The increasing distribution of illicitly manufactured fentanyl (IMF) across the United States, and the sharp rise in overdose deaths linked to this drug, are causing more concern about a growing threat to public health and safety.
According to a report published online August 25 in Morbidity and Mortality Weekly Report (MMWR), the number of drug products obtained by law enforcement that tested positive for fentanyl (fentanyl submissions) increased by 426% from 2013 through 2014. Deaths related to synthetic opioids (excluding methadone) increased by 79% during that period.
“An urgent, collaborative public health and law enforcement response is needed to address the increasing problem of IMF and fentanyl deaths,” said the report’s authors, led by R. Matthew Gladden, PhD, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC).
Pharmaceutical fentanyl, a synthetic opioid 50 to 100 times more potent than morphine, is approved for the management of surgical/postoperative pain, severe chronic pain, and breakthrough cancer pain. IMF, which is unlawfully produced fentanyl obtained through illicit drug markets, is commonly mixed with or sold as white powder heroin.
Starting in 2013, the production and distribution of IMF increased to unprecedented levels. In 2015, the Drug Enforcement Administration (DEA) and the CDC issued nationwide alerts identifying increases in fentanyl-related overdose deaths in multiple states.
The current report documents changes in synthetic opioid–related overdose deaths among 27 states where death certificates consistently report drugs involved in overdoses. These changes were highly correlated with fentanyl submissions, but not with fentanyl prescribing, which remained relatively stable.
The report identified eight states where increases in fentanyl submissions and synthetic opioid deaths were primarily concentrated. In these “high-burden” states, the synthetic opioid crude death rate increased 174%, and the rate of reported fentanyl submissions increased by 1000%.
These high-burden states were located in the Northeast (Massachusetts, Maine, and New Hampshire), the Midwest (Ohio), and the South (Florida, Kentucky, Maryland, and North Carolina). Increases in synthetic opioid deaths in high-burden states disproportionately involved non-Hispanic white men aged 25 to 44 years.
The strong correlation between increases in fentanyl submissions, primarily driven by IMF, increases in synthetic opioid deaths, mostly related to fentanyl, and uncorrelated stable fentanyl prescriptions rates supports the hypothesis that IMF is driving the increases in fentanyl deaths, according to the report’s authors.
“The high potency of fentanyl and the possibility of rapid death after fentanyl administration, coupled with the extremely sharp 1-year increase in fentanyl deaths in high-burden states, highlights the need to understand the factors driving this increase,” the authors write.
The authors note a number of limitations to their findings. One is that because synthetic opioid deaths include those involving drugs other than fentanyl, the absolute number of synthetic opioid deaths should be considered “a proxy” for the number of fentanyl deaths.
Also, whereas drug submissions vary over time and from region to region, the findings are restricted to 27 states, and testing for fentanyl deaths might vary across jurisdictions.