Heroin and Other Opioids: A Wisconsin Epidemic? | Wisconsin Public Television

Heroin and Other Opioids: A Wisconsin Epidemic?

Heroin and Other Opioids: A Wisconsin Epidemic?

Record date: Apr 19, 2017

Lori Edwards, Senior Chemist at the Wisconsin State Laboratory of Hygiene, discusses the history of opium use in society and in Wisconsin. Edwards looks at narcotic impairment indicators and presents case studies of individuals using opioids.

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Episode Transcript

- Welcome, everyone, to

Wednesday Nite @ the Lab.

I'm Tom Zinnen.

I work here at the UW-Madison

Biotechnology Center.

I also work for UW-Extension

Cooperative Extension,

and on behalf of those folks and

our other co-organizers,

Wisconsin Public Television, the

Wisconsin Alumni Association,

and the UW-Madison

Science Alliance,

thanks again for coming to

Wednesday Nite @ the Lab.

We do this every Wednesday

night, 50 times a year.

Tonight, it's my pleasure to

introduce to you Lori Edwards.

She's with the Wisconsin State

Laboratory of Hygiene.

She was born in

Stoughton, Wisconsin,

graduated from Stoughton

High School,

and then got her undergraduate

degree in biology

at the University of Wisconsin-

La Crosse

and also her master's

at UW-La Crosse.

Then she worked for the

US Geological Survey,

and about 16 years ago started

at the State

Laboratory of Hygiene.

Tonight she's going

to talk with us

about a rather sobering

issue in Wisconsin,

the issue of

heroin and other opioids

running through Wisconsin now.

Is it epidemic with us

and what can we do about it.

Please join me in

welcoming Lori Edwards to

Wednesday Nite @ the Lab.

[applause]

- Let's see if this works.

Can you hear me all right?

- Yes.

- All right, thank you

so much, Tom,

and I'm going to

tell you right now

that I am not that funny.

So you got your

chuckles in for the night.

The State Lab

of Hygiene

is your state

public health lab.

We have recently been adopted

into the School of Medicine

and Public Health here at UW.

So I am very proud to represent

the forensic toxicology section.

A couple of my colleagues

are here tonight,

and a shout out to those who

might be listening remotely.

I'm going to introduce you to

the forensic toxicology section

at the Hygiene Lab and tell you

a little bit about what we do,

and then the majority of my

presentation, of course,

is going to focus on heroin

issue in our state,

also other opioids in Wisconsin.

It turns out this is not the

only time in history

where heroin has reared

its ugly head.

It has a very interesting,

I found,

very interesting

history originating

from the opium plant.

And so I'll include a

little bit of information

on the formation, chemistry,

and the metabolism

of heroin and other opioids

in the human body.

And then the forensic challenges

that we experience at the

Hygiene Lab in trying to

determine whether or not someone

is driving under the influence

of heroin or perhaps have died

as a result of using heroin

and other opioids.

And last, I'll try

to keep on time,

I have some

case studies.

And we find when we give

presentations and do training

that people always enjoy

to see the case studies.

Some of it is sad

and disturbing.

I have a couple of

videos to show you,

and I'll warn you

ahead of time

that they can be a

little upsetting.

And also some scene

investigations.

So the toxicology section,

this is the group picture

of a very serious

group of scientists.

We've been testing in

Wisconsin for over 30 years.

We are certified by the American

Board of Forensic Toxicology,

which we pursued voluntarily.

This is a very prestigious

accreditation for our

laboratory, as we are one of the

busiest laboratories in the

United States and one of maybe

only 35 labs in the United

States that are accredited

by this organization.

We test over 20,000

specimens every year,

and you might be wondering

what those specimens are.

We test biological specimens

for the presence of alcohol

and drugs in operating

while intoxicated cases.

In other words, drunk driving

and driving under the

influence of drugs.

We also test specimens

that have been submitted

to the Hygiene Lab

by Wisconsin coroners

and medical examiners

in death investigations.

We receive well over 3,000

subpoenas per year because our

data is often used from a

prosecution standpoint in

litigation cases involved with

people that are arrested

and prosecuted for OWI

or drug driving, DUID.

And we also give expert

testimony in court.

And I would say, on average,

our chemists probably testify

two to three times per month.

So this is an example

of the workload

just of OWI casework

from 2003 to 2016.

And in giving a title

to my topic tonight,

when I put the question mark,

"A Wisconsin Epidemic?"

because we are a

public health lab,

we are very concerned with things that affect our health.

For example, flu epidemics.

So I'll let you be the judge

tonight to see if you think

that the issues with heroin

and driving is an epidemic,

and maybe even give

some consideration

to the bigger picture

of just drugged driving

and driving under the

influence of alcohol

because that too is a public

health concern in our state.

You can see from this bar chart

that we test well over

20,000 specimens per year.

Starting to decline

in about 2010.

We did have some administrative

changes to manage our casework,

but what I would like

to also point out

are the dark bars

on this graph.

That represents the

proportion of cases

that required drug testing.

We always test alcohol first.

If the concentration

of alcohol exceeds

the prohibitive alcohol

in the state,

which used to be

0.1 and now is 0.08,

we cancel drug testing

if it's above that 0.1.

And there are some

exceptions to that

if there's a crash or

a fatality or injury.

But we continuously see

the proportion of cases

requiring drug testing increase.

So, for example, in 2003,

approximately 7% of our cases

required drug testing,

and in 2016

that increased to nearly 30%.

