Cincinnati’s Fentanyl Crisis: An In-Depth Interview with Dr. Sammarco, Hamilton County Coroner

Dr. Lakshmi Kode Sammarco is the Hamilton County Coroner and a board certified neuroradiologist. She founded and runs NeuroRadPro LLC, which provides specialized consulting services in neuroradiology. Dr. Sammarco earned her BA from the University of Cincinnati College of Engineering and her Medical Degree from the University of Cincinnati College of Medicine. She served her residency in Diagnostic Radiology at Case Western Reserve University and completed a fellowship in Neuroradiology at UCLA.

In 2016, Dr. Sammarco was selected by the Cincinnati YWCA as Career Woman of Achievement honoree. In presenting the honor, the group noted: "[All her] firsts pale in comparison to the dramatic improvements she has made in the Coroner’s Office since her appointment and to her unceasing support of law enforcement, crime victims, and family members whose loved ones’ deaths she must investigate [….]. Described by colleagues as ‘a public servant who makes citizens believe in government again,’ Sammarco is credited with improving the facilities, technology, laboratory, and reputation of the coroner’s office, as well as increasing the number and responsibilities of women who serve as physicians and scientists in its crime lab [...]. Dr. Sammarco has brought the work of the Coroner’s office to the people, speaking across the county from senior citizens’ centers to the Duke Energy Center. She has made it a personal crusade to reach the children of this county in their schools on the need to avoid drugs, to stand up against bullying and abuse. Day and night, this public servant serves us.”

In February 2024, the Smith Research Fellows (SRF) interviewed Dr. Sammarco on the scope of the fentanyl crisis in Cincinnati. She also shared with us her experiences as Hamilton County Coroner and her work with the Hamilton County Heroin Task Force.

SRF: YOU ARE ONE OF THE LEADERS IN THE HAMILTON COUNTY HEROIN COALITION TASK FORCE, HOW WAS IT CREATED?

Dr. Sammarco: Back in 2016, the Hamilton County Chief of Police had a meeting where we talked about the increased numbers in drug overdoses and what law enforcement was encountering on a regular basis. At that time, they didn't have Narcan. So, they would call EMS, and they would have to wait. They also were not educated in dealing with the drug crisis and emergencies. At that time, we were getting a flood of drug-emergency phone calls and our emergency rooms were being overrun with overdoses. No one was prepared to handle this.  So, we formed the Hamilton County Heroin Coalition Task Force. We called it heroin at the time because, up until about 2014-15, that's what we were primarily seeing— not fentanyl. The Task Force was formed with jurisdictions over Hamilton County over suspected overdose deaths. The Task Force would operate by going to a death scene where they would find the cell phones and other information at the scene, and then work backwards, trying to figure out who sold the drugs. We began to work as a team with the Feds and the US Attorney’s Office.

SRF: HOW MANY HEROIN DEATHS A YEAR WERE THERE IN HAMILTON COUNTY WHEN THE TASK FORCE WAS FORMED?

Dr. Sammarco: If I had to break it down (I'd have to go look it up), it probably maxed out at around 200 in 2015. And then we really started seeing a big influx of fentanyl; so, we called in the Heroin Task Force—really an opioid task force. Think about it: the task force was started by law enforcement and not the commissioners of treatment centers. We were just seeing this massive shift. So, it started with law enforcement alerting everybody to this crisis for the first time. We also were being informed by Cuyahoga County, that they were seeing a big increase in fentanyl, as well an increase in overdose deaths.  In Cuyahoga County, they were looking into doing what we did with the Heroin Coalition.

SRF: WHAT ARE SOME OF THE OTHER ACTVITIES OF THE HAMILTON COUNTY TASK FORCE?

Dr. Sammarco: We formed a quick response team, a QRT, where we worked with social workers. When there was an overdose death, they would talk to the family members and see if they could find others that they could help. They would also go to the homes of those who had overdosed in hospitals to try to get them help and encourage them to get into treatment. So, we expanded the reach of the QRTs in the area.  

SRF: I REMEMBER A COUPLE OF YEARS, THERE WERE A LOT OF HIGH-PROFILE MONEY LAUNDERING CASES DOWNTOWN. IS THAT TRUE?

