Crimson, opaque, clear. The fluids fill small tubes in a walk-in freezer at the Milwaukee County Medical Examiner’s Office.
The fluids represent all races, but the bodies they were taken from are mostly white. Mostly male. Their average age: 41 years and 4 months.
The bodies once worked in hospitals, sold insurance and sat in college classrooms. They fixed machinery in manufacturing plants, painted pictures and played instruments.
Then, one day, they were found. Their hearts had stopped beating.
Blood was taken, and urine. A clear gel was extracted from a space in the eye between the lens and retina. Each fluid was put in a vial. The vials were placed in the freezer to await testing.
The samples from each body are indistinguishable to the naked eye. But the compounds inside them spell their addictions.
Diamorphine, oxycodone, hydrocodone, fentanyl. Opioids – a broad classification for drugs that act on certain sensors in the brain to relieve pain.
They are highly addictive and nationwide, the number of deaths caused by opioid overdose has been increasing at an alarming rate, particularly among a demographic that wouldn’t have been a large part of the opioid discussion two decades ago.
“The demographics that we’re seeing are more white than black, more men than women and more middle-aged,” said Sara Schreiber, forensic technical director at the Milwaukee County Medical Examiner’s Office. “They’re typically between 40 and 60 years old. It’s not the young people in their 20s that some people would suspect. We’ve seen as old as 80.
“These are the working class. This is the group that is still well in the workforce. They’re not retired and they’re not fresh out of college looking for a job. They come from all walks of life, all demographics, all counties, all suburbs.”
And in many cases, the addictions are well hidden – at least for a time.
An upwardly mobile addiction
“Opioid addiction used to be a relatively uncommon thing,” said Dr. Michael Miller, medical director of the Herrington Recovery Center at Rogers Memorial Hospital in Oconomowoc. “There were two populations: people largely in big port cities who were using heroin. Places like Boston, New York, Baltimore, Los Angeles, Miami, New Orleans, San Francisco. And you had health care professionals who were taking painkillers from hospitals. That was the case from the early 20th century through the 1980s.
“(Today) it’s everybody. It’s every ethnic group. It’s men and women, it’s old and young and everybody in between. One of the most surprising statistics that people didn’t expect to find was that the deaths weren’t peaking in the 20s. The deaths were peaking around age 50. People who may have been employed and in the workforce for 30 years, maybe with the same employer for 20 – suddenly they’re not alive anymore.”
Forces collided in the mid-90s and early 2000s that set the conditions responsible for the rising number of opioid-related deaths in towns and cities across the U.S. And to understand those conditions, it is important to understand the history of the opioid drug family.
Diamorphine is more commonly known as heroin – the name under which it originally was marketed by German pharmaceutical company Bayer as a cough suppressant in the late 1890s and early 1900s. It has a long history of use in medicine, along with the drug it was derived from: morphine. Both morphine and heroin are derivatives of opium, the dried latex produced by the seed pods of the opium poppy, a species of flowering plant.
Opium has been used for centuries as a recreational drug and in medicine as a sedative and anesthetic. It is the root of multiple families of drug compounds with similar qualities. One such drug family includes morphine and heroin. Another, codeine, is used frequently in pill form to manage pain in modern medicine. Codeine is the base material used to create more powerful medications prescribed by doctors, such as oxycodone and hydrocodone.
A synthetic opioid, a powerful drug called fentanyl, was introduced in the mid-90s as a slow-release painkiller for people with terminal illnesses such as cancer.
All opioids share similar basic qualities in terms of how they affect human brain chemistry.
Neurotransmitters that are similar in structure to opioids naturally occur in the human body to help manage low-level pain, but the body is unable to produce enough of them naturally to block or relieve severe pain.
When opioids enter the body as a drug, they are similar enough in structure to attach to that type of neurotransmitter’s receptors and send signals to the brain that block pain and produce a calming effect. Because of their difference in structure from the natural neurotransmitter, however, opioids also send different messages to the brain that flood its reward center with dopamine and create a euphoric effect the body would be unable to produce on its own.
The flood of dopamine is the cause of the addiction.
“Most of the heroin (in the past) has come in out of southeast Asia and Europe and ultimately was so diluted that it was less than 10 percent purity,” said Dr. John Schneider, chief medical officer of the Milwaukee County behavioral health division. “Probably in the 4-to-8 percent range. The only way to use it to get high was to inject it.”