This is some data from a 2016

project that we worked on.

Now here, these are individuals

that were arrested for OWI.

They had alcohol concentrations

exceeding our 0.1 lab cancellation limit,

so we did not perform

drug testing.

But in context of this project,

we had received money from the

Department of Transportation to

go back and look at a random

sample of drivers and look

and see are they driving

with just alcohol alone or

are there drugs present?

And you can see clearly

from this graph

that there are people driving

not only with

alcohol above a 0.1

but they have drugs

present as well.

And I would ask, does

anybody want to guess

what the number one drug

we consistently see from year

after year in our testing?

- Marijuana.

- Exactly. Marijuana.

Marijuana is number one and has

been for a number of years.

But we do see the opioids

in our top five,

and that's really what my talk

is going to focus on tonight.

So this problem in our

state continues unabated.

The Center for Disease Control

estimated that the use of

prescription opioids has

quadrupled since 1999,

and the heroin epidemic, if we

decide that it is an epidemic,

is very closely linked to

prescription opioid abuse.

The one thing we can't really

determine is people that jump

from prescription

opioids to heroin.

Is it because they had valid

prescriptions for those opioids

or is it because they got it

through some diverted method?

And that's an important concern

because there are people out

there that do have chronic

pain management issues,

and those are wonderful

drugs when taken properly

for controlling that and

improving quality of life.

We continue to see heroin listed

as a suspected drug

in our OWI casework.

And we continue to have an

increased number of people

operating under the influence of

drugs in addition to alcohol.

And then, of course, sadly,

I'm sure you're all aware

in the news that we continue

to have a large number

of overdoses and deaths

in our state.

This data shows a graph from the

Department of Health Services.

The trend lines, the gold is

prescription opioid deaths

between 2005 and 2014, and the

blue line is the heroin deaths,

pointing out the increase

between 2013 and 2014

where we have a big jump.

So it's continuing to climb.

This is a map of 2015.

A little bit more current.

Where we're seeing a big hot

spot for overdose deaths

would be in Milwaukee County

and up the Fox River Valley.

We continue to get a lot of

case from Sheboygan County,

Brown County of both deaths

and drivers under

the influence of the opioids.

And in here,

closer to home,

this is from last spring.

Sheriff Mahoney estimated

that the city of Madison

was going on about 12 to 15 overdoes calls per week.

And that's a lot of resources

for our police department

to be attending to, and if you

factor in the cost to society,

the cost of the antidotes when

they use the naloxone to try to

reverse the opioid effects, to

try to resuscitate those people.

Just a year ago they had

peaked with 70 calls

in the month of April.

So where is the

heroin coming from?

I wish they would talk a little

bit about in the news

of trying to stop the supply

because the law of economic

supply and demand.

It's most likely coming

from Mexico through previous

routes established by marijuana

and the cocaine trade.

Mexico is number two in the

world for producing heroin,

with Afghanistan number one.

The quality of heroin coming

from Mexico continues to

improve, and they can harvest

about 300 grams of the raw opium

paste per day from

their poppy fields

in the mountains of Mexico.

They have poor Mexican farmer

that the Cartels control.

They're not making any money,

but the Cartel is.

And the main route

into Wisconsin

coming through Milwaukee.

I've heard there is some coming

through the Twin Cities as well,

but Denver seems to be a big hub

for the transmittal of it

into Wisconsin

according to the DEA.

We always like to get some

interesting prices for some of

these illicit drugs, and so law

enforcement are big resources

for us at the Hygiene Lab.

So a dub is a nickname for a

hit, maybe a single use,

which might cost you $20.

A hit is about a

tenth of a gram.

Last pricing I heard was about

$12 to $15 in Milwaukee.

So a serious addict can be

spending about $200 a day.

And perhaps some of you

saw the paper on Saturday

where the young man was

arrested from Sauk City,

and he told detectives

that he was spending

$300 a day on heroin.

And in 2016, he

estimated that he spent

$70,000 to $80,000 on heroin.

And, I mean, it's

just astonishing.

As a comparison, very high-

quality marijuana might cost

about $5,000 to $6,000 a pound,

and a gram of heroin

might be $90 to $120.

So if you do the voodoo math,

it might end up to be

$45,000 to $50,000

for a pound of heroin that these

drug dealers are making.

So I found a lot of interesting

trivia about heroin.

The street grade is

about 2% to 6% pure,

but I keep hearing that the

strength and potency

is approaching 30% and higher.

And that could be because of

some of the other opioids

that they're cutting it with

that I'll talk about

in a little while.

The most common old nickname

for heroin is smack,

and that's believed to come

from the Yiddish neighborhoods

of New York in the early 1900s.

Some of our little slang in

terms about goosebumps and cold

turkey, those are slang from

individual responses to

withdrawing from heroin

or other opioids.

The body has lots

of violent responses

if you're going

through withdrawal.

So you get involuntary

goosebumps or they refer to it

as going cold turkey when they

try to stop using the drug.

It can cause very

violent muscle spasms,

and hence the phrase

"kick the habit"

because when you're

trying to quit,

you're going to go through

those violent withdrawals.

And I just recently found out

that heroin is legally

manufactured outside

the United States,

I think in three countries,

Australia, India,

and Turkey, I believe.

And I'm not sure what

their issues are there,

but it's we don't

need it anymore

in our state or our country.

And all of this for that intense

rush or high that they get,

the addicts get, it really only

lasts for a couple minutes.

