These substances will change how the user thinks, feels, and acts. They produce a rewarding experience that the user will feel compelled to repeat. They may be administered in a variety of ways, including swallowing, smoking, snorting, or injecting. Some of these substances are extremely high risk and can result in rapid lethality to the user; others are a risk for first responders to be exposed to.
Opioids:
- Fentanyl
- Krokodil (Desomorphine)
- Purple Fentanyl
- Methylfentanyl
- Nitazenes
Opiates/Opioids Have Similar Effects:
- Analgesia (Pain relief)
- Euphoria (A very relaxed, pleasurable feeling)
- Somnolence (nodding)
- Feeling of warmth & flushing (face will turn red)
- Dry mouth (a lip-smacking sound may be evident when the person is speaking)
- Nausea & Vomiting
- Constipation
- Itching, which is described as felt down to the bone.
- Miosis (Pupils constricted to pinpoints).
- Respiratory depression, slow, shallow breaths.
- Bradycardia (slow heart rate).
Users are seeking the euphoric effects, which in the absence of severe pain will initially feel orgasmic. The user will then get a very relaxed, drowsy, peaceful, warm feeling that will persist for hours. Once the body adapts to an opiate, it produces violent illness about 12 – 24 hours after the last dose. The symptoms are fever, sweating, nausea, vomiting, diarrhea, cramps, headache, goosebumps, chills, watery eyes, and a runny nose. This will feel like a severe case of the flu by many multiples.
Fentanyl
Fentanyl is a strong opioid intended for the relief of pain from terminal cancer, to assist with anesthesia for surgical procedures, and for post-operative pain management. While Heroin is 10 times stronger than Morphine, Fentanyl is 50-100 times stronger than Morphine. Heroin is never sold in its pure form; it is cut with inert ingredients, e.g., baking soda, confectionery sugar, or mannitol, to maximize weight and volume and therefore profit for the dealer. Any water-soluble white powder can be used to cut opioids.
The amount of heroin in a batch might only be 10% or less. Fentanyl is mixed into heroin to increase the strength of the product, while minimizing the volume of actual heroin sold to a user, and to maximize profit for the dealer. This is advantageous for the dealer, as Fentanyl is very potent and inexpensive.
Krokodil (Desomorphine)
According to the Journal of Drug and Alcohol Dependence, Desomorphine is Codeine treated with gasoline, red phosphorus, and iodine. Codeine is a weak opiate, but when chemically treated, it becomes a strong opiate, about 100 times stronger than morphine. Desomorphine is commonly referred to as Krokodil. Krokodil is primarily used by IV (Intravenous) injection, though it can also be snorted. The effects will be the same as other strong opiates, e.g., orgasmic rush & euphoria. It has a very strong addictive potential and severe withdrawal upon cessation of use. Injection and snorting can result in necrosis (tissue death and decay).
When injected, it initially produces a dry, scaly patch at the injection site. Tissue death will occur gradually due to the caustic chemicals used in the manufacturing process. If use continues, the tissue death will spread, and skin, fat, and muscle will decay and slough off the bone. The limb will no longer function and cannot be restored. The appearance is grotesque, and the decayed flesh will have a putrid odor. The affected limb may eventually need to be amputated to prevent the infection from spreading to vital organs.
Purple Fentanyl, aka Purple Heroin, aka Purp
According to the US Customs & Border Protection, this is fentanyl or heroin cut with lidocaine and/or carfentanil and dyed purple. Lidocaine is a local anesthetic, commonly used in dentistry and for minor procedures such as suturing. Carfentanil is a large-mammal (Elephant, Rhinoceros, and Hippopotamus) sedative/analgesic. The purple dye is a marker to identify it as something much more potent than typical heroin or fentanyl, and to make it more attractive to young users. The introduction of Lidocaine is significant as lidocaine will make the heroin and fentanyl resistant to Narcan.
Carfentanil
Carfentanil is an opioid sedative/analgesic intended for large land mammals, such as elephants, hippopotamus, and rhinoceros. Carfentanil is 10,000 times more powerful than Morphine.
Ortho-Methylfentanyl
This is fentanyl that has been chemically altered to increase the strength of fentanyl when taken orally. Oral fentanyl is poorly absorbed and does not produce an intense high unless it is snorted, inhaled, or injected. This particular type of fentanyl can be taken orally and produces the intense high the user is seeking through snorting, injection, or inhalation.
Nitazenes:
Nitazenes are a class of synthetic opioids that include Isotonitazene, Protonitazene, and Metonitazene. They are all 100 times stronger than intravenous morphine and ten times stronger than morphine when taken orally. Again, all opioids and opiates will have similar effects.
DANGERS TO FIRST RESPONDERS:
An opioid/opiate overdose leading to respiratory failure and cardiac arrest can occur within seconds.
All opioids/opiates have a triple action effect on respiration:
- Slow, shallow breathing
- Relaxation of the muscles in the back of the throat, causing the airway to collapse.
- shut off the reflex in the brainstem that tells us to take a big, deep breath if we do not have enough air.
Follow Universal precautions:
- Assume any powdered substance is a strong opiate, regardless of color or texture, as this is inconclusive and unreliable.
- Use of nitrile gloves. Latex is porous, and powdered opiates may infiltrate. Remove and dispose of gloves as per standard protocol.
- Surgical masks are insufficient; NIOSH (National Institute of Occupational Safety and Health) approved masks must be used.
- Do not touch your face or mouth until thorough handwashing.
- Inhalation of fentanyl, especially in an enclosed area, can result in OD.
