Purple heroin is a new danger on the streets of Central New York

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Oneida County has recently seen a wave of overdoses, some involving a more dangerous purple-colored heroin. Dr Ross Sullivan is here to talk about this drug. He's an emergency physician at Upstate and also the director of medical toxicology. Welcome back to The Informed Patient, Dr. Sullivan.

Ross Sullivan, MD: Thanks for having me, Amber. Nice to be back.

Host Amber Smith: Why is this purple colored heroin such a concern?

Ross Sullivan, MD: Well, you know, anytime there's a new drug in the area, obviously, that becomes linked to perhaps increased deaths that we see across the population, it's something that's a real cause for concern. Specifically here, the purple heroin, we think it's maybe a marketing ploy, but it does work in people who use drugs. And, unfortunately, we don't know exactly what's in it, but normally across the country when there are purple heroins, there are additional synthetic opioids added to the heroin. And unfortunately this makes it much more dangerous to use.

Host Amber Smith: So it appears that it might be more potent than just regular heroin?

Ross Sullivan, MD: Yes. Anytime we see a spike in deaths across the population, we feel that there's something going on with the drug supply. Normally it's either tainted or some type of additive or potency, and purple heroin has been seen in the past in other parts of the country, and maybe even Oneida.And normally in these purple heroins, there is an added opioid to it, so we know that there's fentanyl -- which is a very potent opioid and much stronger than heroin -- already added to the heroin supply. And purple heroin may even have another opioid on top of those two added to it. And this is a pretty dangerous, a dangerous combination to occur.

Host Amber Smith: So the drugs that are added to the heroin might make it change the color to more of a purple, or there could be a coloring agent that's added, you're just not sure?

Ross Sullivan, MD: Absolutely. Most experts really don't completely know exactly what is making the purple color itself. We don't know if it's necessarily the actual additive drugs. We think that the purple itself is something that's done in the lab, to kind of denote or market a different type of drug in the market. We don't necessarily believe that the extra drug is actually purple in color. We think, though, that it's more of maybe like a marketing ploy to try to get this type of drug, or maybe even brand, to the users on the street. It does make it extraordinarily dangerous, but again, the exact reason it's purple, we're still not quite sure.

Host Amber Smith: Do the authorities think this is being made locally or is this purple heroin being imported from somewhere else?

Ross Sullivan, MD: You know, I can't say exactly what the authorities do or don't think. Since this purple heroin has really been around for the past several years in different parts of the country, normally we feel that these things are being brought in from other areas, and are kind of part of some type of distribution type of system. There's been outbreaks of this in areas of Michigan and some other areas in the Midwest. So it's most likely part of a larger type of distribution plan, and which makes it really makes it scary. So, it has entered our area and is something really to keep an eye on.

Host Amber Smith: Now, in addition to heroin, you mentioned some of the drugs that are mixed with it, perhaps fentanyl and some other opioids. Mixing these multiple opioids together, does that necessarily mean that their strength is going to be multiplied?

Ross Sullivan, MD: I think that when someone is using anything in one sitting or over one use, the more of it in there, the worse, the more dangerous it can be. An example might be you think of alcohol. You know, if someone were to sit down and have one alcoholic drink at a time, compared to sitting down and immediately having two or three alcoholic drinks, there's definitely an additive effect, right? And this is the same thing with the opioids. By taking different opioids but all at the same time, there's an additive effect. And, added to that, that some of these opioids are more potent than other ones. Like we already know that fentanyl is much more potent than heroin, anywhere up to 50 times stronger. So when you have these things mixed together, you definitely have an additive or even multiple effect, on the effect that it would have on somebody. So, using these things in even one single sitting or one use can be really dangerous.

Host Amber Smith: What is brorphine, B R O R P H I N E?

Ross Sullivan, MD: Brorphine is another opioid that's synthetic, so it's not naturally occurring. So when we talk about the naturally occurring opiates, we actually talk about opiates. And I'll talk a little bit about opiate history, and really that comes from the poppy, which we've heard of. And in the poppy, there's something called latex. And this latex in it is filled with opiates, and in it is morphine and codeine,and that's really it. And from the morphine and codeine and the poppy we can make heroin. So heroin we say is semi-natural, or semi synthetic. Almost all the other opioids that we hear about are synthetic to some degree, so as we call opioid like an android. So brorphine is another one of these synthetic opioids that has been created by drug makers at some point. Now I believe it was actually made as an analgesic or a pain medication, at some point. It is really not used in this country, but we're starting to see it more in this country as an additive to our drug supply. And, we really started seeing it again in the Midwest around 2018, 2019, and now we've seen it crop up at other points. So, again, it's another one of these opioids, it's just another one that has a good potency within the body and, again, when added to other opioids is very dangerous.

