Synthetic Opioids Now Most Common Drugs in Overdose Deaths

Batya Swift Yasgur, MA, LSW

May 01, 2018

Synthetic opioids have surpassed prescription opioids as the most common drug class involved in overdose deaths in the United States, especially when combined with other prescription or illicit drugs, new research shows.

Investigators used data from the National Vital Statistics System to analyze drug-related overdose deaths from 2010 to 2016.

They found that synthetic opioids were responsible for the largest number of opioid-related related overdose deaths in 2016, followed by prescription opioids and heroin.

Moreover, the percentage of opioid-related deaths in which synthetic opioids were involveed roughly tripled during that time. Most deaths involved another drug or alcohol.

"What was novel about our study is that it looked at the interplay between synthetic opioids and other psychoactive drugs, such as benzodiazepines, and other substances, such as cocaine and alcohol, not only at opioids," lead author Christopher Jones, PharmD, MPH, director, National Mental Health and Substance Use Policy Laboratory at the Substance Abuse and Mental Health Services Administration, Rockville, Maryland, told Medscape Medical News.

"We need to increase awareness among the public and high-risk populations that the illicit drug supply is increasingly being contaminated with highly potent, very toxic synthetic opioids," he said.

The study was published online May 1 in JAMA.

National Data

"Prescription opioids have been the most common drug involved in overdose deaths, but heroin and synthetic opioids (primarily illicit fentanyl) are increasingly implicated in overdoses," the authors write.

Moreover, "synthetic opioids are increasingly found in illicit drug supplies of heroin, cocaine, methamphetamine, and counterfeit pills," they continue.

Implementing effective clinical and public health strategies has been "limited" because "the involvement of synthetic opioids in overdose deaths involving other drugs is not well characterized."

"We certainly had been seeing risks in synthetic opioid-related deaths, and it was very concerning to see the proportion of deaths involving nonopioid drugs that also involved synthetic opioids," Jones recounted.

He explained that the term "synthetic drugs" primarily refers to fentanyl or analogues of fentanyl (eg, acetylfentanyl, furanylfentanyl, and carfentanil, which are not approved for human use). Illicitly manufactured fentanyl is 50 to 100 times more potent than morphine.

Previous studies, including studies by the Centers for Disease Control conducted in selected states, have documented an increase in overdose deaths from synthetic opioids.

The current study utilized data from the National Vital Statistic System, which includes information on all deaths throughout the United States, he said.

Drug overdose deaths were classified according to International Classification of Diseases, Tenth Revision codes T40.0 - T40.4 and T40.6

Included in the analysis were prescription opioids (natural/semisynthetic opioids and methadone), heroin, synthetic opioids excluding methadone, cocaine, psychostimulants with abuse potential, benzodiazepines, antidepressants, antipsychotics and neuroleptics, barbiturates, other illicit drugs (cannabis, lysergic acid diethylamide, and other hallucinogens), and alcohol.

The researchers calculated the number of synthetic opioid-involved overdose deaths by year from 2010 through 2016 overall, as well as the number and percentage of overdose deaths involving both synthetic opioids and psychotherapeutic or illicit drugs.

Make Naloxone Available

The researchers found that 19,413 (49.5%) of the 42,249 opioid-related overdose deaths in 2016 involved synthetic opioids, up from 877 of 3007 opioid-related deaths (14.3%) in 2010 (P < .01).

The percentage rose steadily from 2014 to 2016, with the sharpest spike from 2015 to 2016 (from 29.0% to 45.9%; P < .01).

Of the 17,087 prescription-opioid related deaths in 2016, 4055 (23.7%) also involved synthetic opioids, in contrast to 64% of 939 deaths in 2010. In 2015, the percentage was 10.0% of 1489 prescription opioid-related deaths (for both, P < .01)

The researchers also found significant increases in synthetic opioid involvement in all other illicit or psychotherapeutic drugs from 2010 through 2016.

For example, among synthetic opioid–related overdose deaths in 2016,

79.7% involved another drug or alcohol; the most common substances were another opioid (47.9%), followed by heroin (29.8%), cocaine (21.6%), prescription opioids (20.9%), benzodiazepines (17.0%), alcohol (11.1%), psychostimulants (5.4%), and antidepressants (5.2%).

Overdose deaths from synthetic involvement with benzodiazepines rose from 11.5% in 2010 to 31.0% in 2016.

"Benzodiazepines have long been associated with an increase in overdose risk in prescription opioids, and seeing the overdose rate increase so dramatically with synthetic opioids is certainly concerning," Jones commented.

One of the drivers of this problem is the "proliferation of counterfeit tablets that look like a benzodiazepine but is actually fentanyl or a fentanyl analogue, so individuals using benzodiazepines who may not be exposed to opioids on a regular basis are at increased risk for overdose because they have no tolerance for opioids," he noted.

For this reason, "the population of who is at risk is broader than just the population of those misusing opioids," he said.

He emphasized that, given the high risk for overdose in many populations, "we should make sure we have broad coverage of naloxone to reduce overdose, not only by equipping those getting opioid prescriptions."

Individuals in the community who might provide care to those having an overdose should be trained in the use of naloxone, he said.

"Underlying all of this is largely substance use disorder and addiction," he added.

"We need to make sure we're putting a system in place in our country to identify people with substance use disorder and connect them with high-quality, evidence-based treatment for this serious public threat."

Information concerning the authors' relevant financial relationships is available through the original article.

JAMA. Published online May 1, 2018. Abstract

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