OPIATES FROM PILLS TO HEROIN Pat Kneip Special Assistant Attorney General Drug Diversion Investigator S.D. Division of Criminal Investigation
What I Will Cover OBJECTIVES: DESCRIBE THE EXTENT OF THE CURRENT PROBLEM OF DIVERSION AND ILLICIT USE OF CONTROLLED SUBSTANCES FROM THE NATIONAL AND SD PERSPECTIVE OUTLINE THE RELATIONSHIP BETWEEN PRESCRIPTION OPIOID DRUGS AND HEROIN, HOW THESE DRUGS ARE GETTING HERE, THE SCIENCE BEHIND IT, AND WHAT WE CAN DO NOW!
History - Opiates, derived from opium poppy, have been used recreationally and medicinally for thousands of years. Sixteenth century opium was pared with an alcoholic solution to form a painkiller. Nineteenth century morphine is extracted from opium in pure form and used as a painkiller, especially during the American Civil War.
PRESCRIPTION PILLS Prescription Narcotics are the most used and abused substances in America today. From 00 to 13, the amount of painkillers prescribed and sold in the U.S. quadrupled, and along with this, overdoes deaths quadrupled as well. The US constitutes 4.6% of the world s population and consumes 99% of the world s hydrocodone supply Vicodin Est. 1984 OxyContin (Oxycodone) Est. 1995 Hydrocodone Est. 1920 s
WHAT HAS AMPLIFIED THE PROBLEM? AKA, HOW DID WE GET HERE? WHAT CAN WE CHANGE? Mid 1990 s Pain is the Fifth Vital Sign increased opioid pain reliever (OPR) prescribing Unrealistic expectations of the health consumer for zero pain and immediate gratification Social acceptance and the perception of safety by parents and youths Lack of understanding about risks Lack of resilience skills in our youth Storage of Prescriptions in areas accessible to friends and family Imbalanced doses (e.g., Oxycodone 30mg for wisdom teeth removal) 5
EPIDEMIC OF OPIOID ADDICTION New way of thinking: A Disease epidemic, not a Behavior epidemic - Opioid Addiction vs. Opioid Abuse Opioid Addiction is chronic, life-long, difficult disease to treat and is a key driver to opioid related morbidity and mortality Primary prevention includes reduction in disease through medical and non-medical exposure reduction more cautious and selective opioid prescribing Secondary Prevention includes increased screening for the disease after onset before major consequences difficult because patients try to conceal history PDMP is key Tertiary Prevention includes rehabilitative and therapeutic measures to ultimately prevent overdose death from OPR or Heroin expansion of treatment options 4 of 5 heroin users report that their addiction started with OPR use (previous statistics rate this as a much lower percentage, including those on the next page) Annual Review of Public Health 2015, 36:25.1-25.16, Kolodny,. et al; The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction,
In the United States, prescribe enough pain pills to give every man, woman, and child 1 every 4 hours, around the clock, for 3 weeks. ALARMING STATISTICS 5,784 adolescents used prescription pain relievers non-medically for the first time on an average day during the last year In 2013, more than 44,000 people died in the United States as a result of a drug overdose (120 people per day). In 2016, more than 64,000 people died as the result of a drug overdose (176 people per day), 2/3 of those from opiods. The latest data from 2013 shows that drug poisoning deaths involving opioid analgesics, surpasses the deaths due to cocaine and heroin combined
NUMBER OF PILLS PRESCRIBED IN SOUTH DAKOTA Opiate Opiate Ambien Benzo Sedative Benzo Sedative Benzo Sedative Amphetamine Amphetamine Opiate Opiate Opiate Ambien Benzo Sedative Opiate Benzo Sedative Benzo Sedative Amphetamine Amphetamine Opiate Opiate December Most Prescribed Drugs RX's Quantity Days Supply Quant/Rx HYDROCODONE BITARTRATE/ACETAMINOPHEN 25,002 3,476,381 644,918 139 TRAMADOL HCL 15,353 1,202,306 288,879 78 ZOLPIDEM TARTRATE 8,832 290,691 287,967 33 LORAZEPAM 8,441 424,684 201,909 50 CLONAZEPAM 7,709 953,874 472,064 124 ALPRAZOLAM 5,826 339,117 152,422 58 DEXTROAMPHETAMINE SULF-SAC/AMPHETAMINE SULF-ASP 5,689 256,577 170,672 45 METHYLPHENIDATE HCL 5,259 239,909 159,658 46 OXYCODONE HCL 4,968 417,394 94,589 84 OXYCODONE HCL/ACETAMINOPHEN 4,884 631,418 120,184 129
35.5 MILLION doses of opiates (582,048 Prescriptions) were prescribed to South Dakotas in 2014. Enough to medicate every South Dakota adult 24 hrs/day for 14 straight days. 82 Opioid Deaths between 2004 to 2011 (approximately 10 per year). 2013 = 17 Opioid Deaths 2014 = 16 Opioid Deaths (including one death where heroin was present) 2015 = 1 Heroin OD resulting in Death and multiple OD s resulting in hospital visits. 2018 = 9 overdoses in 9 straight days in Sioux Falls, 2 resulting in death. Narcan HOW IS SOUTH DAKOTA DOING?
