Increased Fentanyl Presence, Overdoses, and Deaths

Pain management physicians, especially those whose patients may be taking or seeking opioid painkillers, should remain aware of news reports of fentanyl hitting the street drug scene in disguised and more lethal forms, in some cases linked to illegal exports from China.

In California's Bay Area, cases of counterfeit pills sold by street dealers as Norco (oxycodone and acetaminophen) were actually found to contain fentanyl, according to The Mercury News in San Jose.1

Health officials in the Bay Area are trying to warn the public that prescription drugs should be obtained only from licensed pharmacies and medical professionals, the Mercury News reported. In pill form, the fentanyl-laced drugs appear as fake OxyContin, Xanax, Norco, and other club drugs, according to Contra Costa Health Services. In powder form, it's being sold as other illicit drugs such as heroin, methamphetamine, and cocaine, according to the newspaper. Pills were recovered in one overdose case testing positive for fentanyl, appearing oval-shaped and labeled "M367."

Fentanyl has been appearing increasingly in other US cities, including New York, leading the New York City health department and mayor's office to issue public warnings and alerts to health care providers to begin testing for the drug in overdose cases.

The US Drug Enforcement Administration is investigating where the drugs are coming from, and a representative told the Mercury News that she couldn't release details of the ongoing probe. DEA spokesperson Casey Rettig told the newspaper that agency staff believe such counterfeit narcotics are produced in China, shipped to Mexico, and smuggled into the United States. In February, a smuggler attempted to sneak 1183 tablets of fentanyl that were labeled as oxycodone, and 5.4 grams of powdered fentanyl, across the Mexican border but was arrested.

Preliminary data show a dramatic increase in the number of unintentional drug poisoning (overdose) deaths in New York City, according to an email alert sent by the city's health department to health care professionals. The largest increase in overdose deaths was among Bronx residents, which increased 39% from a rate of 15.5 per 100,000 in 2014 to 21.5 per 100,000 in 2015.1, 2 By age group, the largest increase was among decedents aged 15-24, an increase of 33% from a rate of 4.6 per 100,000 in 2014 to 6.1 per 100,000 in 2015.1

New York health officials asked health care practitioners who treat substance abusers to educate them about overdose prevention strategies, including recommending that patients participate in overdose-prevention education at a local harm-reduction program or participating pharmacy. States such as New York and Maryland make naloxone available for overdose reversal. For further information on the New York program, contact the New York City Department of Mental Hygiene. Treatment locators for methadone and buprenorphine programs are available at: http://www.oasas.ny.gov or http://www.buprenorphine.samhsa.gov.

Fentanyl is a synthetic, short-acting opioid analgesic with a potency 50 to 100 times that of morphine. Fentanyl carries a high risk of overdose, and recent national cases of fentanyl-related morbidity and mortality have been increasingly linked to illegally manufactured fentanyl and fentanyl analogues. These drugs are sold illicitly for their heroin-like effects and may be mixed with heroin and/or cocaine as a combination product with or without the user's knowledge. In addition, recent law enforcement seizures in several jurisdictions across the United States, including New York City, have identified fentanyl sold in powder and pill formulations, which may be marked as other substances, including benzodiazepines and opioids analgesics.

The New York City Department of Health and Mental Hygiene is alerting medical personnel that: (1) a higher dose or multiple doses of naloxone per overdose event may be required to revive some opioid-involved overdoses due to the presence of fentanyl; and, (2) patients presenting to emergency departments with symptoms indicating opioid intoxication may be unaware they ingested fentanyl. Providers should be mindful that fentanyl is not detected by standard urine screens.

Furthermore, New York health officials reminded clinicians that:

* Fentanyl is an opioid analgesic. The biological effects of fentanyl are indistinguishable from those of heroin.

* Treatment is the same as for other opioid overdose, however, larger than usual doses of naloxone (2-10 mg) might be required for reversal of the opioid effects.

* Fentanyl is not detected by standard urine opioid immunoassays; therefore, opioid exposure should not be ruled out based on toxicology screen results. Consult your laboratory for preferred testing methods.

* Symptoms of overdose are characteristic of central nervous system depression: lethargy, respiratory depression, pinpoint pupils, change in consciousness, seizure, and/or coma.

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