The Price is Right

 

I have been writing much lately about heroin with the backdrop of Hartford's Park Street which is one of many epicenters of the current heroin epidemic. Today, I am going to briefly change the backgrounds. Instead of Park Street with its back drop of bakeries, bodegas, Spanish restaurants, and young tattooed men, with crooked baseball caps, standing in the doorways minding their own business, we are going to your typical elderly housing/assisted living facility. Imagine a room of geriatrics in the common room, with their walkers on tennis balls or canes at the side of their chairs. Imagine perhaps also a 50 gallon aquarium, with clean bubbling water and a large lazy fish or two.

Now let us focus on our subject -- a Caucasian woman of 62.  She is obese, maybe two hundred sixty pounds, her hair is grey and tied back behind her head in a pony tail.  Her clothing is threadbare and could use a laundering. She has two canes beside her with which she walks slowly and painfully on skinny legs that can barely support her girth. Instead of the fish tank, she and her mates are watching The Price is Right.

The host challenges a contestant to guess the price of the next item -- not a toaster or blender or even a new TV.  The item is --wallah! -- a bag of heroin.

While the contestant ponders on TV, the guesses start from others in the common room. $50, $100,

Our heroine shakes her head. Well, it depends, she says. The going rate is $5. If you are buying a bundle and you're a good customer, your dealer might give it to you for $4 a bag if the junk's not primo.  Course if you're a sucker, or live in the suburbs, and your friend/dealer is jacking the price he paid on Park Street like that mutherfucker Monte did to me for six months so he can afford his own habit, you might be asked to pay more.

I said I would change backdrops so I am going to do that again. Let's lift the geriatric common area backdrop up, and then lower behind a new backdrop. Lower Albany Avenue in Hartford.  Six in the morning.  Still dark. Our old lady and her canes sit on a concrete barrier near the bus stop. She fell walking down the avenue and her leg is killing her. 10 of 10 pain. It doesn't help that she's been up doing crack cocaine all night. When my partner asks her about her medical history, she says arthritis and cardiac arrest. The cardiac arrest was from an overdose earlier in the week in the South end. She says her chest is still sore from the CPR. They intubated her and also gave her Narcan. (Hopefully not after the intubation).

We ask her if she remembers what the bag of heroin she overdosed on looked like. She says it was white -- no stamp.  She says she bought it from a King, who was not her regular dealer. She only bought two bags and it knocked her out. She says it was white heroin. We show her the pictures of some of the bags we have been seeing lately. She nods her familiarity with some and others she says she has not seen. She says the generic one was particularly strong and there is also a potent batch going around in yellow bags with no markings.

We ask her how a 62 year old woman from the suburbs came to be buying heroin in Hartford.  She says she has bad arthritis and the medicine her doctor gave her was expensive and after awhile, didn't help.   Monte, the maintenance guy who sometimes sold her Percocets offered her heroin. He wanted $10 a bag.  She learned she could get it herself for $5 a bag. A girl in her beauty salon with tattoos gave her a beeper number she could call for a hookup, and she'd take the bus in to meet the man. $5 a bag was cheaper than $30 for a Percocet 30mg.  Of course now she is homeless (she maintains a friend's suburban address for her mail), has hep c, and sore ribs from the CPR she got on the day she couldn't find her regular dealer, and ended up getting the white heroin from a Latin King.

I ask her how she knew she bought it from a King. The Latin Kings used to boldly wear their colors-black and gold, but they have gone somewhat underground now so as not to stand out to law enforcement or the public (should they want to use a stolen credit card or commit another nonviolent crime). Better for business.  They still control much of the drug trade in the city. By the tattoo on his arm, she says. A lion with a crown. Plus everybody knows the Kings rule the Park.

Street gangs tone down use of colors, tattoos

I bet she would beat her old neighbors in the elderly housing common room at Heroin Jeopardy.

Yes, Alex, I'll have gangs for $400."

Their colors are blue and red?

Who are the Los Solidos.

Drug Administration for $500.

Skin popping.

What is injecting drugs under the skin rather than in a vein?

Packaging for $300.

5 Bundles

What is a brick?

She could buy a lot of $5 bags with her winnings.

Plus some crack cocaine to share with the old North end dudes she was partying with last night.

