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INCINNATI — The medical examiners are puzzled, and the bodies aren’t giving up their secrets.

The bodies belong to overdose victims, and when they arrive on autopsy tables here, many are laced with substances that officials have never seen before. Drug screens weren’t designed to identify them.

The drugs are synthetic opioids, a growing collection of chemicals cooked up in labs and responsible for an increasing number of overdose deaths across the country. In this city and elsewhere, they are spinning mysteries for the medical examiners who are called upon to identify them.

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In some cases, bodies that by all indications shut down because of overdoses still show nothing on drug screens.

“We have to go back to the drawing board and say, ‘What is this that’s making this person overdose?’” said Dr. Thomas Gilson, the medical examiner in Cuyahoga County, which includes Cleveland.

The opioid epidemic has grabbed attention as a problem that demands responses from both public health and law enforcement officials. But these scientific puzzles, while being solved quietly in county morgues and city crime labs, are crucial if authorities are going to stem the crisis. If health officials know what drugs are ravaging communities, they can develop better prevention and treatment strategies. Identifying the drugs can also help law enforcement track the source.

And, sometimes, families of overdose victims simply want to understand what exactly killed their loved ones.

One of the most common synthetic opioids is fentanyl, which is up to 100 times more potent than heroin. There are also so-called analogs of fentanyl, with slightly altered chemical structures that can be missed by drug screens.

Here in Ohio, a rash of overdoses has been attributed to an opioid known as carfentanil, which is 100 times more potent than standard fentanyl and which, until recently, was most commonly known as a sedative used by zoo veterinarians. It was blamed for a spike of 78 overdoses in Cincinnati over two days this summer.

Forensic pathologists say their job is complicated by the fact that they often have little information about how much of a drug was consumed or how soon before death. Even if there are witnesses, they may not have accurate information. In some cases, synthetic drugs are used to lace heroin or passed off as heroin to unsuspecting buyers.

“There are so many variables here and there’s so much information that we don’t get that it’s really hard to evaluate scientifically what’s significant and what isn’t,” said Dr. Lakshmi Sammarco, the coroner in Hamilton County, which includes Cincinnati.

As officials here tried to tease apart how many of the overdoses over the summer could be attributed to carfentanil, they were flying blind. Toxicologists needed a clean sample of the drug — what’s called a standard — to adjust their screening procedures for it, and the companies that normally supply standards didn’t have any. The lab wound up getting its first sample from the toxicology lab in Akron, which had gotten it from a zoo.

Eventually, the Drug Enforcement Administration also provided a standard.

Cincinnati coroner
Toxicologist Katie Gabbard does presumptive screening for carfentanil at the Hamilton County Coroner’s Office in Cincinnati. Samantha Grier for STAT

Meanwhile, medical examiners had questions about how carfentanil affects the body and had to rely on limited scientific literature — just a few studies done in goats and antelopes.

“No one has any idea what level would cause someone to die,” said Robert Topmiller, a Hamilton County toxicologist. “No one has any idea what level would cause somebody to be impaired. No one knows this stuff.”

Since the summer, officials from Wisconsin to Florida have called Hamilton County asking how they adapted their screening protocol for carfentanil. But many labs still have to outsource confirmatory tests to private labs, officials say, creating another expense for these public agencies already crunched by a surge of opioid-related investigations.

Another problem with synthetic opioids is that lab equipment can prove insufficient to identify minuscule amounts of drugs in a victim’s system, even if that amount is enough to prove deadly.

“You’re actually pushing the limits of detection,” said Gilson, the Cuyahoga County medical examiner.

Dr. James Gill, the chief medical examiner in Connecticut, said that people who overdose can go into a coma but keep breathing and pumping blood for hours. During that time, the drug keeps being metabolized, so at death, the level might actually be quite low. Plus, people can build up tolerance to drugs.

“There’s a bit of a fallacy that there’s this so-called fatal concentration,” said Gill, who has studied the wide range of fentanyl concentrations overdose victims have shown.

Some officials say they are concerned about what’s known as renarcotization.

The idea is that a drug like carfentanil lasts in people’s systems so long that they can overdose, be revived with an antidote, and then hours later pass out without using drugs again.

Sammarco, the coroner in Hamilton County, said that she hasn’t seen a definitive case yet, but has told local emergency crews to be on the lookout.

As she drove through Cincinnati on a recent day, heading back to her office from an event about the opioid epidemic’s impact on children, Sammarco was talking about the presentations she gives to schools about drug use. She paused when she came across a police car and fire engine pulled to the side of the road with their lights flashing.

“God,” she said, “I hope this isn’t another overdose.”

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  • Sad to see the technologist in the picture not wearing appropriate PPE, meaning a lab coat and eyewear when preparing specimens for testing. Photographers need to be cognizant of taking an accurate picture depicting laboratory personnel instead of just having someone pose for a picture.

  • Is classifying these drugs only as “opioids” (substances that act on opioid receptors) accurate, or should this category be expanded, so the can be classified differently due to their primary purpose, that being for drug abuse? Is fentanyl made in a Chinese warehouse the same molecular and pharmaceutical grade as pharmaceutical fentanyl, or is it a one-off or two-off in its design? If not, why is it called fentanyl? This seems to only add to the problem.

  • I guess you are aware that Fentinel has been used by hospitals and other facilities for several years in surgery and other procedures for pain relief.