So I think, hopefully over the

course of my presentation

tonight, you'll get a better

understanding of why it is such

a powerful, addictive class of

drugs because once you get a

little taste of that rush,

you want more of it.

And so it keeps bringing

you back for more.

The next series of

slides are some slides

from scene investigations.

The lower left-hand is

confiscated by DEA.

And this is black tar heroin.

It has a lot of

impurities in it.

It's very potent, but

the impurities can cause

a lot of problems in the users.

But they have it formed

in the shape of shoe soles

to try to hide it for smuggling.

The other picture shows two

different types of heroin

that are cut with

different agents.

Both of them quinine

was detected in them,

and then the lighter gray

color that's more powdery

had lactose in it,

which is milk sugar.

Here's another

scene investigation

from Port Washington, Wisconsin.

They have their kits.

This is a flannel rum

bag from alcohol.

The tie off, the little plastic

is a nugget of their heroin.

And I'm sure that you will never

look at those little tealight

candles the same again after

you leave here tonight

because that's what that is.

And they put the heroin in there

and they burn it so that they

can dissolve it to shoot

it up or smoke it.

Seizures in Dane County, this is

a good example of someone that

was probably dealing because

they have their heroin packaged

up into these foil balls.

Another example of cutting it.

If you notice, again, see how

the color is lighter?

That can be due to what

they're cutting it with,

but also it is associated with

better quality and more potent.

The lighter the color gets, the

better quality the heroin is.

We see it compressed

into tablets,

and that's true for some of the

other prescription opioids.

There are fake oxycodone

tablets out there for sale.

Here's one that I was

astonished to see.

The heroin is actually embedded

into these lollipops.

And so really, really devious

way of smuggling it.

It's very important when we do

training with coroners and

medical examiners because

if they go on to a scene,

people that use these

types of drugs,

family members will often

clean up because it is--

There's a social

stigma with that,

with IV drug use in particular.

And they want to

save their loved one

from that embarrassment.

So sometimes they

clean up the scene,

and it's only until they get the

toxicology report can they

actually determine

what they died from.

So when they go in to

investigate a scene,

you want to keep that hairy

eyeball on anything that might

be a way to hide the drug.

Here's another photograph.

This is actually a

closeup of tinfoil.

The heroin has been

burned onto the tinfoil.

It will boil and turn into

kind of a gelatinous ball,

and then they use the flame

to move it across the foil,

and then they smoke it.

And that's called

chasing the dragon

and one way to

administer your heroin.

So heroin is not, as I said,

new to this country.

It's not a drug that is--

It isn't any longer--

Let me rephrase that, for where

you have the poor junkie

that's in the alley.

There are people, every day

professionals that are using

these drugs, and some of them

can manage their addiction

and function fine.

When they start driving,

that's when we get worried.

So man's quest for

pain management

has a very long history.

They have found records

of the opium plant

as far back as 5,000 years ago

with the ancient Sumerians.

The Chinese were big

smokers of the opium.

They were trading

the British for tea.

And they had opium wars

over it when they tried to

ban the import of

the opium itself.

In the early 1800s,

the first extraction,

the chemical extraction of

the opium leading to a drug

that we now know as morphine,

was performed.

They named it morphine after

the Greek god Morpheus,

the god of dreams.

So right away they were learning

about the euphoric and sedating

effects of this drugs.

And in those days, the

apothecaries that did these

kind of extractions,

they were experimenting,

and they would use the

drugs on themselves

and then write up what,

how they would wake

up hours later.

Or they would sometimes give

it to their pets or dogs

to find out what

would happen to them.

So once they discovered

the morphine,

it wasn't too much longer that

they were extracting other

opioids from the opium plant,

including codeine that we all

know that we can get

from cough syrup

because it has very great antitussive properties.

Thebaine and papaverine, these

are also from the opium plant,

and we do see that in our

testing and toxicology.

And then, finally, people were

using morphine religiously,

and people were getting

addicted to it.

And so in the effort to try and

find something that was less

addictive, a chemist in Germany

was boiling it in vinegar,

and lo and behold formed heroin.

And so Tom's reference to the

heroin is based on a German word

meaning great warrior or

fearless because you feel so

good when you're high on heroin.

So to start in grandma's garden,

this is an example

of the seed pod.

My grandma had a huge garden

of poppies in Stoughton,

and I was one of those kids that

liked to cut up the fish.

I cut open the worms.

I wanted to cut one of those

seed pods open in the worst way,

and you were forbidden

and now I know why.

This is a great example

of the vertical cuts

that they make in that seed pod.

The white exudate is

actually raw opium paste.

And that naturally contains

morphine and codeine.

So this is the top of Mother

Nature's pharmacological

superstore because there

it is, right there.

Nobody made morphine up.

It comes right from

Mother Nature.

Well once they made heroin, the

Bayer company jumped on that

and were marketing it.

They were producing metric tons

of it and marketing it for

anything from treating children

when they're cutting teeth

or ladies' days, women's

monthly, ladies' days,

and pretty soon lots of people

are getting addicted to it.

There were many soldiers coming

home from the Civil War

that were addicted to morphine

because they were mixing

it into laudanum,

which was alcohol

and morphine.

So I can't even imagine what

kind of buzz you'd get on that

because I think it was

like 70% ethanol

mixed in with the morphine,

and you could just go

to your pharmacy

and buy it in the bottle.

And, in 1914, the United

States got on board

and they actually banned heroin in the United States.

