How Toxicology Revealed Fentanyl Behind New York City's Overdose Surge, 2000–2017

Unintentional drug overdoses killed about 70,000 people in the United States in 2017. Much of the rise came from illicitly manufactured fentanyl — a synthetic, short-acting opioid 50 to 100 times as potent as morphine — mixed into heroin, cocaine and counterfeit pills, sometimes without users knowing.

Nationally, it's hard to measure fentanyl's role: testing for it isn't standardized, death certificates list it inconsistently, and at least 15% of overdose death certificates don't name any drug. New York City does better by linking death certificates with toxicology results from the city's Office of the Chief Medical Examiner. The city's health department described what that revealed.

The numbers

• Among 10,673 fatal overdoses from 2000 to 2014, 7,822 (73%) involved an opioid, and fentanyl was involved in 246 (2% of all overdose deaths).
• Starting in 2015, fentanyl's share climbed steeply:

• From 2014 to 2017 the rate of fentanyl-involved deaths rose almost 3,000%, from 0.4 to 12.1 per 100,000, driving an 81% rise in the overall overdose death rate, from 11.7 to 21.2 per 100,000 — the highest since this tracking began in 2000.
• In 2017 fentanyl was involved in 69% of heroin-involved deaths (531), 53% of cocaine-involved deaths (387), and 39% (146) of deaths involving cocaine without heroin.

Number of overdose deaths and percentage involving fentanyl, New York City, 2000–2017. Figure from the report.

Spotting the surge

The medical examiner tested all overdose cases for fentanyl from 2000 to 2012, but universal testing was suspended from late 2013 until July 2016, so how many deaths were tested in that period is unknown. Even so, the health department first detected a rise in fentanyl-involved deaths in October 2015 — by 2015 the share with fentanyl found already exceeded that of the years of universal testing — and issued a health advisory in April 2016. Working with the health department, the medical examiner restored universal fentanyl testing by July 1, 2016. The department also worked to have death certificates name specific drugs ("fentanyl," not just "opioid").

Responding

With fentanyl involved in about half of the city's overdose deaths by 2016, the department went beyond advisories to clinicians (April and October 2016). It reached out neighborhood by neighborhood to syringe services programs and others serving people who inject drugs, advising them to:

1. avoid using alone;
2. start with a small amount;
3. carry naloxone;
4. avoid mixing drugs.

Rapid responders handed out flyers and fact sheets in neighborhoods with more fentanyl deaths.

Lessons for other places

• Monthly overdose surveillance made timely detection possible; routine toxicology testing made it possible to measure fentanyl's role.
• Where toxicology data aren't available, health authorities can work with medical examiners and coroners to put specific drug names on death certificates.
• Nationally, deaths involving synthetic opioids rose about 45% from 2016 to 2017, so systematic fentanyl testing and targeted prevention education matter everywhere.

Limitations: fentanyl deaths may be undercounted for 2013–2016, when testing was not universal; and the data can't separate illicit from pharmaceutical fentanyl — though stable prescribing and soaring law enforcement seizures suggest illicit fentanyl drove the increase.

Sources

• Colon-Berezin C, Nolan ML, Blachman-Forshay J, Paone D. "Overdose Deaths Involving Fentanyl and Fentanyl Analogs — New York City, 2000–2017." Morbidity and Mortality Weekly Report 68(2), Centers for Disease Control and Prevention.