County Medical Examiner shares thoughts on how to intervene to prevent more overdoses

by Victoria Shea

(Plain Press, July 2018)           It is a topic Doctor Thomas Gilson is passionate about. It shows in every presentation he gives. Yet, people in his county, young and old, are still dying. The numbers are still rising. He wonders as many others do in law enforcement-what else can they do to stop the senseless deaths. Taking a deep breath, he sighs, pointing to the graph displayed by the projector on the wall. “There is a lot going on in this story that I’m gonna spend the next hour talking about.” Gilson’s right-there is. And what he is going to touch on, is only going to be the tip of the iceberg.

Since 2011, Doctor Thomas Gilson has served as the Cuyahoga County Medical Examiner and Director of the Crime Lab. His audience was a group of concerned licensed funeral directors from the State of Ohio attending the Buckeye State Funeral Directors Convention on June 15. His topic is the evolution of the opioid epidemic in Ohio. His focus is mainly the overdose deaths from heroin and fentanyl that have risen since his arrival in the county.

Ohio has the second highest per capita of opioid overdoses death rates in the country, Gilson announces. This catches the attention of several of the directors. “We have the most absolute highest number of deaths in the country as well,” Gilson adds.

For Gilson, the crisis has what he refers to as the three phases: prescription drugs, heroin and finally, illicitly-manufactured fentanyl. The state, he says, is partially to blame for the first phase. He is, of course, referring to pill mills, which Ohio pioneered to have, and then when they realized there was a problem, pioneered to close. Gilson says with the pill mills gone, prescription drug overdoses have declined.

While many would say that is a good thing, Gilson notes that while the prescribing of opioid pain relievers is declining, there have been recent rises in the number of people using heroin and illicitly-manufactured fentanyl.

In 2007, a total of 97 prescription opioid drug overdoses were reported in Cuyahoga County. Forty additional overdoses were contributed to heroin.

In 2008 and 2009, the number of heroin deaths rose to and stayed at 64. By 2010, 91 deaths reported were due to heroin. In 2012 and 2013 the number of heroin-related deaths passed the total of opioid overdose deaths by 161 to 111 and 194 to 124 respectively. Since then, that number has only continued to rise in the county. By 2016, which is the last completed year data available, the number of heroin overdoses was 320 deaths.

“The heroin issue was brought up by a good employee doing her job in the toxicology lab at the medical examiner’s office,” Gilson has been quoted saying. She brought it up because she had worked in the toxicology lab once before, had left and then returned. Gilson said it reminded him of a conversation he had in New Hampshire in 1998 where Gilson himself expressed concern in the rising number of oxycodone deaths. He said it made him take the employee’s concern seriously.

Hitting his stride in his presentation, Gilson continues. He knows that while funeral directors may not be able to stop the drug overdoses, they understand where he is coming from. They are like him, speaking for the dead, and on the behalf of the dead. They are in the front lines like himself and the law enforcement officers. They see what the drug overdoses do, not just to the user, but to the families.

“Why does the mortality rise so fast in heroin?” Gilson asked rhetorically. “Because if I buy 80mg of oxycodone off the street that was diverted, that went through a quality assurance process. It’s 80mg of oxycodone. Heroin is just a product you buy on the street. Is it this pure, or that pure? Don’t know. As a result, the mortality takes off a lot faster.”

He goes on to explain that the decline in prescription overdoses is because heroin is cheaper and easier to obtain. Although heroin comes as either a white or brown powder or as a sticky black substance known as “black tar,” in Cleveland, Gilson and his staff are seeing the brown powder more frequently. He explains that between the two coasts, knowing the difference in what heroin type is used makes a difference as fentanyl is introduced as the drug epidemic becomes worse.

“People on the west coast are more use to black tar heroin. People on the east coast, white powder, brown powder,” he explains. “Fentanyl is a white powder. So, if you sell white powder to somebody on the west coast, they’re like wait a minute, that’s not my heroin.”

A chemistry major, Gilson cannot avoid the quick chemistry lesson that comes when talking of heroin. Used to wean morphine addicts, Gilson declares that this was a terrible drug to use because as it breaks down in the body, it becomes morphine. The good, that came out of the morphine abuse in the early 20th century, was the drug schedule system, which assigned numbers to drugs based on their acceptable medical use and the drug’s abuse or dependency potential. According to the Drug Enforcement Administration’s website, heroin falls into Schedule 1, which are defined as drugs with no currently accepted medical use and a high potential for abuse.

The number of heroin deaths in Cuyahoga County, Gilson said, was like taking a jumbo jet and crashing it into Lake Erie every year. With this in mind, the Poison Death Review Committee was formed to review all heroin deaths. It featured representatives from medical, treatment, public health and law enforcement areas to ensure a well-rounded panel of experts.