But over the past 20 years, that has changed.
Experts theorize that when the U.S. government cracked down on the cocaine trade in the 1980s and ’90s, targeting the cash crop of drug cartels in South and Central America, the cartels adjusted and began to use their existing distribution networks in the United States to push a different drug: a higher purity heroin.
“It has had a purity of 30 percent to 50 percent in general, and at times has increased to as high as 70 percent,” Schneider said of the heroin available on the streets for recreational use today. “That means you can smoke it; you don’t have to shoot it. There’s lots of other ways to do it. It’s less of a jump for other recreational users to get into.”
To achieve the euphoric high addicts crave, heroin can be snorted, swallowed or smoked. Intravenous injection, which carries with it a strong stigma and the risk of passing serious diseases, such as HIV, is becoming less common, Schreiber said. External signs of drug abuse on the bodies of those who overdose are now few and far between, and the drug’s method of delivery is not always clear to the staff at the medical examiner’s office examining the bodies.
The increase in potency of street opioids has coincided with an increase in the number of people willing to buy them.
Physicians began writing prescriptions for opioids such as hydrocodone and oxycodone more liberally around two decades ago. The trend began out of both a sincere effort from doctors to better manage pain and a more dubious push from certain pharmaceutical companies to increase sales.
Milwaukee County opioid-related deaths
In December 2016, several executives and managers formerly employed by the Arizona-based pharmaceutical company Insys Therapeutics were arrested on charges they orchestrated a “nationwide conspiracy to bribe medical practitioners to unnecessarily prescribe a fentanyl-based pain medication and defraud health care insurers,” according to a statement released by the U.S. Department of Justice.
A 2016 investigation by the Los Angeles Times found evidence that employees of Purdue Pharma, maker of the brand-name opioid painkiller OxyContin, told doctors to prescribe stronger doses of the drug to patients who complained it didn’t last as long as its advertised 12-hour duration, instead of encouraging those doctors to prescribe lower doses at more frequent intervals. This was done in order to protect the company’s competitive advantage in the marketplace; having a longer duration of pain relief than its competitors would allow Purdue to charge more for OxyContin. It also was done in spite of the company’s knowledge through various clinical trials that many patients who took the drug did not experience 12 hours of pain relief, according to the investigation.
As a consequence, more people have found themselves accidentally hooked after receiving prescriptions to manage pain caused by things such as workplace injuries or routine surgeries. And when their prescriptions run out or are no longer strong enough to quiet their urges, they turn to stronger, illegal versions of the drug.
“Liberal prescribing practices in the past, which were supported by large medical organizations and government and big pharma, led to people becoming, in many cases, accidentally dependent on opioids and prescription pain pills,” said Dr. Lance Longo, medical director for addiction services for Aurora Behavioral Health Services. “As the medical community has cracked down in the last few years, and as the government has supported mandates to monitor prescribing and limit liberal prescribing, people who used to be addicted to pills have switched to heroin, which is more readily available and cheaper.”
Addicts use everywhere they can, including at work. Some view it as a performance-enhancing drug that numbs them to the daily grind, reduces anxiety and boosts confidence. But eventually, their initial confidence slides into desperation. Their behavior becomes more unpredictable as they turn to new – and often illegal – methods to sustain their expensive habits. Productivity falls. They isolate themselves.
And eventually, if they don’t receive treatment – or if they get clean and relapse – their bodies are found. Their blood is drawn. It is placed in a vial. It is stored in a freezer. It is tested.
Over the past five years, the results of those tests have been staggering. The medical examiner’s office has determined 1,082 people and counting have died from an opioid-related overdose in Milwaukee County since Jan. 1, 2012.
Local experts believe the worst is yet to come. Over the past 15 years, opioid drugs have changed as dramatically as the people who use them. The most potent and dangerous opioid analogs available on the black market have yet to hit the streets of Milwaukee in force, although some have begun making appearances.
Fentanyl is more powerful than heroin and is increasingly being cut into heroin supplies to increase potency. The consequence: addicts, unaware of the potency, take the same amount they would if it were a lower-potency heroin and overdose.
Fentanyl was involved in the death of pop music icon Prince in the summer of 2016. Investigators said it was cut into pills at Prince’s home that were labeled as “hydrocodone.”
