Poisoned Paper
Want to know how someone goes from completely normal to unconscious in minutes with nothing around them. What drug was deemed too dangerous for medical use but is now a drug of abuse? What new way is contraband being smuggled into prisons?
This is the Pick Your Poison Podcast. I’m Dr JP. ER doctor. Toxicologist, and unapologetic lover of all things poison. Want to know how someone goes from completely normal to unconscious in minutes with nothing around them. What drug was deemed too dangerous for medical use but is now a drug of abuse? What new way is contraband being smuggled into prisons?
Stay right here to find out.
This is an interactive story.
What happens next depends on you. Will our patient live or die?
It's up to you and the choices you make.
Brace yourself. Today’s episode starts in a prison.
You’ve agreed—somewhat reluctantly—to accompany a friend. She runs a nonprofit that teaches inmates to write and tell their stories. Stories have even been published in literary journals. Some inmates come back after release to help others. Today, you’re one of the volunteers.
You sit in a large room with rows of tables, scattered pencils, and stacks of paper. It almost feels like a school. Until the warden walks in. He thanks you for volunteering, and then says that the prison is a dangerous place and they can't guarantee your safety around violent felons. He says if anybody wants to leave, now is the time
You seriously consider it. As an ER doctor you know full well the extent of violence that can happen inside of a prison: broken bones, dislocations, Stab wounds. In many prisons, trauma is the number one cause of medical problems.
Your friend glances at you. A small smile. A subtle shake of her head.
You give her a look… but you stay.
The inmates file in.
For the next hour the group discusses writing, journaling, and storytelling. When you break down into small groups, your inmate partner tells you the story of his life, how he ended up in jail and his dreams after release in a few years.
At the end of the session the inmates are taken back to their cells. You, your friend, and the other volunteers strategize while cleaning up about future directions given how well it went.
Then—
An alarm sounds. The guard stiffens; his radio squawks. He says,“Medical issue. Stay here and I'll escort you out afterward.”
You tell him you're an ER doctor and ask if they need help. Of course, in real life the prison has its own medical staff but this is fiction so he waves for you to come.
You follow him down one beige hallway after another until you reach an open cell door. Your partner is inside, unconscious and slumped over the toilet. You scan the room. There's not much to see: two bunk beds bolted to the wall and a fixed steel toilet. No food, no powder, no weapons. Just some loose pieces of paper scattered on the floor, some with writing from the story he was working on.
Ten minutes ago he was awake and talking to you. Now he's unresponsive. The guards handcuff him even though he's completely unresponsive, scoop him up and transport him to the emergency department. This is fiction so you guessed it, you're the ER doctor.
You have to figure out what happened to your partner, how he collapsed in minutes in an empty cell. What happened inside?
The nurses cut off his orange jumpsuit, hook him up to the monitor and obtain IV access. Noticing that he's turning blue and barely breathing, the intern applies a bag mask onto his face and starts bagging. The nurses get vitals as follows: His temperature is normal, 98.6°F (37°C). The monitor shows a heart rate of 80 beats per minute, a blood pressure of 110/60, a respiratory rate of 2, and an oxygen saturation of 80% on room air.
Question number one: As we move on to the physical exam, what finding will be helpful to tell us if a classic poisoning toxidrome is present?
A. pupils
B. Lung sounds
C. Rash
D. Muscle tone
The answer here is A. pupils. Of course we want a thorough physical exam and all the information but in a patient with an altered mental status and a low respiratory rate. I want to know immediately about the pupils to decide if this is a classic opioid toxidrome.
The intern opens his eyelids, shines a light back and forth, and says "pupils are normal and reactive."
As for the rest of his exam, he's completely unresponsive including to pain. His heart and lungs sound normal. His abdomen is soft, non-distended. He's not currently moving any of his extremities. His skin is warm and dry without a rash.
