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LORAIN COUNTY COMMISSIONERS MATT LUNDY, TED KALO, LORI KOKOSKI Volume 5, Number 1 JULY - SEPTEMBER, 2016 This newsletter is provided by the Lorain County Crime/Drug Lab discussing technical and general information dedicated to local agencies within Lorain County. The information has been collected from various sources and journals. FENTANYL AND ITS ANALOGUES FENTANYL, a potent synthetic narcotic pain reliever and local anesthetic with a rapid onset and short duration of action, is more potent than morphine. There are more than thirty (30) Fentanyl analogues, but will briefly discuss two (2) analogues due to its potency, Acetylfentanyl and 3-Methylfentanyl. Acetylfentanyl is a designer drug and fentanyl analogue with potency 40 times greater than Heroin and 80 times greater than Morphine. With 14 reported fatal overdoses in Rhode Island, Center for Disease Control (CDC) Prevention issued a health alert in June, 2013. 3-Methylfentanyl (3-MF) is another analogue of Fentanyl that is approximately up to 7,000 times more potent than Morphine depending upon the arrangements of its molecules (cis/trans). This analog is only for research and not for human consumption. This was also identified at the County Crime/Drug Lab and have seen mixed with Heroin. Because of this you ll never know what you are buying, especially when you purchase something like this online! U-47700 U-47700 is a synthetic opioid that is 7.5-fold more potent than Morphine. It was a research drug that was synthesized in the 1970s. This product has been abused also with serious and fatal consequences in North Texas, North Carolina and other states. People who ordered this online became sick in the Dallas- Fort Worth area, thought it was Cocaine. Other areas involving U-47700 across the country led to deaths. [www.keranews.org] In February, the United Nations on Drugs and Crime issued a statement regarding a death that was linked to a combination of Fentanyl and U-47700 in Belgium. The drug has been linked also to deaths throughout Europe, as well, prompting Sweden and Finland to make it illegal. U-47700 poses a risk for potential overdose and respiratory depression. Page 1 of 9

U-47700 poses a risk for potential overdose and respiratory depression, and ultimately a fatal overdose. This drug is only available for research use only, but drug seeking individual will find it in the internet. You never really know what you are buying, especially when you buy something like this through the internet. Governor John Kasich signed an emergency Executive Order to place U-47700 to Schedule I controlled substance on May 3, 2016. www.drugabuse.gov [NIDA] A child s first 8 years critical for substance abuse prevention. T a b l e 1 : T o p 1 0 s t a t e s b y t o t a l F e n t a n y l S e i z u r e s, 2 0 1 4, u n p u b l i s h e d D E A N F L I S d a t a Rank State Number of Fentanyl seizures 1 O h i o 1 2 4 5 2 M a s s a c h u s e t t s 6 3 0 3 P e n n s y l v a n i a 4 1 9 4 M a r y l a n d 3 1 1 5 N e w J e r s e y 2 3 8 6 K e n t u c k y 2 3 2 7 V i r g i n i a 2 2 2 8 F l o r i d a 1 8 3 9 N e w H a m p s h i r e 1 7 7 1 0 I n d i a n a 1 3 3 Source: Centers for Disease Control and Prevention (CDC) Page 2 of 9

LEVAMISOLE ADULTERATED COCAINE A 50-YEAR-OLD MAN presented with a painful rash over his extremities for the past 2 days. He said he had been in his usual state of health until the day he woke up with the rash. The rash was initially limited to his upper and lower extremities, but the next day he noticed similar lesions over his cheek and hard palate. He was a smoker and was known to have hepatitis C virus infection. He denied recent trauma, fever, or chills. He said he had snorted cocaine about 24 hours before the rash first appeared. On examination, his vital signs were normal. He had an extensive retiform rash involving the upper and lower extremities, earlobes, right cheek, and hard palate. Otherwise, the physical examination was normal. LEVAMISOLE AND VASCULITIS Levamisole used to be used as an antihelminthic and as an adjuvant chemotherapeutic agent, but it is also added to cocaine to increase its euphoric and psychotropic effects. 1 It has been withdrawn from the market for human use because of toxic side effects including agranulocytosis, vasculitis, and autoantibody positivity. Levamisole-induced vasculitis is a diagnosis of exclusion but should be strongly considered when the rash is associated with recent cocaine use. If cocaine use is discontinued, the syndrome is expected to resolve. Source: Cleveland Clinic Journal of Medicine; CCJM 2016 Apr; 83(4): 252-253. Reference: Chang A, Osterloh J, Thomas J. Levamisole: a dangerous new cocaine adulterant. Clin Pharmacol Ther 2010; 88:408 411. 3-METHYLFENTANYL (3-MF) 3-Methylfentanyl (3-MF, methfentanyl) is an opioid analgesic that is an analog of Fentanyl. 3-Methylfentanyl is one of the most potent drugs that has been widely sold on the black market, estimated to be between 400 (trans) and 6000 (cis)times stronger than morphine, depending on which isomer is used (with the cis isomers being the more potent ones and trans isomers being the less potent). Page 3 of 9

