Increases in self-reported fentanyl use among a population entering drug treatment: The need for systematic surveillance of illicitly manufactured opioids

Highlights

• Total fentanyl abuse increased modestly from 2012 to 2016.

• Abuse of branded fentanyl products remained stable over the study period.

• Abuse of ‘unknown’ fentanyl presumed to be illicit fentanyl significantly increased.

Abstract

Background/purpose

Recent reports indicate a sharp increase in fentanyl-related overdose deaths across the United States, much of which is likely related to the introduction of cheap, illicitly manufactured fentanyl derivatives. In this study, we sought to estimate the magnitude of illicit fentanyl use from 2012 to 2016 using a national opioid abuse surveillance system.

Methods

The study program surveyed 10,900 individuals entering substance abuse treatment for opioid use disorder, with participants asked to endorse past month ‘use to get high' of fentanyl drugs, stratified by identifiable (i.e., branded) fentanyl formulations or a ‘type unknown' drug alleged to contain fentanyl.

Main findings

Total past-month fentanyl-use rose modestly from 2012 to 2016. While use of known fentanyl products remained relatively stable (mean = 10.9%; P = 0.25), endorsements of ‘unknown’ fentanyl products nearly doubled from 9% in 2013 to 15.1% by 2016 (P < 0.001). Data show no discernable indication that this increase is diminishing or stabilizing.

Conclusions

This first attempt to assess the prevalence of illicit fentanyl use shows that recent increases in fentanyl use seem to be due almost entirely to ‘unknown' fentanyl presumed to be illicitly manufactured. Given that it is difficult to assess the extent to which fentanyl may have been substituted for another drug (i.e., oxycodone, alprazolam, etc.) or was used as a heroin admixture, our data likely represent an underestimation of the full magnitude of illicit fentanyl abuse. As such, this growing public health problem requires immediate attention and more systematic efforts to identify and track its abuse.

Introduction

There has been a substantial increase in overdose deaths that are at least partially attributable to fentanyl and/or its closely related synthetic derivatives (CDC, 2015, Gladden et al., 2016, Peterson et al., 2016) in recent years across the United States. Since, according to the Centers for Disease Control (CDC), the number of prescriptions written and filled for fentanyl products has remained relatively constant over the past five years (Peterson et al., 2016), it is unlikely that an increase in diversion from a static therapeutic pool can explain the observed increases in use of fentanyl products over the past several years. Rather, there are reports that newly synthesized fentanyl, in a variety of analogues (e.g., carfentanyl, acryl fentanyl), is being sold as a standalone product (i.e., tablet or powder), as an additive to increase the potency of heroin at little cost, or as a substitute ingredient for more expensive sedative-hypnotic and opioid drugs such as alprazolam, oxycodone and hydrocodone (Coopman et al., 2016, DEA, 2015a, DEA, 2015b, Lucyk and Nelson, 2017).

Given the widespread claim that inexpensively synthesized fentanyl has become a major problem, with considerable mortality, it is surprising that the depth and magnitude of the “epidemic” and time-related trends in its severity are largely unknown. The reason for this is fairly straightforward. Most large scale, national surveillance systems do not track or inquire about illicitly manufactured synthetic opioids because they do not distinguish drugs by individualized products. Some provide write-in options, but these gather very limited amounts of data (e.g., NSDUH 2014 had just 4 write-ins for fentanyl). More importantly, there is no practical way to distinguish between authentic and illicitly manufactured fentanyl, or whether illicit fentanyl was used in counterfeit drugs sold as oxycodone, hydrocodone or alprazolam, without chemically analyzing these products – a formidable and nearly impossible task on a nationally representative level. Consequently, most of what we know about the increase in the use of licit and illicit fentanyl products in the last few years stems from anecdotal case reports, analyses of drug overdose deaths or warnings issued by regulatory agencies (Arens et al., 2016, Armenian et al., 2017, CDC, 2015, Coopman et al., 2016, DEA, 2015a, DEA, 2015b, Gladden et al., 2016, Green and Gilbert, 2016, Kansas Bureau of Investigation, 2016, Lucyk and Nelson, 2017, Peterson et al., 2016).

We utilized data from a well-established post-marketing surveillance system that, unlike other national surveillance programs, is focused on systematically tracking the use of various categories of opioids, including fentanyl products stratified by known brands identifiable by their unique properties (e.g., color, size, engraved markings, etc.) or products thought to be fentanyl but not identified by any brand (i.e., characterized as “type unknown”). In order to assess, albeit indirectly, the extent to which illicit fentanyl has entered the pool of opioids on the black market, our analysis assumes that products known to the respondent as illicit fentanyl would be captured through “type unknown” endorsements, realizing that the presence of illicit fentanyl as a heroin additive or in a counterfeit drug would not. While this is a recognized limitation, our approach is the only logical approach at this point in time.

A sample of treatment-seeking individuals with an opioid use disorder was selected for this analysis because they are highly experienced and acutely aware of the availability and quality of opioid drugs in their catchment area. Thus, while generalizability to the entire opioid using population is a limitation of this approach, we can at least provide an estimate of the degree to which the use of branded and non-branded fentanyl products has changed over time in a well-defined population of experienced users.