The Fentanyl-Tainted Drug Supply Requires EDs to do More

A middle-aged male found at the bottom of stairs, mild abrasion to his head. Pinpoint pupils and unresponsive. Improved mental status post-naloxone.

A 60-year-old male patient found unresponsive alongside his friend in a subacute rehab facility. Status for both post-naloxone: alert and oriented.

A 19-year-old female found in respiratory distress. She was given naloxone in the field and became hyperactive, tachycardiac, and hypertensive.

And a 43-year-old man found by his neighbors, with altered mental status and barely breathing, given naloxone in the field. He was here yesterday for the same thing.

These were 4 of the patients I cared for in just 2 weeks at my busy emergency department in New York City. They all had something in common beyond receiving naloxone: They admitted to using crack cocaine and denied intentionally using opiates. Yet when first responders found them, they were in acute opiate overdoses. Four self-admitted crack cocaine users — all accidentally overdosed on opiates.

It’s clear that the scourge of fentanyl has taken a new deadly turn.

Fentanyl’s widespread infiltration of the black-market opiate supply has been a devastating phenomenon that emergency physicians have been battling for years in both urban and rural communities.^1,2 But as my recent experiences demonstrate, fentanyl is increasingly ending up in other drug supplies, presenting a new threat to patients who use recreational drugs.

Between 2010 and 2014, the rates of cocaine overdose deaths in New York City were relatively stable, but between 2015 and 2016 the rates increased significantly. Whereas fentanyl was involved in only 0.7% of cocaine-related overdose deaths in the first half of 2010, that percentage jumped to 48% during the second half of 2016. Researchers found that this increase in fentanyl’s contribution to cocaine overdose deaths accounted for 90% of the overall increase in cocaine overdoses during their study period of 2010 to 2016.³ According to federal data, the prevalence of fentanyl’s involvement in cocaine overdose deaths has continued to rise sharply since then.⁴

The ever-growing frequency of patients presenting to the emergency department with fentanyl overdoses — and fentanyl’s surging presence in cocaine and other black-market drugs — demands that we, as emergency medicine providers and front-line stewards of public health, do more to protect our patients and our communities.

Drugs are not inherently good or bad. It’s nearly impossible to imagine getting through a trauma shift without relying on fentanyl to treat patients. When it is pure and the potency is clearly marked on the bottle, fentanyl is an extremely reliable way to alleviate immense pain and suffering. However, when fentanyl finds its way into the illicit drug supply and into the bodies of unsuspecting consumers, it can easily lead to death. Without knowing if it is present in their drug supply, and in what concentration, users don’t know how much to consume at one time, drastically increasing the risk of overdose.

Fentanyl is a perfect embodiment of the unintended, yet inevitable, dangers of prohibition. Because of heroin’s illegal status, drug traffickers are tasked with smuggling a highly criminalized product from its country of production to its country of consumption. This provides motivation to find the most potent product: The more potent the drug, the smaller its volume, and the easier it is to move while evading detection. Thus, this market shift from less potent and more bulky heroin to the more powerful, less voluminous fentanyl is one that prohibition encourages. And the shift from heroin to fentanyl has had profound impacts on our emergency departments and the lives of our patients.

The doses of fentanyl that we use in medicine are measured in micrograms, an order of magnitude smaller than the milligrams that doses of heroin are measured in. Commonly cited as being 50 times more potent than heroin, when even the smallest amounts of fentanyl find their way into the illicit drug supply, it can lead to fatal overdoses.⁵

While fentanyl has likely been present in the heroin supply for decades, in 2013 the DEA started to see a sharp rise in the percent of seized heroin samples testing positive for fentanyl. In 2014, the DEA seized 5,343 drug samples that tested positive for fentanyl. By 2015, that number jumped to 13,882.⁶ It was also in 2014 that the DEA noted that many prescription pills available on the black market were counterfeits and contained fentanyl.⁷ Previously, many recreational drug users would rely on buying pills — be it Percocet or Oxycodone or even benzodiazepines — as a safer option; they knew what drug they were getting and its strength. But the rise in fentanyl-tainted counterfeit pills completely upended that harm reduction approach, leading to innumerable accidental overdose deaths.