One analog, perhaps the most potent and dangerous opioid, is called carfentanil. It is many times more powerful than fentanyl. It is not meant for human consumption. The drug is powerful enough to anesthetize elephants. Even small doses of it cannot be survived. It has been slowly making its way inland from the east and west coasts, where it has devastated addict populations.
“Overwhelmingly, we’re seeing a larger increase in the illicit stuff; in the heroin and now in the fentanyl,” said Schreiber at the medical examiner’s office. “Going back maybe four years ago, if we had a heroin case, there was no fentanyl identified and if we had a fentanyl case there was no heroin identified. Two to three years ago, we began to see an increase in incidences of seeing fentanyl in combination with things like heroin. Then we were led to believe, with supporting evidence from crime lab and (Drug Enforcement Administration), that there was fentanyl cut into the heroin. So it was adulterated, likely to increase the potency without increasing the cost.
“The fentanyl numbers from this year over last year increased three-fold over. And now we’re seeing more fentanyl analogs, like acetyl fentanyl, which are clandestinely prepared. Carfentanil we haven’t identified it yet. For something that has the potency to take down a large animal, the dose has to be so much less in order for somebody to try to survive that.”
Addiction in the workplace
Employees who are addicted to drugs but have stopped using them illegally and are receiving treatment are protected by the Americans with Disabilities Act. If they have been successfully rehabilitated from a past addiction, they cannot be discriminated against in the workplace.
“But the ADA does allow for employers to maintain a workplace that’s free of drugs and alcohol,” said Jesse Dill, a senior attorney at Walcheske & Luzi LLC in Brookfield who specializes in employment and labor issues.
If an employee is observed by co-workers or superiors behaving in a suspicious way that could indicate drug use in the workplace, he or she can be drug tested. If the employee tests positive, he or she can be fired.
“Situations we see … if somebody’s in a safety position, usually it’s zero tolerance,” Dill said. “With smaller employers and family-operated organizations, if something like this comes up with an employee that doesn’t pose a direct threat to the safety of the public, they’re a little more open to trying to get them some help. It just really depends on the employer’s culture.
“Usually with larger employers, there’s a concern for safety and also consistency. If it’s ongoing drug use, that isn’t going to be protected by the law. The employer can terminate based on current use.”
Dill recommended companies interested in setting up procedures for how to handle drug use in the workplace and drug-addicted employees seek professional help.
“It’s best to make sure you’re following the law and there’s different stages that all have different rules and regulations of what you can and can’t do,” Dill said. “It’s easy to misstep and do something that maybe isn’t lawful unless you’re working with someone who knows what they’re doing in this area.”
He said a common situation in which he sees employers getting tripped up is when an employee is drug tested and the results come back positive, but the employers don’t ask any follow-up questions before firing the employee.
“It usually relates to drugs that can be lawfully prescribed,” Dill said. “They can and should be asking questions: do you have a prescription for a medication that would trigger a positive drug test? There could be a need to accommodate rather than terminate without question.”
Stories of addiction
Michelle Laga and John, who has chosen not to reveal his last name, are the same age: 30. They grew up in different places – Michelle is from the Chicago area and John grew up in Grafton – but had similar upbringings. Both were born into more-or-less typical middle-class, Christian families. Both got good grades in school.
And both of their addictions began the same way – with a legal prescription.
In Michelle’s case, the legal prescription wasn’t for her. A friend she had met while attending Northern Illinois University in DeKalb had stolen opioid pills from his grandmother and the two began using them together.
She got hooked. The pills eased some symptoms of psychiatric issues she didn’t realize she had at the time and she liked the effect. Plus, drugs helped her feel like she fit in – something she said she desperately wanted.
As Michelle’s addiction progressed, she began crushing the pills and injecting them intravenously, and eventually moved on to heroin.
Though her drug use set back her education – it took her six years to get her undergraduate degree in art – she eventually graduated and was accepted into a master’s program at Milwaukee’s Mount Mary University for art therapy.
“I somehow graduated undergrad with my degree in art and minor in psychology,” Michelle said. “I decided to come to Milwaukee for the grad school program at Mount Mary. I thought also by switching out people and places and things, it would help me get away from everything, but I found that (opioids are) everywhere. Pretty quickly into grad school, I began spiraling.”
She tried to quit multiple times by herself, but wasn’t able to. One night, after returning from a visit to her parents’ house in Illinois during which she had to rely on ingesting less powerful opioid pills, she picked up heroin from her dealer in Milwaukee. She injected. She was alone, and she passed out immediately.
