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Heroin combined with fentanyl is driving overdose crisis in US
Liz Highleyman, 2017-05-24 18:10:00
New sources of heroin and increasing adulteration with
fentanyl and other stronger analogues are contributing to a growing epidemic of
opioid overdose deaths in several regions of the US, researchers reported at
the 25th International Harm Reduction Conference (HR17) last week in Montréal.
heroin-related overdoses rose by 8% annually from 2006 to 2013, according to
of the University of California San Francisco. But the increase was as high as 50% in some states in Appalachia and
the Southeast, and 30 to 40% in the Northeast and Atlantic Seaboard regions.
For the past decade the US has been in the throes of
an opioid epidemic, largely
concentrated in suburban and rural areas. In January the Centers for Disease Control and Prevention (CDC)
reported that drug overdose
deaths, mainly due to prescription pain relievers and heroin, accounted for
more than 28,000 deaths in 2014, exceeding deaths from motor vehicle accidents
and gun homicides combined. In addition to overdose deaths, the epidemic has
also led to outbreaks of HIV and hepatitis C.
For the Heroin In Transition (HIT) study, Ciccarone
and Jay Unick of the University of Maryland looked at government data from the
US Drug Enforcement Administration (DEA) and National Forensic Laboratory
Information System, which show changes in heroin supply, formulations and
contamination. They also analysed healthcare databases to assess national and
regional trends in heroin-related overdoses, hospitalisations and deaths.
Law enforcement seizures of fentanyl rose 134% from
2009 to 2014, Ciccarone reported. In contrast to the dramatic increase east of
the Mississippi River, the overdose rate has been roughly stable on the West
Coast because it has not seen a big influx of fentanyl like other parts of the
country, he said.
This fentanyl is generally clandestinely produced
using precursors from China, not diverted pharmaceutical fentanyl, according to
the DEA. Agencies are also increasingly seeing other related synthetic opioids – some of which are even stronger – including acetyl fentanyl, furanyl fentanyl and the
animal tranquiliser carfentanil.
Typically drug users intend to purchase heroin and
unknowingly get products contaminated with fentanyl, Ciccarone said. Because
fentanyl is so much stronger than pure heroin – around 30 to
40% stronger by weight – people
injecting what they think is their usual dose are at risk of fatal overdose. Another study presented at the conference showed around 80% of
tested drug samples at a Vancouver supervised injection site contained
Drug 'signature' studies revealed that Mexico has
displaced Colombia as the major source of heroin flowing to states in the
Midwest, New England and the Southeast. Solid black or brown 'tar' heroin from
Mexico has long been common on the West Coast, but the new Mexican heroin is a
light-coloured powder similar to the Colombian product that previously
predominated in the east. Furthermore, an increasing proportion of seized heroin is coming from
unknown sources, Ciccarone said.
New Mexican-sourced heroin, novel formulations with
likely adulteration, and the rise of fentanyl and other stronger heroin
analogues "makes heroin use more unpredictable and deadly than ever before,"
the researchers concluded.
Ciccarone argued that the opioid epidemic should be
treated less as a drug epidemic and more as a poisoning epidemic, warranting
more proactive surveillance and testing of drugs themselves – not just people who use drugs. He also urged faster
response to overdose by making naloxone widely available to people who use
drugs and their loved ones, more harm reduction services and more
evidence-based treatment for drug addiction.
"If synthetic opioids are
in fact becoming the new norm in terms of distribution and consumption, then
drug checking and supervised injection sites ought to become the new public
health norms too," said Rick Lines, Executive Director of conference
"Just as the AIDS crisis
produced innovation in public health strategies such as condoms and sterile
syringe exchange, so too the opioid crisis we are presently experiencing has
the potential to be a game changer," Ciccarone concluded. "This is an epidemic of
crisis proportions, but like HIV it's a crisis of opportunity. HIV came down
dramatically because of treatment and prevention and activism, and the same
thing will turn around the drug overdose epidemic in the United States."