If you've listened to prior episodes, you can answer this question: Is this a classic opioid toxidrome? The answer is no. He has the altered mental status and the depressed breathing but he should have pinpoint pupils.
His saturation has improved and it's now in the low 90s, thanks to the oxygen and the bag valve mask helping him to breathe. Question 2. What is the next step?
A. Intubation?
B. Naloxone i.e. Narcan
C. Physostigmine
My answer is B naloxone though if you said A intubation, you're definitely not wrong. As we've discussed on prior episodes, naloxone (Narcan in the U.S.) is the antidote for opioid overdose like fentanyl and heroin. The indications for giving it are a respiratory rate of less than 8. Yes I did just say he's missing the third part of the opioid toxidrome so if you think intubation is safer I wouldn't say you're wrong. However the pupil exam, like everything else in medicine, isn’t 100%. We know he had a sudden collapse in minutes. We know he has a depressed mental status and respiratory rate, all consistent with opioids. I personally would try a dose of Narcan before intubation.
You ask the intern what dose to give.
“She says start low and go slow, right, to avoid withdrawal.”
You nod in agreement.
“0.5 mg,” she says.
The nurse draws it up and administers it. Nothing happens.
Now what, you ask?
“He's still not breathing but also he's not showing any signs of opioid withdrawal so I think it's safe to give a bigger dose, she says and tells the nurse to give a milligram.
This time his breathing increases from two breaths per minute to four so she orders a 2 mg dose, and he starts to move spontaneously. She takes off the bag valve mask as his respirations come up to 8 and his pulse ox stays at 93% on room air.
He's stable at least for the moment so you and the intern go to your desk to discuss the case further.
She says, "Well it must be an opioid overdose because it responded to Narcan. Weird that he didn't have pinpoint pupils."
You agree saying, “the patients don't read the text books, meaning they don't always follow the rules exactly.”
She says, "How did he overdose on opioids? I thought you said he was in prison."
“Unfortunately there are a lot of drugs inside prisons. Being incarcerated doesn't mean you can't take illicit substances.”
She orders basic labs, a urine drug screen and a chest X-ray to make sure it wasn’t anything else, all of which comes back normal an hour later.
She says, "What do you think happened?"
You say, "What do you mean? We just talked about opioid overdoses.”
She says, "But his urine drug screen came back negative." Also I went in there to check on him a few minutes ago to see if he needed more naloxone and the prison guard asked me what happened. Wouldn't they have found the drugs?
“I hope you didn't say anything,” You respond. “The prison guard doesn't have any legal right to know his medical history.
“No don't worry,” she says. “I didn't tell him anything but he asked because he says that his fellow prison guards searched cell from top to bottom and didn't find any contraband. No drugs.
“What is the urine drug screen test for?”
“Ummm”
“It tests for naturally occurring opioids like morphine and codeine, found inside poppy plants. It doesn't test at all for synthetic opioids like fentanyl or methadone. It has about a 50% sensitivity for semi-synthetic opioids so it's flipping a coin as to whether or not the test will be positive for things like oxycodone and hydrocodone (i.e. Vicodin and Percocet).”
“Meaning there are plenty of opioids it can miss,” She says,
"Exactly, We toxicologists seem to be the only people who don't love urine drug screens.
“Who knows about contraband inside his cell, you say? It's certainly not the first time the guards are outwitted by an inmate or maybe he just took the last dose. And there's nothing to find.” Who knows? It's unclear how these facts are relevant at this moment in time for our patient’s treatment.
You tell her to watch the patient for six hours after the last dose of Narcan. We don't know what he took and we don't know if it's a long-acting opioid so this is a fairly standard observation period to see if someone requires additional doses of naloxone.
Eventually, patient wakes up, has a meal, tells you hospital food is better than the prison food, and is discharged uneventfully.
But that’s not the end of the story. One month later you go back to the prison, returning with your friend and her nonprofit for more journaling and storytelling.
