Drugs of Abuse. Effects of Opioids. Prescription Drugs. Types of Opioid Drugs. Prescription Drugs. Side Effects of Opioids 1/10/2018

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1 Drugs of Abuse Brian Sallee BBS Narcotics Enforcement Training & Consulting, LLC Prescription Drugs More overdose related deaths from prescription drugs than any illegal street drug More drug overdose deaths than traffic accidents 2 Prescription Drugs Methods to obtain drugs Mom and Dad are #1 dealer to kids Theft from medicine cabinet Steal for friends medicine cabinets Most people don t keep track of the number of pills they have Types of Opioid Drugs There are three basic of types of opioid drugs Natural opiates from the resin of the poppy plant Morphine and Codeine Term opiate technically describes only natural opiates others are opioids Semi-synthetic opioids are created from natural opiates with use of other chemicals Hydrocodone, oxycodone, buprenorphine Synthetic opioids are chemical/drug which mimics the effects of an opiate drug, Tramadol, Lorcet, Methadone 4 Effects of Opioids Side Effects of Opioids Opioids increase feelings of pleasure by altering activity in the limbic system, which controls emotion. Abuse and misuse of Opioids can lead the user to feel a rush of euphoria and pleasure Opioids can block pain messages transmitted through the spinal cord up to the brain Opioids act by attaching to specific proteins that are located in our brain, spinal cord, and organs. Opioids will bind to these protein receptors, and reduce the perception of pain There is a tolerance build up with all different types of opioids With street opioids the user needs the drug more often as the high does not last as long and then they will have to use more of the drug With prescription opioids the time frame of the elimination of the pain shortens so the user uses more of the drug to obtain pain relief 6 1

2 Side Effects of Opioids Withdrawal of prescription opioids has the same difficulties as we have learned from heroin addicts Symptoms include nausea, vomiting, chills, insomnia, muscle and joint pains, slowed breathing and headaches Treatment for withdrawal often needs medical treatment Detox, rehabilitation, 12 step program or other types of therapy Effective Use of Opioids Bioavailability- This is a pharmacology term, the absorption method or route in which a medication or substance enters the body and how much of the substance is absorbed by the body Taking an Opioid orally the bioavailability is 20% because the substance is filtered through the organs such as kidneys and liver So you only feel 20% of the effects So instead you decide to use a different delivery method to increase the percent of the substance so the effects are more enhanced. Smoking or snorting may bump that 20% up to 60% Injecting intravenously may bump the bioavailability up to 90%!!!!!!! 7 8 Effective Use of Opioids It is very common for first time drug users to favor the least intrusive method of absorption Unfortunately as the addiction grows and gets worse, these individuals switch to a different method Prescription Opioids There are many legitimate reasons for a person to use a prescription opioid drug Even using an opioid drug properly there is a risk of becoming addicted Over prescribing the different opioid drugs is part of the problem Over 207 million opioid prescriptions were written in Prescription Opioids Prescription Drugs Some of the reasons to use a prescription opioid drug besides pain reliever, which is the most common reason Cough suppressant- liquid form Suppress diarrhea- opioids cause constipation Shortness of breath- advanced diseases such as cancer or COPD (chronic obstructive pulmonary disease) Seems odd since one dangerous side effect is severe respiratory depression United States has 5% of the world s population but uses 80% of all prescription opioids 91+ opioids overdoses each day in the US Unit

