Anatomy of an Outbreak: A Mystery Drug Brings Trouble to Town

---

One day last September, a few patients turned up at HCMC presenting a baffling range of symptoms: aggression, confusion, catatonia. A week later, ambulances were dropping off dozens of patients.

Doctors knew Minneapolis was suffering an outbreak of overdoses. But identifying the drug—and stopping its distribution—would test the city’s ability to cope.

The Outbreak

The paramedics found Mark Eliason on the ground, almost unconscious, near a bus stop on the far southeastern edge of downtown Minneapolis. He had just been to lunch that Tuesday afternoon in early October 2017, then walked a couple of blocks toward the I-94 and 35W interchange. The ambulance ride to Hennepin County Medical Center was a short one—about a mile. But on the way, Eliason, 41, became combative. 

According to his medical records, first responders initially suspected alcohol: His symptoms included an elevated pulse and a low respiratory rate. And he had been treated for overdosing on alcohol in the past. But a Breathalyzer test came back negative. A six-person medical team monitored Eliason, keeping his airway clear, while they waited for their patient to regain his faculties. They hoped to ask him what had occurred before the paramedics arrived on the scene. 

Over the course of a few weeks in late September and early October, the triage nurses were seeing a worrying number of emergency admissions like Eliason’s. Or something like his. Though many patients arrived from the same neighborhood, around Phillips, they presented a confusing array of symptoms. Some turned up in a seizure state, others catatonic. Still others appeared highly agitated and aggressive. 

Michael Trullinger, a paramedic and deputy chief of operations for Hennepin Emergency Medical Services (HEMS), said, “We were getting these repeat calls and sometimes the same day—some within hours of each other.” 

HCMC is a level one trauma center; it’s where the ambulances go during mass emergencies—say, when a bridge falls down. Ultimately, 140 seemingly related cases, according to HEMS records, resulted in ambulance runs during those three weeks, and all but eight would be directed to HCMC. (Toxicologists would later revise down the hospital numbers to a little over 100.)

Doctors and medical staff there knew they were seeing a drug outbreak. But what was it? 

Nearly three months would pass before medical authorities received lab results that could identify a compound likely responsible for the spate of bizarre clinical presentations that shook HCMC. That drug was a synthetic cannabinoid called K2. Though medical responders knew the stuff from previous medical encounters, most of the public had probably never heard of it. 

In a sense, the name K2 didn’t answer a lot of questions. While medical authorities treated the drug’s users, police fanned out in a series of raids and arrests to try to interdict the drug at its source. Where had the K2 come from and what made this particular strain so noxious? In the midst of a national opioid epidemic—395 Minnesotans died of opioid overdose in 2016, the last year with firm numbers—how could Minnesota public health authorities respond to a parallel crisis, localized but intense? 

The K2 crisis that engulfed Minneapolis last fall posed an unusual challenge in one other way. Researchers had never encountered the specific variant on U.S. streets.

“When you say K2, it’s sort of like saying ‘drugs,’” explained Dr. Jon Cole, a medical toxicologist with HCMC and director of the Minnesota Poison Control System. “You don’t know what a person has taken. When blips happen, we don’t know the slope of the line.”

How many more patients like Mark Eliason would encounter the drug? And what would happen to them? 

The Compounds 

The short name for the form of K2 that seems to have shown up in the fall is 5F-ADB, a tidy abbreviation of its chemical formula: methyl(S)-2-[1-(5-fluoropentyl)-1H-indazole-3-carboxamido]-3, 3-dimethylbutanoate. 

Users call it spice or potpourri, depending on where they get it, the compounds involved, and the form of its presentation. Manufacturers sometimes make it out to look vaguely like marijuana: that is, chopped and dried vegetative material (essentially a filler sprayed with active chemical ingredients). Another drug family, synthetic cathinones, bears some chemical similarities to drugs like amphetamines, cocaine, and MDMA. These compounds often look like a crystal or even a powder, and have been marketed as bath salts. State law enforcement differentiates those two drugs, explained Brian Marquart, the statewide gang and drug coordinator for the Minnesota Department of Public Safety. 

“We are as concerned about K2 overdoses as we are about heroin or opioid overdoses,” Marquart added.