So a little bit about

how they form morphine.

Here's another example of the

seed pod from the flower.

This sap has been allowed to

come out of the pod,

and it has oxidized so it's

a little bit darker.

And it firms up a little bit

so they can scrape it

off with these tools.

And the lower picture shows

the actual raw opium paste

that will be processed

into heroin.

So, remember, the morphine is

naturally in that opium paste.

You can acetylate it with

something as simple as vinegar.

And these, the thing that I want

to just point out here for,

if there are any geeky chemists

in here, these hydroxyl groups,

the OH, oxygen and hydrogen,

are what we're going to

change to get our heroin.

Water is H2O, so they're

just one hydrogen short.

We acetylate them, and then

it changes the structure.

So now we have those

two acetyl groups,

and we've changed our morphine

to diacetyl morphine,

or what we now know as heroin.

So here's some nice photographs

of grades of heroin.

The nastier it is,

the lower the number.

So number one and two

is just after the heroin

production process.

So there's a lot

of junk in there,

and people can use this

and get high on it

but it has a lot

of consequences.

They can get skin infections

and things from it

because there are

some many impurities.

Number three is getting better.

This is brown sugar, which my

favorite rock and roll band,

The Rolling Stones, I

always thought that song

was about an

interracial relationship.

And now I know that it's

not because they have many

songs that allude to the use of

heroin and sister morphine.

And then, finally,

the crème de la crème

would be the China white.

And so that would be,

let me find it here,

this white powder here.

That is heroin hydrochloride. It's water soluble.

It has the highest potency

and gives you the best buzz.

But the dealers

want to make money

so they cut it with things.

Sometimes they cut it,

they whack it.

They stomp on it to increase

their profit margin.

Sometimes some of the things

they cut it with have a purpose.

For example, diphenhydramine

is the active ingredient

in Benadryl or over-the-counter

sleep medications.

And when you use heroin

or other opioids,

even prescription

pain medicines,

sometimes they cause itching

because it causes a release of

histamine in your blood,

and that is the antihistamine.

So my theory is maybe they're

trying to lure people into

thinking that, ooh, this is

really good, I don't get itchy.

I don't get that one

annoying side effect.

Scopolamine would be the kind of

antihistamine that is in the

patches for motion sickness.

Some of these other things,

common caffeine, sugar,

lactose, and even dried milk.

I mean, these are, they're

adding weight to their product

so they can make more money.

But last and certainly

not least is fentanyl.

And fentanyl has been

in the news,

along with some

of its chemical variations.

And we see heroin cut with this

and we are seeing fake heroin

out there that is fentanyl,

and it is deadly.

And we will--

I will tell you why.

This is a graph from

Dr. Alan Wayne Jones,

who is a retired

toxicologist in Sweden.

I just want to

quickly go through.

So, again, we're going

to start at the top

with our raw plant material

from the poppy plant.

It gets acetylated.

We get our heroin here.

Once the heroin is

ingested in the body,

however you administer, whether

you're smoking it, snorting it,

it is going to rapidly convert

to the 6-monoacetylmorphine.

There we go.

And this is really the smoking

gun in forensic toxicology.

That's what we see

in our testing,

and that's what we look for and

confirms that heroin was used.

Your liver does a lot of work to

try to metabolize these drugs,

and once they metabolize they

all will ultimately convert back

to morphine because that's

our mother structure.

The human body will try

to get rid of this,

and so we try to make

it water soluble.

It will glucuronidate

the forms of morphine

and basically add sugar

structures to them

so they could be

eliminated in the urine.

So I kind of went back

from heroin and opioids.

Opioids are really any chemicals

that can act on the receptors

that we have in our

central nervous system

and in our

gastrointestinal track.

If you have ever had to use a

prescription opioid for, say,

a surgery, one of the side

effects can be constipation,

and that's because of

the central nervous

system depression.

It slows down the peristaltic

actions in your GI tract,

but now they have medication for

that too that I see advertised.

So if you have the

opioid-induced constipation

syndrome, you can get another

medication for that.

The natural opiates, again,

are going to be the morphine

and codeine that I've

already talked about.

Semisynthetic opioids are going

to be some that have been

modified by man based on that

natural morphine structure.

And those are common ones

that you have heard before,

hydrocodone, which is Vicodin,

oxycodone, Buprenorphine.

I don't know if you've

heard of that.

You might recognize

that as Suboxone.

This is a drug currently

used to help treat addicts

to recover from

heroin addiction.

And then here is our

diacetylmorphine.

So heroin is a semisynthetic.

Fentanyl is considered

fully synthetic.

That is a man-made chemical.

And when I'm talking about the

heroin being cut with fentanyl,

this is not pharmaceutical

fentanyl that might be in a pain

management patch for someone

that could be in a terminal

stage of cancer or some serious

illness where they need chronic

pain management

around the clock.

This is illegally

manufactured fentanyl,

which China is our number one

source of that right now.

And the reason we have, as we

talked about a couple minutes

before the presentation started,

that we have these receptors in

our body because we have our own

natural opioid-type chemicals,

neurotransmitters, endorphins,

and enkephalins.

So they help us manage pain.

They, if you burn your

finger on the stove,

your body will respond to that

and try to mitigate that pain

and interrupt those signals.

The users of heroin, their

biggest thing is that euphoria.

But we know that it's

very short-lived.