3 Prescription Drugs 5 top states with drug overdose deaths: West Virginia New Mexico New Hampshire Kentucky Ohio 2015 NM now ranked #8 13 Prescription Drugs Methods to obtain drugs Mom and Dad are #1 dealer to kids Theft from medicine cabinet Steal for friends medicine cabinets Most people don t keep track of the number of pills they have 14 Prescription Drugs The prescription drug getting the most media attention is OxyContin OxyContin is the trade name for the narcotic drug hydrochloride OxyContin is time released hydrochloride Available in different does amounts 10mg, 20mg, 40mg and 80mg mg is milligrams Pill had OC or OP on one side and the dose amount on the other side 15 Legitimate use of oxycodone is for long term pain relief Used by cancer patients, arthritis and injuries Designed to give pain relief for 12 hours Doses from 10mg to 80mg per pill Certain pills contain other drugs in them Percodan- oxycodone and aspirin Percocet- oxycodone and acetaminophen 16 With the use of opioid prescription there will be tolerance build up with the user This is normal over time with any user of opioid drugs Not everyone considers this addiction Can be considered addicted if they have to use drugs to avoid any type of pain Emotional pain Physical pain Familiar pain 17 Within the medical profession there is a fear of being investigated by law enforcement or being accused of over prescribing the drug OxyContin is listed as a drug of concern by the DEA This increases oversite and investigations involving OxyContin Monitoring is also being done by Perdue Pharma the maker of OxyContin 18 3

4 OxyContin OC pills were time released but it was easy to crush the pill and defeat the time release Now pills have been reformulated and have OP stamped on them Purdue pharmacy claims pills cannot be crushed and defeat the time release Drug abusers report the OP can be defeated Heat it up until it is melted and then freeze it Then crush the remains Then smoke or inject it Pharmacists advise people are not refusing the OP pills like they used to Perception is reality in the drug trade Smoking Effects of abused OxyContin Produces an euphoric rush and feeling to the user How is it used determines how quickly the effects hit the user Injecting and smoking give the quickest effects Effect is very similar to heroin Abuse of OxyContin will result in the user developing a tolerance to the drug Requiring more of the drug to get the euphoric effect being sought Long term abuse can create a physical addiction Short term will create a psychological addiction OxyContin abusers switch to heroin due to the cheaper cost for the same type of high Pills can run $1.00 per milligram so a single pill can cost as much as $80.00 Dose of heroin $

5 As users find it more difficult to buy or steal OxyContin they switch to heroin which is much cheaper per dose Danger with heroin versus OxyContin is unknown purity Hydrocodone Hydrocodone is the #1 abused opioid- even more than (OxyContin) Due to abuse drug was moved from Schedule III to a Schedule II This creates more control and restrictions on its prescribing to the public Estimates 99% of worldwide supply of hydrocodone was used in the U.S. (2007) Hydrocodone Hydrocodone is a semi-synthetic opioid synthesized from codeine Synthesized in 1920 by German chemists Pharmaceutically only designed to be taken orally Many brand names- Vicodin, Lortab, Lorcet, Maxidone, Norco, Zydone Hydrocodone Hydrocodone is habit forming as with other opioid drugs It has both physical and psychological addiction qualities Some adverse side effects Nausea, vomiting, dizziness, constipation and anxiety Abnormally happy and sad moods Hydrocodone Hydrocodone is designed for moderate to severe pain (pill) and cough (liquid form) Potency is less than (OxyContin) is 50% more potent than Hydrocodone When used for pain relief both have approximately same effectiveness Many have mixture of other drugs Hydrocodone One form of hydrocodone is in pure form and brand name is Zohydro ER (Zogenix Pharmaceuticals) Approved by FDA in 2014 This form is up to 5 times more active opioid as the highest strength in mixture form Zohydro ER is intended to be slowly released over 12 hours Doses from 10mg to 50mg per pill- increments of 5mg

