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Cleveland: Cocaine, Crack Remain Drugs of Choice, But Illicit Fentanyl in the Mix

Cuyahoga County Medical Examiner Dr. Thomas Gilson recently drafted a dark portrait of the prevalence of opioid addiction on the community in Cleveland.

Though cocaine and crack remain “drugs of choice” there, in the rust belt city sitting on the shore of Lake Erie, drug dealers increasingly mix cocaine with fentanyl. The reasoning is simple and scary: Dealers foster hidden opioid addictions in their customers to keep them coming back, until they are dead.

Fentanyl has also been linked the drug-related deaths of white people in suburban Cleveland communities.

But, data released last year shows that within the past year, the drug has made massive inroads, particularly in the black community of Cleveland.

Fentanyl contributed to the deaths of 58 black people last year in Cuyahoga County, up from 25 in 2015. Just five black people died from fentanyl use in 2014, statistics show.

“Cocaine had been the only drug that victims were predominately African American,” Gilson recently told a Senate panel. “The covert introduction of fentanyl into the cocaine supply has caused a rapid rise in fatalities and in 2017, the rate of African American fentanyl related deaths has doubled from 2016.”

Gilson made the remarks recently whilst testifying at the hearing “Stopping the Shipment of Synthetic Opioids: Oversight of U.S. Strategy to Combat Illicit Drugs.” Ohio Senator Rob Portman, a Republican, in front of the Permanent Subcommittee on Investigations…

…The medical examiner’s office is also worried that the increased number of overdose deaths will adversely affect the operations of his office. Last year, the office saw a 16 percent increase in post-mortem examinations and an 8.6 percent increase in toxicology tests; officials recently requested a $200,000 budget increase to support the increased workload.

Gilson said he hopes his recent appearance before the Senate subcommittee will raise awareness.

“I really think the support needs to come from our state, needs to come from our federal government,” he said. “We didn’t ask the crisis to land on our doorstep. But it’s here.”

If you live in Cleveland, and have fallen victim to substance abuse don’t hesitate to seek treatment. There are enormous resources in at your disposal.

Increased Drug Overdoses in Cleveland

The powerful synthetic opioid analgesic, Fentanyl was the primary reason 666 people were offed by drug overdoses last year in Cuyahoga County, up from 370 in 2015. The drug was a factor in 399 drug overdose deaths, up from 92 in 2015. 

Still, opioids kill far more white people than black people in Cuyahoga County; 85 percent of the people killed by fentanyl and 88 percent of the people killed by heroin last year were white, statistics show.

Cocaine also was responsible for the untimely deaths of more white people than black people, but the numbers were slightly different. Only 70 percent of its victims were white, statistics show.

Cocaine-related deaths also rose sharply in 2016. There were 260 people who died after overdosing on the drug, or on cocaine mixed with other drugs, statistics show.

Cocaine resulted in 115 deaths in 2015; in fact, cocaine-related deaths have not risen higher than roughly 125 at any point in the past decade, the medical examiner’s office said.

“The driver of mortality in Cuyahoga County is going to be fentanyl, but what we’ve really started to notice at the end of 2016 and beginning of 2017 is a higher representation of cocaine,” Gilson said last week in a statement. “Cocaine stayed relatively stable, in terms of mortality, for about 10 years up to 2016. And then it really took off in 2016.”

Cocaine deaths were much prevalent among black people when it was ingested alone, and not mixed with other drugs such as heroin or fentanyl. A total o 85 people killed by cocaine alone in Cleveland included 49 black people and 36 white people. Nearly 58 percent of the victims were black, statistics show.

“The strategies to combat this crisis is not a matter of innovative creation but of sheer will, cooperation and adequate resources,” Gilson said.

