Fentanyl Overdoses Are Rising And

Science Cant Keep Up

Synthetic opioid formulas are evolving at a breakneck pace.

ALISSA SCHELLER/THE HUFFINGTON POST

Erin Schumaker-01/09/2017
Bribery. Conspiracy. Racketeering.

Those are just three of

the accusations that federal prosecutors leveled against two
Alabama physicians in April as part of a 22-count criminal
indictment alleging that Drs. John Couch and Xiulu Ruan ran an
opioid pill mill in exchange for hundreds of thousands of dollars in
kickbacks from a pharmaceutical company.
Couch and Ruan were arrested in 2015 after prescribing Medicare
patients a combined $4.9 million in Subsys a potent form of
fentanyl, taken via mouth spray and designed to treat severe
cancer pain between 2013 and 2014.
Some of those prescriptions were diverted and/or abused by
drug traffickers and addicts, prosecutors say, and may have
contributed to the opioid crisis currently gripping the nation.
Couch and Ruan deny the allegations.
A third doctor, Michigan neurologist Dr. Gavin Awerbuch, pleaded
guilty in November to health care fraud and to prescribing Subsys
without a legitimate medical purpose. Awerbuch prescribed more
Subsys than any other dispenser in the country, according to the
U.S. Attorneys Office.
Couch, Ruan and Awerbuchs alleged misdeeds signify more than
a few rogue doctors attempting to turn a profit at the expense of
patient health. The accusations against the physicians are part of
a larger story about Americas insidious fentanyl problem and the
doctors and pharmaceutical companies whove fueled it.
Many Americans first heard of fentanyl last year, when the
singer Prince died after accidentally overdosing on the drug.
Officials found pills in the pop icons home that were labeled as
hydrocodone. Upon testing, it turned out these pills contained
fentanyl. (Its not clear whether the pills were mislabeled or
illegally produced, or whether Prince even knew they contained
fentanyl.)

But fentanyl has been a growing presence in the U.S. for some
time now. According to the Centers for Disease Control and
Prevention, the number of drug products seized by law
enforcement that contained fentanyl increased by 426
percent between 2013 and 2014, and synthetic opioid overdose
deaths rose by nearly 80 percent in that period.
Fentanyl is a synthetic opioid that doctors typically prescribe to
chronic pain patients, like those with end-stage cancer, as an
injection, a patch or a lollipop. It has a high potential for abuse
and can be fatal even in small amounts.
Because it induces extreme relaxation and euphoria, fentanyl is
also sold on the black market. And since fentanyl is cheap, its
frequently mixed with more-expensive heroin or
cocaine, something users arent always aware of when they buy
it.
Fentanyl is not a joke, Dr. Sanjay Gupta, a neuroscientist and
chief medical correspondent for CNN who serves on the American
Pain Associations board of directors, told The Huffington Post.
Its 100 times stronger than morphine. Its really lethal.
Now, a HuffPost analysis of available state-by-state data on
synthetic opioid and fentanyl deaths and fentanyl seizures by law
enforcement illustrates a troubling trend: Synthetic opioid
overdose deaths driven by fentanyl, one of the strongest opioids
on the market, are rising.
These data highlight pockets of the United States the Eastern
Seaboard and Appalachia in particular where fentanyl seizures
and overdose deaths indicate a rapidly evolving problem that law
enforcement and science arent keeping up with.
We have not peaked yet, said Dr. Peter Friedmann, associate
dean for research at the University of Massachusetts Medical
School and chief research officer at the nonprofit Baystate Health.
Its going to be a big issue over the next couple of years, said
Friedmann, who has spent more than two decades studying

substance abuse and addiction treatments. I really think that the

policy hasnt caught up to the pharmacology.

The rise of fentanyl

Although reports of fentanyl abuse date back to the 1970s, the
current crisis has roots in the 1990s movement to end chronic
pain.
It grew out of a series of compounding missteps. Pharmaceutical
companies aggressively marketed opioids to doctors as safe and
non-addictive during a period when those same doctors were
under pressure to eliminate patient pain. The logical answer
seemed to be to write more pain-pill prescriptions.

By 2003, 20 percent of 20- to 25-year-olds were abusing

painkillers, compared to 7 percent of early-20-somethings a
decade earlier, according to The New York Times. When the
government restricted opioid prescriptions and cracked down on
so-called pill mills, addicted patients turned to a cheaper and
prescription-free alternative: heroin.
Its a well-trod path. Forty percent of injection drug users abused
prescription opioids before they tried heroin, according to a small
study published in the journal Substance Abuse and Rehabilitation
in 2011.
Fentanyl is just the latest iteration of cheap and potent synthetic
opioids. (In fact, authorities are battling an even newer synthetic
drug, known as U-47700, in several states.)
Other fentanyl analogues include sufentanil, which is
approximately eight times more potent than fentanyl, and
carfentanil, which is about 100 times more potent than fentanyl
and 10,000 times more potent than morphine.
Carfentanil is used for tranquilizing elephants, Friedmann said,
noting that overdoses tend to happen when theres a mismatch
between a persons tolerance level and the potency of the opiate
they use.
When the government restricted opioid prescriptions and
cracked down on so-called pill mills, addicted patients
turned to a cheaper and prescription-free alternative:
heroin.
In addition to prescription fentanyl, Mexican cartels smuggle
black-market fentanyl across the border, and Chinese suppliers
sell both the drug and the equipment to make it online.
We have seen an influx of fentanyl directly from China, Carole
Rendon, now the U.S. attorney for the Northern District of Ohio,
told the health news site Stat last year. Its being shipped by
carrier. Its hugely concerning.

