Rx Summit: Fentanyl overdoses outpace heroin

One of the most useful early predictors of fentanyl overdose deaths is the rate of fentanyl confiscations by law enforcement, according to epidemiologists speaking at the National Rx Drug Abuse & Heroin Summit in Atlanta this week. The fast-growing overdose problem attributed to illicit fentanyl in some areas is outpacing heroin and prescription opioids.

It’s important to exchange information with the harm reduction community to find out what users are observing and to warn them about fentanyl. Often, suppliers themselves don’t even know that fentanyl—a substance that is stronger and more deadly in many cases than heroin—is what they are selling. They believe it’s heroin, and so do their buyers.

The presenters were all researchers: R. Matthew Gladden, PhD, a behavioral scientist with the Division of Unintentional Injury Prevention at the Centers for Disease Control and Prevention (CDC); John Halpin, MD, MPH, medical officer with the same division at CDC; and Traci Green, PhD, associate professor of emergency medicine and associate professor of epidemiology at Brown University in Providence, Rhode Island.

Follow the seizures

The researchers showed how clearly fentanyl overdoses are aligned with law enforcement seizures, or confiscations, of the drug.

In terms of urgency, there have been two recent surges of fentanyl overdoses and related seizures, said Gladden: one time period at the end of 2013 to beginning of 2014, and one at the end of 2014 to the beginning of 2015. Notably, 80% of fentanyl seizures are concentrated in 10 states east of the Mississippi, he said.

Gladden also cited the toxicology testing that is reported to the Drug Enforcement Administration’s National Forensic Laboratory Information System (NFLIS). In particular, Ohio, Pennsylvania, Kentucky, Massachusetts and New Hampshire had high rates of seizures and overdoses. The overdose data in terms of cause of death comes from medical examiners and coroners, and that data usually takes a lot longer to come through. So it’s essential to look at the seizure data, which is available earlier, to better prepare for an outbreak.

There are limitations. Not all jurisdictions test for fentanyl, and it’s difficult to distinguish between illicit fentanyl and pharmaceutical fentanyl. It’s also difficult to test for different fentanyl analogs. But the concept of using seizure toxicology results is important to saving lives.

Law enforcement should do rapid testing of evidence from drug overdose scenes, said Gladden. And when medical examiners and coroners see an increase in fentanyl seizures in their area, they should start testing for it, he said.

Because fentanyl is so strong—it can kill in minutes—multiple doses of naloxone might be needed in order to reverse an overdose, the epidemiologists said. This is important for first responders as well as friends and family members of users.

The Ohio story

In September 2015, the Ohio department of health issued an alert throughout the state noting a dramatic rise in fentanyl-related overdose deaths. The number had risen from 84 in 2013 to 502 in 2014—a 500% increase in one year.

Halpin’s group used quantitative data (vital statistics, medical examiner reports, the state’s prescription drug monitoring program, emergency room triage and chief complaint data, and emergency response data) as well as qualitative data (from coroners, harm reduction groups, state and local public health, treatment providers, and the state’s Office of Substance Abuse Monitoring, which conducts interviews with drug users and treatment professionals).

The curves on the state graph demonstrated the link between seizures and overdose deaths, just as they did on the federal graph.

“The rise in fentanyl confiscation mirrors fentanyl-related deaths,” said Halpin. “You get seizure data many months before you get death data, so seizure data could serve as an early warning system.”

In 40% of the fentanyl overdose deaths, naloxone was administered. However, when it wasn’t used, it was often because the victim was already deceased by the time first responders arrived. The increased potency of fentanyl in most cases required at least two and sometimes up to six doses of naloxone for a rescue, said Halpin.

Everyone thinks it’s heroin

Sources of illicit fentanyl include Mexico, India and China, according to drug enforcement sources. In many cases heroin cut with fentanyl is marketed as pure heroin. Green, the epidemiologist from Rhode Island, delivered a compassionate presentation in which she portrayed the importance of user perspectives.

“People don’t want fentanyl. They know it’s deadly,” she said.

When even the sellers don’t know if fentanyl is present, the users have to guess, by looking at the color of the substance. But many are in withdrawal and take the chance.

Now 50% of the overdoses in Rhode Island are fentanyl-involved, and 80% are illicit-opioid involved.

The solution in Rhode Island has been based on evidence: the first initiative is a focus on treatment with methadone, buprenorphine and naltrexone, said Green. There is also an effort to increase the number of physicians who can prescribe buprenorphine, and there is an education initiative to encourage safer prescribing of benzodiazepines.