Cocaine ‘Highly Available’

According to the recent Ohio Substance Abuse Monitoring Network Report, published by the Ohio Department of Alcohol and Addiction Services, powdered cocaine remains highly available in the region. Participants most often said the drug’s current availability as ‘8’ on a scale of ‘0’ (not available, impossible to get) to ‘10’ (highly available, extremely easy to obtain); the previous most common score was ‘10.’ Participants stated that acquiring powdered cocaine necessitates a phone call or a drive. A participant reported. “I think it (powdered cocaine) is easy to get. It’s a phone call. In Cleveland you could probably just walk around, but it’s mainly phone calls, and you can get it within an hour.” Another participant stated,”(Powdered cocaine) it’s harder to get if you don’t drive.” Other users agreed that dealers keep powdered cocaine, and while getting it is not difficult, it often requires a relationship with a dealer to secure the drug: “(Powdered cocaine) it’s more expensive because you can blow it up (turn it into crack cocaine). Other users agreed that dealers retain powdered cocaine, and while obtaining it is not difficult, it often requires a relationship with a dealer to secure the drug: “(Powdered cocaine) it’s more expensive because you can blow it up (turn it into crack cocaine). Dealers hang on to it to double their money; I don’t know if it would be easy for newcomer to get it (powdered cocaine.) Law enforcement most often reported the drug’s current availability as ‘8;’the previous most common score was also ‘8.’ A law enforcement officer said, “(Powdered cocaine) it’s there, but it’s still more expensive. It’s there for the high-end user.”

A treatment provider contrasted the availability of powdered cocaine to that of crack cocaine, reporting, “For IV (intravenous) drug users, speed balling (concurrent use of cocaine and heroin) went from being powder(ed) cocaine and heroin in the needle to heroin in the needle and smoking crack. It’s easier to get crack (cocaine) than powder.”

Heroin Epidemic

Cuyahoga County is also truly experiencing the devastating effects of a heroin epidemic. 
Heroin deaths continue to rise and with fentanyl now in the community with a vengeance, deaths by overdose are staggering. Deaths by heroin overdose have increased from 161 in 2012, to more than 666 in 2017. These individuals fatally overdosed from use of opiate, heroin/fentanyl/carfentanil, and these drugs mixed with other street drugs, such as cocaine. This epidemic is here in Cuyahoga County and it is devastating families. 

Heroin use is increasing because demand is increasing among younger users,  there is a [ill progression from prescription opiates, and there is pressure from dealers to switch from crack and prescription drugs to more-profitable heroin.

According to Farid Sabet, M.D., Chief Clinical Officer of the ADAMHS Board of Cuyahoga County, heroin is a brain disease that can lead to physical changes like depression, personality changes, G.I. problems, and general infections. When the drug is first ingested into the body, it engenders a feeling of euphoria in our brain, and works to mimic many of the body’s numerous systems. After a user’s first time getting high, it takes a higher and higher dose to recreate the feeling in the body. 

Corroborating data also indicated that powdered cocaine is readily available in the region. The Cuyahoga County Medical Examiner’s Office reported that 12 percent of all deaths it investigated during the past six months were drug-related (had an illegal substance present or legal drug above the therapeutic range); in the last reporting period, 11.5 percent of all deaths were drug-related. Furthermore, the Coroner reported cocaine as present in 26.8 percent of all drug-related deaths (this is a decrease from 35.7 percent from the six-month reporting period. Note: Coroner’s data is aggregate data of powdered cocaine and crack cocaine and does not differentiate between these two forms of cocaine).

In addition to the coroner’s data, media outlets throughout the state reported on significant arrests during this reporting period involving cocaine trafficking in the region. In October, The Plain Dealer reported that the Ohio State Highway Patrol arrested two individuals from Michigan during a traffic stop on the Ohio Turnpike in Amherst Township (Lorain County) for possession of an astounding two pounds of cocaine.

Other Drugs Available

But there are other drugs that pose a threat to the populace there too, including bath salts, crack cocaine, Ecstasy, heroin, marijuana, methamphetamine, PCP (phencyclidine), powdered cocaine, prescription opioids, prescription stimulants, sedative-hypnotics and synthetic marijuana remain highly available in the Cleveland region; also highly available for the first time is DMT (dimethyltryptamine), a psychedelic compound with natural and synthetic versions.