Now fentanyl and related compounds are blamed for up to 150 overdose deaths a day in the United States.⁸ Fentanyl analogs are being increasingly identified in the drug supply. Drugs like acetylfentanyl, furanylfentanyl, carfentanil, and the ominous-sounding U-47700 belong to a broad class called synthetic opiates, and some are many times more potent than fentanyl.⁹ Whereas fentanyl is thought to be 100 times as potent as morphine, carfentanil is thought to be 10,000 times as potent.¹⁰

In 2020 alone, 56,000 deaths were attributed to fentanyl and other synthetic opiates, representing 82% of all opiate overdose deaths. Overdoses attributed to synthetic opiates increased by 56% in just one year, from 2019 to 2020. Compared to 2013, in 2020 there were 18 times as many overdose deaths attributed to synthetic opiates.⁴

When fentanyl first started infiltrating the opiate supply in greater numbers, many long-time users lamented this change, preferring the heroin that they were used to, given its more predictable effects and longer duration of action.¹¹ But a shift has occurred over the past several years with recreational opiate users now often seeking out fentanyl for its more intense high.¹² This change in preference has large implications for the health and safety of users, as the shorter duration of action leads to more frequent consumption. Increased frequency of use and increased potency deepens users’ tolerance and degree of physical dependency, resulting in more agonizing withdrawals. For first responders and front-line providers, this potency also means that the doses of naloxone required to reverse an overdose are often far greater than what we are used to.

Investigators are beginning to study ED patients who use recreational opiates to assess the prevalence of fentanyl in the illicit drug supply. A study published in 2018 looked at patients of an urban, New England-based emergency department who presented after receiving naloxone for presumed opiate overdose.¹³ All participants reported seeking heroin, and zero participants reported intentionally seeking fentanyl. All but one of the participants’ urine samples tested positive for fentanyl. The presence of the even more potent fentanyl analog acetylfentanyl was found in 30% of the urine samples, whereas the less potent yet less tested and understood analog, U-47700, was found in 7% of the urine samples. Of those testing positive for fentanyl, 55% correctly self-identified their drug as containing fentanyl, 31% were unsure if their drug contained fentanyl, and 14% incorrectly thought their drug contained no fentanyl. In 2020, researchers reported that 91% of self-identified recreational opiate users presenting to a medium-sized urban emergency department preferred heroin, while only 4% reported a preference for fentanyl. Despite this, of the participants who provided urine samples, 81% tested positive for fentanyl.¹⁴

While it is easy as emergency medicine providers to become cynical about the challenge of opiate addiction and see our patients as being reckless with their health, it is imperative that we understand that these patients want to stay safe as much as any of our other patients. In the absence of strong harm reduction messaging from the government, community leaders, and health-care providers, drug users and their advocates are filling this gap by coming up with new harm reduction strategies and disseminating them among their community. Through tactics like switching from injecting to smoking or sniffing, taking test shots (using a much smaller amount initially to see how potent it is before increasing their dose), injecting very slowly, and asking their friends about the potency of a new batch before consuming, opiate users are doing their best to adapt to the unpredictability of the illicit opiate supply.¹⁵

Deadly overdoses from recreational opiate use are not inevitable, and we don’t have to wait until an overdose has already occurred before we can help our patients. We can educate ourselves about fentanyl, about the specifics of drug use, and about harm reduction. The growing number of emergency departments that provide naloxone kits to patients who use drugs is an encouraging and life-saving new trend.¹⁶ But we should not stop there. We can encourage our leadership to start providing fentanyl test strips to our patients, helping to prevent overdoses instead of merely responding to them.

Fentanyl test strips allow users to detect the presence of fentanyl by dissolving a small amount of their drug in water, into which the test strip is dipped. These strips are a low-cost harm reduction strategy supported by the Center for Disease Control (CDC) and are becoming increasingly available at harm reduction and needle exchange organizations throughout the United States.¹⁷ Signaling the positive impact on public health and rates of fatal overdoses that these test strips can engender, the CDC and the Substance Abuse and Mental Health Services Administration announced in 2021 that their grant funds can now be used to purchase fentanyl test strips.¹⁸

However, there is skepticism about these test strips among many who work in the emergency department. In light of the tragic consequences of opiate addiction that we face shift after shift and the ways we observe that opiates seem to hijack our patients’ free will, one might think that these strips will do little to impact our patients’ behavior. If our patients are routinely chasing the highest high, will knowing that their drug contains fentanyl truly lead to less overdoses?

