Originally published October 26, 2015
The Centers for Disease Control and Prevention (CDC) and the Drug Enforcement Administration (DEA) are investigating recent increases in fentanyl-related unintentional overdose fatalities in multiple states across the U.S. The purpose of this HAN advisory is to: (1) alert public health departments, health care providers, first responders, and medical examiners and coroners to the possibility of additional increases in other jurisdictions, (2) provide recommendations for improving detection of fentanyl-related overdose outbreaks and (3) encourage states to expand access to naloxone and training for administering naloxone to reduce opioid overdose deaths.
Fentanyl, a synthetic and short-acting opioid analgesic, is 50-100 times more potent than morphine and approved for managing acute or chronic pain associated with advanced cancer. Although pharmaceutical fentanyl can be diverted for misuse, most cases of fentanyl-related morbidity and mortality have been linked to illicitly manufactured fentanyl and fentanyl analogs, collectively referred to as non-pharmaceutical fentanyl (NPF). NPF is sold via illicit drug markets for its heroin-like effect and often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge—to increase its euphoric effects. While NPF-related overdoses can be reversed with naloxone, a higher dose or multiple number of doses per overdose event may be required to revive a patient due to the high potency of NPF.
In March 2015, DEA issued a nationwide alert identifying fentanyl as a threat to public health and safety. This was followed by a DEA National Heroin Threat Assessment Summary, which noted that “beginning in late 2013 and throughout 2014, several states have reported spikes in overdose deaths due to fentanyl and its analog acetyl-fentanyl.” Similar to previous fentanyl overdose outbreaks, most of the more than 700 fentanyl-related overdose deaths reported to DEA during this time frame were attributable to illicitly-manufactured fentanyl—not diverted pharmaceutical fentanyl—and either mixed with heroin or other diluents and sold as a highly potent form (sometimes under the street name “China White”). The DEA report noted that the “true number is most likely higher because “many coroners’ offices and state crime laboratories do not test for fentanyl or its analogs unless given a specific reason to do so.”
Reports on state drug seizures (or confiscations) from the National Forensic Laboratory Information System (NFLIS), a program of the DEA’s Office of Diversion Control, indicate a significant increase in the total number of fentanyl drug seizures reported by forensic laboratories around the country from 2012 to 2014 (618 in 2012; 945 in 2013; 4,585 in 2014). More than 80% of drug seizures in 2014 were concentrated in 10 states (Table 1). The number of states reporting 20 or more fentanyl seizures every six months is increasing. From July to December 2014, 18 states reported 20 or more fentanyl drug seizures (See Figure 1). Previously, six states reported 20 or more fentanyl drug seizures from July to December 2013.
|Table 1: Top 10 states by total Fentanyl Seizures, 2014, unpublished NFLIS data|
|Rank||State||Number of Fentanyl seizures|