The original K2 compounds were created about 20 years ago by John W. Huffman, a professor of organic chemistry at Clemson University. Funding for Huffman’s research, ironically, came from the National Institute on Drug Abuse. Conducting research with actual marijuana, a Schedule 1 drug in the federal substance-control regime, had presented legal and practical barriers. Huffman’s goal was to study how the compounds in marijuana plants target receptors in the brain. 

Single doses of K2 cost perhaps $5 for a loosely packed baggie. Users will generally smoke K2 in rolling paper or a pipe, or vape the juice. It’s a novelty that way and generally a cheap high. 

Which is another way of saying that users rarely know conclusively what’s going to happen after they smoke. Though the drug material may superficially resemble marijuana, it doesn’t mimic the effects. In the brain, Dr. Cole explained, the compounds act like keys to different locks. This is especially true when the compounds have been altered, even slightly. Synthesizing the compounds requires a chemist with sophisticated skill, he added. But it’s not necessarily a sophisticated high. 

Kenneth Solek, an agent with the Drug Enforcement Agency’s Minneapolis–St. Paul Division, compares taking K2 to “playing roulette.” 

“There is no quality control with these substances,” Solek said. “By the time people start showing up in the ER, we don’t know what’s going on. It’s more reported by paramedics. People talk about bad doses, but in my opinion no batch is going to be a good batch of this stuff.”

K2 incidents around the country in recent years have garnered press coverage, earning scary labels like zombie outbreaks. However, upon closer examination, the medical story inevitably proves to be more complicated. The fear is that K2 compounds, lacking an antidote and possessing unknown potency, will prove lethal. Yet actual K2-involved deaths usually implicate a constellation of problems, including trauma, exposure to the elements, or a mixture with other chemical substances. 

Minnesota’s struggles with K2 began in the mid-2000s, as they did in much of the country. That’s when the drug first began to appear in bodegas and convenience stores, tobacconists, and head shops: generally, places that also vend a colorful variety of pipes and vaporizers. The state’s most prominent battle to control the chameleonic drugs resulted in a 17.5-year prison sentence for Jim Carlson, the owner of the Duluth head shop The Last Place on Earth (now closed). Prosecutors charged during Carlson’s trial that he traded in synthetic drugs labeled as incense, glass cleaner, bath salts, and potpourri. 

His defense—unsuccessful though it may have been—asserted that the substances Carlson sold weren’t explicitly illegal at the time he sold them. Yet synthetic cannabinoids in the K2 family have earned federal listing as Schedule 1 illicit drugs. Minnesota statute criminalizes their sale as well.

Marquart describes a strenuous state effort to curb the open sales of K2. “Through education and change in legislation, we’ve seen a dramatic decrease in the sales of synthetic drugs,” he said. 

When overdoses occur now, he added, they may appear in the types of bursts seen recently in St. Paul and Minneapolis. 

One explanation is that purchases come in small shipments through the dark web. Dealers then resell the drugs within a “small geographic area of acquaintances”: the recipe for an outbreak. 

The latest generations of vaporized drugs could pass for tobacco products. “There are a number of substances, many odorless, that could be smoked that way,” Marquart said. “We have no idea as a casual observer.”

K2 has been a drug of choice for people who must test clean for work (for example, commercial vehicle drivers or military personnel) or people who must take court-ordered drug tests (for probation or child protection services). 

John Tribbett, program manager of the street outreach team at St. Stephen’s Human Services, said, “It’s a chemical that packs a very significant high for folks for a very low cost. Easy access means more people are going to migrate to that particular chemical.”

In response to legal crackdowns, sellers (or dealers) will reformulate not only the packaging and marketing slogans for K2, but compounds themselves, substituting formulas that ostensibly have not yet been banned by the DEA. Some local K2 users report that savvy users can still find cousins of K2 stocked in some businesses, despite a crackdown. Who can begin to guess the actual substance inside a crinkly packet of shredded material, which may have been laced with something or other? (Sales continue on the dark web, too—and, of course, on the street.) 

Another workaround for sellers has been to label products as “not for human consumption.” In fairness, that assertion often enough proves to be true. 

