US deaths from synthetic opioids, especially fentanyl, rose more than 10-fold in 5 years, new research shows.

A report from the Rand Corporation, a research and analysis nonprofit organization that consults on public policy worldwide, notes that deaths in the United States involving synthetic opioids increased from approximately 3000 in 2013 to more than 30,000 in 2018. In addition, this type of drug is now involved in twice as many deaths as heroin.

Although synthetic opioid overdose deaths have stayed predominantly in the Eastern US, authorities in other areas "must remain vigilant," the researchers note in a press release.

They add that this particular epidemic is "unlike others that have struck the nation."

"This crisis is different because the spread of synthetic opioids is largely driven by suppliers' decisions, not by user demand," lead author Bryce Pardo, PhD, associate policy researcher at Rand Corporation, said in the same release. "Most people who use opioids are not asking for fentanyl and would prefer to avoid exposure."

Asked to comment for Medscape Medical News, Jill M. Williams, MD, chair of the Council on Addiction Psychiatry for the American Psychiatric Association (APA) called this an important, substantial, "and quite comprehensive" report.

"I think it really helps to show the scope of the issues in clear terms. A lot of this is unprecedented," said Williams, a professor of psychiatry at Rutgers University's Robert Wood Johnson Medical School, New Brunswick, New Jersey, and an addiction psychiatrist.

"Clinicians just need to be aware in terms of screening. We really need to continue to talk to patients and the public about the need for medication-assisted treatment, which is a key component of the problem of opioid-use disorder," she added.

The report, titled "The Future of Fentanyl and Other Synthetic Opioids," was published online August 29 by Rand.

Worldwide Epidemic

For the study, the investigators assessed both mortality and drug seizure data, conducted interviews with noted experts, reviewed literature, and included case studies from around the world.

They found that US rates of overdose deaths mentioning synthetic opioids rose from 1 per 100,000 individuals in 2013 to 9 per 100,000 in 2017. In contrast, the 2017 death rates were much lower for heroin (4.9 per 100,000) and for prescription opioids (4.4 per 100,000).

Although deaths by heroin overdose were declining in some regions, more than half of the deaths nationwide in 2017 from heroin overdose involved synthetic opioids, as did more than half the deaths that year from cocaine overdose. Synthetics were also involved in 1 out of 4 deaths from psychostimulant overdose.

The state with the highest synthetic opioid overdose death rate in 2017 was West Virginia, followed by Ohio and New Hampshire.

The increase in availability of synthetic opioids is due to several sources, including Mexican drug-trafficking organizations, the underregulation of China's pharmaceutical and chemical industries, and the ease with which the Internet aids in both trafficking and the sharing of how to make these drugs, the researchers note.

The study also looked at the rise in synthetic opioids in other parts of the world and found a "recent emergence" of fentanyl in Canada, Latvia, and Sweden.

In Canada, detection of fentanyl was first noted in 2012. Today it and its analogues are the "dominant cause of opioid-related harms" in the country, the researchers note.

"Problems in parts of Canada are as severe as in the Eastern United States despite substantial differences in drug policy, and the delivery of public health and social services," study coauthor Jonathan Caulkins, PhD, professor of operations research and public policy at Carnegie Mellon University, Pittsburgh, Pennsylvania, noted.

Although a small country, Estonia has dealt with a fentanyl epidemic for almost 20 years. Recent record-high arrests and seizures of the drug — and subsequent shutdowns of production — led to the drug becoming more scarce. In addition, drug-related deaths in that country decreased from 110 in 2017 to 40 in 2018. Since then, however, the drug supply has been at least partially restored.

The investigators note that new and innovative strategies are needed to combat the synthetic opioid epidemic in the US, including testing of a drug's content; disrupting the drug supply "creatively," such as with efforts that confuse online sourcing; and creating supervised consumption sites. Another option is increasing accessibility to novel therapies that are currently available in other countries, such as heroin-assisted treatment, they add.

"It might be that the synthetic opioid problem will eventually be resolved with approaches or technologies that do not currently exist or have yet to be tested," coinvestigator Beau Kilmer, PhD, director of the Rand Drug Policy Research Center, said in the release.

"Limiting policy responses to existing approaches will likely be insufficient and may condemn many people to early deaths," Kilmer added.

Supply-Driven Problem

Williams noted to Medscape Medical News that many prior reports have focused predominantly on prescribing issues. Because of the rapid onset of the synthetic opioid epidemic, the current report "may be the most comprehensive report of fentanyl and the most timely. It certainly fills a gap," she said.

Williams noted that she has been involved with patients suffering from fentanyl abuse for several years; New Jersey is one of the states that has been disproportionately affected.

"The East Coast is so much more affected than the rest of the country. I'm not clear why that is but attention needs to be paid to it," she said.

"Even being familiar with some of this, I found the report striking and really defining in key areas, including noting that this is a supply-driven problem. I thought they made that argument so well: that if we manage to control the influx from Asia and Mexico, we can maybe get a handle on this," Williams said.

She added that there are two important factors with fentanyl: the dramatic potency of the drug and the cheap price to synthesize it. "This really contributes to the lethality that we've never seen before," she said.

Williams noted that, until recently, it was difficult to determine fentanyl use because of the lack of high quality tests, and that this may have led to serious underreporting of its use. She also pointed out that stigma around abuse problems still exists, often deterring patients from seeking treatment.

She said that economic hardships and healthcare issues in the US have contributed to a "perfect storm" of factors leading to fentanyl abuse and overdoses. "All of the factors were aligned," she added.

Although the APA doesn't currently have a specific policy statement on fentanyl and other synthetic opioids, Williams said that a multitude of ongoing collaborative efforts between the APA and other organizations/government agencies are attempting to eradicate the epidemic.

"I think we're just scratching the surface in terms of access to treatment. We need to continue expansion efforts so that every medical and healthcare provider is able to do this within their scope of practice. We're not yet there and I'd say that's the greatest area of need," she concluded.

The full 265-page study report is available for download on Rand's website.

Funding for the study was provided by Rand Ventures. Williams has disclosed no relevant financial relationships.

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