Dr. Sammarco: There was a big bust in Cincinnati a few years ago with 23 warrants issued. The DEA, FBI, and local law enforcement agencies were involved. They caught 21 of these guys.  I remember a call from the US Attorney at 11:45, asking me for a favor: “Doctor, we apprehended 21 of these guys, but not the two ringleaders. We're trying to get them. We seized a bunch of drugs, and I need your office to confirm it’s purity.” Under federal jurisdiction, when the purity of the cocaine, heroin, or fentanyl is above a certain level, it carries twice the sentence—instead of 20 years, we're talking 40 years in the federal penitentiary. So, if we could get that result of the drug’s purity to him quickly, the Fed would be able to pressure the ones being held in custody. I told the US Attorney that somebody would be in the office at 6 AM; so, “have your guys bring it over and we'll process the drugs as quickly as we can […]. I said, no guarantees, but we'll do the best we can.”  We just set aside regular bench work, worked on that, and got them resolved by noon. It had an impact.

SRF: SO, IT'S A COMMUNITY-WIDE EFFORT, NOT JUST LAW ENFORCEMENT.

Dr. Sammarco: Absolutely. It's a three-pronged approach: prevention, enforcement, and treatment.  If you don't address all of the aspects of these three pillars at the same time, you'll just be playing catch up. If you spend all of your time on prevention and don't help with the enforcement, then the dealers are still going to be here. You also have to do it in such a way that people are not afraid of law enforcement.  The tone of our messages is intended to get them to reflect:

• “Look, we're just here to help. You're not going get arrested.”

• “Come in, exchange your needles”  

• “Let us talk to you about what programs there are out there. You don't want to live like this.”

• “You don't want to be this person for the rest of your life.”

• “Is this the way you want your family to see you?”

• “Do you want your family to remember you this way?”

• “Is this the picture that you want as their last memory of you?”

SRF: ON THE PREVENTION QUESTION, ONE OF THE SPEAKERS AT XAVIER’S FENTANYL FORUM SAID THAT THERE IS NO MORE RECREATIONAL DRUG USE BECAUSE EVERYTHING IS LACED. IS THAT ACTUALLY TRUE? 

Dr. Sammarco: In our toxicology section, we have seen seized marijuana mixed with other substances. In our investigations of motor vehicle deaths and DUI cases, we have also seen which marijuana in their blood that is mixed with other drugs. I will tell you that last year we were looking at overdose deaths and found 42 percent of the deaths involving fentanyl also had a compound called Xylazine in it.

SRF: WHAT DOES THAT DO? DOES IT ENHANCE THE OPIOID OR SOMETHING?

Dr. Sammarco: It does. It's actually a veterinary drug. It's an alpha-adrenergic agonist, and it basically enhances the effects of fentanyl. So, it takes less fentanyl to cause respiratory depression.  We're seeing more of it being cut into the street drugs.  Do you know why? Because it's cheap. Dealers can mix it in with the fentanyl, making it go a lot longer. They can sell it to more people.

SRF: WHAT IS YOUR POSITION ON LEGALIZATION OF MARIJUANA?

Dr. Sammarco: Very disturbing. I was a hundred percent against Issue 2. Legalizing marijuana, has been disastrous for Colorado.  How are you going to regulate marijuana if you can't even properly regulate alcohol?  The point is that if you let that horse out of the gate, it's never coming back.  And it is definitely a gateway drug. In Canada, they did a long-term study of 3,300 plus students. They tested students from middle school through high school and found that students who smoked or used some form of marijuana on a regular basis scored significantly lower academically than those who did not. We know that it definitely affects your brain cells, as does alcohol and other street drugs. The fact that it impairs your judgment and you're more likely to try something more dangerous, puts other people at risk. We don't want these people out on the streets; we have too many wrong-way deaths on the highways as it is. How are we going to deal with the THC?  Unlike a standard impairment number for alcohol (0.08), there is no standard THC number where one is considered impaired. So, how are you going to regulate that? 

SRF: IN THE CASE OF FENTANYL, IS THE ADDICT JUST LOOKING FOR SOMETHING MORE INTENSE? WHAT IS IT? WHAT IS THE EFFECT OF THESE DRUGS THAT USERS ARE SO WILLING TO THROW AWAY THEIR LIFE? 

Dr. Sammarco: If you talk to addicts, they will tell you that the sense of euphoria that they get is like nothing they've experienced before in their lives. They say that once you experience it, you just want more of it. So, when they come off the drugs, they tell us that the crash is a horrible feeling that you never want experience. So, they will do anything to get back that euphoria.

SRF: WHAT DOES THE WITHDRAWAL FEEL LIKE TO THOSE WHO HAVE NEVER USED FNETANYL?