“I scared myself,” she said. “It could’ve easily turned into an overdose.”
Michelle reached out to a friend and confessed her addiction – she had been hiding her habit from those closest to her for years. Her friend contacted her parents. Eventually, she went into a residential treatment program in Illinois. Michelle has been clean since March 8, 2011.
She now works as a certified peer specialist at La Causa on Milwaukee’s south side. She assists other addicts, and incorporates her background in art therapy into her sessions.
“The programs I am involved in at La Causa, which include Targeted Case Management, Community Linkage and Stabilization Program and the Peer-Run Drop-In Center, are all Milwaukee County Behavioral Health Division contracted programs and La Causa and myself are very grateful for that partnership and the opportunities it provides,” she said.
John, who said he had already begun experimenting with alcohol and marijuana as a teen, injured himself while working in a warehouse in his early 20s. He was moving a dumpster outside, it hit a bump in the sidewalk and he sustained a bad sprain in his ankle trying to keep it from falling over. A doctor prescribed a supply of hydrocodone pills that lasted about a month.
He went back to the same doctor and got another prescription, and another. After his fourth script from that doctor ran out, he said he laid off the pain pills for a while.
“It didn’t turn into a problem then, but at that point I realized I was fascinated by and loved opiates,” John said.
Sometime later, he was playing guitar with a drummer. John was, and still is, in a band. He described his current band’s sound as “Alice in Chains on anti-depressants.” The drummer he was playing with at the time offered him a line of crushed up pain pills to snort. He accepted. The problem began.
“I feel like there are two different kinds of people,” John said. “Either you love (opioids) or you hate them. Some people don’t like them. For me, it brought this warmth and euphoria. It felt like all your problems and worries disappeared. That was the initial fascination with it.”
John paused while describing his experience with addiction over the phone.
“It sounds weird to say this, but it almost becomes like a love relationship,” he said. “Like a romance. It consumes your life. It becomes all you care about. You put it before anyone and anything, even your own health and your own safety.”
By age 23, John had resorted to stealing things from his father and selling them to help pay for opioids. He had a job working in manufacturing, but his wages weren’t enough to cover the habit.
He remembers driving down to a specific intersection in Milwaukee – North 14th Street and West Keefe Avenue – to buy drugs from dealers who held guns in their laps.
At one point, he was charged with operating while intoxicated on two consecutive days.
“I’m guilty,” John said. “I was driving around and they got me. But it didn’t stop me.”
Without a license or a car of his own to drive, he stole his dad’s car to drive down to Milwaukee to buy drugs. At one point he got into an accident, totaled his dad’s car and put his head through the windshield.
His dad – tired of being robbed and lied to by his son – gathered evidence and turned John in to the police. John served seven months in jail and still is on probation.
“I was pretty bitter about it because I was still under the influence and all that,” John said. “I was worried about my job, I was dating this girl. We were using partners and codependent on each other. She passed away a few months after I got out of jail. She succumbed to the addiction.”
John has been clean since Nov. 4, 2014.
“I work for a tremendous company that has continued to employ me throughout my addiction,” he said. He declined to name his employer, but said its leaders have taken multiple chances with him and shown him a tremendous amount of empathy and respect.
He’s been promoted twice since he got clean, he said.
John also now works with the Ozaukee County Heroin Task Force as a consultant.
“I sit on a board with the same judge and prosecutor who prosecuted me,” he said. He also runs a Facebook page for the county and posts advice and information about what people can do to get treatment and help address the local opioid epidemic.
“There’s a ton of stigma,” he said. “It seems like a lot of people don’t want to talk about addiction because it’s not pretty. I get it. I understand that, and if you want to keep your distance, I get that. But some people say things like, ‘stupid junkie, they deserve to die.’
“It’s a mental disease. It affects your behavior. As cliché and stupid as it sounds, if you don’t have anything nice to say, just don’t say it at all.”
John urged employers who encounter employees with drug problems to show them the empathy and respect his company has shown him.
Michelle offered this advice to employers: “Don’t be afraid to ask those hard questions about your employee if you see something that’s off and different. Be sure to have resources available if they do ask for help, and be empathetic and supportive of them, rather than judgmental.”
To get help:
Wisconsin Area Heroin Anonymous – www.hawisconsin.org/
Heroin Anonymous World Services – www.heroinanonymous.org/