This time things are a little different. Your friend hasn't brought paper, journals, pens, pencils or markers. She says the prison rules have changed due to some unusual circumstances.
Which of the following have been recently banned in prisons around the world? Question 3.
A pens,
B pencils,
C paper,
D markers.
You wonder if the prisoners have been eating the pens and pencils. Think that's crazy? It's not. Unfortunately, prison is a difficult place filled with difficult people and for reasons of secondary gain some prisoners prefer to be in the hospital as it's a safer and less difficult place to be. In other cases prisoners swallow pens and pencils due to severe psychiatric illness. I know the gastroenterologists out there have probably all removed four or five pens or pencils from a patient's stomach after someone swallowed them whole.
No it's not the pens and pencils your friend says. She has iPads for the inmates to use instead. The answer is C. paper. Why? Excellent question. Earlier you told the intern that it was easy to get illicit drugs in prison so let's talk about how these substances get into prisons.
I think everybody knows that most prisoners get a body cavity search to look for Concealment of illicit substances in places like the rectum or vagina. We've talked before about swallowing drugs for the purposes of concealment (i.e. body stuffers and body packers). People do do this to smuggle them into prison not just to smuggle them into a different country.
I'll tell you a funny story from residency I was training at a level one trauma center and was on the trauma team along with the orthopedic intern. Two patients were brought in under arrest by police after a rollover motor vehicle crash. As you're well aware one of the first things we do is cut off the clothes and do a full physical exam to look for potential injuries. A full physical exam includes a rectal exam (i.e. a finger in the rectum) to check for rectal tone.
Usually when you put your finger in somebody's rectum, their sphincter clamps down, meaning their spinal cord is working normally. If you put your finger in and nothing happens, this raises concern for significant spinal cord injury, directing you towards imaging for further evaluation.
Not surprisingly the rectal exam is the intern's job. I did the rectal exam on my patient, noting normal rectal tone. I also felt a foreign body and pulled out a plastic baggie with white powder (i.e. drugs). The two patients were evaluated, didn't have any significant injuries, and were discharged to jail. A few hours later I was telling the orthopedic intern about the drugs. I said yeah, when I put my finger in there, there was a plastic bag so I pulled it out.”
A funny look passed over her face and she said, "Oh."
After a few seconds she said, "I felt something weird in there on my patient too but I didn't know what it was."
One of the two patients was discharged from the emergency department with the internal concealment intact, I've always wondered if it got through into the jail or if it was discovered on a body cavity search.
Anyway in order to get around well-known methods of smuggling drugs into jail inmates, friends and family are always trying to come up with other more creative methods. I'm sure you've seen movies where people pass plastic bags or balloons filled with drugs over a kiss, via a handshake, or concealed in food and drink. I saw a case in the news recently where tragically a little baby was used to pass the drugs that were hidden in his diaper.
Sometimes it's as easy as bribing the staff to allow drugs in, along with shipments of food or equipment. Drones have been used to try to drop packages into an exercise yard. Drugs have been concealed inside tennis balls or dead animals and then thrown over the fence for an inmate to pick up.
There's one pretty ingenious way that's been increasing in popularity recently, you may have heard about it on the news. And I should add the toxicity of the drugs concealed on them is also increasing in toxicity. It's putting the drugs onto paper and smuggling the paper in the prison.
This isn't new. Think about LSD. It it's been put on on blotter paper since the 1970s. Liquid LSD is put onto absorbent paper. Users put a small piece in their mouth. The paper dissolves, the LSD is released and gets absorbed. I didn't actually know until I did this podcast it was in response to evading law enforcement. After LSD was criminalized in the 1960s, penalties were related to the weight of the drug. Blotter paper was light weight and easy to hide.
So it's not just LSD that's been put on paper but just about every other drug you can think of, including meth, fentanyl, and cocaine. Why? Because prisoners, of course, are allowed to receive letters. Smuggling became even more sophisticated when people mailing drugs inside prisons posed as Amazon resellers sending books to prisoners with pages of the books coated in drugs.
