Experts: 'killer heroin' may be something else

Posted: Saturday, April 26, 2014 

The so-called “Killer Heroin,” which is blamed for a string of recent overdoses in Bucks County, may contain little — if any — actual heroin.

Instead, it could be all fentanyl, posing a greater risk for users since the powerful painkiller used in street heroin isn’t manufactured by pharmaceutical companies, experts say. The black market fentanyl acts like pure heroin but it’s cheaper, so dealers are more likely to use higher amounts as a cutting agent, significantly escalating the overdose risk.

The popularity of fentanyl-heroin combinations also reflects another trend, which is how modern drug dealers are tailoring their products to match customer demand, according to David Fialko, a prevention specialist with the Drug and Alcohol Council of Southeast Pennsylvania.

And with street heroin, death is a selling point.

“Dealers are, in fact, using a person’s overdose/death as a form of marketing,” Fialko said.

The popularity of the fentanyl-laced heroin also appears to be prompting counterfeit brand-stamps. Ambitious dealers will use the counterfeit stamps to imitate best-selling heroin brands, Fialko said.

The Pennsylvania State Police Drug Law Unit is aware of recent cases where street fentanyl has been marketed as heroin, state police spokesman Adam Reed said.

Two overdose deaths in Bucks County this year, which police initially linked to the popular brand “Bad News” — a fentanyl-tainted heroin — turned out to be the result of “pure” fentanyl, according to the county coroner.

And Coroner Dr. Joseph Campbell said none of the nine confirmed fatal heroin overdoses so far this year have involved the combination, just one or the other.

At least four nonfatal overdoses reported locally in February and March also were linked to the “Bad News” brand, but law enforcement officials haven’t said whether it was the original fentanyl-tainted heroin or a counterfeit brand with 100 percent fentanyl.

As of late March, a Bensalem lab confirmed 45 instances of fentanyl-laced heroin over a four-day period, according to Fialko. The results came from hospitals and drug treatment programs in areas between Camden, N.J., and Reading. Urine samples were sent for comprehensive opioid screening after initially testing positive for heroin.

Last year, heroin was listed as the cause of death in 38 accidental overdose deaths and fentanyl was listed as the cause in four accidental fatal overdoses, according to the annual county coroner’s report. One death was blamed on a fentanyl-heroin combination, the report said.

Fentanyl-tainted heroin returned to the public consciousness after it was suspected in at least 50 fatal overdoses in Pennsylvania, Michigan and Maryland since January, according to news reports. Vermont state police are now warning pure fentanyl is being sold as heroin, and police in Lorain, Ohio, confirmed that black market fentanyl was responsible for 23 overdoses and two deaths in November.

The federal Drug Enforcement Administration recently issued a warning to law enforcement about a circulating heroin brand that contains up to half fentanyl. The DEA is also urging first responders to use “extreme caution” when dealing with street heroin since fentanyl can sicken them if it’s absorbed through the skin.

FAUX HEROIN, REAL RISK

Fentanyl is a narcotic that is typically administered to people in chronic pain, including end-stage cancer patients. It’s also used as an anesthetic. The drug is a synthetic opioid, meaning it contains a chemical that resembles the natural morphine — or opiate — found in the opium poppy.

Opioid and opiate drugs react the same way in the brain, and they kill the same way, by suppressing breathing. Pure fentanyl is 50 to 100 times more powerful than most street heroin, which typically has a 20 percent to 60 percent purity level, Fialko said.

Chemically, the black market and pharmaceutical-manufactured drugs are identical, but that’s where the similarities end, drug experts said.

The street version comes in a powder form, but the legitimate version is manufactured only in gel patches and liquid designed for a slow release. The black market fentanyl is one-tenth the cost to manufacture as pure heroin, Fialko said.

Black market fentanyl is made outside a regulated, sterile medical lab, which means it could be contaminated and its potency level is unknown, said pharmacist Ken Dickinson. He’s a co-founder of SARPH Pa., a substance abuse recovery program for pharmacists and pharmacy students and a marketing director for Gaudenzia, a nonprofit drug treatment center.

To understand why a potentially deadly kind of heroin would attract users, it’s important to understand how the addiction manifests, drug counselors explained. The body builds a tolerance to opiates, meaning that, over time, it takes larger amounts of the drug to achieve a high or prevent painful withdrawal symptoms.

Once an opiate user starts injecting heroin, the addiction accelerates, said Ellen Unterwald, a professor of pharmacology and director of the Center for Substance Abuse Research at the Temple University School of Medicine.

“The reason that fentanyl is preferred over other opioids is because it is very potent and has a very rapid onset of action after IV administration. The more rapid the onset, the faster and more intense the high,” Unterwald said.

But that extra kick also creates extra danger, experts said.

Heroin users base a purchase on tolerance levels, and if a person usually takes a one-bag shot, but that bag is laced with fentanyl, then “they actually are doing a 10- or 20-bag shot at once,” increasing the risk of overdose, said Fialko, the prevention specialist.

Heroin dealers know their street reputations and sales are based on the product. To promote their brand stamp, dealers include one so-called “hot bag” containing fentanyl or pure heroin in every 50 or 100 bags of heroin, said Fialko. Opiate users, particularly heavy users, seek brand stamps associated with overdoses looking for the “prize” or next “great” high.

UNDER THE RADAR

There were 1,013 fentanyl-associated deaths in six states among heroin users between April 2005 and March 2007, according to the U.S. Centers for Disease Control and Prevention. In Bucks County, fentanyl-related deaths spiked to 18 in 2006, then dropped to nine the next year. At least six deaths were attributed to a fentanyl-heroin combination in 2006, according to the coroner.

The monthly death rate dropped to zero after federal agents closed an illegal fentanyl lab in Mexico in 2005, and the DEA started regulating access to a chemical used to make non-pharmaceutical versions of the drug, according to a 2013 CDC report.

At the time, the perception among drug treatment centers and law enforcement was that the deadly drug combination had disappeared, said Shane Moes, director of specialty programs at Livengrin Foundation, a Bensalem substance treatment center. But what more likely happened is that drug dealers made their product less lethal; users adjusted how much heroin they used to avoid an overdose; and/or more people were using prescription opioid drugs instead of heroin, which drug treatment centers didn’t track in admissions until recent years, Moes said.

“We were watching heroin use going down and thought that was great,” Moes added. “(Prescription painkillers weren’t) on the radar.”

One reason it likely took treatment centers so long to recognize the prescription opioid abuse phenomenon is how patients were typically assessed, Fialko and others said. Treatment providers relied on patients self-reporting their drug use and used blood toxicology screens only to confirm the presence of opiates.

And while standard drug screening tests confirm the presence of opiates, they don’t distinguish between synthetics or natural sources, pharmacist Dickinson said.

Until a few years ago, most standard drug tests for opiates checked only for morphine or codeine, Dickinson said. Consequently, a death or overdose would be listed as heroin, when it could have involved fentanyl or another synthetic opioid, which mimic morphine overdoses.

More sophisticated screening tests that looked for a large group of synthetic opiates were available, but most medical professionals didn’t seek them because of the cost, Dickinson and others said. However, with the attention on prescription drug abuse and overdose deaths, detailed toxicology tests have become more standard in recent years.

But Dickinson doesn’t believe that the surge in heroin is dropping anytime soon.

“The trend is not something that (has) peaked yet,” he said.

Jo Ciavaglia: 215-949-4181; email: jciavaglia@calkins.com; Twitter: @jociavaglia