By Rose Hoban
Even as the number of heroin overdoses ticked up in 2016, the number of deaths tied to the powerful opiate fentanyl skyrocketed in North Carolina at the same time.
According to a report released this month by the North Carolina Department of Health and Human Services, overdose deaths related to fentanyl increased by 93 percent in 2016.
“It’s rising very quickly,” said study co-author Alison Miller, an epidemiologist who works at the Office of the Chief Medical Examiner, which is part of DHHS. She said that even since the release of their report on April 3, her office had completed the toxicology reports on several deaths and found they were related to fentanyl analogues.
They revised the number upwards.
Fentanyl is a powerful opiate, usually used for surgery or cancer pain, and is anywhere from 30 to 100 times stronger than morphine. It’s also become a common additive to heroin to make it stronger.
“A kilo of heroin coming across the border is about a thousand dollars,” said Scott Proescholdbell, who works with the Injury and Violence Prevention Branch of DHHS. Much of the heroin used in North Carolina comes from Mexico, as well as from China.
But there’s a powerful incentive to import fentanyl, too.
“A kilo of fentanyl is about a million dollars,” Proescholdbell said.
In the past, fentanyl appeared in the community in the form of slow-release Duragesic skin patches used for people with serious long-standing pain. Some folks found ways to extract and abuse the drug contained in the patch.
But in just the past few years, illicitly manufactured forms of fentanyl, or fentanyl analogues, have been appearing in the toxicology reports of people who’ve died from overdoses. That’s been the case in North Carolina, which saw the appearance of illicit fentanyl analogues as a heroin additive in late 2015.
Illicit fentanyls were in other parts of the country as early as 2013 and 2014, as detailed in a separate report written by researchers from Massachusetts and published in early April by the Centers for Disease Control and Prevention.
“I always get nervous when I see something in the Northeast or the West,” said Proescholdbell. “We’re always about two years behind.”
According to Miller, the number of deaths related to fentanyl analogues in 2016 was 165. That tally is provisional, she said, as the toxicology reports haven’t come back on all the cases yet. She wrote that the medical examiner’s toxicology lab can test for more than 600 compounds during an autopsy.
But some of the analogues are so new that toxicologists have to invent ways to identify them as they go.
“They’ve taken the parent drug and modified it to stay ahead of the laws, or provide a more potent product,” said Chief Medical Examiner Deborah Radisch. “Whatever the reason… it could be whatever chemicals they have in their lab determines what analogue they manufacture.”
“Change a molecule and they’re OK, they’re within legal limits,” Miller added.
That’s why a bill slowly making its way through the North Carolina legislature adds many drug analogues to the list of illegal, controlled substances. That bill has a section dedicated solely to fentanyl analogues, making them illegal and subject to stiffer penalties for use and possession.
“Furanyl fentanyl is more common, but come back in two months, and that could change,” Miller said. “We have one we can’t even pronounce that’s just starting up and nationally Carfentanil is more prevalent.”
She said different parts of the state might even have different fentanyls showing up in the local heroin.
“We saw Acetyl Fentanyl a year ago, we don’t know what we’ll see next,” Miller said. “It depends on what people are doing.”
And the numbers of deaths are rising so quickly, it’s starting to backlog the work at North Carolina’s nine medical examiner sites. The state autopsies anyone suspected to have died as a result of overdose and right now that accounts for about 55 percent of the autopsies.
“Last year we were at 115 a month and now average is closer to 140, 145 a month,” Miller said. “That’s a significant increase.”
Use of opiate-reversal drug naloxone has become more accepted over the past decade as law enforcement agencies, social service agencies and even the state health director have promoted its use as a harm reduction agent.
People in the recovery community say, “Dead people can’t find recovery,” and promote naloxone use for people who are using heroin and other intravenous drugs to keep them alive until they’re ready to quit.
But with fentanyl, that chance might not come. Usually, a heroin overdose can be reversed with one or two doses of naloxone. But when fentanyl is in the mix, it can take a half dozen doses to get someone to wake up.
If they wake up at all.
“They’re found dead with paraphernalia around them, or a needle still in their arm,” Radisch said.
She said most of the time, users have an idea of how much they need in order to get high.
“But they’re basing what they know about their dose on heroin,” she said. “And then they’re sold something with fentanyl, they end up dead because of the increased potency.”