What was discovered was that heroin overdoses were mainly of the male predominance with a four-to-one ratio. They lived in the suburbs, not downtown Cleveland as one would expect. Those dying were predominantly white, and as Gilson called it, the shocker, was that this was not the cause of death for those in the teens and twenties, but rather, those 45 to 60 years of age. In fact, those in their teens and twenties were the least likely to die from heroin overdoses. The rationale behind this was those dying were ones who had gotten hooked on prescription pain medication and had switched to heroin.

It was also discovered that the number of people dying of heroin overdoses while in the proximity of another person was approximately seventy percent, with fifty-eight percent of the bystanders not using drugs. It was determined that wider access to naloxone might save lives from heroin overdoses, which was the creation of Project DAWN.

Shocking still was that forty-eight percent of those who had died of a heroin overdose had received substance abuse treatment or detoxification within two years of their deaths. Forty percent of those who died had been incarcerated within two years of their deaths. This allowed the committee to realize that treatment facilities and jails were potential intervention points for educational activities such as how to handle a drug overdose and use naloxone.

He also knows that if given the chance, two-thirds of them will stop using if they live long enough 

While the numbers do most of the talking for him, Gilson knows facts the numbers don’t always reflect. He knows that while many, including those sitting before him, may think drug users are just party people, many drug users want to quit using. He also knows that if given the chance, two-thirds of them will stop using if they live long enough. But he knows his numbers don’t clearly show that. He must use his words to explain that to the audience. He must try and made them understand.

“I don’t want to see people go back to using drugs,” he announces to the crowd. This statement does not appear to catch anyone off guard. For those in attendance, the shocker would be if he said he did. “But I’m smart enough to know that won’t happen.”

So, he explains what happens as you take heroin and how as you use the drug. The doses at which you use it begin to rise to increase the high. He also explains the downfall when something happens like going to a treatment facility or jail. You come out and go back to using the same amount you were using before you went in.  Instead of getting the high with everything alright, you wind up on his autopsy table instead.

Proving that prescription drugs were helping the cause of the heroin overdoses, it was determined that seventy-three percent of heroin overdose victims had a file with the Ohio Automated RX Registry System and within two years of their deaths had received a legal prescription for a controlled substance. This information showed that a high percentage of fatal overdose victims were receiving legal prescriptions for narcotics despite a state prescription drug monitoring program.

Despite the negative information discovered by the committee, according to the State of Ohio Board of Pharmacy, the Ohio Automated Rx Reporting System has worked. In 2011, there were 782 million solid doses of opioids prescribed in Ohio. By 2015, that number had decreased seventeen percent to 701 million solid doses.

If only that was the end of the story, Gilson thinks, as he ready’s himself to begin the final phase. He knows the story-he lives it-everyday he sees it. While the numbers are starting to decrease, even slowly, in heroin, fentanyl is on the rise. He knows what he is about to say as he looks at the graph once more showing the deaths from heroin, cocaine, fentanyl and all opioids…

“This purple drug is fentanyl, and fentanyl started to take off,” He says before pausing. “We had thirty-seven overdose deaths in 2014, but I can tell you, thirty of those happened in November and December of that year.”

An already silent room has suddenly become even more silent if that is possible for a moment. He knows that his audience is processing this information. How is that possible? He knows it is. He saw it happen. So, he continues.

“The number rose up to ninety, ninety-two in 2015,” he announces. “This drug is starting to make its appearance.” But he continues with the numbers. By 2016, there are 399 dead from overdoses. 2017 he sees the number up to 492.

But why is fentanyl on the rise? He knows this a question on everyone’s minds. It must be. It was certainly on his at one point he is certain. He explains, now in greater detail than before when he first started his presentation. He knows that this has to do with the potency of fentanyl. He knows that the potency has to do with the high. “Its potency is substantially more than heroin,” he explains. “We use morphine as a baseline, and heroin is about four to five times the potency of morphine. Fentanyl is about eighty to a hundred times the potency.”

But he continues. He must make those here that could help make a difference understand. Fentanyl is unforgiving. Much more so than heroin.

Naloxone can help in a fentanyl overdose, he states, but you have to be there with it fast and you better have a lot of it. You must have those things on your side to have a chance with a fentanyl overdose.

But like everything else, the real reason it is on the rise is that it is cheap to make. And therefore, cheap to sell and cheap to purchase.

Yet, even after saying his peace, he knows that he cannot in good faith send these funeral directors back into their neighborhoods without a bit of hope. He has some good news-it is not much, but still, it is a start, so he announces it. He’s not seeing as many deaths from drugs this year. He doesn’t have all the numbers yet, but he knows it is going down.

He knows that his county has much more to do to combat the drug epidemic. But with the numbers going down, even slightly, he knows that something they are doing is helping.

He is making a difference.

Even if it’s a small one.

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