- K-9’s are also in danger from inhaling fentanyl.
- In the event of accidental exposure and overdose, follow standard department procedures for use of Narcan.
- Someone revived from an overdose with Narcan will awaken immediately, and may respond with violence due to disorientation, or because from their point of view, you ruined their high.
ALWAYS FOLLOW DEPARTMENTAL APPROVED PROTOCOLS
Other Veterinary sedative/analgesics:
Xylazine is a sedative, analgesic (pain reliever), and muscle relaxant intended exclusively for veterinary medicine, specifically for equine, canine, and feline species. Both are being used to cut heroin and fentanyl. The appearance varies, but it is typically a clear liquid solution, which may also be in the form of a powder or salt, appearing white or brown.
Effects:
- Respiratory Depression
- Central nervous system depression
- Bradycardia (Low heart rate)
- Hypotension (low blood pressure)
- Cardiac arrest
- Disfiguring and life-threatening skin ulcers from injection (Papudesi et al, 2023)
Tranq’ (Xylazine)
According to the NYS Dept of Health, Users who inject xylazine or drugs adulterated with xylazine often develop soft tissue injuries that can lead to necrotic tissue and may result in amputation, similar to Krokodil. Users may develop physical dependence. Some users report withdrawal from xylazine is as bad or worse than heroin or methadone; symptoms include chest pains and seizures.
- Xylazine is typically not used alone, but combined with:
- Opiates, e.g., heroin or fentanyl
- Methamphetamine
- Benzodiazepines, e.g., Valium, Ativan, Klonopin, or Xanax
It can be:
- injected IV or IM (Intra-muscular)
- Smoked
- Snorted
- PO (Taken orally)
Designer Benzodiazepines, aka Benzos:
Benzodiazepines are a common drug of abuse, and there is a great deal of diversion. They are used to potentiate the effect of opiates or to come down from cocaine, crack, and methamphetamine. They have potentially fatal withdrawal effects, including seizures and respiratory failure. The difference between the different types of benzodiazepines is the potency and how long they last.
All Benzodiazepines have similar effects:
- Sedation
- Hypnotic (sleep-inducing)
- Anxiolytic (anxiety reducing)
- Anterograde amnesia (blackout)
- Muscle relaxation
Medically used for:
- Amnesia (for minor surgeries)
- Muscle relaxant
- Anti-convulsant
Synthetic Cannabinoids:
- Spice aka K-2
- Kush
Spice aka K-2
This is not a single drug but a combination of 20 or more chemical compounds, in any combination, whose potency and composition vary from one batch to another. These chemicals are applied to cannabis. They can include, but are not limited to:
- AKB4, AB-CHMINACA, AB-FUBINACA, AB-PINACA, XLR-11, UR-144, and/or AM-2201, which are all synthetic cannabinoids.
- Cannibicyclohexanol, a synthetic cannabinoid.
- Phenazapam (benzodiazepine)
- JWH-018, JWH-073, JWH-200 and/or JWH-018 analgesics which bind to CB1 and CB2 receptors.
- Acetone (organic solvent).
- Alcohol (organic solvent).
- Hydrochloric acid (strong acid).
- Ammonia (strong base).
- Orthophosphate (agricultural fertilizer)
Effects:
- Incoherence & confusion
- In and out of consciousness
- Unresponsive or minimally responsive to verbal stimuli
- Disorientation
- Agitation & mood swings
- Paranoia & hallucinations which may persist long-term 2
- Anxiety & Panic
- Aggression
- Suicidal feelings
- Delirium
Kush
This is not the familiar slang term for cannabis. Kush is Cannabis combined with:
- Fentanyl (Strong opiate)
- Tramadol (weak opiate)
- Formaldehyde (embalming fluid)
- Reportedly, ground human bones, though this is not verified.
It is currently used in West Africa, specifically Sierra Leone, Guinea, and Liberia. It is unclear whether it is available in the US. Still, as the components are readily available and there are immigrants from this region of Africa in the US, it is worth being aware of. It is reported that in Africa, it kills about 12 people a week and has resulted in hospitalization for thousands, mostly from losing consciousness while walking and striking their heads.
The reported effects of Kush are:
- Euphoria
- Disorientation
- Sudden Loss of Consciousness (LOC)
Miscellaneous Substances:
- Etomidate
- Tianeptine (Tricyclic Antidepressant).
Etomidate is a non-benzodiazepine sedative, commonly used to render a patient unconscious, quickly and briefly, for rapid intubation. It has a rapid onset and is very short-acting. There are reports that people are abusing this for the brief experience of unconsciousness.
According to the US Food and Drug Administration, Tianeptine, aka Gas station heroin, is a tricyclic antidepressant that also binds to the same receptors that opiates and opioids do; it will produce the same effects. It is not FDA-approved but is used in some parts of Asia and Latin America. Narcan will not work to reverse an OD on it.
Closing Thoughts:
Police, Fire, EMS, and Corrections staff will encounter addictive and toxic substances or people who are under the influence of them. The variety and availability of substances will vary from year to year and from one geographical location to another. It is important to stay up to date on novel psychoactive substances for first responders to stay safe on the job and provide the best service to the public.
Endnotes:
- The terms opiates and opioids are used interchangeably, but they have two different meanings; an opiate is a chemical compound extracted from a botanical source, the opium poppy. Opioids are synthetic copies of the opium molecule. The effects are identical.
- Anecdotally, I have had three patients who experienced long-term psychosis following use of Spice/K-2. One was in a psychotic state for about one year, one was in and out of psychosis, and one had probable permanent psychosis.
