloxone.

Sara: So you see people wake up very quickly once that drug is administered. And if you can get enough of the receptors to have Naloxone in place instead of the opioid knock that off. The difficulty with that drug is it has a very short half-life or a short duration of action for how long it will work on a patient, and oftentimes that's shorter in time than the amount of time it takes for your body to remove the opioid from your system. So you get rebound respiratory depression and that central nervous system depression. So if an individual isn't monitored and continued to be treated they could rebound and go back into that respiratory depression and be just as at risk to dying as if they were the first time before they, that the first dose was administered or, or multiple doses. As it turns out, it needs to be sometimes.

Sara: Real important to call 911 when that's administered. If, if you, you know, if a bystander or you know, a family or friend administers that to somebody, still need that follow up care because so many of these drugs are so potent to hang around for much longer than that naloxone does unfortunately in that, you know, treatment regimen.

Mike: That's exactly, I was just gonna say that I, I'm sure medical professionals all know what you just said, but I talk to a lot of people who are "using buddies", "Narcan buddies", and I don't hear them knowing that. So they think once, once done we're, we're good to go.

Sara: That's real sad and it's really unfortunate for the instances where that does happen and they, you know, you, you're there with your friend, you use together, maybe you revive your friend and then you leave. I mean, how awful must they feel if they, you know, return them. You know, hours later, day later, whatever, you know, just over, you know, their correspondence and to find them unresponsive again.

Sara: And to know that maybe that was the circumstance, that would be extremely unfortunate. So I believe all training for Naloxone administration tells individuals to, to call 911. And I know that's not the end all be all. Cuz we can still leave without medical advisement. It is very important that individuals be seen all the way through and, and through a long enough period of time to know that that opioid has left the system and that they're now in a safe space.

Sara: But with that comes precipitous withdrawal, and that, of course is a bigger side effect than most want to deal with. So.

Mike: Back to the Xylazine for a second. I read somewhere that, and I don't know, you know, I've not, I've seen it, but I've heard that there's some tissue damage to it, so that the word on the street is that it rots your flesh.

Sara: I have seen that as well in literature. I have not identified that in any of the case work that we have here. So a couple of things come to mind. As I think about those. I think the drug would need to be injected kind of under the skin and in order to cause that necrosis, to cause an infection at that site that would cause that real unhealing wound.

Sara: If individuals, you know, Google this, you'll find images. They're, they're really gross. They're very, they're very disturbing. So if, if that is something that somebody is struggling with it's certainly an opportunity for our medical personnel to intervene to talk about that wound. How did you get this, you know, how long have you had this, what, you know, what kind of led to this sort of a thing?

Sara: And to maybe be mindful of the fact that that could be a source of it is, is using the Xylazine as an injection. So the cases that we've had, I have not identified any that have those very necrotic unhealing wounds. And we did dig back and look through case work after I was, you know, advised about that.

Sara: I wanted to see if we've just, you know, documented that as something else and really unrelated to the drug use, but I couldn't I, couldn't support that. So we don't have any of those wounds in our casework that we have, but that just may mean that the route of administration was different.

Mike: Sure. Law enforcement tells me that methamphetamine, cocaine are, not that it would ever went away, but it also is making a comeback again, adulterated with a variety of substances.

Mike: Are you seeing that in your office as well?

Sara: We are, unfortunately. And you're right, we never really saw cocaine fully go away. We've had individuals die with cocaine use for, for years and years, and years. What's different now is the combination, about 80% of our cocaine deaths do have Fentanyl on board as well at that time.

Sara: So again, the question rises is where is that originating? Are they consuming one product that contains both cocaine and Fentanyl in it and maybe they don't know, or are they consuming two products you know, fully understanding that one is an opioid and one is a stimulant cocaine or a methamphetamine.

Sara: That speed ball, if you will, a combination of things was real popular in the eighties and it was cocaine and heroin. So maybe we're in a transition to something new with Fentanyl here. Within the office, I've, I've termed it the, the curve ball. I tried to stay with the baseball analogy and maybe allude to the fact that they might not, but that Fentanyl and cocaine combination is extremely popular right now.

Sara: To whether or not they know it, you know, in, in consumption or, or if they know full well that that's what they're consuming and, and it's just the additional risk.

Mike: Sarah, you had to have read about speed ball. You're too young to know about the eighties .