Dr. Sammarco: It's painful. It is shakes and chills—just an overall horrible feeling. Like, the worst case of the flu; in fact, I've heard an addict describe it as the “worst flu-like feeling he'd ever had in his life.” They can't stop shaking; they can't stop their teeth from chattering. Their whole-body aches and their skin hurts. So, withdrawal is really bad. They will do whatever they can to not feel that way again.

SRF: HOW IMPORTANT IS NARCAN?

Dr. Sammarco: That's a great question. One of the things that the Heroin Coalition Task Force did was encourage law enforcement to seek outside help when they encounter overdose cases. They had nothing to treat them. They had nothing to address the crisis situation that was happening. So, we made a push to try and get nasal Narcan out there.

SRF: YOU WERE TALKING ABOUT THE PUSH TO MAKE NARCAN MORE READILY AVAILABLE. NOW THAT YOU CAN BUY IT AT WALGREENS AND CVS, HAS THAT HELPED?

Dr. Sammarco:  Absolutely. In fact, for a long time, we had grant money that we used to hand it out free. We were trying to get it into the hands of family members of addicts, as well as these quick response teams. I think that made a big difference.

SRF: THE POLICE AT THE XAVIER FENTANYL FORUM WERE COMPLAINING THAT AFTER YOU REVIVE AN OVERDOSE ADDICT WITH NARCAN, THEY QUICKLY GO BACK TO USING THE DRUG— IN FACT, THEY GO BACK TO IT MORE INTENSELY.  SO, DOES NARCAN SOLVE THE PROBLEM.

Dr. Sammarco: Yes and no. We know that Narcan has saved a lot of lives, especially if we get it in the hands of family members and fellow addicts. We know of drug parties where they make one person stay sober so that if any of them do overdose, they can give them Narcan. So, we know that it really does save lives. I think that Narcan in the hands of more people has definitely saved lives. On the other hand, one of the Corinne firefighters told me that he had administered Narcan six times to the same man in a 24-hour period. I know that he was very frustrated.

SRF: WHAT IS AN ADDICTIVE PERSONALITY?

Dr. Sammarco: It is a genetic prevalence for addiction. It's a real disease, where some people's receptors are stronger than others to opiates, drugs, and alcohol. Some people are addicted immediately. Their body depends on it—an immediate chemical reaction. Others can take an addicting substance five, ten, and even a hundred times and still not be addicted. Everybody is different and everybody's receptors are different. Even when the receptors are the same for two people, circumstances can differ. Some people are looking for a crutch, while others are strong. If you're bemoaning the fact that you flunked an exam, you're going to be more vulnerable to try and find an out with drugs that can make you forget your hardship for a short period of time—even though you know that it's not going away and your brain is telling you this is a really stupid thing to do; yet you still do it. Fortunately, there is some destigmatizing of addiction in society. The terminology of junkie has disappeared.

SRF: I GUESS THAT GETS US TO A BROADER QUESTION OF HOW, ESPECIALLY AS THE CORONER, YOU KEEP YOUR COMPASSION.  WHAT STOPS YOU FROM JUST GIVING UP, FROM JUST SAYING THERE'S NO SAVING THEM, THAT THEY'RE ACTING IN SELF-DESTRUCTIVE WAYS, THAT I JUST DON'T CARE. 

Dr. Sammarco: You know, it goes back to remembering that medicine is a calling. I would say the vast majority of my colleagues went into the field because they truly believe that we're here to help people. I believe judging people impairs our ability to help them. Everybody has their strengths and weaknesses. It may not be your weakness; it may not be something you can understand. I mean, I would never touch x, y, and z, but other people may look at some of my weaknesses and say: “well, I would never do that.” I think you have to remember that we're all human. We all have weaknesses. We all have moments of strength, as well as times of weakness and vulnerability. So, we do what we can for our fellow mankind.

I will tell you that the hardest thing for me to watch and where I find it difficult to feel compassion is when a child is hurt or when they are left behind as orphans—opioid orphans.  So, it's hard for me to look at the parents and feel compassion for them because of what they did to these kids, knowing that these kids are going into foster care system, not experiencing any family love, knowing that they were abused, and now are wards of the state. This is really hard.

I remember one case of parents in Madisonville. In their apartment, there was not one horizontal surface that wasn't covered in dirty dishes. Their three-year old little girl, seven-year old boy, and 11-month old baby boy were at a neighbor's house while the parents did their drugs. The poor children came home to find the parents on the floor in their living room overdosed. With an 11-month-old on his hip and a three-year-old holding his hand, the seven-year-old had to make the 911 phone call with his mom and dad dead on the floor. That's a trauma one is never going to recover from. When we investigated this case, we found there wasn't anything in the refrigerator that one could possibly eat; the food was gross, rotted, and moldy—I don't know what they were eating. Looking at that, I thought: “and now you've got three orphans under the age of eight.”  You ask: “What will happen to these kids? Who is going to raise them?” You think about the seven- year old who has spent most of his life watching his parents doing drugs.  So, it is difficult to feel compassion for the ones that are on drugs that abuse their kids.