WHERE ARE THESE CONTROLLED PRESCRIPTION DRUGS COMING FROM?
USING PILLS Prescription Pill Addiction (Caution: Language)
PRESCRIPTION PILL DECLINE TURNED TO HEROIN INCREASE In 2010, funded by DOJ grants, the Prescription Drug Monitoring Program (PDMP) was founded. In 2013 Federal regulations were released recommending stronger restrictions. In 2015 South Dakota Hospitals began to closely monitor Doctors prescriptions. Reports indicate up to 66% of opiate pill addicts move into heroin (NEJM.org)
INTRODUCING HEROIN
From Plant to Drug Heroin originates from countries such as Mexico, and across southern Asia from Turkey to Pakistan. After the poppy plant pedals have fallen an egg-shaped seed pod is exposed. Inside the pod is an opaque, milky sap. This sap is opium in its crudest form. To get to the sap producers will slit the pod and once the sap seeps out will scrape it with a knife. This sap will be formed into balls/cakes and shipped to heroin labs. Opium-Morphine-Heroin
FROM PLANT TO DRUG CONTINUED Once at the lab the opium will be mixed with lime in boiling water. At the surface of the water a white band of morphine forms. This morphine will be reheated with ammonia, filtered and boiled again until it is reduced to a brown paste. First, equal quantities of morphine and acetic anhydride are heated in a glass or enamel-lined container for six hours at 185F. The morphine and the acid combine to form impure diacetylmorphine. Second, water and chloroform are added to the solution to precipitate impurities. The solution is drained and sodium carbonate added to make the heroin solidify and sink. Third, the heroin is filtered out of the sodium carbonate solution with activated charcoal and purified with alcohol. Fourth, this solution is gently heated to evaporate the alcohol and leave heroin, which may be purified further. At this point the heroin is Black Tar (Dirty)
In order to complete the production of heroin the black tar must go through a process called acetylation. Acetylation includes using acetic anhydride, a colorless, highly combustible liquid. After 5 hours of cooking a mixture of water, acetic acid, and diacetylmorphine (heroin), water and chloroform are added. This base is treated with charcoal and filtered leaving a light brown or white powder. PURIFYING HEROIN
Heroin CHEMISTRY MAKEUP Hydrocodone Morphine
HOW DOES IT GET HERE?
WHAT TO LOOK FOR
Watch for the Signs What does withdrawal look like?
WHO IS USING HEROIN
HOW DO THEY SUPPORT THEIR HABIT? LIE THEFT ROBBERY BURGLARY MOTOR VEHICLE THEFT BEG MANIPULATE Etc.
COST COMPARISON Heroin $10 - $25 per dose $80 - $100 a gram $225 a 8 ball $350 - $400 a ¼ ounce $700 a ½ ounce $1400 a ounce Beginning User = $20 - $50 a Day Heavy User = $150 - $170 a Day Purity Average = 7%-10% Hydrocodone $1 - $3 a milligram Pill sizes: 5mg - 7.5 mg - 10 mg Beginning User = 20 mg-30 mg a time approximately 50-60 mg a day ($50-$100) Heavy User = 200 mg a day ($200-$500)
HEROIN USER REVIEWS From the day I started using, I never stopped. Within one week I had gone from snorting heroin to shooting it. Within one month I was addicted and going through all my money. I sold everything of value that I owned and eventually everything that my mother owned. Within one year, I had lost everything. I sold my car, lost my job, was kicked out of my mother s house, was $25,000 in credit card debt, and living on the streets of Camden, New Jersey. I lied, I stole, I cheated. I was raped, beaten, mugged, robbed, arrested, homeless, sick and desperate. I knew that nobody could have a lifestyle like that very long and I knew that death was imminent. If anything, death was better than a life as a junkie. (drugfreeworld.org)
The Face of Heroin THE NEW HEROIN ADDICT
FENTANYL AND ACETYL FENTANYL A strong synthetic opioid medication first developed in the 1960 s. Fentanyl is 50 to 100 times more potent than Morphine and 15 times stronger than Heroin. Available in patch form, pills, and lollipop. Scheduled II Substance. WEAR PERSONAL PROTECTION EQUIPMENT IF HANDLING! Field Testing for Law Enforcement? Illegally produced, Acetyl Fentanyl is a closely related cousin to Fentanyl. Less potent than Fentanyl, it delivers the same in vitro binding affinity to the opioid receptors. Acetyl Fentanyl comes in a white powder form. Scheduled I Substance. WEAR PERSONAL PROTECTION EQUPMENT IF HANDLING!
FENTANYL VS ACETYL FENTANYL
WHAT TO DO NOW? BE THE POLICE! Use the Prescription Drug Monitoring Program (PDMP) Work with Hospital Staff (are they telling you when an OD comes in) Share Intelligence Develop sources of information.
QUESTIONS?