As is often the case in the world of medicine, it is best to listen to and learn from our patients directly. Significant research is starting to be published exploring the attitudes of recreational opiate users on fentanyl test strips and their impact on behavior. One study investigated clients of a harm reduction service in North Carolina who had previously used fentanyl test strips.¹⁹ Of the respondents who reported detecting fentanyl in their most recent batch of opiates, 43% reported subsequent changes in their drug consumption. Changes in behaviors included using less of the drug at one time, snorting instead of injecting, injecting the drug more slowly, and throwing out that batch. Furthermore, 77% reported that the availability of fentanyl test strips increased their sense of protection against overdoses.

In a study surveying young people in Rhode Island who recreationally used opiates or cocaine and were subsequently trained in how to use fentanyl test strips, 70% reported concern that their drug supply may have fentanyl, 95% stated that they plan to use fentanyl test strips when given the chance, and 71% thought that their friends who also use drugs would be interested in using these strips.²⁰ In this study, 38% of respondents who had a positive test result engaged in subsequent harm reduction strategies.²¹

While most fentanyl test strips are distributed by harm reduction organizations, more and more emergency departments are also starting to supply them. One hospital in Chicago started including fentanyl test strips alongside naloxone in its take-home opiate overdose prevention kits, which are distributed by an ED pharmacist who also provides overdose education. The results of a pilot study that focused on this initiative supported the feasibility of such ED-based fentanyl distribution programs and again found that, when confronted with a positive test result, patients altered their behaviors to reduce their exposure to harm.²²

The substantial individual and community-wide harms that can be caused by a tainted illicit drug supply demand innovative solutions and bold advocates who are willing to speak up on behalf of one of the most marginalized populations we serve. As emergency physicians, we are uniquely equipped with the skills and experiences that lend credence to our voices, prompting decision-makers to pay attention when we sound the alarm about growing public health crises like fentanyl overdoses.

We can use our experiences and hard-earned expertise to not only help the patient in front of us, but also to create societal and policy-level changes to improve public health. We can, and we must, start by insisting that our emergency departments become disseminators of harm-reduction knowledge and supplies. Handing out naloxone kits is a meaningful start, and distributing fentanyl test strips is the logical, and critical, next step.