* Recently several drug dealers have been charged with murder for selling drugs that caused a fatal overdose as the guy who boasted of his "KD" stamp found out last April (see below Hartford article). Some dealers have responded by going to blank bags so it is harder to be linked to the killing powder.  Some have speculated it may eventually lead to the demise of stamped bags.

Prosecuters Charging Drug Dealers in Heroin Deaths

The New War on Drug Dealers

After Two Deaths, Feds Charge Alleged Hartford Heroin Dealers

 

I mentioned that we had a patient this week who said she stayed away from the white powdered heroin because of her fear of Fentanyl.  Powdered Fentanyl is white and very hard to distinguish visually from white powdered heroin.

A number of years ago drug dealers started enhancing their heroin with Fentanyl. Fentanyl is stronger than heroin, so adding it was a good way to boost the reputation of their product. Deaths increased as users were hit with more potency than they expected, or in some cases, the heroin and Fentanyl were not evenly mixed and so even a user with high tolerance might die with the syringe in their arm if they got a hot spot of disproportionate Fentanyl in their buy.

The deaths and subsequent warnings of dangerous heroin only drew more users to the brands as many users sought the powerful mixtures. More dealers began adding Fentanyl to their batches. Also, while years ago, it was common practice to cut heroin to increase profits, many dealers now keep their heroin strong in order to compete with the Fentanyl brands as well an ever increasing supply.

Fentanyl can be obtained in two ways.  The low rent way to extract it from Fentanyl patches. The other way is to make it in a lab or get it from a lab. Most of the street Fentanyl in the United States now comes from labs in Mexico or China, and is smuggled into the country in the same matter as heroin.  Because it is stronger, more can more smuggled for the same potency. The prevalence of Fentanyl is increasing to such an extent that some law enforcement officials have on occasional found 100% pure Fentanyl being sold as heroin.

This week in Hartford, a SWAT team broke into a drug dealer's home and detonated a flash grenade to stun the suspects who were known to have firearms.  The explosion aerosolized some of the Fentanyl and heroin in the apartment and 11 of the team members were hospitalized for nausea, dizziness and vomiting. This bust yielded over 50,000 bags of Fentanyl-laced heroin.

11 Hartford SWAT Officers Exposed To Heroin, Fentanyl During Drug Raid

The woman we talked to used the bag stamp system to know which brands to avoid as she was not a death seeker like many users. 

Back in 1991 when Tango and Cash stamped heroin bags that were laced with Fentanyl were killing people on the streets of Hartford, the New York Times wrote about officials driving the streets using loud speakers to warn people about the deadly mixture. At the same time, the alerted junkies suddenly sought the brand out much like Super Bowl tickets or people today seek the latest I-phone.

Toxic Heroin Has Killed 12, Officials Say

While our woman friend avoids the dangerous Fentanyl mixture, others seek it. This is reflected in the branding. I found a heroin bag labeled "Dead Man," another bag had a picture of the Grim Reaper on it and the words Strike Dead. Some bags just have a skull and crossbones on them.  This does that necessarily mean that those brands are the baddest of the bad.  It could just be marketing.  A user who trusts their regular dealer will hopefully learn what brand will fit their needs.  

Another problem with Fentanyl for the user (besides higher risk of death) is that it does not last as long as heroin.  Users need to fix again sooner and end up having to buy more. I suppose the dealers are willing to lose a few clients to overdose to gain the added volume from other customers.  Talk about business ethics. 

The picture in the paper of the Hartford bust and the 50,000 bags of heroin all laid out on a table seems like a lot, but if a user had a two bundle a day habit - 20 bags, 50,000 is a year's supply for just 7 addicts.  I don't think the users in Hartford will have to look too far tomorrow to get their fix. Someone on Park Street will be hawking Undertaker,Six Feet Under, or Dead Man. And money will change hands.  

And another 911 dispatch will go out.

EMS Distributes Naloxone

 

Paramedics in North Carolina and in Cleveland, Ohio are providing Narcan kits to high risk patients in their communities.

Cleveland EMS Providers to Distribute Overdose Kits

N.C. County Allows Paramedics to Provide Precautionary Narcan Kits

My partner and I often spend time on heroin overdose calls educating the patient's family, friends or bystanders/social circle on the availability of Narcan (where to get it -- local clinic, pharmacy, etc) and how to administer it. We recently had one patient's neighbor (who had found his friend unresponsive) express gratitude for our lesson and say he would immediately go down to the clinic and get a kit. A woman this week told us she had Narcan in the bathroom, kitchen, living and bedroom in her apartment, and had one kit always in her purse (which unfortunately had been taken from her while she nodded off in the bushes -- thus prompting the 911 call for the woman unresponsive). Leaving a Narcan kit with people who were present at an overdose scene makes clear sense.

