Deaths From Fentanyl, Fentanyl Analogs Have Risen Sharply

Deaths from fentanyl and fentanyl analogs, such as carfentanil, have more than doubled since 2015, according to a report from the Centers for Disease Control and Prevention (CDC), with synthetic opioids now clearly being the largest class of drugs causing overdose-related deaths.

The increase results from an increased supply of illicitly manufactured fentanyl and fentanyl analogs, which are sold as heroin or mixed with heroin, and from the combination of fentanyl analogs with nonopioid drugs, such as benzodiazepines and cocaine.

The CDC's Health Alert Network Update revises two previous reports published on October 26, 2015, and August 25, 2016. The current update reflects the sharp rise in drug supply and related overdoses and provides recommendations for healthcare professionals, coroners and medical examiners, first responders, and public health departments.

According to the US Drug Enforcement Administration's National Forensic Laboratory Information System, drug cases submitted to forensic laboratories for analysis (drug submissions) that tested positive for fentanyl rose from 14,440 in 2015 to 34,119 in 2016, with an additional 25,460 reports during the first 6 months of 2017.

Fentanyl Analogs, Synthetic Opioids

Drug submissions containing carfentanil — an ultra-high-potency fentanyl analog — rose from 1251 in 2016 to 2268 during the first half of 2017. Drug submissions containing furanylfentanyl, 3-methylfentanyl, acrylfentanyl, and U-47700 increased from 2273 to 3322, 427 to 432, 26 to 1508, and 533 to 1087, respectively, in 2016 and during the first 6 months of 2017.

Deaths involving synthetic opioids, including fentanyl and fentanyl analogs, also increased dramatically, from 3.1 to 6.2 deaths per 100,000 between 2015 and 2016, "marking the first year that synthetic opioids became the most common type of opioid involved in all opioid overdose deaths," according to the report.

During the 12 months ending November 2017, upward of 55% of national opioid overdose deaths —more than 27,000 deaths — involved synthetic opioids. That number is higher than the total number of all opioid overdose deaths during 2013, when fatalities from synthetic opioids first began to rise.

Ten states (Kentucky, Maine, Massachusetts, New Hampshire, New Mexico, Ohio, Oklahoma, Rhode Island, West Virginia, and Wisconsin) have initiated CDC-funded enhanced surveillance of opioid overuse deaths with the State Unintentional Drug Overdose Reporting System. Preliminary data show that from July 2016 to June 2017, at least half of fatal opioid overdoses in seven of those states tested positive for fentanyl; 5 of the 10 states reported that at least 10% of opioid overdose deaths tested positive for fentanyl analogs.

Fatal opioid overdoses that tested positive for fentanyl or fentanyl analogs increased substantially from the second half of 2016 to the first half of 2017 in those 10 states: Total fentanyl-involved deaths rose from 2986 to 3303, and fentanyl analog–involved deaths rose from 764 to 1511. "Notably, carfentanil deaths nearly doubled from 421 in the last half of 2016 to 815 in the first half of 2017, and became the most commonly detected fentanyl analog overall during this period in the 10 states reporting (1,236 deaths, 11% of all opioid deaths)," according to the report.

Florida and Ohio have been particularly hard hit: More than 90% of carfentanil deaths reported in the 10 states occurred in Ohio. Independent of the surveillance system, Florida reported 1274 fentanyl analog deaths in 2016, 43% of which involved carfentanil.

Recommendations

The CDC recommends improved surveillance and detection of fentanyl outbreaks to promote effective response by public health departments, medical examiners and coroners, law enforcement, and laboratories. Existing surveillance systems, including data from poison control centers and emergency departments, can identify individual overdose cases, and local laboratories and High Intensity Drug Trafficking Area Units can provide information on drug supply.

The CDC also recommends expanded use of naloxone and opioid use disorder treatments. Multiple doses of naloxone may be needed because fentanyl and fentanyl analogs are much more potent than other opioids. Toxicity can be delayed in people who orally ingest counterfeit pills laced with fentanyl or fentanyl analogs; therefore, prolonged dosing of naloxone may be required.

Healthcare providers should encourage patients with opioid use disorder to undergo medication-assisted treatment and facilitate access. After an overdose, emergency departments should prescribe naloxone and connect patients with case management services or peer navigators to help them obtain treatment.

Access to naloxone should be expanded to family and friends of those with opioid use disorder and in the correctional setting, and those who use illicit opioids should be instructed on naloxone administration.

Public health messaging related to the potency of fentanyl-laced counterfeit pills and fentanyl analogs should be widely distributed. Those who misuse prescription oral pain and sedative medications and those who use cocaine are also at risk for fentanyl overdose.

Medical examiners and coroners should have a high index of suspicion for fentanyl in cases of opioid overdose and use an enzyme-linked immunosorbent assay that can detect fentanyl to screen specimens.

Law enforcement personnel should be particularly cautious "when handling suspected illicitly manufactured fentanyl, white powders, and unknown substances," the CDC recommends.

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