  • This is a problem that has surfaced in the past, and I’m will only expand in the future. The number of synthetics produced but never marketed is significant.
    In respect to the other poster’s comment, heroin is medically accepted in many countries, and a number of drugs are acceptable for human and animal use. Clearly not the one listed in this article however.

  • After breaking a bone, I was given pain killers. It’s weird how after they ran out I didn’t become addicted to opiods. The people who do are mostly loses who have no real goals in life other than to get high!!!

    • Yeah right bozo. A broken bone on the pain index rates very very low. Try for instance getting a 1 inch by two inch top 1/2 inch of your tongue removed. That is real pain. And genetics and epigenetics plays a massive role in how susceptible a person is to addiction.

    • Wow, anecdotal evidence to the rescue!! Here’s a thought: do a little research before saying awful statements like that. I am a bright, well-educated, previously successful professional with major long-term goals, dreams, desires, and a LOT to contribute to society. Unfortunately, I had several horrific events take place in my life and I made bad decisions in order to try and cope with these events. Heroin came into my life and as I got deeper and deeper into the addiction cycle, I watched everything I had worked so hard for crumble in front of my eyes. I’m but a shadow of my former self, and it isn’t because I started out as a “loser” with ambitions no greater than to get high. I made choices that I wish I could take back, true, but I’m working very hard to get back to where I used to be in life.

      If you still don’t believe that addicts aren’t as easily categorized/dismissed like you are trying to do, do your mind a huge favor and read up about Rat Park – a series of research experiments involving rats and narcotics. They kept a group of rats in excellent conditions – lots of exposure to peers, lots of opportunities for food, breeding, everything a rat would value. Then they had another group that they kept in awful conditions – isolation, discomfort, scarce food sources, and overall low-quality of life. Then they brought drugs to the rat community and added it to water bottles evenly throughout the two communities of rats. The rats quickly realized which bottles had the drugs in them and which ones were plain. Researchers found that the rats who lived in the bad living conditions were far more likely to access the drug-spiked water bottles than the ones who had happy, healthy lives. When they removed rats from the poor conditions and upgraded them to the good conditions, they found that they rarely showed any preference toward the drugs at that point.

      Point being – when life is really bad, animals and humans have a natural inclination towards making it more tolerable by artificial means. When life’s good, it’s not even on the table for most people. Why do you think that is? Can you honestly dismiss people as “losers” because of their quality of life, including factors they had little to no say-so in? Really?

    • Wow, Craig! Anecdotal evidence to the rescue!! Here’s a thought: do a little research before saying awful statements like that. I am a bright, well-educated, previously successful professional with major long-term goals, dreams, desires, and a LOT to contribute to society. Unfortunately, I had several horrific events take place in my life and I made bad decisions in order to try and cope with these events. Heroin came into my life and as I got deeper and deeper into the addiction cycle, I watched everything I had worked so hard for crumble in front of my eyes. I’m but a shadow of my former self, and it isn’t because I started out as a “loser” with ambitions no greater than to get high. I made choices that I wish I could take back, true, but I’m working very hard to get back to where I used to be in life.

      If you still don’t believe that addicts aren’t as easily categorized/dismissed like you are trying to do, do your mind a huge favor and read up about Rat Park – a series of research experiments involving rats and narcotics. They kept a group of rats in excellent conditions – lots of exposure to peers, lots of opportunities for food, breeding, everything a rat would value. Then they had another group that they kept in awful conditions – isolation, discomfort, scarce food sources, and overall low-quality of life. Then they brought drugs to the rat community and added it to water bottles evenly throughout the two communities of rats. The rats quickly realized which bottles had the drugs in them and which ones were plain. Researchers found that the rats who lived in the bad living conditions were far more likely to access the drug-spiked water bottles than the ones who had happy, healthy lives. When they removed rats from the poor conditions and upgraded them to the good conditions, they found that they rarely showed any preference toward the drugs at that point.

      Point being – when life is really bad, animals and humans have a natural inclination towards making it more tolerable by artificial means. When life’s good, it’s not even on the table for most people. Why do you think that is? Can you honestly dismiss people as “losers” because of their quality of life, including factors they had little to no say-so in? Really?

  • Opioids don’t “spread,” and “epidemic” in this context is metaphor, not a literal epidemic. Heroin is an illicit drug, not a virus. Some people decide they want to shoot heroin, and there you have heroin in a new location. Stop vilifying and demonizing Percocet and Vicodin along with heroin. Many sick and injured people desperately need pain medication. Go after doctors who overprescribe, and fight your drug war if you must, but leave innocent patients out of it.

  • Just a layman’s thought: maybe there needs to be a new word, other than overdose, to emphasize the danger. Overdose implies there is a medically acceptable dose of illicit/illegal/non-prescribed drugs. There is no medically acceptable dose for a human of heroin, or of the drugs that are used by veterinarians. Nimi does?

    • “One man’s med is another man’s poison” Dunno who coined that first, wasn’t me. But i do know the man with mestastic bone disease, who can walk by me, and is still attempting to find some sense of self respect, is constitutionally protected in his endevors. If i were to raise my hand and say, “hey, i’ll take some of that”, it would roll my eyes back in my head.
      Really doesn’t matter what you call it, the name does not make it an evil, illegal drug per se. Morphine alone is morphine. Its an easily tweakable molecule though. Add acetyl groups, its much more active. Bayaer gave it a name, Herion. Add hydrogen groups instead, you have Dilaudid, also much more active. Then there is methylmorphine, a pro drug with little activity unless you have the enzymes to cleave away the methyl groups.
      Talk to your doc

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