Discussion

The findings in this report suggest the need to improve fentanyl death surveillance with a focus on distinguishing deaths involving IMF and PF, and enhancing public health support of persons using heroin through increased access to medication-assisted treatment and expanded access to the opioid antagonist naloxone. Although toxicologic panels cannot distinguish IMF from PF, the findings suggest that the surges in fentanyl deaths in Florida and Ohio during 2013–2015 were closely related to increases in the IMF supply, as opposed to diverted PF. This is supported by multiple factors including 1) the stability in prescribing and dispensing of PF in Florida and Ohio, even as fentanyl deaths sharply increased; 2) the implication of acetyl fentanyl and beta-hydroxythiofentanyl, both illicitly produced fentanyl analogs, in a significant number of fentanyl deaths in Florida; 3) recent DEA reports linking most U.S. fentanyl deaths to IMF (4); 4) demographic characteristics of fentanyl decedents in Ohio and changes in the demographic characteristics of fentanyl decedents from 2010–2012 to 2013–2014 in Florida were similar to heroin decedents nationally; and 5) interviews with persons using illicit drugs in Ohio indicating that fentanyl appears to be mixed with or sold as heroin.†† DEA reports have noted that IMF is often mixed with heroin, and then sold as a heroin product on the illicit market (1,4). In Ohio and Florida, a substantial proportion of fentanyl decedents tested positive for heroin (39% and 19%, respectively); it is likely that this represents an underascertainment, because heroin is quickly metabolized to morphine, thus morphine-positive fentanyl deaths can indicate prescription morphine or metabolism of heroin (5).

The changing demographics of fentanyl decedents in Florida from 2010–2012 to 2013–2014 and the demographics of fentanyl decedents in Ohio in 2014 mirror the evolving demographics of persons who use heroin in the United States.§§ Risk profiles changed notably during the current epidemic, with fentanyl deaths in Florida increasing almost 2.5 times faster among men (163%) than women (68%), with the most rapidly increasing rate among persons aged 14–34 years. In contrast, U.S. death rates involving prescription opioids are highest among persons aged 45–54 years, a slightly older group than this cohort of fentanyl decedents (6). In addition, the demographic of fentanyl decedents in Ohio closely matched those of heroin overdose decedents, but diverged from prescription opioid overdose decedents.

The findings in this report are subject to at least five limitations. First, since toxicologic panels cannot distinguish between PF and IMF, this study does not provide precise counts of overdoses involving IMF compared with PF. Second, the numbers and rates of fentanyl deaths are underestimated because not all overdose deaths were tested for fentanyl and testing for fentanyl analogs is not systematic statewide in either state. Third, NFLIS data might vary over time and geography because of differences or changes in law enforcement testing practices and enforcement activity. Fourth, part of this investigation was limited to abstraction of information collected during the medical examiner and coroner death investigation, and information collected might vary among counties within both states. Finally, analysis of medical examiner and coroner records was limited to high-burden counties in Ohio, and findings might not be generalizable to the entire state.

The rapid increase in fentanyl deaths indicates the need for timely surveillance and response. The relationship between fentanyl deaths and fentanyl submissions in both Florida and Ohio suggests that fentanyl submissions data could act as an early warning system to identify changes in the illicit drug supply. Distinguishing whether an overdose involves IMF or PF is critical for targeted interventions because overdose risk profiles differ. Additional work is needed to determine the extent to which medical examiners and coroners can use decedents’ substance use history, scene evidence (e.g., white powder consistent with IMF or patches consistent with PF), toxicology (e.g., presence of heroin or cocaine), and prescription drug monitoring program data to distinguish IMF from PF overdoses. Similar to national NFLIS data, Florida began detecting increases in fentanyl analog submissions in 2015. Because the lethality of fentanyl analogs vary, increased testing for analogs in areas experiencing large numbers of fentanyl deaths or increases in overdose deaths might be needed.

The U.S. Department of Health and Human Services has launched an initiative to reduce opioid misuse and overdose by expanding medication-assisted treatment, increasing the availability and use of naloxone, and promoting safer opioid prescribing.¶¶ Past misuse of prescription opioids is the strongest risk factor for heroin initiation and use, particularly among persons who report past-year dependence or abuse (7).

The rapid increase in fentanyl deaths in Florida and Ohio illustrates the high potency of fentanyl, with the possibility of rapid death (8), highlighting the importance of quickly recognizing an overdose, calling 9-1-1 promptly, facilitating rapid administration of ≥1 naloxone doses, and the need to expand naloxone availability. The presence of bystanders in Ohio suggests the opportunity to improve overdose response including increasing support for community naloxone distribution programs. In Ohio, naloxone was administered in four of 10 cases. Multiple doses of naloxone and/or emergency medical treatment might be needed to reverse a fentanyl overdose. Community members might want to have several naloxone doses available and should be instructed to call 9-1-1 immediately, even when administering naloxone (2).***

Linkage and access to treatment and to naloxone are needed for persons at high risk. In Ohio, a significant percentage of fentanyl deaths involved persons recently released from an institution and persons with a current diagnosed mental health disorder, placing both groups at increased risk for overdose. Persons recently released from an institution are at particularly high risk for opioid overdose because of lowered opioid tolerance resulting from abstinence during residential treatment or incarceration (9). Interventions such as provision of naloxone and continuation of medication-assisted treatment after release have been shown to be effective for this group (10).