More than 1,000 Americans died in 6 cities between 2005 and 2007 from overdosing on nonpharmaceutical fentanyl (NPF), in the biggest ever epidemic of overdoses involving illegally produced versions of the painkiller. Health officials predict there will be further outbreaks of NPF overdose because the illegal narcotic is easier and cheaper to produce than heroin.
The figures are being reported today by the US Centers for Disease Control and Prevention (CDC), in the 25th July issue of the Morbidity and Mortality Weekly Report (MMWR).
Illicitly manufactured nonpharmaceutical fentanyl (NPF) is 30 to 50 times more potent than heroin. It is a synthetic opioid and classed by the US authorities as a narcotic.
The findings of a CDC and Drug Enforcement Agency (DEA) investigation showed that between 4th April 2005 and 28th March 2007, a total of 1,013 deaths occurred in six US jurisdictions; the largest NPF epidemic to date. This is nearly 10 times higher than an epidemic in the 1980s when 110 people died of fatal overdoses of different fentanyl analogs, said the report.
The largest number of deaths were in metropolitan Chicago (349), Philadelphia (269), and Detroit (230). The other areas were St. Louis, Missouri, and the states of Delaware and New Jersey.
Emergency medical staff said some of the victims were found with the needle still stuck in their arms. The drug was so powerful that they died before completing the injection, said Dr Stephen Jones, a co- author of the report who is now retired from the CDC, reported Reuters.
The authorities decided to carry out the investigation after receiving a number of reports of overdoses linked to NPF. For instance in April 2006 increases in overdoses among illegal drug users were reported in Camden, New Jersey, which triggered similar reports in other jurisdictions, including Chicago and Detroit, which had been discovered earlier but falsely attributed to heroin overdose until urine samples of some of the dead showed traces of fentanyl.
Thus in May 2006 the CDC started ad-hoc case-finding surveillance in six state and local jurisdictions. This was later taken over by the DEA. This is how the 1,013 NPF related deaths were identified. After this the DEA started regulating access to N-phenethyl-4-piperidone, which is used to make illegal analogs of fentanyl.
The CDC report said the pattern of NPF overdoses points to illegal distribution networks, citing as an example that the NPF found in Chicago and Detroit most likely came from a clandestine production site in Mexico. However, they can’t explain why they did not find any NPF-related deaths in other areas of high heroin use, such as in New York City.
As well as the deaths discovered through the CDC/DEA surveillance system, over the same period there were reports of other NPF-related deaths from suburban and rural areas of Illinois, Michigan, and Pennsylvania and in Kentucky, Maine, Maryland, Massachusetts, New Hampshire, Ohio, and Virginia.
The CDC suggested that although the number of NPF-related deaths spotted by the CDC/DEA surveillance system fell substantially in 2007, they predict further epidemics of NPF overdoses are likely because the drug is easier and cheaper to produce than heroin.
Deaths related to heroin and other illicit drugs are well documented in the US. From 1999 to 2005, the figure went up by 87.5 per cent, from 4.0 to 7.5 per 100,000 of the population (age-adjustied deaths from unintentional drug poisoning, mostly linked to pharmaceutical and/or nonpharmaceutical drugs).
The CDC said their report had four limitations: first the figures could be under-reported because for example only participating centers in six jurisdictions were included in the surveillance; second, there is no standard toxicology definition of cause of death for fatal drug overdoses; third, some of the deaths could be misclassified as NPF when they were really pharmaceutical fentanyl-related deaths (ie legal use); and finally, in addition to fentanyl, other substances may have contributed to the overdoses, including alcohol.
Nevertheless, the CDC said the figures are sufficient to warrant improvements in a number of areas relating to drug overdoses. These include improvements in identifying and reporting drug overdose, so law enforcers and public health officials can act more quickly (eg to seize drugs and provide outreach support).
The agency also said there was a need to develop or expand:
- National standards for toxicologic testing and classifying cause of death in drug overdose and poisoning.
- Professional standards for referring overdose surivivors for addiction treatment and education, such as those that exist for suicide survivors.
- Public health programs to help drug users get treatment, be educated about risks of overdose, and learn ways to avoid and deal with overdose.
Jones said in a telephone interview reported by Reuters that the report highlights “an extraordinary episode of fatal drug overdoses”.
“But it’s got to be recognized as part of the bigger problem of the increasing numbers of drug overdose deaths in the United States,” he added.
“Nonpharmaceutical Fentanyl-Related Deaths — Multiple States, April 2005–March 2007.”
CDC, MMWR, July 25, 2008 / 57(29);793-796.
Source: CDC, Reuters.
Written by: Catharine Paddock, PhD