It used to be that shutting down a major production site would

help curb fatal overdoses. When fentanyl-related deaths surged in
2007, for example, the Drug Enforcement Administration traced
the outbreak to a single site in Mexico. They shuttered the lab and
the deaths stopped. Today, with decentralized units popping up
around the country, its harder for law enforcement agents to
crack down.
The cheapest and deadliest of drugs
Part of whats driving this public health crisis is that fentanyl is
almost unthinkably potent. Patients with fentanyl prescriptions
have overdosed even when they took the medication exactly as
prescribed. DEA agents in St. Louis are learning to self-administer
overdose reversal drugs in case theyre exposed in the line of
duty. Theres a good reason officers are taking precautions: A
speck of fentanyl the size of a few grains of salt can kill a 250pound man, according to The Associated Press.
Fentanyls potency means that the overdose reversal drug
naloxone, sold under the brand name Narcan, is less effective at
reviving fentanyl overdose victims. A person overdosing on
fentanyl could need twice as much naloxone to recover as a
person overdosing on heroin and if the emergency responder
doesnt know which drug the person took, they might not
administer enough medication to save them.
When Cathy Messina found her 21-year-old son David overdosing
on her bathroom floor in 2014, she prayed her 911 call would
bring first responders who could save her son. What she didnt
know at the time was that the batch of heroin her son overdosed
on which came in a package stamped with the label Bad
News was laced with fentanyl. David was pronounced dead at
the hospital.
Messina isnt sure whether David knew his heroin was cut. He
may have wanted a better high than pure heroin could provide. Or
he, like many drug users, simply may not have known that Bad
News heroin contained fentanyl. Some dealers mix the cheap

and powerful drug with heroin to improve their profit margins, and
may or may not tell customers that their product is cut. Other
dealers may be too far down the supply chain to know if the
heroin theyre selling is tainted.
Clandestine fentanyl is available throughout the United States,
most commonly in the white-powder heroin market, Melvin
Patterson, an agent with the DEA, told U.S. News & World Report
last year. Fentanyl is added to heroin to increase its potency, or
is mixed with and sold as fentanyl or disguised as highly potent
heroin.
Its all about money, Friedmann said. Back in the day, dealers
didnt want to kill their clients. You want them to be repeat
customers. But now, there are just so many people that they just
dont care.

Tracking fentanyl east of the Mississippi

Simultaneous growth in synthetic opioid and fentanyl overdose
death rates in the East suggests that fentanyl is fueling the
regions epidemic of opioid overdose.
Between 2014 and 2015, 15 states and Washington, D.C.,
reported at least a 50 percent increase in their synthetic opioid
death rates. The areas in question were all east of the Mississippi
River. The fentanyl death rate surged in the East that same period
New Hampshire, for example, saw a 95 percent increase in its
fentanyl-related death rate between 2014 and 2015, nearly
double the 2015 figures of any other state.
In New England and Appalachia, law enforcement reported more
fentanyl seizures than anywhere else in 2014, with Ohio (1,245
seizures), Massachusetts (630) and Pennsylvania (419) in the top
three fentanyl confiscation slots.
So far, only 18 states and D.C. have made available any 2015
data on fentanyl overdose deaths (three of those had less than a
50 percent increase in their synthetic opioid death rates between
2014 and 2015, so they are not included in the chart above).
Those limited data arent encouraging. Massachusetts saw a 103
percent increase in fentanyl deaths between 2014 and 2015, and
West Virginia recorded a 229 percent increase year over year. The
CDC doesnt release data on fentanyl-specific deaths by state, so
these data come from statewide health departments or medical
examiners, and are based only on cases where medical examiners
actually test for the presence of fentanyl meaning these
numbers may be undercounts.
Experts arent sure why fentanyl seizures and death rates have
risen on the East Coast and in Appalachia more than in the West.
Its [a] really hard problem to say theres one cause, said Nancy
Campbell, a professor at Rensselaer Polytechnic Institute in
Troy, New York, who has published several books on drug policy
and treatment.

