Fentanyl East of the Mississippi

A recent report from the Centers for Disease Control and Prevention (CDC) paints a grim picture of fentanyl overdose deaths in the US. In 2011 and 2012, fentanyl was involved in nearly 1,600 drug overdose deaths, but from 2012 to 2014, the number doubled each year. In Massachusetts alone, state data show 89% of fatal overdoses through October 2018 involved fentanyl.

Overdose deaths involving fentanyl are rising faster among Blacks and Latinos than Whites for the first time, and men are dying at nearly three times the rate of women. But more notably, fentanyl is appearing far more often in overdoses east of the Mississippi than in the western US. Northeastern states experience more fentanyl-related deaths than any other part of the country, though there is a rising rate in the Midwest more recently.

The rise in fentanyl-related deaths nationwide has been dubbed the “Third-Wave” of the opioid crisis. First, there were deaths due to overuse of prescription pain medications, like Oxycontin. Then, when pills became too expensive or hard to find, opioid users turned to heroin. Now, fentanyl, a synthetic opioid, 50 to 100 times more powerful than heroin, has emerged as a top killer. Even in small doses, fentanyl can be fatal.

In a medical setting, fentanyl is frequently used as a general anesthetic and is closely monitored. But when mixed with illicit drugs and injected or ingested without medical supervision, it can shut down breathing in less than a minute.

Because fentanyl can be reduced to a powder, it’s easy to mix with other powder-based drugs and can be difficult to detect. East of the Mississippi, fentanyl is commonly found mixed with heroin and cocaine. West of the Mississippi, the use of brown and sticky “black tar” heroin often precludes fentanyl mixing; heroin (and cocaine) in the East is powder-based and fentanyl is more easily incorporated.

Drug users often do not know they’re using fentanyl until it’s too late. One study conducted in Rhode Island found that few drug users want to use fentanyl, knowing its risks. They use it because it’s hard to avoid.

Reports indicate that cartels lace heroin supplies with fentanyl before smuggling them to the US largely because the mixture is less expensive and yields more product. Pure heroin is derived from poppies, which require a lot of time, space, and labor to grow. Fentanyl is a combination of synthetic chemicals that are inexpensive to manufacture.

Drug users often do not know they’re using fentanyl until it’s too late. One study conducted in Rhode Island found that few drug users want to use fentanyl, knowing its risks. They use it because it’s hard to avoid.

To help drug users detect fentanyl, some needle exchange programs and public health departments are handing out fentanyl testing strips, small pieces of paper that when exposed to fentanyl can detect its presence. If the strips test positive for fentanyl, drug users can take measures to protect against overdose by using less, being prepared with Naloxone, a medication which reverses overdose, or not using alone. Test strips have been effective in Europe and Canada, but are only beginning to emerge in the US because of significant federal legal barriers.

More and more state health department are also providing Naloxone for free to combat the high chance of overdose associated with fentanyl. Getting Naloxone into the hands of every-day people has proven to be an effective life-saving measure. According to the CDC, more than 80% of overdose reversals are administered by fellow drug users, family, or friends. In Massachusetts, anyone can go to a pharmacy and request or buy Naloxone.

While fentanyl continues to wreak havoc east of the Mississippi, some reports indicate there is growing demand for fentanyl in California. Yet death tolls in California thus far have not spiked the way they have in the east. San Francisco and Los Angeles have long-standing harm reduction communities that provide Naloxone and test strips to prevent overdose.

Naloxone and fentanyl test strips are among the promising strategies that are spreading to combat the overdose epidemic, but distributing these resources remains an uphill public health challenge.

Image by David Mark from Pixabay