It has the analgesic effect

because it interrupts

those pain signals through

the nerve endings,

and so we get analgesia, and

because of that it can make you

very relaxed and feel

very care-free,

very apathetic to

your surroundings,

and because you're very relaxed

and very sedated sometimes,

some people like

it because it has

that anti-anxiety

component to it.

But long-term use of it can

have many negative effects.

It's very hard on your organs.

There's not only the

physical addiction

but there's a powerful psychological addiction

because you crave it.

You crave it.

You want that euphoria.

That euphoria has been

described from interviews

that I've seen with addicts

as almost a sexual experience.

And so, hence that very powerful

draw to get more and more of it.

They're always chasing

that euphoria.

It can cause nausea

and vomiting.

And prescription opioids

can cause that too.

Some people might say they're

allergic to codeine

because it made them throw up,

but it's not really an allergy,

it's just a response

to that drug.

Skin abscesses and that can

come from using injections.

We've already talked

about the constipation

and some of the

effects of withdrawal.

If you inject your heroin,

you're putting yourself at risk

not only for the heroin effects

but bloodborne pathogens.

And, again, that is a public

health concern for all of us.

Here's a little cartoon

that kind of adds

a little humor to withdrawal.

It really-- I've read that

it's similar to having

a terrible bout of the flu.

But, again, in interviews

with addicts,

they just find that offensive

because they find it

much more violent

than surviving the flu.

And it can take maybe 14 days of

withdrawal before these symptoms

go away or these side effects.

The addicts, they know

how long they can go

before they need another fix.

It might only be hours

before they go start

to have signs of withdrawal,

and they don't want that.

And so, hence, it leads us into

that issue with finding the

money to get another fix for it.

So routes of administration.

Injection is the best way

that you can get high.

You mainline,

you do a direct dump.

If your veins are starting

to get scarred,

you can do something that's

called skin popping.

So you see in this

right-hand picture,

these nasty abscesses on

this individual's arms.

That's from skin, shooting

it underneath the skin,

if you will.

You can also snort your heroin.

It has to be chopped up.

People can-- If you get the

water-soluble kind,

you can dissolve it in

water and aspirate it

into your sinuses

like nasal spray.

They call that shabanging.

And there are nicknames

for everything.

I mean, there's

probably 20 nicknames

for drugs combined with heroin.

For example, speedball,

heroin and cocaine.

That's famous for anyone

from my generation

that remembers John Belushi.

Or Chris Farley,

unfortunately, I believe

also passed away from speedball.

If you smoke your heroin,

you have to burn it like that

tinfoil picture we saw earlier.

It's called chasing the dragon.

So the smoke, when it gels up

and starts to burn,

it emits this smoke, and they

snort that up in a straw.

And then one extreme use or way

to administer your heroin could

be from what's called plugging.

And sometimes the use

of these drugs,

especially intravenous use,

is a very private thing.

They don't want people

to see their arms.

They wear long sleeves

when it's 95 degrees out.

Plugging is a way that, if you

don't like needles and you don't

want anybody to know, you

administer your heroin either

anally or vaginally, and those

areas of your body are highly

vascularized so the drug can be

absorbed very quickly.

Here's a classic example

of track marks.

This is what law enforcement

looks at when they pull someone

over and they look like they're

under the influence of heroin.

Sometimes they can document

that there are track marks.

I've heard it estimated that

one-inch of track mark is worth

about 50 to 60, or, excuse me,

50 to 100 injections.

So once that person is stopped

and the blood is collected,

the blood will come

to the Hygiene Lab,

and here starts the

forensic challenges.

Heroin, because of those two

acetyl groups that I talked

about, is not very stable once

it enters the human body.

In fact, it's very unlikely that

we would ever measure heroin

in a living person.

It gets converted to that

metabolite that I mentioned,

6-monoacetylmorphine,

in just a few minutes.

We call it 6-MAM for short.

And this is, if we detect this

in our toxicology testing,

this is definitive evidence

that heroin has been used,

whether it's in a driver or

in a death investigation.

So this is just a quick chart to

show how stable or unstable,

depending on how you look at it.

If you use heroin, we would

expect to see that 6-MAM

metabolite, but we would also

see some morphine and codeine

because, remember, it's coming

from the opium plant.

We can look at that

morphine-codeine concentration

ratio, and studies have shown

that when that ratio is greater

than one, that is indicative

of heroin use,

even if we didn't see the 6-MAM.

The half-life of the 6-MAM is

only about one-half hour.

So we can detect it maybe for a

couple hours in the blood.

In Wisconsin, for OWI arrests,

they try to collect the blood

within a three-hour window.

That's considered prima facie

evidence of driving

under the influence at

the time of driving.

So if they can get the blood

quickly and it's analyzed in a

timely fashion, we have a

higher likelihood of confirming

the presence of 6-MAM.

And just a little bit about

some of the other opioids,

particular fentanyl.

I personally, and my colleagues,

believe this is much worse.

It's difficult to see in

our toxicology testing.

We don't see it as

easily as the natural

or semisynthetic opioids.

It's about 50 times stronger

than heroin and 100 times

stronger than morphine.

We use morphine sort of

as our measuring stick

because that's Mother Nature's

original recipe.

They don't get as much

euphoria from that.

The onset is very rapid,

and it has a very short

duration of action.

Again, this type of fentanyl

is coming from China.

Those chemists are better

chemists than I'll ever be.

They are making all different

kinds of versions of fentanyl,

and people are buying it

thinking they're getting heroin.