Many social, economic and political conditions would lead

fentanyl to becoming available in these kind of places on [the]
Eastern Seaboard, Campbell said.
Some people start out using opioids to manage physical pain,
Campbell said, but transition to using them for emotional reasons.
They realize as they are using these pharmaceutical opioids, that
they dont just relieve pain from sports injuries or dental work,
Campbell said. Their problems become less compelling.
Deaths from fentanyl overdose are most highly concentrated
among white men ages 25 to 54. And while heroin users once
clustered around major trafficking hubs like New York City,
Chicago or Los Angeles, today people living on the outskirts of
large metro areas and in medium-sized cities are more likely to
die from fentanyl overdose than people in metro areas with a
population of 1 million or more, according to the CDC.
Potentially contributing to the East-West fentanyl discrepancy is
the fact that white powder heroin is easier to cut with fentanyl
than darker heroin, because the two light-colored drugs look so
similar.
The West Coast is really marked by a kind of heroin called black
tar, said Traci Green, an epidemiologist and deputy director of
the Injury Prevention Center at Boston Medical Center. On the
East Coast we see a lot of white powder heroin, which looks
disturbingly like fentanyl powder.
Experienced heroin users may think they can distinguish fentanyl
from heroin by color, smell or taste. But when mere grains of
fentanyl can trigger an overdose, theres no room for
miscalculation.
The margin of error is very small with fentanyl, Green said.
The case of Ohio
The moment we saw the first few cases of fentanyl coming
across from the Department of Health, we did a deep dive, said

Andrea Boxill, deputy director of an opiate action team

established by Ohio Gov. John Kasich (R).
It seemed odd to Boxill and others that they were seeing fentanyl
on the streets of Ohio but that there had only been a few reported
deaths from the highly lethal drug. As it turned out, not all of the
states coroners and medical examiners were testing for it.
Once they started testing, we started seeing more numbers,
Boxill said.
Testing isnt just a problem in Ohio. Synthetic opioids are evolving
so rapidly that its hard for emergency rooms and forensics labs to
keep pace. Many of the emergency departments around the
country dont test for fentanyl, Green said. If a lab hasnt
previously encountered fentanyl or a fentanyl analogue, the
drugs fingerprint probably isnt in the labs database, and wont
show up on a toxicology or forensic report.
In Ohio, better testing indeed yielded higher overdose statistics.
The states number of recorded overdose deaths hit a record high
in 2015, with 3,050 people dying that year. Ohio officials cited
fentanyl overdoses as the culprit.
The danger isnt just that fentanyl is potent and deadly.
Its that the landscape of synthetic drug use is changing
so quickly that law enforcement and science cant keep
up.
Boxill also noted that the shipping routes to and from
several major drug-source areas including the Southwest
border, Chicago, Detroit, New York City, Atlanta and Canada go
through Ohio. The states central location makes it especially
vulnerable. Ohio has the eighth-largest national highway system,
which carries the seventh-highest volume of traffic in the nation,
allowing drug transporters to blend in with the natural flow of
traffic, a 2011 Justice Department report notes.
States and emergency rooms that arent yet testing for fentanyl
could be dealing with more of a problem than they realize.

[High] level of testing isnt necessarily coming to every

emergency department and every forensic lab, Green said. We
hope its getting to everybody. But the pace of change is
exceptionally fast for the synthetic area.
Jonathan Caulkins, a professor at Carnegie Mellon University who
researches drug control strategies, made a similar observation.
The pace of change may be even greater in the next decade, he
said. I dont just mean increasing use. I can imagine significant
changes in types of opioids, source of supply, relations to crime
and violence. Its a fluid situation.
In other words, the danger isnt just that fentanyl is potent and
deadly. Its that the landscape of synthetic drug use is changing
so quickly that law enforcement and science cant keep up.
Rethinking addiction discrimination
Some authorities are beginning to push back. In July, U.S. Surgeon
General Vivek Murthy issued an unprecedented letter to 2.3
million health care professionals, asking them to commit to
solving the countrys opioid epidemic.
In his letter, Murthy emphasized that doctors need to change how
they prescribe opioids for pain. He also urged doctors to lead the
way in reframing addiction as a chronic medical condition, not a
moral failing. Murthy has authored a 400-page report, Facing
Addiction in America, that outlines evidence-based treatments
and advocates for prevention and treatment funding.
We need everyone in our country to help change how we think
about addiction, he said. For far too many people, the stigma
around addiction prevents them from stepping forward for help.
Murthy is calling for better access to medication as a way to treat
both heroin addiction and prescription opioid addiction.
What many people dont realize is that these are scientifically
proven treatment strategies, which help people live productive

and fulfilling lives, he said. Thats why we have to make sure

that those are accessible to more people.
Although Friedmann thinks the surgeon generals report is a
positive step, he wishes it had come sooner.
Weve known that this is a problem this is a disease for
some time, he said. I wish he would have [issued the
report] years ago.
Messina, for her part, is putting Murthys ideas into action in
Bucks County, Pennsylvania, where her son David overdosed. She
educates the families and friends of people with substance use
problems about overdose reversal drugs, and has worked to
ensure that local police officers carry naloxone.
People have to realize that this is a disease, Messina said. Yes,
drugs are illegal, but everyone has to open up their minds and
stop judging people.
Im not ashamed of David, she said. Im proud of him.
Posted by Thavam