I said earlier that drugs are pretty easy to come by in prison but what they aren't is cheap. You can imagine smuggling increases the cost of these already illicit drugs. One source said a 12 by 12 piece of paper coded with drugs could be worth as much as $10,000 inside. This is a lot of money and a lot of incentive.
The prisoners file in. You're paired with the same partner as before. He sits down and picks up an iPad. You ask how he's feeling. He says he's doing great and can't wait to continue to share his story. He picks up the stylus and starts writing. The person sitting on the other side of you asks a question. As you finish answering you look back towards your partner, and see him slip a tiny piece of paper into his mouth.
A few minutes later his eyelids drift down and he stops writing on the iPad.
Uh-oh. I think you just figured out what happened to him last time.
You look at the prison guard, wondering what to do next. You don't want your partner to have another life-threatening event but you have no idea what kind of trouble he'll get into if you report this to the authorities. You keep a close watch on his breathing for another few minutes but then he slumps over the table, attracting the guard's attention.
The guard can't wake him up and his breathing gets slower.
“Probably paper again,” the guard mutters. This time your partner is taken to the prison medical area for further observation.
Let's talk first about what's been smuggled on paper and then we'll talk specifically about what's happened to our partner. Looking up some facts, I was absolutely astonished to see what the number one contraband drug, is in U.S. prisons from the year 2019 to 2023. Can you guess? That's question number 4.
A. Fentanyl
B. Marijuana
C. Methamphetamine
D. Buprenorphine
The answer is actually D. buprenorphine. This is according to a U.S. Sentencing Commission fact sheet on prison contraband. The next most commonly smuggled contraband was marijuana, then meth, followed by opioids and cocaine.
Buprenorphine is an opioid but it's a partial agonist, meaning we use it to treat opioid withdrawal much more often than it's used as a drug of abuse. I'm not at all surprised people inside prison are having opioid withdrawal. We use buprenorphine very commonly in the emergency department and in psychiatry to treat opioid Use Disorders and Withdrawal. I am honestly surprised it's contraband and not something you could get as a prescription. Anyway maybe somebody listening who knows more about this than me can tell us.
The most common contraband inside U.S. prisons are: Cell phones, followed by Drugs, then Weapons. The consequences for getting caught with drugs as Contraband are significant with individuals receiving an average of 16 months in prison.
Just how common is drug use inside? Well one study suggested about 30% of incarcerated people were using drugs, with a range, however, from 3% to an astonishing 90% depending on the prison.
Let's get back to specifically what's being smuggled in on paper. As I said it can be anything and methamphetamine is definitely a common one but what's often being smuggled these days are what we call novel psychoactive substances. What does that mean? They're synthesized variations on drugs of abuse. For example you've probably heard of K2, it's synthetic cannabinoid derivatives. There are synthetic opioid and benzodiazepine derivatives. Why bother with these? Well first of all, often times these drugs may not be illegal because they are new and not scheduled under existing laws. Second of all oftentimes they don't make the urine drug screen positive. We've talked about its weaknesses. And third they can be highly concentrated and very potent, making them smaller and easier to smuggle. Often times they're cheap to manufacture.
Drug-laced paper has become such a significant problem that in many countries, including prisons in the U.S., Germany, and Scotland mail is photocopied and the photocopy is given to the prisoner rather than the original paper in case it was impregnated with drugs. Interestingly it's reported photocopying paper reduced drug-related incidents in Scottish prisons by almost 60%.
The warden comes in and tells you that they're monitoring your partner in the medical ward and tells you what you've already concluded, that his overdose last month was due to a drug-laced paper. He says they sent the paper off for analysis and it recently came back as impregnated. This is a tough one because it's a very novel psychoactive substance and it's Question 5. Time to pick your poison. Is it?