Sara: [laugh] That's very kind of you .

Mike: I, but I'm not, so I actually do remember that.

Mike: Can you tell when you do toxicology, can you tell if somebody dropped it at the same time or if it's in the system at different times of the day, like to go to sleep after a high?

Sara: No unfortunately that's really difficult to discern. You can see sometimes in a metabolism ratio, you know, the parent drug to the metabolite that it was in them long enough that, that the drug did metabolize as opposed to just being in there really acutely without any metabolites.

Sara: And they obviously died very quickly. But it's really difficult to put a timeline together for, for folks without some more information. And something we get asked, you know, once in a while when we do testify in court for things like that and it's really difficult to discern that timeline. Especially if individuals are real chronic consumers where they, they're, they're dosing multiple times during the day to be able to really separate out one dose from the next as it relates to those ratios.

Sara: So real difficult to discern. Once it gets in the body, it's in the body, and that's how we have to interpret it. So I don't know if it came in one at a time.

Mike: And even though people can get healthy again or well. Some of the drugs do permanent damage to the organs in the body and the tissues that doesn't rejuvenate. Correct?

Sara: Correct.

Mike: Now do you see that when you work with somebody who died of let's say alcohol poisoning?

Sara: So these are one questions for the pathologist. Cause they do all of the organ dissection and make notes of those things. But I can say that, that you're correct. We do see some chronicity in those exposures and that causing longer term damage to organs within the system.

Sara: I can't speak about it in any real specifics, you know, of what that damage looks like or how acutely it can show up in a patient. But it is something that is noted in, in those investigations.

Mike: Okay. Now I wanna, speaking of curve ball, can I throw you one?

Sara: Sure.

Mike: Alright, so thanks for answering all of these questions. I know they're really technical, but I find 'em fascinating, I think. How are you supposed to help if you don't know, right. But what you do for a living. Not that this is career day at grade school or anything. But you seem like such an opti..., you're, you are an optimistic person. We've chatted on the phone.

Mike: So is there a fatalism about your work? Do you have a sense of hope? Can we turn it around? Can we get it better?

Sara: I do have a sense of hope. It's a difficult work to do, to constantly be looking at what causes an individual to die, especially as we look at things related to the drug related causes.

Sara: Because all of this really can be categorized into an avoidable death, right? These don't have to happen. But unfortunately, far too many do, and I'm a firm believer that if we continue to have this conversation and we continue to produce the data that we have from our office about what substances are trending and what individuals are using and what could be in that mixture of things that they maybe didn't realize that they could get exposed to.

Sara: If we can provide that data to individuals in harm reduction, to individuals that are using drugs to, to all, you know, a variety of community partners, then we can help to provide some education and hopefully put a, put a turn on some of this. Getting ahead of it with education is obviously a really great place to start. And you gotta start real young, you know, younger than you probably think to start having these conversations about what's harmful and how quickly those addictions can take hold of an individual's life. And, and then you see them transition through a variety of substances. Far too often that's the story.

Sara: So the sooner we get in front of it the, the greater hope I have for, for success in turning this around.

Mike: Oh, that's awesome. I would absolutely endorse that. That's part of what I do for a living is prevention And it's never too early. I mean, we put Mr. Yuck stickers on bleach and whatnot, and you don't see a lot of kids doing that.

Mike: And every drug we've been successful with, you can point back to an educational effort, a large one that resulted in the usage going down. Just look at cigarettes to start with. All of it.

Sara: I, I definitely agree. I think if we put the efforts in the right place, all of that can happen. You know, there's, there's always these masterminds working on the next substance to take the place of the one that was there.

Sara: But as more sophisticated instrumentation is utilized, we can become better predictors of where these trends turn and get ahead of those in identifying the substances just as fast. So it's, it's all good stuff.

Mike: Sounds great. Well, Sarah, I wanna be respectful of your time. I can't thank you enough for joining us today.

Mike: I greatly appreciate it and if we can have you on again down the line. Oh, goodness gracious. Hopefully there isn't some other new drug coming down the pipe, but I'll give you a call again. So, thank you.

Mike: And for those of you listening, I hope you leave this half an hour, a little bit more informed. And until we meet again, please stay safe.

Mike: And I think it's probably common sense. Don't take drugs meant for animals.