This is an edited copy of the June 2018 Ohio Substance Abuse Monitoring Network, Surveillance of Drug Abuse Trends in the State of Ohio. Specifically edited for this post and as an information source for Chronic Pain Patients in the State of Ohio. The full report can be downloaded here.
As the chronic pain community continues to struggle under the burden of government failures, i.e. the three year delay for corrections following the 2016 CDC Guidelines, misinterpretation of those guidelines by state agencies, hospitals, clinics and doctors, it is important for CPP to be fully informed on the issues which drive government policy and prescriber response.
Ohio continues its effort to improve data collection and building rational guidelines which thwart illicit use while protecting access for legitimate use. CPP being aware of the challenges which law enforcement faces will hopefully encourage CPP to aid and assist law enforcement whenever possible, specifically in the area of diversion. In the long run, such efforts benefit CPP as policy makers come to a better understanding of the sources for abuse and opiate related deaths.
CPP’s should also be aware of an increased risk and threat of theft from visitors and robberies specifically directed at older individuals who live alone. As street drug users continue to suffer the consequences of adulterated substances combined with a decreased supply of prescription opiates or rapid identification of abuse from OARRS, the safety and reliability of prescription opiates has driven up the street price, making them highly sought after.
CPP’s should exercise caution and be aware if approached with offers to sell their script to any individual. Any attempt should be reported to law enforcement in their area immediately. This is for your protection.
The respondents in this report are selected patients from treatment centers, law enforcement and practitioners from across the state of Ohio involved with treatment and prescribing.
The most frequent used cutting agent for powdered cocaine is Fentanyl and its analogs Carfentanyl.
An Akron-Canton participant remarked, “They’re putting Fentanyl in everything, that way they can get you physically addicted to it.” A Cincinnati regional law enforcement officer stated, “I don’t know if there’s a misconception that cocaine’s going to be safe … we’re seeing people overdose on cocaine. We’re having professionals tell us that [clients] are overdosing on fentanyl [when] they were trying to use cocaine….” Law enforcement in Cleveland reported seizing fentanyl-laced cocaine in the region during the past six months.
Drugs most often abused in combination with powdered cocaine include, alcohol, heroin, marijuana, methamphetamine, prescription opioids, and sedatives.
Most drug users are injecting crack as opposed to smoking it now, resulting in dealers adulterating crack with heroin and Fentanyl to increase profits.
Drugs of abuse most often used in combination with crack cocaine include alcohol, heroin, marijuana, methamphetamine, prescription opioids, and sedatives.
Heroin remains highly available, respondents overall found it difficult to discuss heroin apart from Fentanyl. Participants and law enforcement frequently commented that finding “pure heroin” (heroin not adulterated with fentanyl) is difficult. A participant commented, “They’ll tell you it’s heroin, and when you overdose and wake up in the hospital, they tell you it was Fentanyl.”
Profits for dealers in the Cincinnati and Columbus regions remain high, high enough that they are giving away heroin “testers” (a sample of their product) free of charge and often unsolicited. Dealers recognize the benefits in pushing opiates for their ability to quickly get a user physically addicted to the product, unlike other drugs. This strategy also contributes to why Fentanyl has become the adulterant of choice when cutting heroin or as an additive for other drugs such as powdered cocaine, crack or for dusting on products such as marijuana. The goal seems to be a continual effort to graduate buyers to opiates because of their physically addictive properties.
Columbus respondents reported increased availability of Heroin, a law enforcement officer in the Columbus region stated, “The investigative units … are taking in kilos [of heroin] at a time, which used to be unheard of.”
A new form of gray heroin is gaining in popularity for those who can afford it, the gray color is a result of cutting the heroin with Fentanyl which gives a more intense high and goes by a street name of “gray death”. For dealers, the cost of Fentanyl is significantly cheaper than Heroin and other drugs which is why it is used as a cutting agent or additive in most street drugs. Another reason for the popularity of Fentanyl with dealers is because it is shorter acting. The more intense high followed by a more rapid clearing from the system, results in users buying the product more often.
Respondents report that Heroin is not heroin no more; Most of the ‘dope’ (heroin) is cut with ‘fetty’. You can’t get heroin in this town without fentanyl.” thus, heroin and fentanyl have become almost synonymous terms. With the addition of Fentanyl as a cutting agent and because of its potency, street purchases now come in 1/10 of a gram by weight, ranging from $10-20. The average medical dose of Fentanyl is 100 micrograms or 1/10,000 of a gram which quickly puts into perspective why it is an all-around cheap cutting agent which moves the user to a physically addictive substance.
Drugs abused most often in combination with Heroin include alcohol, crack cocaine, marijuana, methamphetamine, Neurontin, powdered cocaine, prescription opioids, and sedatives.
There was almost universal consensus among participants, treatment providers and law enforcement that fentanyl remains highly available throughout Ohio given the high number of positive drug screens. Straight Fentanyl by itself has low availability supporting its use as a cutting agent. Coroners in Cuyahoga and Hamilton counties reported that 53.8% and 76.4%, respectively tested positive in drug related deaths. Montgomery County reported 90.3% occurrence of Fentanyl in 189 drug related deaths in the first half of 2018.