6 The illicit heroin trade started up right after the passage of The Federal Act (Harrison Narcotics Tax Act of 1914) Demand did not go away just because heroin was outlawed is smuggled into the United States from different locations around the world Illicit labs are created around the world to manufacture heroin is a schedule I drug Active chemical is Diacetylmorphine Opium to Morphine which is treated with acetic anhydride changing it into does not require a chemistry lab to produce It can be made outside with the proper chemicals Increase in quantity and quality of heroin coming from Mexico Mexican Drug Cartels are increasing their involvement in the heroin trade More poppy fields being grown in Mexico than ever Poppy plants provide the opium for making heroin Profits and increased use in the U.S. are reasons for Mexican Cartels involvement Over 47,000 drug overdose deaths a year Over 24,000 of these deaths are heroin/opioids overdose deaths Increase of heroin users in United States 2007 had 106,000 users 2014 had 212,000 users This increase mirrors the increase of opioid prescription drugs abuse There are three basic types of heroin Tar heroin Brown heroin White heroin The type or color of the heroin does not determine the quality of the heroin (purity) It is an indicator where it was produced Tar and brown heroin indicates South America or Mexico White heroin from Middle East or Southeast Asia 35 Powder White powder most likely from Golden Triangle or Golden Crescent Brown powder indicates that it comes from Mexico Powder tends to be granular in appearance similar to sugar 36 6

7 Tar Looks like roofing tar Sticky like tar Odor of vinegar Controlled Substances not one of the four basic food groups do not taste or smell Tar comes from Mexico Most common type of heroin in Southwest When a person first shoots up there is a euphoric feeling This can last for several minutes Next the person goes into the nod stage This can last for hours A person can go into withdrawals 6-12 hours after shooting up Withdrawal can last for days to weeks Danger with the heroin use is lack of control can range from 7% to 80% purity This lack of control of purity can result in hot shots of heroin Overdose from too high of purity of heroin Trends of Mixtures w/ Xanax Is a benzodiazepine which is used to assist people anxiety disorders and panic disorders Oral dose is 0.25 to 0.5 mg per pill Generic name: Alprazolam / is not always strong enough for the addict so dealers/users want to increase the high by adding other drugs One method which has made a comeback around the country is adding fentanyl to heroin / This was trend in the Upper Midwest area approx. 20+ years ago Chicago PD had so many overdose deaths they made PSA warning public Increased drug sales in areas where heroin/fentanyl combination was sold George Marquardt Considered main person responsible

8 / Trend now in the Northeast portion of the country DEA estimates that nationwide over 2000 overdose deaths from heroin laced with fentanyl Over 755 overdoses in Massachusetts and 247 in Rhode Island In One of the worst years ever Nearly half of these overdoses were heroin/fentanyl mixture Mix just a few tablespoons of fentanyl with one kilogram of heroin It is in New Mexico too History of has several brand names Actiq, Duragesic, Fentora, Matrifen, Haldid, Onsolis, Instanyl and others First synthesized in 1959 by Paul Janssen Used as a surgical anesthetic Safe when properly monitored Accurate measurement of a dose of pure fentanyl cannot be measured without proper scientific equipment Amount between lethal dose and effective dose is not detectable with naked eye doses are in micro-grams or one millionth of a gram How much? Who knows? The Duragesic (fentanyl transdermal system) patch is a powerful opioid pain medication for moderate to severe chronic pain. is a pain killer which is 80 times stronger than morphine and 50 times stronger than heroin Schedule II drug Often prescribed in a patch for time release Patch contains in gel form Powder form has a similar appearance to cocaine Because the drug is not completely eliminated from the patch even after a three-day period of use, discarded patches remain a soughtafter commodity by some abusers, and can pose a risk to young children who may come into contact with them. Also sold in liquid form Different influxes of illicit fentanyl over years over 1,000 overdose deaths Currently DEA has identified 15 other fentanyl related compounds These are not pharmaceutical grade and are Schedule I substance Coming from Mexico and China Often produced in illicit labs in Mexico Illicit forms of fentanyl first came up from Mexico A few fentanyl labs have been seized in the US In 2015 Canada saw an uptick in fentanyl overdoses Imported in from Asia