NATIONAL HEROIN THREAT ASSESSMENT SUMMARY [Source: www.dea.gov] Heroin use has spread to a broader group of users This new population of users is more diverse. Whereas in the 1970s and 1980s heroin use was largely confined to urban populations, heroin use in the 1990s and 2000s spread to users in suburban and rural areas, more affluent users, younger users, and users of a wider range of races, according to academic research. There is no longer a typical heroin user. Heroin in the United States is largely controlled by Mexican traffickers Mexican traffickers have taken a larger role in the U.S. heroin market, increasing their heroin production and pushing into eastern U.S. markets that for the past two decades were supplied by Colombian traffickers. This is notable because Mexican traffickers control established transportation and distribution infrastructures that allow them to reliably supply markets throughout the United States. Heroin is far more deadly to its user population than other drugs Heroin, while used by a smaller number of people than other major drugs, is much more deadly to its users. The population that currently uses prescription pain relievers non-medically was approximately 15 times the size of the heroin user population in 2013; however, opioid analgesic-involved overdose deaths in 2013 were only twice that of heroin-involved deaths. Current cocaine users outnumbered heroin users by approximately 5 times in 2013, but heroin-involved overdose deaths were almost twice those of cocaine. Deaths involving heroin are also increasing at a much faster rate than for other illicit drugs, more than tripling between 2007 (2,402) and 2013 (8,260). ETIZOLAM Etizolam is a benzodiazepine analog. Etizolam is not authorized by the FDA for medical use in the U.S. However, it currently remains unscheduled and is legal only for research purposes. As of March 2016, Etizolam is a controlled substance in the following states due to overdoses: Alabama, Arkansas, Mississippi, Virginia and Georgia. Etizolam is available in other countries, Italy, India, Japan and others. Page 4 of 9

OVER-THE-COUNTER (OTC) PRESCRIPTION COUGH &COLD MEDICINES [Source: www.drugabuse.gov] Some over-the-counter (OTC) prescription cough and cold medicines contain active ingredients that are psychoactive (mind-altering) at higher-than-recommended dosages and are frequently abused for this purpose. These products may also contain other drugs, such as expectorants and antihistamines, which are dangerous at high doses and compound the dangers of abuse. Two commonly abused cough and cold medicines are: Dextromethorphan (DXM, DM), a cough suppressant and expectorant found in many OTC cold medicines. It may produce euphoria and dissociative effects or even hallucinations when taken in quantities greater than the recommended therapeutic dose. Promethazine-codeine cough syrup, a medication that contains codeine is an opioid that acts as a cough suppressant and can also produce relaxation and euphoria when consumed at a higher-thanprescribed dose. It also contains promethazine HCl, an antihistamine that additionally acts as a sedative. Although only available by prescription, promethazine-codeine syrup is sometimes diverted for abuse. How are Cough and Cold Medicines Abused? Cough and cold medicines are usually consumed orally in tablet, capsule, or syrup form. They may be mixed with soda for flavor and are often abused in combination with other drugs, such as alcohol or marijuana. Because they are easily purchased in drug stores without a prescription, cough syrups, pills, and gel capsules containing DXM particularly extra strength forms are frequently abused by young people (who refer to the practice as robo-tripping or skittling ). To avoid nausea produced by high doses of the expectorant quaifenesin commonly found in DXM-containing syrups, young people may instead abuse Coricidin HBP Cough & Cold capsules (street name C-C-C or Triple-C), which contain DXM but lack quaifenesin. Label will include Dextromethorphan as active ingredient (e.g., Robitussin-DM, etc.) Drinking promethazine-codeine cough syrup mixed with soda (a combination called syrup, sizzurp, purple drank, barre, or lean) was referenced frequently in some popular music beginning in the late 1990s and has become increasingly popular among youth in several areas of the country. A variation of purple drank is promethazine-codeine syrup mixed with alcohol. Users may also flavor the mixture with the addition of hard candies. Page 5 of 9 DEATHS FROM OPIOID OVERDOSES