Some participants thought DMT, an emerging drug in the region, was powerful. The drug is popular among younger users (16-25 years of age). Increases in availability also exist for heroin and marijuana, and data indicate likely increases in availability for methamphetamine and sedative-hypnotics. While prescription opioids generally remain highly available, participants and community professionals noted that methadone is gaining in popularity. Both law enforcement and treatment providers reported that methadone is increasingly prescribed for pain. The majority of participants and community professionals reported that the availability of of heroin has increased during the past six months; no respondent felt heroin’s availability, according to the county’s drug epidemiology reports.

Officials who are grappling with the epidemic see no end in sight. In fact, drug overdose deaths are projected to increase from 666 in 2016 to 775 in 2017, the medical examiner’s office said.

Heroin deaths are projected to drop, but officials are projecting an additional 200 cases involving fentanyl or cocaine.

“We are seeing epidemic levels of drug overdose deaths in this country,” Medical examiner, Gilson said in a statement. “It’s a big issue.”

The Recovery Process

Many patients take a long time to come around to the point where they are assessed for a possible substance abuse disorder. There are many social reasons for that, and some biological and some psychological factors. The stigma of addiction, though very real society-wide, is most keenly felt by the person struggling with it. Shame drives most denial and is a huge barrier to treatment. The counter to this problem is a combination of trust and privacy, and a move away from treating SUDs as an acute disorder rather than a chronic illness driven by biopsychosocial factors.

Local mental health providers can assess a prospective patient’s readiness to change and the severity of one’s substance abuse disorder with a few simple diagnostic questions. These include the following:

– How many days of heavy drinking have you had in the past year?

This helps assess, advise, and assist at-risk drinkers or those who already have alcohol use disorder.

– Have you used any tobacco products in the last year?

Smoking and drinking behaviors are often paired, due to the social element of substance abuse, like alcohol abuse. Advising the patient to quit can be beneficial, and determine their readiness to abandon destructive behaviors.

– How many times have you used illegal drugs or prescription drugs for non-medical reasons during the past year?

This question was developed by the National Institutes of Health and is a validated screening tool. If the patient has not used during the past year, the clinician can reinforce that behavior and offer supportive counseling. But if the question is answered in the affirmative, it is a sign they patient may be a candidate for therapy.

There are, literally, hundreds of potential screening tools that a local caregiver or clinician can utilize when working with a new patient in Cleveland.

“Specific instruments are available to help counselors determine whether further assessment is warranted, the nature and extent of a client’s substance use disorder, whether a client has a mental disorder, what types of traumatic experiences a client has had and what the consequences are, and treatment-related factors that impact the client’s response to interventions,” according to a substance abuse treatment guide developed by the federal government. “Screening is a process for evaluating the possible presence of a particular problem. The outcome is normally a simple yes or no. Assessment is a process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis.”


The first step to tackling a drug or alcohol problem is acknowledging the problem. The next step is seeking structured treatment. According to government statistics, in Ohio, about 93,000 youths (10.0% of all youths) per year in 2008-2012 reported using illicit drugs within the month prior to being surveyed.

In Ohio, about 645,000 persons aged 21 or older (7.9% of all persons in this age group) per year in 2008-2012* reported heavy alcohol use within the month prior to being surveyed. Of these, about 1 in 27 (3.7%) received treatment for alcohol use within the year prior to being surveyed.

About 285,000 persons aged 12 or older (3.0% of all persons in this age group) per year in 2008-2012* were dependent on or abused illicit drugs within the year prior to being surveyed. The percentage did not change significantly over this period.

Nearly 94,000 youths (10.1% of all youths) per year in 2008-2012 reported using cigarettes within the month prior to being surveyed. This is the most recent year for which statistics are available. About 3 in 5 (63.3%) 12- to 17-year-olds in Ohio in 2011- 2012 perceived no great risk from drinking five or more drinks once or twice a week. In Ohio, about 31,000 youths with MDE (40.1% of all youths with MDE) per year in 2008-2012 received treatment for their depression within the year prior to being surveyed. About 366,000 adults (4.2% of all adults) in 2008- 2012* had serious thoughts of suicide within the year prior to being surveyed. The percentage did not change significantly over this period.