The Patient

I met Mark Eliason on January 4, in the burn clinic at HCMC. He had agreed to recount the events that led to his K2 overdose, as he dealt with the fallout of another emergency hospitalization during the week of Thanksgiving. Back in November, he had appeared barefoot in the vestibule at HCMC, having endured overnight temperatures of 19 degrees. Eliason is not homeless—he lives currently in an efficiency apartment in Stillwater—but he’d been using meth. A side effect of hypothermia is a sense of unbearable warmth, and so he’d started undressing. 

And now, six weeks later, he was back for a follow-up appointment to bandage up his fingers—or the ones he’s got left. He lost a middle finger to a fight almost 10 years ago and a few fingertips to frostbite in December 2014. 

“I’m a drug addict,” Eliason said. Leading up to the fingertip amputations, he was high on methamphetamine and hallucinating. He’d dug in the snow for hours with bare hands, looking for imaginary drugs.

Eliason traces his drug use to the day he discovered the “jingly, tingly high” he got from bingeing on his Ritalin prescription, starting at age 13.

Eliason’s medical chart, which he shared with me, indicates that he has used and sold drugs since he was a teenager. (He spent several years in prison.) He traces his drug use to the day he discovered the “jingly, tingly high” he got from bingeing on his Ritalin prescription, starting at age 13. K2 has never been his favorite drug. He prefers meth—“my poison of choice”—and marijuana comes in a distant second. 

But you take what you can get. Today, for instance, Eliason had just finished a prescription dose of Percocet to help endure the frostbite procedure, and he would leave the hospital with prescriptions for OxyContin and Gabapentin. (The latter alleviates pain for burn patients and seems especially helpful to people with the nerve pain associated with missing limbs.) 

Eliason’s account of the K2 outbreak may be most notable for sounding so routine. A lunchmate had offered him the fateful hit of K2. They’d been eating at Catholic Charities Opportunity Center on East 17th Street in south Minneapolis. This is a multipronged social service provider and also a way station for people who live on Social Security, EBT funds, and food stamps. From there, Eliason and his companion had wandered to a bus-stop bench on 11th Avenue.

“It looked like catnip,” Eliason said. “I took a deep hit on a roach and held it.” 

The effect jarred him. “I had smoked K2 before, but it had never been like that. I had to put my head down,” Eliason said. “I told the guy who rolled the joint I didn’t feel so good. He said it would pass.”

Instead, Eliason passed out. Cara Bigelow, a HEMS paramedic, picks up the account at this point. Her ambulance got the call “for one unconscious,” who turned out to be Eliason. She recognized her patient right away, having treated and transported him three times before. But his situation this time appeared different. 

“We arrived on scene to find Mark lying on the sidewalk,” Bigelow said.

Eliason was unable to answer questions. He couldn’t make eye contact and showed dried sputum around his mouth. 

“We asked repeatedly, ‘How are you?’” Bigelow recalled. Eliason’s repeated response? “I love you.”

She had transported almost a dozen K2 patients over a three-day span, all from the same neighborhood. “We were overwhelmed,” she said.

Notes kept by Bigelow’s fellow paramedic indicate that Eliason resisted their attention and tried to “kick, punch, and bite EMS repeatedly.” 

Eventually, Bigelow and her partner “logrolled” Eliason onto their canvas and then transferred him to the stretcher. Once in the ambulance, they placed him in hard restraints: handcuffs that secured each arm to the side of the ambulance cot.

“It was for his safety to restrain him,” Bigelow said. “We didn’t want to be injured as well.”

She added, “Every K2 patient can be so different, which is what makes it so hard. You find people behaving all sorts of different ways. When you respond to a call you don’t know which way it’s going to be—combative, or unconscious, having vomited. It’s all or nothing.”

Bigelow said that despite Eliason’s drug and alcohol troubles, she knew him as a “laid-back, kind gentleman.” He was delivered to the hospital at 12:26 pm.

While Eliason told me what happened next that October afternoon, the burn ward nurse removed soiled bandages and trimmed away black, flaking skin from his damaged fingers.

