Spike in Ohio's synthetic opioid ODs offers grave warning to Western Pa.
DAYTON, Ohio — The cooler is full at the Montgomery County coroner's office in downtown Dayton, Ohio.
White sheets are stacked neatly on cool, metal pull-out trays on racks, the space between just big enough for the body that lies beneath.
Not all of them are overdoses, but most of them are. Not all of those are opioid overdoses, but most of them are.
Not many, however, are heroin overdoses.
Lab-created, designer opioids have far outpaced heroin as a killer of addicts, and they've kept the coroner's office full on most nights.
"If this pace continues, I'm not really sure what we're going to do," said Montgomery County, Ohio, coroner Dr. Kent Harshbarger. "We had 13 (bodies) yesterday, and 12 of them were overdoses."
He has already expanded his cooler once, last year, because space for 36 wasn't enough.
It now holds 42.
"It's full every night," he said.
Two workers from the Montgomery County, Ohio, coroner's office carry out the body of woman who died from an overdose at a Dayton hotel.
One day earlier this year, he still ran out of space — overdoses, again. He had to send some bodies to a funeral home. He rents refrigerated trailers that can be brought in when deaths spike.
Synthetic opioids like fentanyl and its many analogues are killing users at a rate Harshbarger and others say they've never seen.
Southwestern Ohio is on pace to have more than 2,000 overdose deaths in 2017.
"I'm looking at 2,900 autopsies, 2,000 of them overdoses," said Harshbarger, whose office deals with Montgomery County and the two dozen or so surrounding rural counties. "I can't operate at that capacity."
The office handled fewer than 2,000 autopsies total in 2016.
It is the next wave of the opioid epidemic that experts say has already started to hit Southwestern Pennsylvania, and it will almost certainly get worse.
According to Allegheny County health officials, instances of fentanyl-related overdoses surpassed those of heroin for the first time in 2016. Six hundred people overdosed and died in the county last year – most from opioids, said Dr. Karen Hacker, director of the Allegheny County Health Department.
In Beaver County, two deaths in late 2016 were traced to carfentanil, a synthetic opioid generally used to tranquilize large mammals, like elephants. One 2016 overdose death in Butler County was traced to the drug.
Earlier this month in Westmoreland County, investigators seized five grams of the drug – enough for up to 50,000 stamp bags. One grain is enough for a high. Two grains can kill.
The number of deaths connected to those offshoots has remained relatively low locally compared to the rates in Ohio, and carfentanil has yet to show up in Allegheny County toxicology reports.
"I think we're all hoping it doesn't make it here," Hacker said.
Dayton Police secure the scene of an overdose death at a Dayton hotel.
"It's already here," said Special Agent Patrick Trainor, of the Drug Enforcement Administration.
The potent, highly deadly designer opioids are here — they just haven't killed many people yet, Trainor said.
The Allegheny County Medical Examiner's Office has identified 84 overdose cases so far this year, though officials cautioned that's not an accurate reflection of the first third of 2017.
Toxicology results take weeks, and Allegheny County Medical Examiner Dr. Karl Williams said earlier this year that the complexity of some drugs has prompted investigators to send samples to other labs to identify them. It wasn't until April that the office released a tentative total for 2016: 613.
Since then, that number has grown to 635 as officials continue to identify overdose cases from late in the year..
Of 84 cases completed this year, 70 individuals had fentanyl in their bodies. Twenty-nine had heroin.
Other synthetics turned up by toxicology were four cases of a synthetic opioid known as U-47700, six of butyrylfentanyl and five cases of the lab-created opioid furanyl fentanyl.
Hacker said because users often don't know fentanyl or its analogues are mixed in with their heroin, they're overdosing easily.
"What used to get people high, that same dosage, as long as there's fentanyl in there, it's putting people into overodoses," she said. "The only good news is that we've been able to push naloxone out there,"
The health department works with several prevention and rehab centers, including Prevention Point Pittsburgh, which works to get Narcan into the hands of active users.
Trainor said its now impossible to know what you're getting when you go to a dealer.
"We've seen a lot of people will mix low-quality heroin with synthetics to increase the purity of it," Trainor said. "If ... you go and buy a baggie of heroin, you have absolutely no idea at all what you're getting."
Hacker said it is hard to watch.
"It's very, very tragic in a lot of ways," she said. "We're hearing people in the street say things like, 'Now people can overdose the first time they try it.'"
Vials wait for testing at a lab at the Hamilton County Coroner's office in Cincinnati.
On a Thursday in April, Harshbarger has eight bodies in the cooler at his Dayton crime lab. It's not yet 11 a.m.
By noon, the ninth is on the way.
Police found a woman in a third-floor motel room, dead from an overdose. Police at the scene speculate that someone had been there with her but took off upon realizing the woman was dying.
