Joseph Smith bought the heroin that killed his mother, Tiki, who — like her son — had become addicted to the drug after first growing dependent on prescribed opioid painkillers. He was in the room with her when she died, her breathing growing shallower, her skin turning a pale shade of blue.
The toxicology report pinned the blame on a fatal blend of fentanyl and carfentanil present in the heroin Smith purchased in May 2017. By that time, the likelihood that heroin would be laced with fentanyl — a synthetic opioid roughly 50 to 100 times more potent than morphine — was recognized, even among those in active addiction, he said.
But for someone struggling with substance use disorder and staring withdrawal in the face — an experience that can be so severe, users have reported feeling suicidal as they waited for symptoms to abate — rolling the dice can be worth the danger.
“People are aware it’s a problem, but a lot of them have the idea that, ‘Oh, well, it won’t happen to me,’” Smith said. “I’ve had that idea. But you never know what’s going to be in any given batch. I think that’s the scariest thing about being in active addiction. Literally, any dose you get is like a game of Russian roulette.”
The effect of synthetic opioids — once just a small component of overdoses in Maryland, and now one of the single greatest contributors in overdose deaths — is increasingly visible in Frederick County, where the more potent narcotics are leading to a higher percentage of fatal overdoses.
In 2015 and 2016, roughly 15 percent of opioid-related overdoses in Frederick County were fatal, according to statistics from the Frederick County Sheriff’s Office. In 2017, the percentage rose to 17.5. And in the first three months of 2018 — Jan. 1 to April 1 — 20.9 percent of the 98 recorded overdoses have been fatal.
“One of the reasons, I can tell you, is pretty obvious if you look at the numbers,” Sheriff Chuck Jenkins said. “Of the 51 fatal overdoses in 2017, fentanyl was present in 41 percent of those cases. That right there tells you why there’s such a high fatality rate.”
While a lethal dose of heroin is equivalent to roughly 30 milligrams, just three milligrams of fentanyl is enough to kill an average-sized adult man. Carfentanil, a tranquilizer used on large animals, can be lethal at the two-milligram range, according to the Drug Enforcement Administration.
For both synthetic opioids, a fatal dose is the same size as a few grains of sand. But levels can range dramatically from batch to batch, and there are few — if any — ways for most buyers to determine the composition of their drugs.
Some heroin users even seek out dealers who are known to have sold a particularly potent batch, searching for a better, stronger high, Smith said.
“A lot of time, if you hear that a certain batch has made people overdose, you’re like, ‘Oh, I want some of that stuff,’” he said. “Because when you’re in active addiction, you’re looking to get more bang for your buck.’”
Smith, 21, said he first tried heroin at the age of 17, while he was still attending Tuscarora High School. He had already become dependent on Percocet after the medication was prescribed for two fractures on his lower spine. One of his friends told him that heroin was essentially the same thing as prescription painkillers — just a purer form of the same basic drug.
While he didn’t realize it at first, his mother, Tiki, was also battling a dependence on opioid painkillers that were prescribed after a hysterectomy. The two “teamed up,” Smith said, after learning of each other’s mutual addictions. He eventually became responsible for procuring the drugs.
When Tiki died, she and Smith were homeless and living from their car, or bouncing from motel to motel. At the time, Smith said he didn’t know about Maryland’s Good Samaritan Law — which prevents officers from arresting victims or callers during an emergency overdose situation — and didn’t notify 911 in time to save his mother.
“I just kept thinking, ‘Oh, she’ll be OK, she’ll be OK,’” Smith said. “But then a handful of hours passed and she was barely breathing, and I knew the jig was up.”
Smith went from feeling disbelief over his mother’s death — “like a nightmare I couldn’t wake up from,” he said — to grieving the loss of his best friend. But it took turning himself in for an armed robbery and several months of forced sobriety in the Frederick County Adult Detention Center for him to feel fully open to treatment.
In May, he’ll celebrate 10 months of recovery and is still in the process of crafting plans for the future. He’s currently in the second stage of Drug Treatment Court, which helped him earn his GED, and volunteers as a speaker for the Youthful Offender Program with the Frederick County State’s Attorney’s Office.
Smith also leads Alcoholics Anonymous meetings twice a week and is working on an associate degree in business administration from Frederick Community College. He’s currently taking the Vivitrol shot — a medication-assisted treatment for addiction — and eventually plans to transfer to the University of Maryland and go to law school, with a minor in substance abuse counseling.
“I know people might look at me and say, ‘You only have 10 months sober — who are you?’” Smith said. “But one of the best things you can do to stay clean is help other people get clean. And after everything I’ve gone through, that’s what I want to do.”
His own experiences have also made him a staunch advocate for more awareness and training on overdoses in the community. Twice, Smith said, he’s administered the overdose reversal medication Narcan after finding someone unconscious along Carroll Creek. But he also wants people to realize that the nasal spray doesn’t always work for fentanyl or carfentanil overdoses.
Because the synthetic opioids are so potent, it sometimes takes two or more doses of Narcan to revive an overdose victim, said Sarah Drennan, a clinical services manager for behavioral health at the Frederick County Health Department. The medication can also wear off before synthetic opioids completely exit the system, which leaves patients vulnerable to a second overdose.
“When we look at people who have died from opioids, fentanyl is the number one cause because it is so potent,” Drennan said. “That makes it more important than ever to apply harm reduction tactics so we’re reaching more people.”
Some of those tactics include encouraging patients in active addiction to not use heroin alone. The department is also examining the feasibility of a syringe services program — which can reduce blood-borne infections and encourage more drug users to enter treatment by establishing sites where they can access sterile needles and syringes — or distributing rapid fentanyl testing strips at clinic locations.
Encouraging and distributing Narcan in the community is also a vital service, Drennan said. Jenkins also supports the use of Narcan, which his deputies have carried since late 2013, but worried that the medication may lead to fewer reported overdoses.
While there was a decrease in both fatal and nonfatal opioid-related overdoses from 2016 to 2017, Jenkins doesn’t believe that the numbers have actually decreased. He estimated that at least 25 to 30 percent of overdoses go unreported in Frederick County — a belief mirrored by the Health Department — and that Narcan might play a role.
“I really believe that because of the stigma of it,” Jenkins said. “If your loved one overdoses and you have Narcan around and can revive them, are you going to call in and report it? I doubt it. That’s still a big problem in the community.”