If we had Narcan kits that we could give out, we could easily disburse them to high-risk individuals.

In North Carolina, EMS is giving Narcan to patients who refuse treatment. I have not had a patient in years who refused treatment after Narcan.  Many years ago when my practice was to give 1.2-2.0 mg IV, I did have quite a number of patients refuse. Well, instead of saying, I refuse, they used more colorful language as they ripped the IV out of their arms and walked down the street the colorful language continuing. Now, I mainly use Intranasal (IN) Narcan or IV at very low doses (0.1 increments), and my patients are much more subdued, and go to the hospital. The ones that refuse are the ones who are simply on the nod, and who wake with stimulation (like the woman in the bushes, who actually was roused by a bystander as we arrived, and started walking down the street on her own, although she did stop and let us talk with her).

If opiate overdose patients are going to refuse transport, leaving them Narcan as well as persuading them to have a friend watch them for awhile seems reasonable.

We did have an very interesting conversation with the woman, who not only told us what brand of heroin she had used, she provided commentary on a number of different brands we had seen. She told us that she avoided Chief and OMG because they were white heroin known to be mixed with Fentanyl. She preferred the brownish powder. Every time she foolishly tried white powder brands, she said, she ended up surrounded by firefighters and EMS. She wasn't looking to die nor was she looking for a magic high. She just needed her daily fix, and for that she had to walk to Park Street everyday to meet her guy.

She got hooked on heroin because it was cheap and she had issues of loneliness and self worth that had caused her to seek escape. She uses heroin every day now. It is as much a part of her life as getting up in the morning, drinking water, eating her daily bread, and forgiving her trespassers.

Kudos to North Carolina and Cleveland.

Park Street

 

I only went to one heroin overdose this week and one PCP overdose.  The heroin overdose was on Park Street in the South end and the PCP was on Capen in the north end.  You get get called for an overdose on Park Street and it is pretty much always heroin.  You get called for an overdose at Garden and Capen, it is going to be PCP. The North end is mainly black, the South end Hispanic.  The blacks control the PCP trade, the Hispanics most of the heroin. There is some mixing, but that is pretty much the divide. You go to Keney Park in the north end, and you find lots of tiny empty clear plastic baggies with no markings. PCP. Not too many heroin bags. You go to Pope or Colt Park in the South and you will find empty glassine envelopes with stamps on them marking the heroin brands.  In just one month of looking, I have already counted 96 different brands (some of the envelopes are likely months old (one was branded Super Bowl 50), others freshly tossed from the car window where the junkies sit low in the seats shooting up, and chilling before driving off).  Some brands I have only found one of, others are scattered everywhere, often in clumps of five or more bags.  I find it fascinating to see what brands are the hottest. Black Jack gave way to OMG, which gave way to Chief, Public Enemy, and now to Fastrack, which we found in nearly every location we looked last week.  Who knows what next week's hot brand will be?

The heroin overdose I went to was a woman I had treated before. She had gone into a public restroom and not come out. When the first responders got there, she was unresponsive and blue. The fire department gave her 2 mg of Narcan IN. By the time we got there, she was already in the back of the BLS ambulance, breathing on her own, and rousable with a good shake. She was in her thirties, wearing a short skirt and a low cut top with a pushup bra. At one time had obviously been good looking, but there were hard miles on her. She had cellulitis and abscesses on her arms and a bad ankle that had never healed right from a fall. When we put her name in our laptop, her address came up in as a Hartford suburb, but she said she was now homeless. I tried to ask her some questions about what brand she had used, but she kept nodding off. She was at least able to identify the Fastrack brand from the picture I showed her on my iPhone and say she heard it was dangerous. She told me she bought from her usual dealer.  I asked her again what brand she had used, and she said she was trying to remember, then she nodded off again. I let her sleep. Her ETCO2 was 42 and her SAT was 96 on room air, her respiratory rate was 14. Power to her. At the hospital, they said they were going to give her more Narcan. I guess they were pretty full and didn't have a sitter to watch her sleep in case she started hypoventilating again. 

