Opioid Overdose Death: Fentanyl and Fentanyl Analogs
Currently, the largest concern amongst national opioid experts is the emergence of illicit fentanyl and other synthetic opioids. Compared to other states, fentanyl and fentanyl analogs involved deaths in Minnesota are substantially fewer than prescription opioid and/or heroin deaths. William R Brownfield, Assistant Secretary for the Office of National Drug Control Policy (ONDCP) warned that “Massachusetts is a preview of coming attractions” with 900 opioid overdose deaths that involved fentanyl in 2015, and 1500 opioid overdose deaths that involved fentanyl in 2016.
- Fentanyl, in its prescription form, is known by such names as Actiq®, Duragesic®, and Sublimaze®. Street names for fentanyl or fentanyl-laced heroin include Apache, China Girl, White China, Dance Fever, Jackpot, Murder 8, TNT, and Tango and Cash.
- Fentanyl is a prescription medication for pain most commonly associated with a terminal illness. The Drug Enforcement Agency (DEA) recommends that fentanyl patches should be flushed down the toilet. However, there is a real concern about fentanyl and other prescription drugs contaminating the water supply. The Environmental Protection Agency (EPA) recommends that fentanyl patches should be folded upon themselves and put in the garbage. However, used fentanyl patches have been known to stick to children and pets, causing unintentional overdoses. Both agencies agree that bringing unused medications to a drop-box location or using the carbon-activated pouches for at-home disposal are safe methods. In non-medical use, users boil fentanyl patches to extract the drug for injection, ingest the patch, and other means.
- A fentanyl analog is a drug that has been designed to mimic the pharmacological effects of the original drug. Some manufacturers create new fentanyl analogs to avoid classification as illegal, policy restrictions on manufacturing, and/or detection in standard drug tests. New fentanyl analogs are being made regularly.
- Carfentanyl is an odorless, white powder. Carfentanyl is an analogue of the synthetic opioid fentanyl, and is one of the most potent opioids known and used commercially. According to the National Institute on Drug Abuse (NIH), it has a quantitative potency approximately 10,000 times that of morphine, 100 times that of fentanyl, and 50 times that of heroin. It is marketed under the trade name Wildnil® as a general anesthetic for large animals. Carfentanyl is not for human use.
- Law enforcement has requested, and in some places obtained, additional protective gear to safely inspect and respond to scenes where carfentanyl or other analogs may be present. Individuals who use commercially produced carfentanyl wear full Personal Protective Equipment (PPE) to administer carfentanyl to sedate elephants and other large animals.
- Carfentanyl has been found cut into heroin and fentanyl sold on the streets, starting in July 2016 in Ohio, when 35 overdoses and 6 deaths occurred in a span of three days. Within Minnesota, there were six overdoses and two deaths in a 12-hour period in Anoka County in October, 2016. In these two instances, and in other dramatic cases like these throughout the nation, it is suspected that one batch of heroin may be the single source for the related overdose cases.
- Drug users and mid-level dealers have no idea what their drug may be cut with or manufactured with, and therefore, may unknowingly be exposed to fentanyl or fentanyl analogs. Users have indicated that fentanyl and carfentanyl smells sweet when being smoked.
- Initially, most opioid users do not intentionally seek out fentanyl or carfentanyl. However, once a person has been exposed to a higher toxicity of a drug, the brain chemistry is altered further, and users will seek out the most potent form of the drug. At the height of addiction, some users are unable to discern risk and are willing to go to any length to obtain the drug.
- Toxicology tests are expensive and time consuming, and delay death certificate finalization. Upon death, toxicology reports test for opioids, including fentanyl. However, carfentanyl and other fentanyl analogs do not show up on traditional opioid toxicology testing, and thus require additional testing. For example, a drug overdose death may include all the scene indications and autopsy findings of an opioid overdose death, but toxicology testing comes up negative for opioids. At this point further testing may be performed for the presence of carfentanyl and fentanyl analogs. However, if the toxicology test was positive for opioids, it is unlikely that further testing would be performed. In the world of very potent drugs and emerging analogs, keeping up with toxicology testing and accurate death reporting is extremely challenging. Further testing for carfentanyl and other analogs is not routinely performed at this time.
- While Fentanyl and carfentanyl are commercially produced, there is a growing illicit production market. When drug overdose deaths are investigated, it is difficult to determine if the drugs were commercially or illegally produced.
- It is increasingly difficult to determine if pills were legally produced for pharmaceutical distribution or illegally produced for illegal drug sales. Recently, anecdotal reports have highlighted the presence of counterfeit prescription medications such as a fentanyl-laced Xany-bar or counterfeit Xanax; these are pills that are made at a “pill mill” or illegal pill press.
- Fentanyl sales are much more lucrative than heroin. A kilogram of heroin is purchased for approximately $6,000 and sold for appropriately $80,000. A kilogram of fentanyl is purchased for approximately $6,000 and sold for approximately $1.6 million. The reason for this vast difference in pricing is that the potency of fentanyl is so great, that it is cut into heroin and other drugs, to expand their volume.
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