Fentanyl-related deaths double in six months; US government takes some action

A new report by the US Centers for Disease Control and Prevention found that the number of overdose deaths involving the potent narcotic fentanyl and variations of the drug nearly doubled between the last half of 2016 and the first half of 2017.

The report analyzed overdose deaths that tested positive for fentanyl and similar compounds from July 2016 to June 2017 in 10 states: Kentucky, Maine, Massachusetts, New Hampshire, New Mexico, Ohio, Oklahoma, Rhode Island, West Virginia and Wisconsin. From July 2016 to December 2016, the CDC found 764 fentanyl and fentanyl analog-related deaths in the 10 states. In the following six months, from January 2017 to June 2017, the CDC tallied 1,511 overdose deaths involving the drugs.

When legitimately prescribed, fentanyl helps patients managing extreme pain, such as caused by cancer. It is typically dosed in the form of tablets, patches or intravenously. However, illicit forms of the drug are commonly sold as a powder or pressed into pills. Fentanyl and chemically similar variations, known as analogs, have been sold on the black market and can be extremely potent.

One such analog is the drug carfentanil. It is 10,000 times as potent as morphine and used to tranquilize elephants. The drug was found to be responsible for overdose outbreaks in Ohio and West Virginia in 2016. The CDC found that deaths associated with carfentanil jumped 94% from 421 to 815 in the 10 states studied during the 12-month period.

The third wave

Nationally, numbers for 2017 are still preliminary, but the CDC expects opioid overdose-related deaths to jump to an all-time high of 49,000. Nearly 60% of those casualties are expected to be related to synthetic opioids like fentanyl and carfentanil.

According to the CDC, there were 20,310 overdose deaths involving synthetic opioids in 2016, and that number is expected to climb 45% to 29,400 in 2017.

The recent rise in popularity of these synthetics has been called the third wave of the opioid epidemic; the first wave was attributed to the overprescribing of painkillers like oxycodone and hydrocodone and the second to heroin. The drugs are all chemically similar and act on the same receptors in the brain.

This increase in overdoses tied to illicit fentanyl and its analogs mirrors an increase in drugs submitted to the Drug Enforcement Administration that have tested positive for fentanyl. According to the DEA, positive fentanyl samples tested by the agency went from 14,400 in 2015 to 34,119 in 2016. In the first six months of 2017, the DEA expects 25,460 submissions to test positive for the drug.

CDC issues alert

This report comes on the heels of an alert from the CDC this week to public health professionals, first responders and medical examiners about the increased availability of illicit synthetic opioids. The alert is an update of a health advisory from October 2015.

The updated advisory warned that fentanyl was being detected in combination with drugs such as benzodiazepines, counterfeit opioid pills, ketamine and methamphetamine.

Because of the potency of the drugs now available, the alert warned health care providers that multiple dosages of naloxone, the opioid antidote, may be necessary to revive someone from an overdose.

Operation SOS

In an attempt to stem the tide of overdoses tied to illicit fentanyl, US Attorney General Jeff Sessions announced on Thursday an aggressive campaign from the Department of Justice to “prosecute every readily provable case involving the distribution of fentanyl, fentanyl analogs, and other synthetic opioids, regardless of drug quantity” in the 10 districts with the highest overdose rates in the country. The effort known as Operation Synthetic Opioid Surge is centered in districts in California, Kentucky, Maine, New Hampshire, Ohio, Pennsylvania, Tennessee and West Virginia.

The effort to stymie the drug overdose crisis has reached all corners of public health and government.

Also Thursday, Democratic Sen. Claire McCaskill of Missouri released a report on the practices of pharmaceutical distributors. The investigation found that three of the country’s largest distributors — McKesson, AmerisourceBergen and Cardinal Health — shipped 1.6 billion pills to the state of Missouri between 2012 and 2017. That’s enough doses to average more than 260 pills per resident of the state during each of those years.

Congressional investigation into distribution practices

The McCaskill investigation focused on Missouri alone but identified lapses in the larger pharmaceutical distribution process.

All three distributors had inconsistencies in reporting suspicious orders over the past 10 years, the report said. Under the Controlled Substances Act, distributors must monitor and report suspicious orders to the DEA, which requires that distributors report orders “of unusual size, orders deviating substantially from a normal pattern, and orders of unusual frequency” to agency field offices. Distributors are wholesalers that work as middlemen between manufacturers and hospitals and pharmacies.

The report found that the three distributors “consistently failed” at reporting.

For example, McKesson and AmerisourceBergen shipped about 650 million pills to Missouri between 2012 and 2017. In that time frame, McKesson reported more than 16,700 suspicious orders to the DEA while AmerisourceBergen made just 224 suspicious order reports in that period. Cardinal Health reported 5,125 questionable orders to the DEA.

Although the report stated that the findings themselves did not note anything illegal, it spotlighted potential failures in the system that could lead to legal drugs being diverted to the black market.

“The opioid crisis these pills have fueled is a failure of policy and oversight by the government and a failure of basic human morality on the part of many pharmaceutical companies and distributors — a failure that has destroyed families and communities all over our state,” McCaskill said in a statement.

Companies confident in their practices

In response to the report, McKesson said that “We have invested significant resources in our anti-diversion program and, since 2008, have blocked and reported more than a million suspicious orders nationwide.”

AmerisourceBergen echoed a commitment to helping end the opioid crisis and tracking suspicious orders. In a statement, the company said, “AmerisourceBergen’s order monitoring program involves two key steps. Flagging orders for review using our complex computer algorithm and conducting a detailed investigation of every single flagged order. We believe this process makes our suspicious order reports to the DEA highly precise and actionable.”

The Healthcare Distribution Alliance, a national trade association representing the distributors, criticized the senator’s report. In a statement, it said the report relied on “debunked, inaccurate statements without acknowledging the need for broader reforms across the pharmaceutical supply chain” and pointed to a trend in overprescribing by physicians as a “leading” contributor to the crisis.

Potential drop in opioid addiction rates

Also Thursday, a report from Blue Cross Blue Shield showed potential progress in the efforts to fight the opioid crisis. New numbers from the insurance giant found that the number of people with opioid addiction (also known as opioid use disorder) dropped for the first time in the eight years the company has been tracking it.

In 2016, opioid addiction diagnoses peaked at 6.2 cases for every 1,000 Blue Cross Blue Shield members. In 2017, that rate dropped slightly, to 5.9 cases for every 1,000 members.

According to the Substance Abuse and Mental Health Services Administration, about 2 million Americans have opioid use disorder. However, only one in five gets any sort of specialized treatment. Blue Cross Blue Shield says about 40% of its clients diagnosed with opioid use disorder are accessing specialized treatment.