The first time I picked her up was in front of the shelter at Hungerford and Park. The police officer who flagged us down said she was drunk. She was motherfucking him to beat the band. My BLS partner said he would tech the call, and after having teched the first nine of the day, I let him. I drove to the hospital and saw him typing the PCR on the computer. When we hit the hospital, and pulled the stretcher out, she was cyanotic, and breathing maybe four times a minutes. I shook her shoulder and she roused enough to tell me to fuck off. I saw the fresh needle mark on her right hand then, the pin point pupils, and was upset with myself for just assuming she was drunk and not taking a closer look just walking to get in the driver's seat when my partner offered to do the call.  

I debated pushing the stretcher back in the ambulance and giving her Narcan then, but since she was rousable we just brought her in.   Unfortunately the triage line was long. Every couple of minutes I had to shake her hard to get to breathe. After awhile, she stopped swearing at me, and I had to cut to the front of the line and ask the triage nurse for either Narcan, an ambu bag or permission to go back out to the truck to get my gear and treat the patient in the their waiting line. They wanted us to bring her to the critical room, but I said she just needed a little Narcan so they finally gave me an ambu bag and a room down the hallway where a nurse practitioner asked us what the dose was. We told her to start low. They gave her 0.4 IM, and took over bagging.  I thought next time I would just go back out to the ambulance and get my gear.  We saw our patient later smoking a cigarette in front of the ED, the hospital ID bracelet still on her wrist.  She didn't recognize us.

I wanted to go back and talk to her after we left her in the room this last time, but we didn't get back to that hospital till four hours later and she was already gone.  I went back to the restaurant where she had ODed in hopes I could find the wrappers in the bathroom, but they had a men's and a women's bathroom, and you had to get the key from the guy making the sandwiches.  I chickened out and asked for the men's room key after buying a turkey sandwich.  I suppose I should have just come out and said I wanted to look in the woman's room to try to identify the brand the woman had ODed on.   I did find two wrappers in the men's room, but they were blank.  Not all the bags have stamps on them.

I have seen her a few times walking along Park Street, particularly in the early morning when the bakeries are just opening up.  They sell pressed bologna sandwiches real cheap and there is often a line out the doors. One of the bakeries sells a pernil (pork) cubano for only $3.  I try to get one if the line isn't too long.  Some mornings they sell homemade tamales wrapped in corn stalks. $0.75. They are run by honest people, and feed many in the community.  There is drug dealing close by but that comes with the territory of Park Street.  Everyone likes sandwiches and cheap coffee and a friendly smile in morning.  Cops eat there, EMS eats there, working folks eat there and drug dealers, junkies and the homeless eat there. We all have our roles. Such is the community of Park Street, the community of Hartford.

Public Enemy

 

Last week I speculated that despite increased access to Narcan, the opiate epidemic would continue to rage with deaths in 2016 exceeding those of 2015.

Narcan Thoughts

Sadly, this was borne out in just released data from the state medical examiner. Through the first six months of 2016, 444 people died of fatal overdoses in CT, which projects to at least 888.  729 died in 2015.

A story in the Hartford Courant lays much of the blame on Fentanyl , which was involved in 25.8% on the deaths in 2015, and already in 50.2% on those in 2016.

Fueled By Fentanyl Spike, Overdose Deaths Continue To Climb In Connecticut

How powerful is a drug that you know can kill you easily, and yet you still take it -- often alone with no one to watch over you?

It isn't a slow death like that one inflicted by cigarettes or gluttony. Most of us have encountered the dead with the needle still in their vein.

To many people giving Narcan to EMTs and to family members was a drastic step, unheard of a few years ago. Maybe we need to think even bolder.

Maybe we should as some other countries do and have safe havens where junkies can go for their daily fix and be observed by medical personnel with Narcan at hand. They can get access to people who will try to convince them to get treatment.

William Proxmire, a former United States Senator, who was a big advocate to eliminate wasteful spending, used to say, " a million dollars here, a million dollars there, and pretty soon you are talking about real money."

To paraphrase for the opiate epidemic. "A hundred opiate deaths here and a hundred opiate deaths there, and pretty soon you are talking about a massacre."

Here is an interesting article on heroin safe havens.

Boston's Safe Space for Heroin Users

"It's not that we don't want people to be drug free. But dead people don't recover." -Barbara Herbert, the president of the Massachusetts chapter of the American Society of Addiction Medicine