In the emergency department, nurses monitored Eliason until his mental status stabilized. He remained in the hospital for about four hours before being released under his own steam. He was given a cup of juice during his stay and an x-ray, because he has latent tuberculosis. But that was the extent of his treatment. Eliason took a bus back to a room he was renting. 

“K2ers like it,” Eliason said of the drug. Personally, he doesn’t care for the stuff.

---

The Police

After the K2 hospital runs in the fall, police in several jurisdictions made arrests. Local media covered the investigation, reflecting a kind of implicit hope that interdiction would break the frightening cycle of overdoses. One arrest followed a warrant served at a Brooklyn Center hotel, based on information from a trusted confidential police source. The individual named on the warrant was not charged, according to Hennepin County courts. 

Another arrest took place November 2, during a traffic stop in the same neighborhood as the Opportunity Center. This one involved a Minneapolis couple: Melisa Moe, 39, and Eric Renfro, 47. Officers reported that within Moe’s vehicle, they located 113.2 grams of suspected synthetic marijuana, as well as baggies and a digital scale. Renfro was driving at the time of the arrest. Officers searched Moe’s home and, according to the report, “located ripped baggies and wrappers containing what appeared to be K2 spice.” 

Both face two felony charges for illegal drug possession with intent to traffic. If convicted, they could each be facing 15 years in prison and $100,000 fines. (Neither Moe nor Renfro has entered a plea. Their respective public defenders declined to comment.)

I encountered Moe at a January court hearing, and she spoke to me briefly. Moe cleans houses for a living, she said, and the late start to the proceeding annoyed her. She had work to do, she said, while out on bail. And she, for one, had made it to court on time. 

She expressed great disdain for the police and the legal process. But on advice from her public defender, she declined to discuss the charges with me. She did, however, take my number.

Police have made few official comments regarding the general success of K2 policing. But the number of people presenting similar overdose symptoms tapered off to baseline by mid-October, with just a few cases a week, Dr. Cole said. Both policing and a better titration of 5F-ADB could explain the late-fall drop in hospitalizations, he said. But he couldn’t say for certain.

The Hospital

The ambulance teams see everything first. “It starts where the medics are talking about how they’re getting all these calls,” said Michael Trullinger, from Hennepin Emergency Medical Services. 

“For some patients, it seems there is an initial euphoria, but we don’t always know what the chemicals are in these drugs. Some people can hallucinate. Others become hypothermic, pass out, and even have psychotic episodes.” 

He added, “They could have high or low blood pressure and even seizures. It was all over the place. You just didn’t know what to expect when you picked people up.”

When responding to overdose emergencies, first responders often look to patient symptoms like these, explained Dr. Ann Arens, a toxicologist and emergency medicine physician at HCMC. “K2 patients can look like someone you were trying to wake up from a nap but can’t,” Dr. Arens said. “It doesn’t always last very long, but if someone is laying somewhere essentially unconscious, it can be very dangerous.”

“I had smoked K2 before, but it had never been like that. I had to put my head down. I told the guy who rolled the joint I didn’t feel so good.” –Mark Eliason

What needs to be added here is that the October explosion of K2 popped up against the backdrop of the state’s opioid epidemic—and the slow, steady drip of alcohol-poisoning cases. In 2017, HCMC saw 864 hospitalizations for opioids and 10,530 for alcohol intoxication. Indeed, on any given day, the emergency department at HCMC may be inundated with these calls. Breathalyzers identify alcohol problems. Police and hospital security will sometimes shuttle these patients to detox just blocks away, at 1800 Chicago Avenue. 

Opioid emergencies, now so familiar, can be recognized by testing vitals, blood pressure, pulse, temperature, and respiratory and heart rate. Opioids depress the central nervous system to the point that organs stop functioning. People stop breathing. The antidote here is naloxone (with the label name Narcan): a drug that blocks the effects of opioids.

In the current climate, when overdose spikes involve unknown compounds, first responders go on high alert. But after doctors have ruled out opioids, explained Dr. Arens, the HCMC toxicologist, no one knows exactly what they’re dealing with. 

“We know what happens with PCP, LSD, marijuana, amphetamines, cocaine, alcohol, and downers. We know how to identify and treat those patients,” Dr. Cole said. “But with synthetic drugs, we never know how long the slope will last or what the compounds will do. It’s a whole new world.” 