Host Amber Smith: This is Upstate's The Informed Patient podcast with your host Amber Smith. I'm talking with Dr. Ross Sullivan. He's an emergency physician and director of medical toxicology at Upstate. And we're talking about purple heroin, which is showing up in the community.

Now, what effects are people seeking when they are going to take this purple heroin? What are they looking for or expecting to have happen to them?

Ross Sullivan, MD: Well, you know, when people use drugs or opioids, it really comes down to a few reasons in the end. One of them is obviously to feel euphoric, right? Or, we talk about feeling high. And then when people use drugs, part of this process actually neurochemically are the chemicals in the brain. We call it tolerance, right? Which means we get used to taking the same amount. And people sometimes can think about this easier when they think about alcohol, right? You know, someone who might have an alcohol problem, you can see they become tolerant, and it can be totally normal having 2, 3, 4, 5, 6, 7, 8 drinks. So this happens with any drug, and with opiates as well. So sometimes people use drugs to just feel euphoric. Sometimes they do it because they just want to feel normal. One of the things that we see is that people oftentimes are just trying to treat, not feeling normal. They want to be normal. And they also don't want to have withdrawal. And that's really one of the No. 1 reasons people use. I think that there's a misconception or stigma that drug users are constantly just always trying to be as euphoric or high as possible. And certainly that's a component of using opioids and drugs. But another big component of it is just keeping themselves out of withdrawal or from feeling pretty sick or ill. So just like anything, though, when there is a new drug in the market that might be having some additional euphoric or high effects, you know, people will seek it out, to see how's it make them feel? Does it maybe allow them to not feel sick or have withdrawal? Maybe it's cheaper. I don't know about the cost, but there's a lot of reasons that would drive somebody to use this.

Host Amber Smith: Is there any way to detect whether heroin includes something like fentanyl before a person ingests it?

Ross Sullivan, MD: So great question. We have been using -- I'm talking about people in addiction -- have been using and distributing fentanyl test strips. And these fentanyl test strips are being deployed more and more by harm reduction agencies and by drug treatment facilities. And really what this basically is, is you can take some of your drug and you can basically put it in some type of water and basically put this fentanyl test strip in it, and it will tell you that there's fentanyl in it. And these are things that are being used and given out to people, and we're really advocating for when people are using drugs, particularly a new type or if they're getting it from a new person or place, or it looks different, we're really advocating using fentanyl test strips, and giving them out as well. It's hard to say exactly where you get them. Most drug treatment agencies now are giving them the patients, and some counties through the department of health, are also distributing them through some anti-drug programs. So, I tell people all the time to look for fentanyl test strips throughout your area, in your county. You can order them on line sometimes. It's really, really lifesaving saving, so it's really something that we advocate strongly for.

Host Amber Smith: Now what about after ingestion? Are there symptoms that would indicate that the person is in danger of overdose?

Ross Sullivan, MD: Overdosing, you know, unfortunately one of the biggest risk factors of overdosing is using alone. And catching one's self or yourself overdosing is almost impossible, right? Because you, you start to become sleepy and tired, you start breathing a little bit less, and then you overdose, you're overdosing. And the self-awareness of it, or being able to treat oneself doing it, is really impossible. So when we talk about harm reduction techniques, in addition to using fentanyl test strips, we talk about using with somebody else, or not using alone, because it's a huge risk factor. The risks and what we see when people are overdosing is, obviously, is a severe altered mental status. So people will become almost in a coma or we use the word obtunded. They really can't respond to you. One of the biggest things is really shallow breathing, to stopping breathing. This is the biggest sign of an opioid or heroin or fentanyl overdose. To really identify this, though, you have to be using with somebody else, because using alone, you really will not be able to be conscious enough to be aware of this. So we advocate tohave people use with other.

Host Amber Smith: Now this purple heroin that's on the market locally, does naloxone work to reverse the effects of that?