They might use their usual dose

or hit that they think, and,

unknowingly, because the

fentanyl is so powerful,

it can induce an

overdose or even death.

Now, even and because

of that strength,

if they do get caught in time

and someone calls 911

to try to save them,

they can give them naloxone.

But, again, because

it's so powerful, oftentimes

they have to administer

multiple does of naloxone.

Naloxone, for an injection,

costs about $60.

The city of Madison

was using some,

was getting expired naloxone

from drug companies

to try to save resources

because of the expense.

So for 150 people

they might have given

250 doses of naloxone.

So, you know, not only is it a

public health concern but it's a

societal concern because

of the finance and resources

that go to treat this

and try to save people.

Here's an example of some of the

easy chemical modifications

they can make on fentanyl.

So the fentanyl structure,

I have it stretched out here

kind of in a long fashion.

This little group right here,

just think of these

as pieces of Lego.

This is fentanyl,

and all they do is

just modify it very quickly.

Here they've taken off

one methyl group.

Here they've added on extra.

And now we have forms

of fentanyl, again,

coming largely in

part from China.

And these are, we're

always chasing,

trying to keep up so that we can

detect these in our case work.

Sometimes people, we turn in a

not detected toxicology report,

and the law enforcement

agency will call us

or district attorney

will call us and say,

"How can that toxicology

report be non-detect?

"That person was wasted

on narcotics."

And we have to go back in

and start looking for these,

and sometimes we find them

and sometimes we don't.

Carfentanyl is well beyond

anything that fentanyl can,

in and of itself, cause

in terms of frightening

public health concern.

This is a extremely powerful

large animal sedative

used in veterinary medicine.

They dress up in hazmat

when they use this.

One drop can be fatal.

You can see the proportion

picture here of the penny,

and that's about a spot of

fentanyl that would be lethal.

It is 10,000 times the

potency of morphine.

Remember, that's going to

be our measuring stick.

The first use that I heard

of it was in 2002.

It was dispersed in aerosol

form in a Moscow theater

where some Chechen dissidents had taken hostages.

The Russian government,

because it killed everybody,

the people they were trying

to save as well as the

perpetrators, but they wouldn't

disclose what it was.

And some time later,

years later,

there was a scientific paper

published where they

actually tested some

of the clothing

and they identified the

chemical as carfentanyl.

So it is a very frightening

possibility if this ever got in

the wrong hands and could

be used as a weapon

of mass destruction.

Supposedly, last month, China

has announced that they have

banned exports of carfentanyl.

But just this week, yesterday

the Milwaukee County Medical

Examiner was in the news because

they have confirmed their first

death to carfentanyl in

the state of Wisconsin.

It's very, very upsetting

because there is no antidote

that can save you

from this drug,

and now it's in

our state as well.

Here's an example

of hazmat clean up.

You can see they're wearing

all the protective gear.

And if law enforcement comes

upon a scene or arrests somebody

where carfentanyl

might be there,

they bring in the K9 dogs.

And that puts them and

the animals at risk.

So now this is, again, another

huge amount of resource.

They have to assume the worst,

so they have to get geared up

for and be prepared in case

there is a drug like this

present in their clean up.

So what does it look like

when you're driving under

the influence of heroin?

If law enforcement pulls you

over because you aren't driving

very well, they're going

to look at your vision.

They're going to talk to you

and see how you

respond to questions.

They're going to ask

you to perform some

divided attention tasks.

These are what we call

standardized field

sobriety tests.

They are standardized on alcohol

but they are very useful

tools for law enforcement

to recognize when

somebody is impaired.

Impairment can be caused by

over-the-counter medicines.

It can be caused by

prescription medicines.

A valid prescription

from your doctor

does not mean that

you're safe to drive.

But with heroin, some of these

certain drug categories,

law enforcement can recognize

some very pronounced clues

that can give them indicators.

We have specialized trained law

enforcement called drug

recognition experts, and they

are trained to look at clinical

and psychophysical indicators

and give opinions on one of

seven drug categories

that you might be

driving under the influence of.

So with heroin and other

opioids or narcotics,

they look at pulse and blood

pressure and your temperature.

Because these drugs are

central nervous

system depressants,

it's going to slow

your pulse down.

And I have what would be

expected an average of 60 to 90.

Everything gets slowed down.

Your blood pressure

is slowed down.

Your body temperature drops.

Here's two standardized

field sobriety tests.

So your balance and coordination

are not very good; you sway.

They look at something

called Romberg test where

they're looking at

how your body just,

you can't maintain

your position.

And so if you think of driving,

that is a divided attention task

because you're looking, you're

responding to the road,

you're accelerating or braking.

Your body clock is very slow,

so your ability to respond to

something is very slow, and your

muscle tone is very flaccid

when you're under the

influence of heroin.

We had our first confirmed

heroin metabolite

in a driver in 2013.

So my colleague Stephanie

Weber and I have been kind of

on the detective

trail ever since.

So this is an example of Hygiene

Lab data from 2012 to 2015.

Once we started seeing some

of the heroin metabolite,

we went back and thought, well,

what about that

morphine-codeine ratio?

How many people out there might

be under the influence of heroin

and we just couldn't tell

that in our testing?

So we had well over 900

individuals that had at least

morphine and morphine-codeine

with a ratio greater than one.

So 270 out of that subset.

And only 15 of them

were we able to confirm

that 6-monoacetylmorphine.

But this, it's probably

underestimating the number

of people that are

actually driving.

And, again, because it's very

short-lived in the body,

so our ability to detect it

is very reduced.