SRF:  YOU'RE ON THE FRONT LINE. YOU'RE SEEING THINGS THAT THE AVERAGE PERSON NEVER SEES.

Dr. Sammarco: Yes, that is true. You know, Ohio has one of the highest infant mortality rates in the country. Many of them are co-sleeping deaths where people are sleeping with their infants while they are passed out from drugs or alcohol. Without knowing, they then rollover on a small child; they don't wake up to the child’s screams.  I'm sorry, but it's hard for me to feel compassion for them when the child suffers. We had a little seven-month old little boy who was burned to death because mom went to work and left the baby with dad. Dad was high on something, and passed out while the baby rolled off and got stuck between the radiator and the bed.  And I can't even imagine how much that baby must have screamed. And dad didn’t wake up.

SRF: WHAT ABOUT BABIES BORN FROM MOMS WHO USE OPIODS?

Dr. Sammarco: The babies of addicts are addicted to the opioids when they are born—the babies are born addicts. They have a different kind of a cry. They are restless and you can't soothe them. It takes a long time to get them off of that. Ninety percent of those babies have ophthalmological abnormalities if they're born of true addicts. So, then they need some special types of surgery for their eyes.  It's a very difficult thing to handle those newborns, and a lot of them are prematurely born. They come with a whole set of medical issues. The horrifying effects that drugs use by pregnant women has on their unborn babies is another sad dimension of the drug crisis.

Related to your question are the cases of fentanyl and other drug deaths of children due to accidental overdoses. We have had several cases where children have wondered into a parent’s cache of drugs, overdosed, and died. The youngest that I remember was only 14-months old. He just happened to find the stuff.  Whether it's pills or powder, these babies don't know what it is. I mean, it looks like a sweet tart for some of them. Then it's too late.

SRF: WHAT ABOUT CASES WHERE PEOPLE GO TO A BAR AND HAVE A DRINK THAT HAS BEEN LACED?

Dr. Sammarco: It happens, but most of the time the laced drinks in the bars are things to immobilize somebody or make them lose their faculties so that they can be taken advantage of. So, we've had date-rape cases like that. The date-rape drugs we're seeing are not laced with fentanyl. The most common date-rape drugs are Rohypnol, ketamine, and gamma hydroxybutyric acid. When I talk to high schools, I often tell them that the most common date-rape drug is alcohol. Students go into these alcohol binges, getting totally drunk. We had a few cases with alcohol toxicity in which the students were flown here to University Hospital or Children's Hospital. 

SRF: WE’VE HEARD FROM FELLOW XAVIER STUDENTS WHO ARE ACTIVE IN CAMPAIGNS IN HAMILTON COUNTY, THAT REPUBLICANS NEVER WANT TO RUN ANYONE SERIOUS AGAINST YOU BECAUSE THEY WANT YOU TO REMAIN THE CORONER. HOW DID YOU MANAGE TO ACHIEVES SUCH A REPUTATION IN SUCH POLARIZED TIMES?  

Dr. Sammarco: I'm not sure I went about actively seeking to do that. Most of my life I have avoided politics like the plague. I mean you can't get away with it if you're working in a hospital. Politics is part of life there.  I was a registered Republican for 30 years, and then became a Democrat to run for Coroner. In fact, the Democratic Party’s nominating committee asked me if I considered myself a Democrat?  I said: “When I introduce myself, I don't say, hey, I'm Lakshmi Sammarco, a Democrat. I don't do that.” I said that “somewhere down the line, I may say that I'm a coroner, Dr. Sammarco, physician, mother, wife, and daughter. I'm all these other things before I even think about my political orientation.” I believe that one of the problems with this country is that we're so polarized and so worried about what team you're playing on instead of what's the right thing to do or what our community needs.

