Illicit Fentanyl the 'Third Wave' of US Opioid Crisis

Alicia Ault

March 22, 2017

A rise in trafficking and use of illicit fentanyl may constitute a "third wave" of the opioid epidemic in the United States, according to members of Congress and federal officials at a House hearing.

The House Energy and Commerce Committee's Oversight and Investigations Subcommittee held a hearing on March 21 to look into an increase in overdose deaths related to fentanyl and also an uptick in seizures of illicitly produced formulations of the drug, including analogues such as carfentanil, which is 100 times stronger than fentanyl.

"Now illicit fentanyl has become a potent additive to heroin, cocaine, or even counterfeit prescription drugs," said Subcommittee Chairman Tim Murphy (R-Pa). "This is the way the drug dealers increase profits, stretch out their supply, and expand the number of addicts, by juicing the potency of heroin or other street drugs," he said.

The number of opioid deaths attributable to synthetic opioids, which include fentanyl, increased 72% from 2014 to 2015 — from 5544 to 9581 — according to the Centers for Disease Control and Prevention (CDC).

Early data for 2016 suggest that overdose deaths continue to rise, Debra Houry, MD, the director of the CDC's National Center for Injury Prevention and Control, told the committee.

The deaths are likely underreported, given that many medical examiners do not have the resources to analyze for fentanyl or its analogues, said Dr Houry. Fentanyl overdose is hitting 25- to 44-year-olds and men the hardest, she said. Dr Houry added that she believes that fentanyl use is often associated with prior, often legal, opioid use.

The agency has assisted several states — including Massachusetts, Ohio, and Rhode Island — in examining a surge in fentanyl deaths and has found that in many cases, the deceased had an active opioid prescription, or had received one recently.

"People are getting exposed to opioids and going on to fuel their addiction through heroin and fentanyl," said Dr Houry.

The Ohio investigation found a 500% increase in fentanyl-involved deaths from 2013 to 2014 — from 84 to more than 526. The CDC and Ohio officials found that 62% of all persons who died from overdoses that involved fentanyl and heroin had been given at least one opioid prescription from a healthcare provider during the 7 years prior to death.

One in 10 who died from a heroin overdose and 1 in 5 who died from a fentanyl overdose had a prescription for an opioid medication at the time of their death.

China Prime Fentanyl Source

Individuals who misuse prescription opioids are at an increased risk for heroin use — and now, fentanyl use also, whether wittingly or unwittingly, through adulterated heroin or other drugs, said Dr Houry.

Wilson M. Compton, MD, deputy director of the National Institute on Drug Abuse (NIDA), told the committee that fentanyl was a particularly dangerous opioid because it can rapidly enter the brain, leading to a fast onset of effects.

"This high potency and rapid onset are likely to increase the risk for both addiction and overdose, as well as withdrawal symptoms," he said.

Emergency responders must use larger doses of naloxone to reverse the effects.

Officials from the Drug Enforcement Administration (DEA), the State Department, and Immigration and Custom Enforcement (ICE) all said that most of the illicit fentanyl in the United States came from China. Chinese laboratories produce the precursor chemicals or raw fentanyl and ship the products to illegal distribution networks in Canada, Mexico and the United States, they said.

Some of the illicit fentanyl — in raw or finished form — is walked across legal points of entry from Mexico to the United States, said an ICE official. Much of the illegal material is sent by regular postal mail or express delivery services. Users can also purchase illegal fentanyl online with little scrutiny, even in the United States.

Chinese manufacturers also ship pill presses — some capable of stamping out thousands of pills per hour ― to drug dealers seeking to make fentanyl formulations. The pill-making equipment has been shipped to Canada, Mexico, and the United States.

Assistant Secretary of State for International Narcotics and Law Enforcement Affairs William Brownfield told the panel that the United States is making some gains in working with China to curb the outflow of illicit fentanyl and its analogues. An agreement was hashed out at a United Nations meeting in March that would compel the signatories to increase monitoring of legal production and shipment, which Brownfield said would help law enforcement get a handle on illicit shipments.

Louis Milione, assistant administrator in the DEA's Diversion Control Division, told the House panel that the agency's National Forensic Laboratory Information System — which collects state and local analyses of drugs seized by law enforcement ― has registered a gigantic rise in fentanyl. In 2013, only 1041 samples tested positive for fentanyl; by 2016, almost 29,000 samples contained fentanyl.

Replacement ACA a Threat to Treatment

Republicans and Democrats agreed that fentanyl was a pressing concern that needed a combination of law enforcement and public health solutions. But Democrats also said the House Republicans' proposed replacement of the Affordable Care Act (ACA), known as the American Health Care Act (AHCA), would threaten access to treatment for those with an opioid use disorder.

"I'm concerned that if money is cut from Medicaid, which is what the [Congressional Budget Office] said could happen with the Republican bill, patients could lose access to care, and this could make the fentanyl problem even worse," said Rep. Frank Pallone (D-NJ). He asked NIDA's Dr Compton what could happen if a patient's care was interrupted.

"We do know that when treatment is interrupted or stopped, whether that's intentional or unintentional, the risk of relapse is extraordinary," said Dr Compton.

"Medicaid has been absolutely vital to address substance abuse and providing access to treatment" in Illinois, said Rep. Janice Schakowsky (D-Ill). Of the 650,000 low-income adults who have received coverage through the ACA Medicaid expansion in her state, a third have mental health or substance use disorders, she said. "Without Medicaid, these individuals would be more likely to end up in emergency rooms or jails, which would drive up costs for state and local budgets," said Schakowsky.

"Trumpcare would eviscerate treatment for individuals struggling with addiction by ending the Medicaid expansion, repealing guarantees of mental health and substance use benefits, and gutting Medicaid to the tune of $880 billion over the next 10 years alone," said Rep. Paul Tonko (D-NY). He said that Medicaid paid for 38% of medication-assisted treatment in the state of New York.

But Subcommittee Vice Chairman Morgan Griffith (R-Va) said Democrats were out of line. "I think we're comparing apples and oranges when we try to bring in fentanyl and the opioid abuse into the debate over whether you want Obamacare, Medicaid expansion, or the American Health Care Act," he said.

He stated that it was incorrect to say that the ACA had helped to solve the opioid problem, saying that Medicaid expansion states had more overdose deaths than those that had not expanded. Griffith said the calculation was likely meaningless, but that the ACA had not caused nor ended the opioid epidemic.

Similarly, said Griffith, Democrats' statements that voting for the AHCA would make the problem worse "is irrelevant to our discussion today."

The same day, a group of more than 400 healthcare organizations, the Coalition to Stop Opioid Overdose, sent a letter to Congress alleging that the AHCA would hurt millions of Americans with mental illness and substance use disorders. The coalition includes the American Academy of Pediatrics, the American Nurses Association, the American Public Health Association, the American Psychiatric Association, the American Society of Addiction Medicine, the National Alliance on Mental Illness, the National Association of Social Workers, and the Partnership for Drug Free Kids.

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