When you're driving on

smack or heroin,

when we talk about how it

affects your vision,

it causes your pupils

to be constricted.

Many of the individuals that we

have seen in the Hygiene Lab

driving on heroin,

confirmed heroin cases,

many of them were

driving during the day.

And if you think about your

pupillary response to light,

the DREs look at your

pupils in room light,

direct light with a flashlight,

and near total darkness.

And these drugs will constrict

the pupils and you will have

little to no reaction to light.

So if you can imagine

driving at night,

in the country where there

are no streetlights,

your pupil needs to open up

probably nearly

filling your iris,

so you get as much light

as possible in there

to see where you're going.

And that can't happen when

you're under the

influence of heroin.

It also causes something called

ptosis or droopy eyelids.

They have a really hard time

of keeping their eyes open.

They are very sedated,

and so that's part of it.

So now your pupils aren't open

and your eyelids aren't--

You're having trouble keeping

your eyes open.

Here's just a little video

of an actual--

Let me see if that's

going to work.

Well, it shows the pinpoint

constricted pupils in darkness.

So you see the

little lights there?

That's actually the size

of that person's pupils.

And it should be all black from

the pupil open in full darkness.

One of the other vision tests

that the officers look at

is lack of convergence.

We all, most people I

should say, not all,

but can cross our eyes if

you look at your nose.

There are some drugs out there

that prevent that

from happening.

Heroin is not one of them,

but that is one of the checks,

the eye checks that the

officers can look at.

Let's see if this--

I don't think this video

is going to work either.

So this is another video

of the droopy eyelids.

Wait, here we go.

All right, let's pass

on that one.

All right, this

is the last video

that I hope is going to work.

This is, we see this in

narratives from law enforcement

in their documentation

of the stop

or when we're preparing

for court testimony.

Something that they

call on the nod.

They alternate between a

state of awake and sleep.

You might think that

they are asleep.

They can hear you, but they're

just kind of out of it

in la la land

because they're stoned.

And this, if you see someone at

the stoplight that they're

either slumped over their

steering wheel or their head's

flopped back, just keep your car

away from them and call 911

because if they're on the nod,

they're under the influence.

This is the video that can be a

little bit disturbing.

This young lady is

high on heroin.

Luckily, she's not driving.

She is on a public bus.

But what is disturbing about it

is that her child is with her.

And her daughter is trying

to attend to her.

Let me see here.

So that's what we

call on the nod.

And that's her daughter

trying to straighten her up.

And if you can imagine someone

driving a car like that.

We've seen fewer

heroin and driving,

and my personal belief on that

is perhaps because the

distribution of heroin is

spreading throughout our state

and I think it's getting

easier to buy it,

and so they don't have

to drive as far.

I'm not sure, I mean,

I can't prove that,

but that is one

of my suspicions.

So that's better if

they're not driving.

But, so let's see.

I think I have time to go

through some case histories.

I call this gentleman

the Jack of all trades.

He was just stopped in

the middle of the road.

He stopped driving.

He said he was tired.

The officer immediately

observed the pinpoint pupils.

He had a slow, raspy speech,

which is another characteristic

of being under the influence

of heroin or another opioid.

He had those droopy eyelids.

The officer also found some

interesting paraphernalia

in his car.

And one thing I've learned

about addicts such as this,

they are very creative in how

they hide their paraphernalia

and how they describe

what its use is.

So, for example, he had

a scale in his car

which might imply that

maybe he was a dealer.

He told the officer

that his brother

is a professional dart thrower,

and so that is

a scale that he uses

to weigh his dart tips.

The razor blades were used to

cut his mother's pills because

he takes care of his mom and he

has to cut her pills up for her.

But they found baggies

of a powder in there,

which could have been heroin

or it could have been

the crushed pills.

He did claim that he was in a

pain management program so he

might have had a little bit too

much of his medicine that day.

And he had tinfoil

bindles, which, again,

might be a clue for

someone that is selling.

He said that those pieces of

tinfoil folded up were used so

that when he moves furniture

around it helps it slide easier.

[laughter]

We've heard of them

hiding their syringes.

They load their syringes so they

have them with all the time

because, again, they know

how long they can go

before they need that fix.

They will pull apart the

steering columns in the cars.

I don't know if you can do

that with the new cars now

with all the computer,

but they would hide the syringes

in the steering column.

So he was arrested,

his blood was drawn,

the Hygiene Lab tested it,

and lo and behold

we have morphine,

codeine, and 6-MAM.

The morphine-codeine ratio,

if you notice,

is much greater than one.

So that confirms heroin because

we have our heroin metabolite.

And we did find some oxycodone,

another opioid, and alprazolam.

So likely he was probably

crushing those oxycodone.

That was a huge problem

for a while.

People like to crush them

and snort them.

And in 2010, Purdue Pharma, had

got a lot of pressure to make a

crush-proof version, and when

they put it in water to try to

snort it, it turned into

this gelatinous mess.

So he might have still had some

of the old formulation there.

Alprazolam is another central

nervous system depressant.

It's in a big family that

you might be familiar with

known as Xanax, and Valium

is in that family.

This person also was

having problems parking.

Another male who was found

passed out in his car.

He was partly in the parking lot

and partly on the street.

And his rear part of

his car was hooked up

on the front bumper

of the car behind him.

And he just said,

"I was tired from parking

"and wanted to take a nap."

He did admit that he had used

heroin earlier that day.

