The Fatal Treatment: In-Depth Investigation

A determined attempt to track U.S. overdose mortality and the medications that generated them offers a snapshot of a fentanyl epidemic on the cusp of a westbound turn.

Research published Friday by the Centers for Disease Control and Prevention explains the synthetic opioid making a swath of death and destruction across the northeastern United States and the industrialized Midwest in 2017.

That year, fentanyl was the medication cited most frequently as a cause of fatal treatments in all five regions lying east of the Mississippi River, as well as the nearby area that includes Iowa, Missouri, Kansas, and Nebraska.

The idea was starkly contrasted in the nation’s westernmost states, where fentanyl barely recorded as a cause of death. Alternatively, methamphetamine was the medicine most often linked to treatment deaths in 2017.

Generally, fentanyl performed a role in approximately 4 out of 10 fatal overdoses in 2017, more than any other medicine. For every 100,000 Americans, there were 8.7 fentanyl-related deaths that year, according to the research from the CDC’s National Center for Health Statistics.

The Medicine Included

Fentanyl, a medicine at least ten times more potent than morphine, is “phenomenally cheap per dose,” according to a new Rand Corp. report on the future of synthetic opioids. Widely used by cartels and particular sellers to improve the potency of other drugs of abuse, it was considered as a cause of death — seldom alone but usually in combination with other medicines — in 27,299 fatal overdoses across the country in 2017.

Those fentanyl-involved deaths were densely clustered in the nation’s northeastern, mid-Atlantic and upper midwestern states. Only 1,769 treatments linked to fentanyl — fewer than 7% of the national total — were published in the regions that comprise Louisiana, Arkansas, Texas, Oklahoma, Colorado, Wyoming, the Dakotas, and all of the states stretching westbound from there.

Illicit fentanyl is thought to have entered the U.S. drug supply most attractive and most settled in New England. In 2017, that region had a fentanyl-overdose death rate of 22.5 per 100,000 — about 15 times higher than the current pace entirely the western United States.

That program has already begun to change, authorities said. In 2018 and the opening months of 2019, evidence of fentanyl’s western diffusion started to develop.

Fentanyl “was rare for a minute on the West Coast,” stated Dr. Daniel Ciccarone, a physician and pharmaceutical anthropologist at UC San Francisco who analyzes courses in illicit medication use. “That’s not true anymore. We are in the resolution fields now.”

As the penalty of fentanyl tightens its grip on western states, it could usher in a new part of the opioid epidemic, he suggested. “The opioid epidemic is growing,” Ciccarone said.

The Pain Treatment

The current public health crisis can be traced to the 1990s when doctors began overprescribing opioid drugs with support from the drugs’ companies.

Through 2010, entrance to medicine pills was squeezed as professors wrote some prescriptions, abuse-resistant formulations included drugstores, and efforts to stop the alteration of pain medication to the black business were stepped up — those addicted to drugs answered with a surge in heroin use, triggering the epidemic’s second wave.

Then in 2013, universal and dangerous fentanyl started reaching American shores from Chinese labs, beginning a third wave of the opioid pandemic. A fourth wave could see fentanyl’s uptake scattered across the country, fed in part by its broader use in fastening drugs such as cocaine and methamphetamine, Ciccarone said.

The synthetic opioid, which can provide death in a non-opioid user at dosages as low as 2 milligrams, has beforehand been seen in a change of illicit drugs in the West. In improvement to being cut into cocaine and methamphetamine, it is being bootlegged into artificial tablets that look like exact replicas of medicine narcotics and anti-anxiety medicines. Ultimately, fentanyl is expected to get its way into heroin across the West.

The current study, which used death documents to glean geographic patterns of medication use, found that methamphetamine was cited as a factor in 5,241 fatal overdoses across the West in 2017. Heroin was usually the second-most-frequently cited drug on death certificates there.

Why fentanyl was slow to reach the western states is a topic of both debate and research.

Experts suggest that geographic differences in the customs of drug suppliers and users may account for the regional disparity seen in 2017. Illicit fentanyl is mostly used by drug distributors to stretch the volume or boost the potency of other drugs, most notably heroin. That appears to be relatively easy with the white-powder form of heroin that circulates throughout the eastern United States and Midwest.

But cartels operating across the western states tend to sell heroin in a form that resembles sticky black or brown tar, which is less amenable to the addition of fentanyl.

“We don’t exactly understand why powder doesn’t go out west,” said Bryce Pardo, a Rand Corp. expert on the illicit drug trade. But the fact that it has not may have protected the region, at least temporarily, from fentanyl’s deadly grip, he added. That barrier may be coming down.

A Sudden Accident

In January, California accident room doctors and county health officials documented a rash of apparent fentanyl overdoses. In Fresno, Chico and Madera Counties — all linked by Highway 99 — three died, and 16 were treated and released after snorting what they thought was cocaine.

Fentanyl is also appearing in the form of counterfeit pills sold as the prescription painkillers oxycodone and hydrocodone, as well as the anti-anxiety drug Xanax. And last year, investigators at the Food and Drug Administration dismantled a network of counterfeiters in Northern California that was turning out fake Xanax and Percocet pills with Chinese chemicals and equipment.

Meanwhile, the Drug Enforcement Agency’s Phoenix Division reported in August that it had seized more than 1.13 million illicitly manufactured fentanyl pills between October 2017 and September 2018. That was up from 380,000 such pills the previous year.

Finally, drug users’ behaviors have changed in ways that create a potential opening for fentanyl in the West. In parts of the East and Midwest, a practice called “goofball” or “speedballing” — in which drug abusers mix heroin with stimulants such as methamphetamine or cocaine — has become a popular way to achieve a more intense high.

The trend has reached the West Coast. In June 2017, experts described an upsurge in heroin use among meth users in Washington’s King County.

“If it’s happening in Seattle, it’s happening here in San Francisco,” Ciccarone said.

As drug distributors cut fentanyl into all the drugs that make up a goofball’s cocktail, deadly overdoses could increase. For people who do not typically use opioid medicines and have not developed a tolerance for them, the result of a double fentanyl exposure could be a rapid death.

Final Words

A database of medication death in California prescribes that fentanyl’s expanded residence is already being felt in the state. In 2018, fatal opioid overdoses linked to fentanyl grew to 743 from 429 in 2017, representing close to a third of the state’s 2,311 opioid-related deaths.

“Fentanyl is still taking off — we haven’t seen that cycle mountain yet,” Ciccarone told. But if current trends remain, he said, the result could be “offensive.”

“Once fentanyl gains a foothold, it appears intelligent of sweeping through a market in a few years,” Pardo and his team of Rand researchers terminated. “The U.S. synthetic opioid difficulty is not yet remarkably national in extent. Some regions west of the Mississippi have been less precious to date. Those operations should be seen as a high prospect of a worsening puzzle.”