Respondents attributed the ease in which dealers can cut other drugs with fentanyl to expand their sales as a primary reason for increased availability. Participants also attributed the increase to greater demand for the drug, noting that Fentanyl is considerably cheaper than heroin; and thus, extremely appealing to dealers who can sell it as heroin at heroin prices. Moreover, participants explained that Fentanyl is shorter acting than heroin, meaning the high it produces does not last as long, so users need more of the drug to maintain a high and to avoid experiencing withdrawal symptoms.
In terms of cutting agents for fentanyl, participants noted that Fentanyl is most often used as an adulterant for other drugs or as a substitution for heroin. Participants commented: “I don’t know that they’re cutting it with anything; [Fentanyl is] the cutting agent for other things.” Crime labs did not report [any] adulterants for Fentanyl.
Drugs abused most often in combination with Fentanyl include alcohol, crack cocaine, heroin, marijuana, methamphetamine, powdered cocaine, prescription opioids, and sedatives.
Prescription opioids are reported as moderately available for illicit use throughout Ohio, except for Akron-Canton and Toledo which report high availability. Respondents commented: “We still see doctor shopping. I’ve had guys go down to the Southern part of the State looking for prescription pills; We see the OARRS (Ohio Automated Rx Reporting System) report and find probationers getting the medication, that don’t report it to us; We see it a lot. ”In addition, a few law enforcement officers in Columbus discussed the prevalence of pressed pills made to look like prescription opioids, but reportedly, these clandestine pills actually contain illicit substances such as fentanyl.”
In most Ohio counties the availability of prescription opioids for illicit use has continued to decrease during the past six months [Q1-Q2 2018]. Respondents noted doctors cutting back on prescribing opioids, which has limited street availability significantly while also dramatically increasing prices for these drugs to where they are cost prohibitive to most users, as the primary reason for decreased availability. Community professionals once again credited OARRS as having a positive impact on the decline of availability of prescription opioids for illicit use. In addition, participants discussed that there are far less expensive and more potent alternatives to prescription opioids in plentiful supply, heroin/fentanyl), which has effectively decreased the demand for [prescription opiates].
Participants reported obtaining prescription opioids for illicit use from dentists, doctors, drug dealers, emergency rooms, family members and friends [who’ve had] prescriptions [written] for them, [by] pain management clinics, theft and through Internet purchase. One participant remarked, “Crime has increased…. You have people breaking into old people’s houses robbing them for pills because they have made it so much harder to get [the drugs prescribed].” In addition, several participants discussed an increase in ability to obtain these drugs from veterinarians: “They’re using their animals’ [prescriptions], too, to get Ultram® and Vicodin®…. They call them ‘doggie trims’ and ‘doggie bites’ and stuff; You would get the same tramadol if your dog needed it.”
Suboxone® remains highly available for illicit use throughout the majority of Ohio. Respondents in every region discussed the presence of Suboxone® clinics where reportedly a user can buy a prescription without treatment participation; many clinics were said to operate on a cash only basis. Comments included: “It’s the pay (cash only) doctors … they pay them $275 [and] they’ll give them three [Suboxone®] a day and then … they’re just out on the street; You can get a month’s prescription at a time on an outpatient basis, and you only have to see a doctor or counselor once; These clinics are popping up everywhere.” Respondents continued to attribute most illicit Suboxone® use to heroin users who trade the drug for heroin or use it to manage withdrawal. One law enforcement officer described Suboxone® as a “stability drug,” meaning Suboxone® is used to counteract withdrawal when the user is out of heroin. A participant remarked, “My heroin dealer always had some. If you could not afford heroin, you could buy Suboxone®.”
Those who perceived an increase [in the availability of Suboxone] most often cited an increase in the number of Suboxone® clinics [in the area] as the primary reason for the increase; more people prescribed Suboxone®, more Suboxone® diversion. Inversely, those who perceived decreased availability most often cited an increase in doctors prescribing Vivitrol® over Suboxone® as the primary reason for the decrease; less people prescribed Suboxone®, less Suboxone® diversion. A law enforcement officer in Cleveland explained, “There is less Suboxone® being distributed … now they have moved that to the Vivitrol® shots because the professionals know about the abuse of Suboxone®. It’s traded for the drugs sold on the street.… We have definitely seen the decline in Suboxone® sales as far as illicit sales.”
In addition to obtaining Suboxone® on the street from heroin dealers, participants reported getting the drug through doctors, clinics and individuals, [then] selling their prescriptions. Participants shared: “Every drug dealer I went to for heroin would sell Suboxone®; I’d definitely buy Suboxone® [to resell] … they were a form of currency.
Suboxone is a drug of last resort for opiate abusers, but it has found popular use with those who use stimulants as a means of increase a high.
Drugs abused most often in combination with Suboxone include alcohol, crack cocaine, marijuana, methamphetamine, Neurontin and sedatives.