- 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 he  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, ar  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   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.  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)