What is already known about this topic?
During 1999–2017, the rate of drug overdose deaths nationally approximately tripled; approximately 70,000 overdose deaths occurred nationally in 2017, with nearly 68% involving an opioid.
What is added by this report?
Using toxicology data, New York City identified fentanyl in 2% of drug overdose deaths from 2000–2012. By 2017, fentanyl was involved in 57% of all drug overdose deaths in New York City.
What are the implications for public health practice?
Universal fentanyl testing by local medical examiners and inclusion of drug-specific language on death certificates can aid surveillance and address the role of fentanyl in drug overdoses. Community-level educational outreach is indicated when an increase in fentanyl involvement is detected.
Unintentional drug overdose deaths accelerated nearly 800% after 2010 but it wasn’t until 2013 that public health officials began to suspect a cause other than prescription opioids, which until that time, were considered the primary cause for rising opioid overdose deaths.
Between 2012 and 2013 some states began performing toxicology testing at their own expense, without the financial support of the CDC and other federal agencies, suspecting an alternative cause for an exponential increase in opioid-related overdose deaths. What they discovered was an increased occurrence of Fentanyl and Fentanyl analogs mixed with heroin and other drugs of abuse such as cocaine, methamphetamine, and cannabis. Because this was a novel idea at the time, the lack of widespread testing probably failed to identify a primary cause for opioid overdoes deaths which had been occurring for some time. Drug traffickers had most likely been mixing fentanyl analogs with other street drugs such as heroin, cocaine, and methamphetamine for two reasons. First, it lowered their cost as these synthetic opioids are much easier to manufacture than using traditional methods such as growing poppies and processing these organic-based substances. Secondly, mixing a new synthetic opioid with traditional street drugs provided camouflage, preventing law enforcement and public health officials from discovering the real source and cause for the rise in abuse and overdose deaths.
Federal agencies failed to respond to this change until 2015-2016, providing need funding for the types of tests required to identify these purely synthetic types of opioids. That effort continues today as documented in this updated alert from the CDC. Toxicology tests for synthetic opioids require sophisticated techniques such as gas chromatography and spectroscopy, the cost for this equipment, supplies needed to support them and the training of individuals to operate and maintain them, is beyond the budgets of state crime labs and country coroners. For this reason, widespread testing in most states did not occur until federal funding was made available sometime after 2015. With this continued funding, states are now able to go back and retest biological samples saved prior to 2015, this report is based on those efforts.
The emergence of illicitly manufactured fentanyl* (a synthetic, short-acting opioid with 50–100 times the potency of morphine) mixed into heroin, cocaine, and counterfeit pills, with or without the users’ knowledge, has increased the risk for a fatal overdose. The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) conducts routine overdose mortality surveillance by linking death certificates with toxicology findings from the NYC Office of the Chief Medical Examiner (OCME). A 55% increase in the rate of a fatal drug overdose in NYC was observed from 2015 to 2017, resulting in the highest number of overdose deaths recorded since systematic reporting began in 2000. Toxicology data indicate that this unprecedented increase in overdose deaths is attributable to fentanyl. Early identification of increased fentanyl involvement enabled DOHMH to respond rapidly to the opioid overdose epidemic by increasing awareness of the risks associated with fentanyl and developing effective risk reduction messaging. These results strongly suggest that, wherever possible, jurisdictions should consider integrating toxicology findings into routine overdose surveillance and work with local medical examiners or coroners to include fentanyl in the literal text on death certificates.
Since 2013, illicitly manufactured fentanyl has been involved in a growing number of overdose deaths nationally and in NYC and has been represented increasingly in seizures of synthetic opioids. The increased presence of fentanyl in the illicit drug market has implications for overdose prevention efforts; however, national reporting on the presence of fentanyl in overdose deaths is limited by the lack of standardized toxicology testing for fentanyl and the inconsistent listing of fentanyl as a cause of death on death certificates, resulting in underreporting of fentanyl involvement in fatal overdoses. Nationally, reporting on drugs involved in overdose deaths relies on death certificate data; despite local efforts to improve drug reporting on death certificates, at least 15% of overdose deaths do not specify any drugs (7). Thus, drug-specific data continue to be underreported, making it difficult to quantify the role of fentanyl in increasing overdose death rates.
Among 10,673 fatal overdoses in NYC during 2000–2014, a total of 7,822 (73%) involved an opioid. Fentanyl was determined to be involved in 246 of these deaths (i.e., 2% of all overdose deaths or 3% of deaths involving an opioid). Beginning in 2015, the percentage of fentanyl-involved overdose deaths increased sharply; in 2016, 624 (44%) of 1,425 drug overdose deaths involved fentanyl, and in 2017, 842 (57%) of 1,487 overdose deaths involved fentanyl.
From 2014 to 2017, the rate of fentanyl-involved overdose deaths in NYC increased by almost 3,000%, from 0.4 per 100,000 to 12.1. This trend is driving the overall increase in the rate of overdose deaths in NYC, which rose 81% during the same period, from 11.7 per 100,000 in 2014 to 21.2 in 2017, the highest rate since tracking of overdose deaths using this methodology began in 2000. In 2017, 531 (69%) heroin-involved deaths and 387 (53%) cocaine-involved overdose deaths also involved fentanyl. Fentanyl also was involved in 146 (39%) deaths that involved cocaine but not heroin.