When Anne Majewski took office as McHenry County coroner five years ago, heroin was the only illicit opioid fueling a major public health concern.
That's not the case anymore.
As communities have gotten smart to the dangers of the drug, so have black-market chemists, Majewski says. The people who create the concoctions that addict and kill suburban residents now are mixing it up -- literally -- so their products contain drugs with potentially lethal potencies unknown to their customers.
Fentanyl, a drug 30 to 50 times more potent than heroin, and synthetic versions of the drug called fentanyl analogs, are becoming common culprits. But the analogs are especially difficult to identify because they don't show up on standard toxicology tests. And that's spilling red ink on coroners' budgets in the six-county area; they have been on the rise since 2010.
Each time a coroner such as Majewski suspects a synthetic opioid is involved in a death, she has to tack on an additional $300 to what starts out as a roughly $185 drug screen. Coroners say they're being forced to order these tests in a growing number of cases.
"It will only get more complicated," Majewski says. "I think we'll see a cost increase because of the technology needed to design the tests."
Toxicology labs say they're doing what they can to keep their costs low. But the influx of synthetic opioids during the past two years is taking its toll.
"It's a drain for everybody," says Dr. George Behonick, director and chief toxicologist at AXIS Forensic Toxicology in Indianapolis, one of two labs where suburban coroners typically send their samples. "We don't want to do anything that's going to make it even more problematic to get the testing done. Yes, we're a private entity and we're there to make money, but not in a way that can cripple the municipal jurisdictions."
Despite the increasing cost, coroners say their commitment to determine precisely what led to every suspected overdose death -- Was it heroin? Fentanyl? Synthetic fentanyl analogs? Some combination? -- remains unwavering. The public needs to know, they say, what is killing those who fall victim to the disease of addiction.
"You have to do your due diligence," Kane County Coroner Rob Russell says, "in order to definitively determine a manner and a cause of death."
Russell, Majewski and Will County Coroner Patrick O'Neil all say they started noticing deaths from fentanyl and its look-alike analogs last year.
They knew something was changing when a case would seem like a heroin overdose but wouldn't test out as one, even with many of the telltale signs, such as white powder in a baggie, a spoon, needle, syringe and tourniquet at the scene; a history of drug use; respiratory depression; and fluid coming out of the mouth.
When a drug is in the samples coroners send for toxicology testing, a certain chemical called a breakdown product will appear. If the breakdown product for heroin or fentanyl doesn't show up in a suspected case, coroners have learned to order more tests.
"If it presents like an opioid overdose ... yet our tox is negative," Majewski says, "I automatically step up to the panel with the fentanyl analogs and the like."
A test called a psychoactive substances panel will determine if a fentanyl analog is in an overdose victim's body. The panel costs about $300 in a price coroners negotiated through the Illinois Coroners and Medical Examiners Association.
Last year, fentanyl and fentanyl analogs were found without heroin in the systems of 147 overdose victims across the six-county area, excluding Chicago. Before that, such deaths weren't separately tracked. This year, the total through June 15 stands at 51, but coroners say that number reflects a four- to six-week lag for cases that are pending toxicology results. Plus, there are more deaths involving fentanyl and analogs where heroin also is present.
In McHenry County, Majewski increased her toxicology budget to $25,000 for 2017 from $20,500 last year, while she cut her overall budget from $535,128 to $494,450. In Will County, O'Neil's toxicology budget rose to $80,000 this year after he noticed increasing costs in 2016, when he budgeted $77,000 for the expense.
"We've known about the opioids and synthetic fentanyls for a number of years, but we really didn't see a spike in it until last year," he says. "Synthetic fentanyls basically cost the county an additional $3,000 last year."
'A step behind'
Just five years ago, Majewski says the precise cause of these deaths would have remained unknown, as labs did not yet have tests to detect synthetic fentanyl analogs, drugs that Behonick says are produced by "illicit, clandestine chemists in overseas areas fooling around."
"The drug dealers are always trying to create different chemical structures to their drugs that aren't detectable to testing, and then the lab has to develop a test to detect that compound," Majewski says. "You're always a step behind."
Working with the U.S. Drug Enforcement Agency and commercial chemistry suppliers, labs have to obtain "certified reference material" of each new drug they encounter. Behonick says these legally produced versions of each new illicit opioid allow toxicologists to form tests that find the substances in the bodily fluids of the deceased.
"We've been dealing with this sort of cat-and-mouse game for some time with new drugs emerging," Behonick says.
An urge more than curiosity drives coroners such as Majewski to determine which drugs cause overdose deaths: It's a commitment to public health.
Majewski, a former obstetrician/gynecologist, says it's important to identify which drugs are causing deaths so law enforcement can understand what's in the drug supply, politicians can change laws and educators can warn youths about new dangers.
"We're losing people who, they're young. I think they're unknowing," Majewski says. "Even though they understand drugs are potentially fatal, these people are addicted, and they don't know what they're going to get."
When users think they're getting heroin but wind up with something stronger, they're more likely to overdose -- even if they take an amount that usually only fulfills their craving or gets them high.
In such cases, Majewski says she's troubled by the increasing need for large doses of the opioid overdose reversal drug naloxone, which knocks opioids off the brain receptors they trigger so users can breathe again. If coroners keep finding overdoses from drugs stronger than heroin, it may mean first responders need to carry more naloxone, or maybe each dose of the reversal drug needs to be more potent.
"Could we get more saves?" Majewski wonders.
Coroners agree these public health decisions must start with data. That's why Lake County Coroner Howard Cooper doesn't give a second thought to the expense of toxicology testing, which his office conducts both in house and at a contracted lab off-site.
"To me, it's a cost of doing business," Cooper says. "I don't even think about it because we have to test."