The officer saw the

indicators of impairment,

and he was very, very sleepy

and sedated.

He fell asleep numerous times

throughout the interview

and the arrest process.

He did demonstrate lack

of convergence.

So, if you remember, the

ability to cross your eyes.

What that looks like is

you might have one eye

that looks like a lazy eye.

It'll just, the eyeball will

roll off into an odd direction.

And that can happen

with marijuana.

So when we tested his blood, we

did find the morphine, codeine,

and the 6-monoacetylmorphine,

the heroin metabolite again.

And then we also found the

marijuana metabolite,

carboxy-THC, which just

is indicative of

that some time he had smoked.

It's not what's considered the

restricted controlled substance.

That has to be the parent

delta-9 compound,

which is also illegal to drive

under in the state of Wisconsin.

This person, a young lady,

she was called in by several

civilians because

she was driving

all over the road very slow.

The officer knew right where her

car was because all the traffic

was held way back, driving slow,

and she was in front

going from one side of the highway to the other.

And she was very upset when

he finally got her to stop.

She was really shy.

She didn't want to open

her arms to show him.

He could tell she was on heroin.

This was an experienced officer. And she cried.

She had been clean

for several months

and had fallen off

the wagon that day.

And when she was going

through her arrest process,

the female officer found

that she had her syringes

hidden in the groin area.

And, again, morphine,

codeine, and 6-MAM.

53 nanograms of 6-MAM per

milliliter of blood.

That is huge, I can tell you.

So that tells us that she

probably had used the heroin

very close to the time

of driving.

I think this is one

of our last cases.

This person just had the unfortunate luck of merging

on the highway and a police

officer was behind her.

She was not having problems

maintaining her lane position.

He did smell alcohol and her

eyes looked watery and glassy,

bloodshot, which

alcohol can cause.

She had a lot of issues with

balance and coordination.

So she had a lot of clues

on the field sobriety test.

She flat out denied

that she drank.

Didn't do drugs.

Nothing.

Again we found morphine,

codeine, and 6-MAM,

and she did have a

little alcohol on board,

just below a .05.

And then there's

that diphenhydramine

that we talked about.

We do consistently see

it in our testing.

We don't always report it

because it's very small amounts.

So, again, it could be

used as a cutting agent.

And then, last but not least,

this is what I call a

poly-opioid case because this

person had a couple different

types of possibly heroin.

This was during the daytime.

So 4:30 when people

are out and about.

You might be getting

finished from work.

Our work day ends at 4:30

at the Hygiene Lab

unless we're out

traveling for court.

The officer that

arrested this person

just happened to be a

drug recognition expert,

and this subject was very

casual, not worried.

He showed clues of poor

balance and coordination,

the constricted pupils.

Only morphine but

this time fentanyl.

So we can't say for sure

if he had used heroin

because we don't have

that 6-MAM metabolite.

But the fentanyl

in and of itself

would be enough to

cause impairment.

So Wisconsin is taking action.

We have the prescription drug

monitoring program.

So if you do get prescription

medication from your doctor,

it is tracked to make sure that

people are not going from doctor

to doctor getting

multiple prescriptions.

We have the Good Samaritan law

that was just recently

updated in 2016.

So if a person is with someone

that overdoses because they like

to get high with their friends,

they won't just take off

and leave them, because we've

seen deaths, many times,

where someone is just found in

the car and lo and behold their

buddies were with them

and they passed out

and got afraid and left.

Or if they're on probation.

The whole purpose of this Good

Samaritan law is that people

will call them and hopefully

they can get 911 help

and resuscitate them

with the antidote.

This is a very important one

that the Hygiene Lab was very--

Played a prominent role in

happening in 2016,

that the heroin metabolite was

finally listed in Wisconsin

as a restricted

controlled substance.

And that means it

is illegal to drive

with the heroin

metabolite in your body.

Heroin itself was

already listed,

but we aren't going

to see that

in living subjects,

very unlikely.

So that was very important.

We continue to have more

and more naloxone training

so paramedics, teachers, family

members of known addicts,

they can get training on

administering the antidote

and hopefully saved

their loved one.

And then the legislature

has taken some action.

There is a task force

on opioid abuse.

I believe that the lieutenant

governor is in charge of that.

And hopefully this month the

legislature is supposed to vote

on a $4.8 million which covers

about 11 different bills

addressing this issue.

So, I don't know if you would

think this is an epidemic,

but it is definitely a public

health crisis in our state.

And people driving under

the influence of heroin

is basically a homicide

in action, in my opinion,

because if they can't

control their vehicle,

that puts all of us at risk.

The abuse of opioids continues

unabated in Wisconsin.

Again, it's very unlikely that

we will ever detect heroin

in blood of a live person.

So if we get that metabolite,

that gives us conclusive

evidence, both for litigation

and for interpretation

that they used heroin.

We have consistently seen the

poor driving and how it affects

your ability to operate

a motor vehicle safely.

Those are very impaired by the

use of heroin and other opioids.

The time intervals

are very critical.

Law enforcement does

a fantastic job.

They get that blood

collected very quickly,

and it is incumbent upon the

laboratory to get it tested

promptly so that we can

identify those drugs

before they degrade

in the blood.

And, again, the increase in

naloxone training throughout our

state is hopefully going to

save more and more people

in the future until we can

get control of this problem.

So it's time for questions.

This is my contact

information too,

if anyone wants to send an email

or contact the Hygiene Lab.

[applause]

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