References

1. Substance Abuse and Mental Health Services Administration. (2022). Drug Abuse Warning Network: Findings from Drug-Related Emergency Department Visits, 2021 (HHS Publication No. PEP22-07-03-002). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/.
2. Vivolo-Kantor, A. M., Seth, P., Gladden, R. M., Mattson, C. L., Baldwin, G. T., Kite-Powell, A., & Coletta, M. A. (2018). Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses - United States, July 2016-September 2017. MMWR. Morbidity and mortality weekly report, 67(9), 279–285.
3. Nolan, M. L., Shamasunder, S., Colon-Berezin, C., Kunins, H. V., & Paone, D. (2019). Increased presence of fentanyl in cocaine-involved fatal overdoses: implications for prevention. Journal of Urban Health, 96, 49-54.
4. CDC/NCHS, National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department of Health and Human Services, CDC; 2021. https://wonder.cdc.gov/
5. O’Donnell, J. K., Halpin, J., Mattson, C. L., Goldberger, B. A., & Gladden, R. M. (2017). Deaths involving fentanyl, fentanyl analogs, and U-47700—10 states, July–December 2016. Morbidity and Mortality Weekly Report, 66(43), 1197.
6. Centers for Disease Control and Prevention. (n.d.). Reported law enforcement encounters testing positive for fentanyl increase across US. Centers for Disease Control and Prevention. Retrieved August 9, 2023, fromhttps://www.cdc.gov/drugoverdose/data/fentanyl-le-reports.html
7. Drug Enforcement Administration. (2016). Counterfeit prescription pills containing fentanyls: A global threat. US Department of Justice. Retrived August 9, 2023, from https://www.dea.gov/sites/default/files/docs/Counterfeit%2520Prescription%2520Pills.pdf
8. National Center for Health Statistics. (n.d.). Provisional drug overdose death counts. Centers for Disease Control and Prevention. Retrieved August 9, 2023, from https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
9. O’Donnell, J. K., Halpin, J., Mattson, C. L., Goldberger, B. A., & Gladden, R. M. (2017). Deaths involving fentanyl, fentanyl analogs, and U-47700—10 states, July–December 2016. Morbidity and Mortality Weekly Report, 66(43), 1197.
10. O’Donnell, J., Gladden, R. M., Mattson, C. L., & Kariisa, M. (2018). Notes from the field: overdose deaths with carfentanil and other fentanyl analogs detected—10 states, July 2016–June 2017. Morbidity and Mortality Weekly Report, 67(27), 767.
11. Carroll, J. J., Marshall, B. D. L., Rich, J. D., & Green, T. C. (2017). Exposure to fentanyl-contaminated heroin and overdose risk among illicit opioid users in Rhode Island: A mixed methods study. The International journal on drug policy, 46, 136–145.
12. Edwards, E. (2022, August 7). Once feared, illicit fentanyl is now a drug of choice for many opioid users. NBC News. https://www.nbcnews.com/health/health-news/feared-illicit-fentanyl-now-drug-choice-many-opioids-users-rcna40418
13. Griswold, M. K., Chai, P. R., Krotulski, A. J., Friscia, M., Chapman, B., Boyer, E. W., ... & Babu, K. M. (2018). Self-identification of nonpharmaceutical fentanyl exposure following heroin overdose. Clinical Toxicology, 56(1), 37-42.
14. Bach, H., Jenkins, V., Aledhaim, A., Moayedi, S., Schenkel, S. M., & Kim, H. K. (2020). Prevalence of fentanyl exposure and knowledge regarding the risk of its use among emergency department patients with active opioid use history at an urban medical center in Baltimore, Maryland. Clinical Toxicology, 58(6), 460-465.
15. Mars, S. G., Ondocsin, J., & Ciccarone, D. (2018). Toots, tastes and tester shots: user accounts of drug sampling methods for gauging heroin potency. Harm reduction journal, 15(1), 1-10.
16. Ramdin, C., Chandran, K., Nelson, L., & Mazer-Amirshahi, M. (2023). Trends in naloxone prescribed at emergency department discharge: A national analysis (2012–2019). The American Journal of Emergency Medicine, 65, 162-167.
17. Centers for Disease Control and Prevention. (n.d.) Fentanyl test strips: A harm reduction strategy. Center for Disease Control and Prevention. Retrieved August 9, 2023 from https://www.cdc.gov/stopoverdose/fentanyl/fentanyl-test-strips.html
18. Centers for Disease Control and Prevention. (2021, April 7). Federal grantees may now use funds to purchase fentanyl test strips. Centers for Disease Control and Prevention. https://www.cdc.gov/media/releases/2021/p0407-Fentanyl-Test-Strips.html
19. Peiper, N. C., Clarke, S. D., Vincent, L. B., Ciccarone, D., Kral, A. H., & Zibbell, J. E. (2019). Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States. International Journal of Drug Policy, 63, 122-128.
20. Krieger, M. S., Yedinak, J. L., Buxton, J. A., Lysyshyn, M., Bernstein, E., Rich, J. D., ... & Marshall, B. D. (2018). High willingness to use rapid fentanyl test strips among young adults who use drugs. Harm Reduction Journal, 15, 1-9.
21. Krieger, M. S., Goedel, W. C., Buxton, J. A., Lysyshyn, M., Bernstein, E., Sherman, S. G., ... & Marshall, B. D. (2018). Use of rapid fentanyl test strips among young adults who use drugs. International Journal of Drug Policy, 61, 52-58.
22. Lima, R. A., Karch, L. B., Lank, P. M., Allen, K. C., & Kim, H. S. (2022). Feasibility of Emergency Department–based Fentanyl Test Strip Distribution. Journal of Addiction Medicine, 16(6), 730-732.