9 Side effects of Many side effects are similar to other opioid type depressants Slow heart rate Unusual thoughts or behavior Dry mouth Constipation White patches or sores inside of the user s mouth or lips Other effects Nervous system side effects which include mental and respiratory depression Stupor Muscle rigidity often involving the respiratory system which will further effect the depression Seizure like events- which could be as result of rigidity Counterfeit pills containing fentanyl Seizures around the country where pills appear to be or hydrocodone pills One example in Arizona over 2,000 pills were blue in color and stamped with an M on one side and 30 on the other 30 is common designation for 30 milligrams or amount of drug in a pharmaceutically made pill Approx. 1,000 counterfeit pills can be made from 1 kilo of fentanyl With 1 mg per pill Profit can be potentially $20,000,000 Sales at $20 per pill Requires a pill press, fentanyl and other powder Routes of exposure Inhalation, ingestion or skin contact Adverse reactions can be: Disorientation, coughing, sedation, respiratory distress and cardiac arrest Reactions can be extensive and sudden; occurring within minutes Officer safety issues Lethal dose of heroin can be approx. 30mg and lethal dose of fentanyl can be 3mg can be absorbed through the skin or inhaled Recommend use of nitrile gloves and unknown respiratory protection- Avoid field testing inside rooms or car Done in well ventilated area DEA recommends testing in lab Extreme danger to drug canines Broward County SO had 3 dogs exposed and treated for overdose of fentanyl

10 Carfentanil Carfentanil is a synthetic opioid and is a schedule II drug Used to tranquilize/immobilize large animals such as elephants It is 10,000 times more potent than morphine 100 times more potent than fentanyl Lethal dose for humans is unknown Carfentanil Carfentanil comes in several forms Powder- appearances similar to heroin or cocaine Blotter paper Pills Spray Carfentanil Carfentanil is being shipped into the U.S. from several different foreign countries Primary country appears to be China Listing of many Chinese companies selling Carfentanil over the Internet One listing for a kilogram of Carfentanil was $8, Mixed with heroin but danger is such a small amount is lethal Dealer cannot be sure it was mixed or diluted down in heroin Carfentanil Carfentanil may have the appearance of heroin or cocaine Over 400 seizures of Carfentanil in U.S. Confirmed seizures in 8 states- Ohio, Florida, Kentucky, Indiana, Michigan, Georgia, Illinois and Rhode Island 34 seizures in Florida Carfentanil Ohio has seen an increase in overdose deaths with heroin now mixed with Carfentanil There has been more overdose deaths in the first six months of 2016 than all of 2015 There has been 118 overdose deaths in the first six months of Synthetic Substitute UT47700 An opioid analgesic drug developed in the 1970s Analgesic is It has only been used in research and not on the open market No legitimate use of the drug Chemical is 7 to 8 times more potent than morphine based on animal testing Primarily manufactured in China and sold on the internet on various websites Often sold openly until noticed 60 10

11 Synthetic Substitute U47700 Appearance Sold as powder- often a bright white or yellowish Light consistency powder Powder can be pressed into pill form Gram of U47700 costs $35.00 to $55.00 Liquid form in droppers or spray bottle Similar drugs are U and AH-7921 Synthetic Substitute Street names- Pink, Pinky, U-4 or PH The U is for Upjohn Pharmaceutical 61 U47700 suspected for deaths of two 13 year olds 62 W-18 Synthetic Substitute W-18 is a chemical first synthesized at the University of Alberta in 1981 It is mistakenly thought to be a opioid Research has shown it does not bind to opioid receptors so it is not an opioid though many claim it as an opioid Narcan is not effect in case of an overdose Potency is 100 times more than fentanyl and 10,000 more than morphine 63 Synthetic Substitute Appearance of W-18 Powder form is a bright white in color Similar appearance to fentanyl Sold over the internet due to not being scheduled as of July 2016 It is a scheduled I drug in Canada 64 Synthetic Substitute Grey Death This drug is not a single drug but a mixture of various opioids Often mixture of UT47700, heroin and fentanyl Quantities of each drug will vary with each mixture Its appearance- looks like powder concrete or a greyish powder or chunky material Grey Death can be injected, ingested orally or smoked Overdose from this drug in Georgia and Alabama 2 in each state- one of the overdoses in Alabama resulted in death 65 is the brand name of a combination of two drugs Buprenorphine and Naloxone Buprenorphine is an opioid medication which produces less euphoric high so it is easier (or thought to be) to stop taking the drug Naloxone is a drug which blocks the effects of opioids (Narcan) Together the drugs are used to treat Opiate addiction 66 11