In-Patient and Outpatient Treatment Centers

There are a number of treatment options, including in-patient and outpatient treatment. Ohio patients in recovery from substance abuse choose both options, according to government statistics. Among patients in Ohio enrolled in substance use treatment in a single-day count in 2012, 29.3% were in treatment for a drug problem only, 15.2% were in treatment for an alcohol problem only, and 55.5% were in treatment for problems with both drugs and alcohol.

In Ohio, among persons aged 12 or older with alcohol dependence or abuse, about 59,000 persons (8.5%) per year in 2008-2012 received treatment for their alcohol use within the year prior to being surveyed.

For this state, about 756,000 adults with AMI (44.9% of all adults with AMI) per year in 2008-2012 received mental health treatment or counseling within the year prior to being surveyed.

For this midwestern state, about 702,000 persons aged 12 or older (7.3% of all persons in this age group) per year in 2008-2012* were dependent on or abused alcohol within the year prior to being surveyed. The percentage did not change significantly over this period.

In a single-day count in 2012, 5,197 persons in Ohio were receiving methadone as part of their substance use treatment, and 1,768 were receiving buprenorphine. That’s done on an in-patient basis usually.

The number of persons in Ohio who received buprenorphine as part of their substance use treatment increased from 2008 to 2012.

For this state, among persons aged 12 or older with illicit drug dependence or abuse, about 41,000 persons (14.3%) per year in 2008-2012 received treatment for their illicit drug use within the year prior to being surveyed.

After assessment, patients in recovery should expect the following steps:

– Pre-Intake

This is where additional information is gathered from you by a clinician or a social worker and a case file is developed for you. You may be asked to gather certain types of information, telephone numbers and contact e-mails for family members, insurance information, and a medical history. A local facility will guide you through the process.

– Intake

Next comes the intake interview, mostly commonly done by a clinical psychologist or clinical psychiatrist.  The reason for the intake interview often includes establishing and diagnosing any problems the client may have. Usually, the clinician diagnoses the patient using criteria from the first two DSM axes. Some intake interviews also include a mental status examination. During the intake, the clinician may determine a detailed treatment plan for the patient.

– Detox

Detox is shorthand for “detoxification.” This is is the physical removal of drugs/toxic substances from the body, which is primarily carried out by the liver. Additionally, it can refer to the period of withdrawal for the patient during which his body returns to normal (also called homeostasis) after long-term use of an addictive substance, like alcohol or heroin.

What is withdrawal and how long does it last?

– Inpatient Treatment

Inpatient treatment is a kind of treatment in which a patient is provided with 24/7 care at a residential facility. Psychiatric and physical health assistance are part of this treatment. Patients will stay often reside at inpatient treatment facilities for months at a time.

– Outpatient Treatment

An outpatient program does not compel you to live at the residence of a treatment facility. In fact, you could complete your treatment in the comfort of your own home or a sober living facility.

There are partial hospitalization programs (PHP), where patients are typically required to sit with a counselor or participate in individual or group therapy meetings for 5-6 hours a day, up to five days a week. The level of demand and involvement varies.There are also Intensive outpatient programs are a level below PHP programs and are considered to be less therapeutically intensive, i.e. allowing patients to work or attend school during the day while regularly participating in evening therapy sessions. There are also OP programs, or outpatient treatment programs, which is less intense and less structured than the other options, listed above. This usually involves regular weekly meetings and up to 2 hours of therapy at a time for the patient. Therapy is treated as continuing care for the patient.

– Aftercare

This is what it sounds like – continuing care after you have had your primary therapy and plunged into the recovery process. This may involve regularly scheduled meetings with doctors and regular therapy sessions.

What happens after discharge?

– Sober Living

Sober living is an option that many choose. It is a kind of half-way house between being back at home and in the community and being in a community of care. Patients who reside at the sober living facility must follow strict rules, and adhere to treatment guidelines, and attend regular therapy sessions, and cooperate with other patients in adopting a sober lifestyle.

“I really think the support needs to come from our state, needs to come from our federal government,” said Gilson. “We didn’t ask the crisis to land on our doorstep. But it’s here.”