Despite increased public efforts to combat opioid abuse, the number of deaths from heroin overdoses surged by 28 percent in 2014, and fatal overdoses from prescription painkillers climbed by 16.3 percent, according to federal health officials. The 10,574 heroin deaths and the 18,893 deaths from prescription opioids were two big contributors to a sharp increase in fatal drug overdoses last year -- a total of 47,055, up 7 percent from 2013, according to the National Center for Health Statistics. The heroin overdose figure was more than three times higher than the 2010 tally. Overall, the CDC said, 47,055 people died from drug overdoses in 2014. That was the same total released by the National Center for Health Statistics, which put out its data last week. Overdose fatalities from heroin alone have more than tripled since 2010, reaching 10,574 last year. West Virginia, New Mexico, New Hampshire, Kentucky and Ohio had the highest rates of drug overdose deaths per 100,000 people. North Dakota, New Hampshire, Maine, New Mexico and Alabama saw the largest increases in their death rates. Page 6 of 9 LORAIN COUNTY CRIME/DRUG LAB Analyzed Drugs: 2015

2015 2014 PRESCRIPTIONS NUMBER PRESCRIPTIONS NUMBE R Alprazolam 295 Oxycodone 268 Hydrocodone 110 Alprazolam 213 Tramadol 52 Hydrocodone 102 Amphetamine 42 Tramadol 66 Lorazepam 30 Diazepam 43 Buprenorphine 24 Methadone 33 Lisdexamfetamine 22 Clonazepam 29 Clonazepam 19 Methyphenidate 29 Morphine 17 Buprenorphine 26 Oxymorphone 17 Amphetamine 25 Diazepam 16 Suboxone 23 Hydromorphone 14 Fentanyl 17 Methadone 14 Hydromorphone 14 Zolpidem 12 Oxymorphone 9 Midazolam & Ketamine 2 Morphine 3 Generic Name Brand Name Alprazolam Hydrocodone Tramadol Amphetamine Lorazepam Buprenorphine Lisdexamfetamine Clonazepam Morphine Oxymorphone Diazepam Hydromorphone Methadone Zolpidem Midazolam Ketamine Xanax, Xanax XR, Niravan Zohydro ER, Hysingla ER Ultram, ConZIP Adzenys XR-ODT, Dynavel XR, Evekeo Ativan Buprenex Vyvanse Klonopin Avinza, Kadian, MS Contin Opana, Numorphan HCl Valium Dilaudid, Exalago, Dilaudid-5 Dolophine, Methadose, Diskets Ambien, Ambien CR, Edluar, Intermezzo Versed Ketalar Page 8 of 9 LORAIN COUNTY CRIME/DRUG LAB Analyzed Drugs: 2015

*FENTANYL, HEROIN, COCAINE NUMBER 6-MAM, Heroin 423 Heroin 45 Fentanyl 23 6-MAM, Heroin, Fentanyl 18 Heroin, Fentanyl 9 Acetyl Fentanyl, Fentanyl 8 6-MAM, Heroin, Acetyl Fentanyl, Fentanyl 7 Heroin, Acetyl Fentanyl, Fentanyl 7 Morphine, 6-MAM, Heroin 6 Cocaine, 6-MAM, Heroin 5 6-MAM 5 6-MAM, Heroin, Acetyl Fentanyl, Fentanyl 4 6-MAM, Morphine 1 Heroin, Acetyl Fentanyl 1 Cocaine, Fentanyl 1 Cocaine, 6-MAM, Heroin, Fentanyl 1 6-MAM, Fentanyl 1 6-MAM, Acetyl Fentanyl, Fentanyl 1 Cocaine, Heroin 1 TOTAL 567 *Analyzed drugs above only describe this specific category. Compiled by: Emmanuel G. de Leon Director, Lorain County Crime/Drug Lab The information gathered for this newsletter is not necessarily the opinion of the County Crime/Drug Lab staff. The LabINFO Newsletter is solely available for informational purposes only. Page 9 of 9