12 While this drug is used to assist people with getting off opiates such as heroin/oxcontin it has an addiction quality to it also is being used as a replacement for methadone This is when the drug is taken properly for this purpose which is orally Can be used by persons over the age of 16 comes in two forms Tablets Film The drug is placed under the user s tongue and let it dissolve This is for both tablets and film The film was designed to dissolve quicker than a tablet Tablet takes 2-10 minutes to dissolve Film is said to taste better than a tablet As with any opiate drug effects the user s brain and body has a physical and psychological dependency quality to it Over time the brain no longer functions normally without Effecting many functions especially those involved with judgment and caution 69 Common effects on user of Headache- 36% Insomnia- 14% Nausea- 15% Constipation- 12% 70 Side effects/overdose of the drug Yellowing of the skin or eyes Nausea Slow breathing Dizziness or confusion Coma Similar effects to heroin Smuggling of can be done different ways Pill form- crush the pill up and smuggle the crushed pills In pill form can try to claim it is another pill but if someone checks it is easy to ID as Shape of the pill and markings on the pill

13 The film makes to an ideal drug to smuggle into a controlled environment Another method is smuggling the strips between items Such as paper, pages in books Strips can be concealed easily Trends of Mixtures w/ Watch for new trends as heroin becomes more popular people will look for ways to make the drug stronger or give a different high This will increase the danger of overdose by the users How Opioids kill People die because they stop breathing Prolonged hypoventilation complications include hypercarbia, hypoxia, aspiration, respiratory arrest and death Generally occurs between 1-3 hours. The chances of a person dying with the needle in their arm is only about 15% 75 Opioid Overdose Narcan Normal Heavy uncontrollable nodding Drooling Heavy breathing or snoring Responsive with stimulation (sternum rub) Overdose Very shallow breathing Gurgling sounds Blueish lips and fingernails Nonresponsive Naloxone hydrochloride is the name of Narcan It is a liquid which is administered through different methods Injection- remember the scene in Pulp Fiction Nasal spray- this is method police departments are issuing to their officers 78 13

14 Why Intranasal? Works almost as quickly as IV route since nasal mucosa is highly vascularized and absorbs drugs directly into the blood stream Considered an antagonist Narcan Blocks the ability of opioids to do what they do Part of what opioids do is get the body to slow down including breathing With an overdose the person s breathing slows to a point where they stop breathing Think of it as heroin wraps around the receptor and shuts the respiratory system down Narcan knocks the heroin off the receptor so the person breathes again 80 Narcan Narcan only works on opioid overdose It removes the effects of the opioid and can have the user feel like they are in withdrawal It takes effect in 2-5 minutes Effect of Narcan is short lived in comparison to the effects of the opioid Narcan will last minutes So if person is not watched they can overdose again when the Narcan wears off Recommend they are watched by medical personnel for several hours Narcan Harmless- for people without opioids in their systems Will not reverse overdoses caused by nonopioids Cocaine, Meth, Benzos, Alcohol, Ecstasy 81 Narcan Danger for first responders is the reaction of the person when they come out of the overdose Most common response is anger You blew my high Even physically attacking the first responders Narcan OD or overdose party People will intentionally overdose because that is the greatest high Have someone there with Narcan to administer it before it is too late to bring the person back

15 Narcan Should the police be given Narcan to administer to people overdosing? Does it differ between urban versus rural police officers? Is it a police function or a medical function? Brian Sallee BBS Narcotics Enforcement Training & Consulting, LLC brian@bbsnarctraining.com Website: Phone: