A rigorous effort to track overdose deaths in the US and the drugs that caused them offers a snapshot of a fentanyl epidemic on the verge of a westward shift.
A study released Friday by the Centers for Disease Control and Prevention shows synthetic opioid. cutting a track of death and destruction in the northeastern United States and the industrialized Midwest in 2017. That year, fentanyl was the most cited drug as a cause of fatal overdoses in the five eastern Mississippi River regions, as well as in the neighboring region including Iowa, Missouri. , Kansas and Nebraska.
The picture was totally different in the western states of the country, where fentanyl was barely registered as a cause of death. Instead, methamphetamine was the drug most often associated with overdose deaths in 2017.
Nationwide, fentanyl played a role in nearly 4 out of 10 fatal overdoses in 2017, more than any other drug. For every 100,000 Americans, there were 8.7 fentanyl-related deaths that year, according to the study by the CDC National Center for Health Statistics.
Fentanyl, a drug at least 10 times more powerful than morphine, is "phenomenally cheap per dose," according to a recent study. Rand Corp. Report about the future of synthetic opioids. Widely used by drug cartels and drug dealers to increase the potency of other drugs of abuse, it has been cited as a cause of death – sometimes alone but often in combination with other drugs – in 27,299 fatal overdoses nationwide in 2017.
These fentanyl-related deaths were densely concentrated in the northeastern, central Atlantic, and midwestern states of the country. Only 1,769 fentanyl-related overdoses – less than 7% of the national total – were recorded in regions including Louisiana, Arkansas, Texas, Oklahoma, Colorado, Wyoming, Dakotas and all states extending west from there.
Illicit fentanyl is thought to have penetrated the US drug supply earlier and harder in New England. In 2017, this region had a fentanyl overdose mortality rate of 22.5 per 100,000 – about 15 times higher than the prevailing rate in the western United States.
That picture has already begun to change, experts said. In 2018 and the opening months of 2019, evidence began to emerge of fentanyl diffusion to the west.
Fentanyl "was rare for a minute on the west coast," he said. Dr. Daniel Ciccarone, physician and medical anthropologist at UC San Francisco who studies trends in illicit drug use. "That's not true anymore. We're in the extermination camps now.
As the scourge of fentanyl seizes western states, it could kick off a new chapter in the opioid epidemic, he warned.
"The opioid epidemic is maturing," said Ciccarone.
The current public health crisis can be traced back to the 1990s, when doctors began prescribing opioid narcotics with the encouragement of drug manufacturers.
In 2010, access to pills was reduced as doctors wrote fewer prescriptions, abuse-resistant formulations reached pharmacies, and efforts to prevent diversion of painkillers into the black market intensified. Opiate addicts responded with an increase in heroin use, triggering the second wave of the epidemic.
Then, in 2013, cheap and deadly fentanyl began to reach the American shores of Chinese laboratories, launching a third wave of the opioid epidemic. A fourth wave may see fentanyl uptake spread across the country, fueled in part by its broader use in combating drugs such as cocaine and methamphetamine, Ciccarone said.
Synthetic opioid, which can cause death in a non-opioid user at doses as low as 2 milligrams, has been seen in a variety of illicit drugs in the West. In addition to being cut into cocaine and methamphetamine, it is being pressed into counterfeit pills that look like exact replicas of prescription narcotics and anti-anxiety medications. Eventually, fentanyl is expected to reach heroin in the West.
The new study, who used death certificates to gather geographic patterns of drug use, found that methamphetamine was cited as a factor in 5,241 fatal overdoses in the West in 2017. Heroin was generally the second most cited drug in death certificates in the country.
Why fentanyl was slow to reach western states is a topic of debate and research.
Experts suggest that geographic differences in the customs of drug suppliers and drug users may be responsible for the regional disparity observed in 2017. Illicit fentanyl is widely used by drug distributors to increase the volume or potency of other drugs, especially heroin. This seems to be relatively easy with the white powdered form of heroin that circulates throughout the eastern United States and the Midwest.
But cartels operating in western states tend to sell heroin in a way that resembles sticky black or brown tar, less favorable to the addition of fentanyl.
"We don't understand exactly why the dust doesn't go west," he said. Bryce Pardo, Rand Corp. Specialist in the illicit drug trade. But the fact that it did not protect the region, at least temporarily, from the deadly claws of fentanyl, he added.
This barrier may be falling.
In January, California first-aid physicians and county health officials documented a rash of apparent overdose of fentanyl. In Fresno, the counties of Chico and Madera – all linked by Highway 99 – three died and 16 were treated and released after sniffing what they thought was cocaine.
Fentanyl also appears in the form of fake pills sold as prescribed painkillers oxycodone and hydrocodone, as well as the anti-anxiety drug Xanax. And last year, researchers from the Food and Drug Administration dismantled a network of counterfeiters in northern California, which produced fake Xanax and Percocet pills with Chinese products and equipment.
Meanwhile, the Phoenix Division of the Drug Enforcement Agency reported in August that it had seized over 1.13 illegally manufactured fentanyl pills between October 2017 and September 2018. This number exceeded 380,000 of these pills in the previous year.
Finally, drug users' behaviors have changed to create a potential opening for fentanyl in the West. In parts of the East and Midwest, a practice called "play" or "fastball" – in which drug users mix heroin with stimulants like methamphetamine or cocaine – has become a popular way to reach a higher level.
The trend has reached the west coast. In June 2017, experts described a increase in heroin use among methamphetamine users in King County, Washington.
"If it's happening in Seattle, it's happening here in San Francisco," said Ciccarone.
As drug distributors cut fentanyl in all drugs that make up a goofy cocktail, deadly overdoses may increase. For people who normally do not use opioid drugs and have not developed tolerance, the result of double exposure to fentanyl can be a rapid death.
A California drug death database suggests that the growing presence of fentanyl is already being felt in the state. By 2018, fentanyl-related fatal opioid overdoses increased from 429 to 743 in 2017, representing almost a third of the state's 2,311 opioid-related deaths.
"Fentanyl is still taking off – we haven't seen this peak cycle yet," said Ciccarone. But if current trends continue, he said, the result could be "horrible."
It's a terrible warning echoed by a report by Rand Corp.
"When fentanyl is established, it seems likely to sweep the market in a few years," concluded Pardo and his team of Rand researchers. “The problem of US synthetic opioids is not yet truly national in scope. Some regions west of Mississippi have been less affected so far. These areas should be seen as at high risk of an aggravation of the problem. "