A. Medetomidine
B. Isotonitazene
C. JWH-018
The answer is B. Isotonitazene. Metetamidine is a contaminant in opioids. We talked about this one in the *** episode. It can cause low heart rate and can cause significant withdrawal symptoms with high blood pressure. JWH-018 is a synthetic cannabinoid. Isonitazene (ISO) is a category of opioid drugs called nitazenes. There are more than 40 different netizens, including Etodesnitazene, Metonitazene, Protonitazene, Protonitazepyne, Isotonitazepyn just to name a few. Most of them are more potent than fentanyl. Isonitazene specifically is about 250-900 times stronger than morphine. To compare, fentanyl is about 25-50 times stronger than morphine. And some nitazenes are even more potent, up to 40 times stronger than morphine. They can be taken any way that your typical opioids are taken, injected, inhaled, snorted, or vaped.
Nitazenes were developed in the 1950s by researchers in Switzerland as an alternative to morphine but they were never actually used in medical practice. I love this, due to an "unfavorable balance between therapeutic and toxic effects". There was a high risk of respiratory depression and addiction. Specifically if you want to get technical, they are a class of synthetic 2-benyzlbenzimidazole opioid receptor agonists. The different compounds vary in potency, side effects, and half-life.
What do they do? They are opioid agonists like fentanyl and morphine, so they can cause altered mental status and respiratory depression, including respiratory arrest and death. Interestingly it's about 50/50 whether they cause constricted pupils like the classic opioid toxidrome we were talking about in the beginning. Other side effects of depressed respiration include: aspiration pneumonitis, ventricular tachycardia, and heart attacks from low blood oxygen levels.
As it was with your writing partner, naloxone is effective and would be the treatment of choice. Intubation and ventilation will work just as well so you can breathe for them until the drug wears off. Sometimes patients do require additional doses of naloxone. Other times they don't. This probably has to do with which specific drug they've been exposed to and the doses. Of course at the bedside in the emergency department we will never know. Essentially you continue to monitor for clinical symptoms, and that'll determine the need for more antidote or not.
Nitazenes had essentially faded into obscurity after the 1950s until 1998 when they popped up as a drug of abuse. Ten deaths occurred in Moscow due to nitazene and this was followed by a chemist manufacturing it in Utah in 2003. Apparently, he made it for himself, converted it into a liquid form, and then used a nasal spray bottle to take it. He was caught by law enforcement and Sadly committed suicide before his trial.
In 2019 is really when nitazenes became much more widespread as a drug of abuse. As with many drug analogs, the legal status is really variable. In the US, Canada and the UK most of these are Schedule I or Schedule A, the highest level of restriction.
I think we're going to see more cases of nitazine toxicity in the U.S. because they're becoming increasingly popular worldwide. Sometimes patients take them intentionally, but other times the exposure is accidental. You never know what you're actually getting with illicit drugs. Interestingly enough in Australia, nitazines analogs are now more common than fentanyl. Some cases of nitazene poisoning occurred in Australia after people vaped what they believed to be cannabis. In the UK people believed they were taking MDMA (i.e. ecstasy or molly) and in fact took tablets containing nitazene instead.
Back to our patient. You are unable to attend the following month's journal article writing thanks to a shift. Your friend inquires about your writing partner, telling you he was observed in the prison medical unit but this time didn't require naloxone or transfer to the hospital. He may, however, get additional jail time for charges related to possession of contraband. The prison continues to crack down on paper to try to reduce poisoning and overdose deaths inside. This is a fictional case, as are all our cases, to protect the innocent. But it is based on real poisonings.
The last question in today's podcast. In United States prisons there are three main types of contraband: drugs, weapons, and cell phones. Weapons are usually manufactured inside the prison by inmates, not surprisingly. Drugs and cell phones are generally smuggled in from the outside. One more commonly by corrections officers and one more commonly by visitors.
Which is more commonly smuggled in by corrections officers?
A. drugs
B. cell phones?
Follow the Twitter and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Until next time, take care and stay safe.