Pat Kneip

Special Assistant Attorney General

Drug Diversion Investigator

S.D. Division of Criminal Investigation

OPIATES

FROM PILLS TO HEROIN

OBJECTIVES:

DESCRIBE THE EXTENT OF THE CURRENT PROBLEM OF DIVERSION

AND ILLICIT USE OF CONTROLLED SUBSTANCES FROM THE NATIONAL

AND SD PERSPECTIVE

OUTLINE THE RELATIONSHIP BETWEEN PRESCRIPTION OPIOID DRUGS

AND HEROIN, HOW THESE DRUGS ARE GETTING HERE, THE SCIENCE

BEHIND IT, AND WHAT WE CAN DO NOW!

What I Will Cover

History -

• Opiates, derived from opium poppy,

have been used recreationally and

medicinally for thousands of years.

• Sixteenth century opium was pared with

an alcoholic solution to form a painkiller.

• Nineteenth century morphine is

extracted from opium in pure form and

used as a painkiller, especially during

the American Civil War.

• Prescription Narcotics are the most

used and abused substances in

America today.

• From ‘00 to ‘13, the amount of

painkillers prescribed and sold in

the U.S. quadrupled, and along

with this, overdoes deaths

quadrupled as well.

• The US constitutes 4.6% of the

world’s population and consumes

99% of the world’s hydrocodone

supply

PRESCRIPTION PILLS

• Vicodin – Est. 1984

• OxyContin (Oxycodone) – Est. 1995

• Hydrocodone – Est. 1920’s

WHAT HAS AMPLIFIED THE PROBLEM?AKA, HOW DID WE GET HERE? WHAT CAN WE CHANGE?

• Mid 1990’s – “Pain is the Fifth Vital Sign” – increased opioid pain reliever (OPR)

prescribing

• Unrealistic expectations of the “health consumer” for zero pain and immediate

gratification

• Social acceptance and the perception of “safety” by parents and youths

• Lack of understanding about risks

• Lack of resilience skills in our youth

• Storage of Prescriptions in areas accessible to friends and family

• Imbalanced doses

(e.g., Oxycodone 30mg for wisdom teeth removal)

5

EPIDEMIC OF OPIOID ADDICTION

• New way of thinking: A Disease epidemic, not a Behavior epidemic - Opioid Addiction vs. Opioid

Abuse

• Opioid Addiction is chronic, life-long, difficult disease to treat and is a key driver to opioid related

morbidity and mortality

• Primary prevention includes reduction in disease through medical and non-medical exposure

reduction – more cautious and selective opioid prescribing

• Secondary Prevention includes increased screening for the disease after onset – before major

consequences – difficult because patients try to conceal history – PDMP is key

• Tertiary Prevention includes rehabilitative and therapeutic measures to ultimately prevent

overdose death from OPR or Heroin

• expansion of treatment options

• 4 of 5 heroin users report that their addiction started with OPR use (previous statistics

rate this as a much lower percentage, including those on the next page)

Annual Review of Public Health 2015, 36:25.1-25.16, Kolodny,. et al; “The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction”,

ALARMING STATISTICS

➢ 5,784 adolescents used prescription

pain relievers non-medically for the

first time on an average day during

the last year

➢ In 2013, more than 44,000 people

died in the United States as a result

of a drug overdose (120 people per

day). In 2016, more than 64,000

people died as the result of a drug

overdose (176 people per day), 2/3

of those from opiods.

➢ The latest data from 2013 shows

that drug poisoning deaths involving

opioid analgesics, surpasses the

deaths due to cocaine and heroin

combined

➢ In the United States, prescribe

enough pain pills to give every man,

woman, and child 1 every 4 hours,

around the clock, for 3 weeks.

NUMBER OF PILLS PRESCRIBED IN SOUTH DAKOTA

OpiateAmbienBenzo SedativeOpiateBenzo SedativeBenzo SedativeAmphetamineAmphetamineOpiateOpiate

OpiateOpiate

Ambien

Benzo SedativeBenzo Sedative

Benzo SedativeAmphetamineAmphetamine

OpiateOpiate

December Most Prescribed Drugs RX's Quantity Days Supply Quant/Rx

HYDROCODONE BITARTRATE/ACETAMINOPHEN 25,002 3,476,381 644,918 139

TRAMADOL HCL 15,353 1,202,306 288,879 78

ZOLPIDEM TARTRATE 8,832 290,691 287,967 33

LORAZEPAM 8,441 424,684 201,909 50

CLONAZEPAM 7,709 953,874 472,064 124

ALPRAZOLAM 5,826 339,117 152,422 58

DEXTROAMPHETAMINE SULF-SAC/AMPHETAMINE SULF-ASP 5,689 256,577 170,672 45

METHYLPHENIDATE HCL 5,259 239,909 159,658 46

OXYCODONE HCL 4,968 417,394 94,589 84

OXYCODONE HCL/ACETAMINOPHEN 4,884 631,418 120,184 129

• 35.5 MILLION doses of opiates (582,048 Prescriptions) were prescribed to South Dakotas in 2014.

• Enough to ‘medicate’ every South Dakota adult 24 hrs/day for 14 straight days.

• 82 Opioid Deaths between 2004 to 2011 (approximately 10 per year).

• 2013 = 17 Opioid Deaths

• 2014 = 16 Opioid Deaths (including one death where heroin was present)

• 2015 = 1 Heroin OD resulting in Death and multiple OD’s resulting in hospital visits.

