Over the past two decades that I have worked in the Toxicology Department of the Cuyahoga County Medical Examiner’s Office, I have seen the drug trends of the county residents come and go.  The most detrimental and deadly trend has been the crossover from heroin to fentanyl use.  The county has seen a tremendous increase in fentanyl and its analogs* in the past 5 years.  Recently, my colleague Rindi Rico and I attended the Society of Forensic Toxicologists (SOFT) meeting in Dallas, Texas to present our data study going back to 2010.  The study titled “Fentanyl Data in Fatalities and Impairment (DUID) Cases: a 5-year Retrospective Study”, exposes the dangerous fentanyl trend in fatalities as well as driving under the influence of fentanyl.  

While presenting our research at the SOFT meeting, we were able to talk to people from all over the country regarding drug trends.  Although the fentanyl problem does not touch every part of the country, it is wide spread and especially apparent in the Midwest.  We were able to share our findings, and learn what other forensic agencies are seeing in their work as well. We reported the increase in fentanyl cases along with the demographics involved. We were able to inform fellow toxicologists about our fentanyl/fentanyl analog findings and compare what is new and trending across the area. This knowledge can help us identify new analogs as they appear on the streets and inevitably at the Medical Examiner’s Office. 

In Cuyahoga County: 

• Fentanyl use has risen from <5% of poisoning deaths (2010) to nearly 50% (2016)
• Fentanyl Driving Under the Influence of Drugs/Alcohol (DUID) has risen 100% since 2010
  • Fentanyl levels in DUID are often at what is considered fatal.
• Our Drug Chemistry Department has seen a 34,000% increase in submissions of fentanyl and its analogs from death scenes, crime scenes, and police drug seizures.
• Cleveland suburbs account for 60% of the all DUID submissions that were positive for fentanyl.
• Users are typically white (80%) males (75%) ranging in age from 19-60 years old.
• The newest and most deadly fentanyl analog is carfentanil.
  • Carfentanil is a large animal tranquilizer being sold on the streets as “Elephant Heroin”.
  • An extremely small amount of carfentanil is deadly
  • Carfentanil has been seen in several Medical Examiner cases as well as DUID cases
  • Carfentanil is also in several surrounding counties.

How do these drug trends occur? There are many variables, but the heroin to fentanyl trend can be traced back to several events.  Prescriptions for opiate painkillers (Oxycodone, Hydrocodone, Hydromorphone etc. ) increased and eventually some people became addicted. The demand for pills increased as supply began to decline. Along with the reformulation of some prescription opiate pain killers and the cost of those pills going up, people began to look for a stronger, cheaper alternative.  This alternative was heroin. The Mexican cartels saw the chance to increase their profit margin by switching from marijuana to heroin sales. Soon the even cheaper, clandestinely produced fentanyl was available. By receiving chemicals to make fentanyl from China and Mexico, it is easily made at a fraction of the cost of heroin. Fentanyl is then being mixed with heroin or used on its own.  Also, some illicit “drug makers” are compressing the fentanyl to make it look like real prescription opiate or benzodiazepine (Xanax, Valuim) pills and selling the fatal pills to an unsuspecting buyer at a high profit margin. 

The illicit “drug makers” are clever because they frequently try to stay one step ahead of the police, DEA, ME offices, and clients.  They anticipate the fentanyl analogs becoming illegal by DEA designation and always have another analog ready to incorporate into the drug market.  We are in a constant battle to try and detect these new analogs and warn people they are out there killing users.   My job analyzing fentanyl and its analogs has become progressively more challenging every week because there is no end in sight to this staggering epidemic.  Our goal is to analyze, research, and report the effects of this crisis in hopes that we can educate and promote recovery programs. 

*Fentanyl analog = drug chemically and physically similar to fentanyl with a few differences in the chemical structure. Equally or more dangerous than fentanyl itself.