The public-health solution is a closed-loop communication network: a physician call center that serves Minnesota and the Dakotas, housed in a basement office of HCMC. Dr. Cole explained how it worked in October. “One of my partners literally sent a message that said, ‘Wow, we’re seeing a lot of K2 in the ED today.’ I heard from my emergency department and EMS colleagues—‘What is going on here? This is really different.’”

K2 overdoses are not new in Minnesota and not isolated events. As many as five cases a week could be considered a baseline in the Twin Cities. No K2 users died locally last year, according to Dr. Andrew Baker, Hennepin County’s chief medical examiner. But not for lack of trying. A previous spike hit Minneapolis in 2015. Another outbreak last spring in St. Paul struck the population near the former Dorothy Day Center, run by Catholic Charities. According to a street outreach worker, some of those users wandered into traffic on West Seventh Street, near the busy highway ramps around the Xcel Energy Center.

In October, some of the patients needed to be restrained to prevent injuries to first responders or to themselves. The users’ upset—even while they’re receiving helpful care—is not that surprising. “They’re disoriented, and they don’t know what’s going on,” Trullinger said. “They fight with their medics, they fight with police, other first responders, things like that. It’s just a very bizarre situation.”

When clinical presentations point to familiar substances like alcohol or THC, doctors can usually confirm a diagnosis with readily available lab tests. But identifying mystery substances requires significant lab time. In these instances, technicians need to break out the complete chemical makeup of random material samples.

A confirmed drug type usually comes long after patients have left the hospital, if at all. The poison center at HCMC would eventually get results through its participation in a new research consortium called PSCAN, or the Psychoactive Surveillance Consortium and Analysis Network. Started in 2016 with a toxicology lab in San Francisco, the initiative aims to study the explosion of synthetic drugs affecting patients across the country. 

Cole said PSCAN test results from four random samples, collected during Minneapolis’s K2 boom, revealed a synthetic cannabinoid that had never been seen before in the U.S. 

“It has been seen in Asia,” Cole said. And it was the likely culprit of the overdose surge. 

Kenneth Solek, from the DEA, also suspects the K2 most likely originated in China. But he—along with all the other experts—struggles to explain what made this dose unusual. Why the increased toxicity, the hospitalization, the street-level crisis? K2 doesn’t provide a lot of answers. 

The hope is that doctors will learn something from each case to bring to the next situation. Dr. Arens, for example, will present a paper on the Minneapolis outbreak and the newest permutation of K2 in Washington, D.C., at a medical toxicology science conference in April. An abstract of the article will follow in the Journal of Medical Toxicology.

What seems especially discouraging, looking back, is that when Dr. Arens reviewed the 100-plus hospital admissions tied to K2, she realized they involved only 49 patients. Several of the users overdosed once, rushed in to HCMC, returned home—and, days later, overdosed again, and possibly yet again. 

The Aftermath

As Mark Eliason finished up his visit to the burn ward, a nurse cleaned up his hands. It was his second visit of the day: He’d spoiled his morning bandages rescuing a cigarette he dropped in the dirty slush.

“Talk with that hand while I work on this one,” the nurse suggested, and they laughed about that. 

“I am done with this,” Eliason said of his struggles with drugs. “I’ve been trying to get there for a while now. It’s been two years. It’s been the most excruciating thing. It’s like I’m trying to leave a girlfriend.” 

That same week, Eliason was due to enter a voluntary drug rehabilitation program. 

Then, at the very end of January, I received a couple of text messages from an unfamiliar phone number. They contained cellphone videos shot near the Opportunity Center. The winter scenes show paramedics, ambulances, and people being treated on the street and loaded for transport to the hospital.

The messages, I realized then, came from Melisa Moe, the woman facing criminal charges for possessing synthetic cannabinoids (with the intent to traffic them) back in the fall. These new videos, she said, suggested that K2 outbreaks were going on without her. 

As a point of law, Moe’s video may not have proved anything. But then, during the two weeks surrounding the Super Bowl in Minneapolis, the Minnesota Poison Control System reported 82 cases of K2 illnesses. Last year, at the same time, the system counted just two.