• 2018 = 9 overdoses in 9 straight days in Sioux Falls, 2 resulting in death.

• Narcan

HOW IS SOUTH DAKOTA DOING?

WHERE ARE THESE CONTROLLED

PRESCRIPTION DRUGS COMING FROM?

USING PILLS

• Prescription Pill Addiction (Caution: Language)

• In 2010, funded by DOJ grants, the Prescription Drug Monitoring Program (PDMP) was founded.

• In 2013 Federal regulations were released recommending stronger restrictions.

• In 2015 South Dakota Hospitals began to closely monitor Doctors prescriptions.

• Reports indicate up to 66% of opiate pill addicts move into heroin (NEJM.org)

PRESCRIPTION PILL DECLINE TURNED TO HEROIN INCREASE

INTRODUCING HEROIN

From Plant to Drug • Heroin originates from countries

such as Mexico, and across

southern Asia from Turkey to

Pakistan.

• After the poppy plant pedals have

fallen an egg-shaped seed pod is

exposed.

• Inside the pod is an opaque, milky

sap. This sap is opium in its crudest

form.

• To get to the sap producers will slit

the pod and once the sap seeps out

will scrape it with a knife.

• This sap will be formed into

balls/cakes and shipped to heroin

labs.

• Opium-Morphine-Heroin

• Once at the lab the opium will be

mixed with lime in boiling water. At the

surface of the water a white band of

morphine forms.

• This morphine will be reheated with

ammonia, filtered and boiled again

until it is reduced to a brown paste.

• First, equal quantities of morphine and

acetic anhydride are heated in a glass

or enamel-lined container for six hours

at 185F. The morphine and the acid

combine to form impure

diacetylmorphine.

• Second, water and chloroform are

added to the solution to precipitate

impurities. The solution is drained and

sodium carbonate added to make the

heroin solidify and sink.

• Third, the heroin is filtered out of the

sodium carbonate solution with

activated charcoal and purified with

alcohol.

• Fourth, this solution is gently heated to

evaporate the alcohol and leave

heroin, which may be purified further.

At this point the heroin is “Black Tar”

(Dirty)

FROM PLANT TO DRUG CONTINUED

• In order to complete the production of

heroin the ‘black tar’ must go through

a process called acetylation.

• Acetylation includes using acetic

anhydride, a colorless, highly

combustible liquid.

• After 5 hours of cooking a mixture of

water, acetic acid, and

diacetylmorphine (heroin), water and

chloroform are added.

• This base is treated with charcoal and

filtered leaving a light brown or white

powder.

PURIFYING HEROIN

CHEMISTRY MAKEUP Heroin Hydrocodone

Morphine

HOW DOES IT GET HERE?

WHAT TO LOOK FOR

Watch for the SignsWhat does withdrawal look like?

WHO IS USING HEROIN

HOW DO THEY SUPPORT THEIR HABIT?

• LIE

• THEFT

• ROBBERY

• BURGLARY

• MOTOR VEHICLE THEFT

• BEG

• MANIPULATE

• Etc.

• Heroin

• $10 - $25 per dose

• $80 - $100 a gram

• $225 a 8 ball

• $350 - $400 a ¼ ounce

• $700 a ½ ounce

• $1400 a ounce

• Beginning User = $20 - $50 a Day

• Heavy User = $150 - $170 a Day

• Purity Average = 7%-10%

• Hydrocodone

• $1 - $3 a milligram

• Pill sizes: 5mg - 7.5 mg - 10 mg

• Beginning User = 20 mg-30 mg a time

approximately 50-60 mg a day ($50-$100)

• Heavy User = 200 mg a day ($200-$500)

COST COMPARISON

HEROIN USER REVIEWS

• “From the day I started using, I never stopped. Within one week I had gone from snorting

heroin to shooting it. Within one month I was addicted and going through all my money. I

sold everything of value that I owned and eventually everything that my mother owned.

Within one year, I had lost everything.

• “I sold my car, lost my job, was kicked out of my mother’s house, was $25,000 in credit

card debt, and living on the streets of Camden, New Jersey. I lied, I stole, I cheated.

• “I was raped, beaten, mugged, robbed, arrested, homeless, sick and desperate. I knew

that nobody could have a lifestyle like that very long and I knew that death was imminent.

If anything, death was better than a life as a junkie .” (drugfreeworld.org)

THE NEW HEROIN ADDICT

• The Face of Heroin

• A strong synthetic opioid medication

first developed in the 1960’s.

• Fentanyl is 50 to 100 times more

potent than Morphine and 15 times

stronger than Heroin.

• Available in patch form, pills, and

lollipop.

• Scheduled II Substance.

• WEAR PERSONAL PROTECTION

EQUIPMENT IF HANDLING!

• Field Testing for Law Enforcement?

• Illegally produced, Acetyl Fentanyl is a

closely related cousin to Fentanyl.

• Less potent than Fentanyl, it delivers

the same in vitro binding affinity to the

opioid receptors.

• Acetyl Fentanyl comes in a white

powder form.

• Scheduled I Substance.

• WEAR PERSONAL PROTECTION

EQUPMENT IF HANDLING!

FENTANYL AND ACETYL FENTANYL

FENTANYL VS ACETYL FENTANYL

WHAT TO DO NOW?

• BE THE POLICE!

• Use the Prescription Drug Monitoring Program (PDMP)

• Work with Hospital Staff (are they telling you when an OD comes in)

• Share Intelligence

• Develop sources of information.

QUESTIONS?