Absolutely. We know that naloxone or Narcan works for almost or all opioid overdoses. Certainly there are some stories out in the press that talk about all this naloxone-resistant drugs. And as a toxicologist -- we study how these drugs work, how they bind in the body -- we don't deny that maybe some people might need some additional dosing here and there, but the kind of fear that naloxone doesn't work is really unfounded. I think that what we're seeing is a couple of things. One we're seeing that naloxone has been so widely distributed and given by such an array of people that people are just giving a lot of it. And of course, when someone's not breathing and they're unconscious, a lay person or someone doesn't have a lot of experience might give multiple doses within just two to three minutes. Those of us who are trained professionals, really should only give one dose every three minutes. So that's one reason we're seeing additional doses. Another is that there are other additives to our drug supply, which cause a lot of sedation. And one of the things that we see a lot is something called Xylazine. And Xylazine actually is a tranquilizer used in veterinary medicine. And we're starting to see this added to our local drug supply in Central New York. We saw it a couple of years ago, really starting in Pennsylvania, the Philadelphia area into the New York City area, and now it's becoming more ubiquitous in Central New York. And the thing about this is that it's not an opioid, so it does not respond to naloxone. And we're starting to see people who do have some type of resistance, so to speak to naloxone, it's mostly due to these other factors, just people giving it much quicker, and people having other drugs on board that don't work with naloxone.

Ross Sullivan, MD: So we absolutely recommend always if someone is in a coma, especially not breathing, that's the point of giving naloxone or Narcan, is to give it and wait two to three minutes and give it again and call the authorities or 911 and get some people there to help. But, yes, it absolutely works, and we don't really believe in naloxone- or Narcan-resistance. We think it's a lot of these other things.

Host Amber Smith: In the emergency room, if you have this patient that the naloxone is not completely working on and you suspect there's other drugs that were mixed in with whatever they took, what else can you do for them in the emergency room?

Ross Sullivan, MD: If someone's breathing, we will give naloxone and can continue to try it until we have reversed somebody not breathing. But there does come a point where, perhaps, there is no more effect, and there is another drug that is contributing. And what we call a supportive care, and supportive care doesn't mean we just watch you. We'll support the patient in ways that we need. So, for instance, like Xylazine, patients can have low blood pressure and low pulse, so we will give a medications or things that counteract those things. Sometimes people are in such a deep coma, they do lose their airway. So, we will intubate them or put a tube in their throat, to help support them, to kind of metabolize and overcome these drugs. So, and there is no way to know, right, when someone's in the emergency department. I think some people think that we can just test for drugs and we know within a heartbeat what people are using, and that's actually not true. We have to use the whole picture of the patient and what's happened and support the patient. In the emergency department, we do a fairly good job. But in a community, or if people don't get to emergency services, that's where people are dying unfortunately, and passing away. This is why we advocate for some of these harm reduction techniques, with such a dangerous drug supply, to help keep people safe.

Host Amber Smith: Well regarding this purple heroin, are there precautions for first responders or the friends of someone who was known to have ingested purple heroin? Are there precautions for those people in trying to take care of someone who may be overdosing on purple heroin?

Ross Sullivan, MD: You know, one of the biggest things that we say is, we try not to get too conflicting here, but it is perfectly safe to walk by, near someone who's using this. These drugs could be on the ground, on the person. Obviously we always talk about, like, just very basic hygiene things, clean your hands maybe after, or maybe even wear gloves if you'd like. Certainly these drugs are safe to get on your skin. I know that there's these stories that we see in the press that often end up getting debunked, but general precautions, of course. You know, the biggest things are be careful of needles and syringes. If there is a lot of drug paraphernalia, or even drug all over the place, sure, you might have be careful and not get it on your hands and whatnot. But it is always safe to take care of these people otherwise. Just remember to make sure you're in a safe environment and you're not around the things like drug paraphernalia or maybe needles or syringes that can cause some type of damage to you, if you were to get a needle stick, let's say.

Host Amber Smith: Well, Dr. Sullivan, I want to thank you so much for making time for this interview.

Ross Sullivan, MD: Thanks for having me. I hope this helps some people. You know, the biggest thing, too, is there is help out there for you. You can look at any place in your county. There's quite a few places that help people that are struggling. And be safe, you know. Use Narcan. Get fentanyl test strips. You can look at your county department of health websites. They'll give you a wealth of information, both in Oneida and Onondaga. And hopefully, use safer and get help when you need it.

Host Amber Smith: My guest has been director of medical toxicology and emergency physician, Dr. Ross Sullivan. The Informed Patient is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host Amber Smith thanking you for listening.