The motel — three floors of doors that lead outside to a rickety walkway and black-grate stairs — looks abandoned. The owner is outside when police arrive but disappears into the motel's office before they finish their work. An employee briefly stops cutting the grass to watch the scene unfold, then starts the lawnmower again.
Two volunteer firefighters stand at the scene, keeping an ear on the scanner. Two calls for possible overdoses come in while they wait.
The old metal walkways are too narrow, too shaky to get a gurney to the third floor. Two investigators carry the body bag down the stairs.
Hamilton County Coroner Dr. Lakshmi Sammarco
Dr. Lakshmi Sammarco nodded knowingly at Allegheny County's 2016 statistics, the first time fentanyl outranked heroin in overdose reports.
That's how it started in Hamilton County, Ohio, too, said Sammarco, coroner for the county, from her office on the edge of Cincinnati, the county seat.
The heroin overdoses began increasing in 2012 and 2013. By the end of 2013, Ohio had fentanyl. Soon, Sammarco was dealing with the fentanyl derivatives as well: acetylfentanyl, acrylfentanyl and, eventually, carfentanil.
Last summer, she watched carfentanil make its way down Interstate 71.
"Cleveland confirmed, then Akron confirmed — they had 24 overdoses in one weekend," she said. "Then Columbus — they once had nine in one hour. I said, 'If it's not already here, it's coming.' Within a week or two, we were getting a lot of overdose calls."
From there, she said, it spiraled: A spike in July, then a single week in August during which EMS crews responded to 176 overdose calls. On one Saturday night, Cincinnati police had 22 officers on the streets, and 20 were responding to overdoses.
Public officials needed to head this off when it began, but they didn't, Sammarco said.
"What are we doing?" she said. "We're going to have an entire generation without parents."
The highest drug enforcement officials in the country can't say why the epidemic seems to have taken root in Ohio and radiated outward from there.
"We have no clue, but Ohio is the epicenter," Trainor said. "Why? We really don't know. But it clearly is."
Beyond the public health implications, both immediate and long term — Ohio saw a 13 percent increase in children in foster care last year, something Sammarco suspects can be linked to the growing number of overdose deaths — the epidemic creates new and distinct dangers for those who work to slow the rising numbers.
A lab tech in the Hamilton County Coroner's office shows some of the testing procedures used to test opioids.
These strong synthetic drugs can be inadvertently absorbed through the skin or inhaled as micro-particles.
In East Liverpool — about 25 miles north of Steubenville and a five-minute drive from the Pennsylvania border — a police officer overdosed earlier this month when he patted down a man who was covered in fentanyl powder.
Patrolman Chris Green was assisting with a May 12 arrest of a man with suspected drugs in his car. Green patted the man down, not realizing until after that fentanyl powder was on the man's shirt. Finding powder on his own shirt, Green used his hand to brush it off.
Within seconds, he was overdosing. It took four doses of Narcan to revive him completely.
In Hamilton County, Sammarco has banned field testing. Investigators will no longer test a suspected drug substance on the scene.
"We were having some EMS people affected and taken to the emergency room," she said.
Samples of opioids await testing at a lab at the Hamilton County Coroner's office in Cincinnati
In Allegheny County, Dr. Karl Williams, the chief medical examiner, and his employees have begun to take precautions.
"We never really had to worry about treating our own workers before," Williams said.
Now, the Allegheny County crime lab and medical examiner's office keeps Narcan on hand in case of exposure during autopsies or evidence analysis.
"We have, I think 14 units of Narcan distributed around the lab," Williams said. "A year ago, there weren't any. We went through training with the health department on overdose response (and) the administration of Narcan."
Procedures like that have been in place in Montgomery County for more than a year, said Ken Betz, director of the coroner's office. Narcan is stocked throughout the lab, and investigators carry the reversal drug with them when they go to collect a body.
"Full protective clothing, gloves, face mask are used whenever working powder cases," he said. "At least two scientists must be present at all times during analysis. No one is permitted in the drug chemistry lab without proper protection. No food, no drinks, no phone calls."
The biggest change, however, according to Harshbarger, is the toll.
"There's no time to decompress anymore — it's just the same tragedy over and over again," Harshbarger said. "The staff is overwhelmed."
"Not only are you working hard, but you now have to worry about whether it's going to enter your life personally," he said.
It's not over yet.
Trainor said that when all is said and done, the death toll for Pennsylvania last year will be near 4,500, with fentanyl and, increasingly, its offshoots, driving the deaths. That total is more than the number of Americans killed during 14 years of the war in Iraq.
It will get worse.
"It may take another year or two before this levels off," he said.
Megan Guza is a Tribune-Review staff writer. Reach her at 412-380-8519, email@example.com or via Twitter at @meganguzaTrib.