In running for Coroner, I literally was not seeking a political position. You know, I was a neuroradiologist, making a good living. When the previous Coroner—a Democratic—died suddenly, the party asked me if I would consider it. My first reaction was: “What? Me? Corner? No. I don't think so!” But then my husband told me that I should at least think about it because the previous Coroner was an old family friend. Like me, he was Indian.  I had known him since I was six-years old. I remember when he took the position as Coroner, he said that we were professors, professionals, engineers, and physicians, but we needed to be more involved with our community. I guess that I agreed to succeed him as a good way to honor his memory. So, I told the Party that I will do it temporarily until they find somebody else. As a radiologist, I had a business and patients to care for. So, that's how it started. In the beginning, I had no idea what I was supposed to do. I mean, honestly, I was just supposed to be a place card holder. I remember my kids, who were nine and 12 at the time, telling me: “Mom you better start watching “Bones” so you can figure out what you're supposed to do!”  I also remember how horrible the old Coroner’s building was when I first arrived.

SRF: WHAT DO YOU REMEMBER ABOUT THE OLD CORONER’S OFFICE?

Dr. Sammarco: No windows! It was very cramped with many people working in small areas. We didn't even have enough electricity. In the DNA section, we had to unplug one machine to plug in another, and then move the specimens. It was just ridiculous. I remember thinking: “How did we pass OSHA?” I thought, “why don’t we have a new building?” So, I began to think this is something I could advocate for. At first, I didn't really understand, like most of the public, how important the crime lab was for all of our safety—that it was the linchpin for processing evidence quickly, helping law enforcement, and facilitating the coroner investigation. To promote the building of a new Coroner’s office, I invited the media to take a look for themselves at our facilities. I told them that “this is your office—you're the taxpayers—do you think this is adequate?”  I think I shocked a lot of people about the conditions.  Whether they were Republicans or Democrats, I gave them both hell.  When they would say something stupid, I told them they had no idea what they were talking about.  I told them to spend one day viewing death scenes, experiencing, like us, the impact of fentanyl, the violence in the community, and the guns in the hands of 11-year old kids shooting at each other across the street. Anyway, I decided to stay and make a difference. But as far as the political aspect of it, like I said, I didn't dwell on that. I try and do what's right.

SRF: THE CORONER’S OFFICE TRULY TRANSCENDS POLITICS.  

Dr. Sammarco: Yes! This is our community.  What our office sees is a reflection of what's going wrong. And it's hard to ignore that. Especially if you feel like you can make a difference. There have been people that have asked me: “Why don't you run for a state office? Why don't you go to Columbus? Why don't you go to DC?” I tell them that I really don't feel like I could achieve anything at those levels. It's just such a quagmire of politics. I would add that you would find my body under an overpass in DC because I wouldn't keep my mouth shut.  So, I'm trying to do what I can in my community. If there was one position that I would want in DC, it would be Surgeon General. It’s a voice that's not being heard when it comes to serious issues like drug use.  The last Surgeon General most of us that are my age remember is C. Everett Koop. He made a big deal about fetal alcohol syndrome caused from women drinking and smoking. When was the last time you remember any other Surgeon Generals speaking out?  Since the eighties, Surgeon Generals have been silent. Why isn't the current Surgeon General out in front of the fentanyl and drug crisis? Why isn't he making this a big deal for the entire country, asking every single city to pay attention. Why isn’t he explaining that it is also the root cause of a lot of the gun violence and gang activities?  

SRF: IN STUDYING THE FENTANYL CRISIS, WE KNOW ABOUT THE MEXICAN CARTELS AND THE DISTRIBUTION OF CHINESE CHEMICALS, THE DESTRUCTION OF COMMUNITIES, THE IMMIGRATION PROBLEM, GANG ACTIVITIES, AND KIDNAPPINGS. IN CLOSING, WHAT ARE YOUR THOUGHTS ABOUT THE DIMINSIONS OF THE FENTANYL CRISIS? 

Dr. Sammarco: We now have had several years of hundred-thousand overdose deaths, gun violence on the corners, and turf wars over selling the drugs. As you say, there are many dimensions to the drug crisis. It’s also not just China and Mexico. India has actually become a big player. China transports fentanyl precursor to different labs in India where there is an extensive coastline. Some Indian nationals smuggle it into Canada where there is an ever more open border than our southern one. So, it's a lucrative global business and that's why more and more people are getting into it.

In the final analysis, I suppose the crisis shows the lack of respect for life that we are seeing in our communities. Whether it's addiction, gun violence, or an 11-year old picking up a gun and shooting at somebody else, the common denominator is the lack of respect. How can those affected possibly understand what the ramifications are if we don't start teaching them?  Our communities must come together.

SRF: VERY POWERFUL. WE APPRECIATE THE TIME YOU'VE TAKEN TO SPEAK WITH US ABOUT THE FENTANYL CRISIS. PLEASE LET US KNOW HOW WE CAN HELP YOU BECOME SURGEON GENERAL.