Fentanyl Involved in Over Half of Opioid Overdose Deaths in 10 States

On October 27, 2017, the CDC published a report that found that more than half of people in 10 states who died of opioid overdoses during the second half of 2016 tested positive for fentanyl. This report described opioid overdose deaths from July through December 2016 that tested positive for fentanyl, fentanyl analogs, or U-47700, an illicit synthetic opioid, in 10 states participating in the CDC’s Enhanced State Opioid Overdose Surveillance (ESOOS) program, Maine, Massachusetts, Missouri (data available for 22 counties), New Hampshire, New Mexico, Ohio, Oklahoma, Rhode Island, West Virginia, and Wisconsin.


The report found that out of a total of 5,152 opioid overdose deaths, almost 3,000 tested positive for fentanyl, and over 700 tested positive for drugs that have similar chemical structures to fentanyl (fentanyl analogs) – including the extremely potent fentanyl analog, carfentanil, which is used to sedate large animals. Fentanyl and fentanyl analogs are highly potent and fast-acting synthetic compounds that can trigger rapid progression to loss of consciousness and death and thus might require immediate treatment and high doses of naloxone.


Preliminary estimates of U.S. drug overdose deaths exceeded 60,000 in 2016 and were partially driven by a fivefold increase in overdose deaths involving synthetic opioids (excluding methadone), from 3,105 in 2013 to approximately 20,000 in 2016. Illicitly manufactured fentanyl, a synthetic opioid 50–100 times more potent than morphine, is primarily responsible for this rapid increase. In addition, fentanyl analogs such as acetylfentanyl, furanylfentanyl, and carfentanil are being detected increasingly in overdose deaths and the illicit opioid drug supply. Carfentanil is estimated to be 10,000 times more potent than morphine.


Fentanyl was detected in 56.3 percent of 5,152 opioid overdose deaths in the 10 states between July and December 2016. Among these 2,903 fentanyl-positive deaths, fentanyl was determined to be a cause of death by the medical examiner or coroner in nearly all (97.1 percent) of the deaths. Northeastern states (Maine, Massachusetts, New Hampshire, and Rhode Island) and Missouri reported the highest percentages of opioid overdose deaths involving fentanyl (approximately 60 to 90 percent), followed by Midwestern and Southern states (Ohio, West Virginia, and Wisconsin), where approximately 30 to 55 percent of decedents tested positive for fentanyl. New Mexico and Oklahoma reported the lowest percentage of fentanyl-involved deaths (approximately 15 to 25 percent). In contrast, states detecting any fentanyl analogs in more than 10 percent of opioid overdose deaths were spread across the Northeast (Maine, 28.6 percent, New Hampshire, 12.2 percent), Midwest (Ohio, 26.0 percent), and South (West Virginia, 20.1 percent).


With few exceptions, fentanyl analogs are illicitly manufactured, because they do not have a legitimate medical use in humans. Fentanyl analogs were present in 720 (14.0 percent) opioid overdose deaths, with the most common being carfentanil (389 deaths, 7.6 percent), furanylfentanyl (182, 3.5 percent), and acetylfentanyl (147, 2.9 percent). Fentanyl analogs contributed to death in 535 of the 573 (93.4 percent) decedents. Cause of death was not available for fentanyl analogs in 147 deaths. Five or more deaths involving carfentanil occurred in two states (Ohio and West Virginia), furanylfentanyl in five states (Maine, Massachusetts, Ohio, West Virginia, and Wisconsin), and acetylfentanyl in seven states (Maine, Massachusetts, New Hampshire, New Mexico, Ohio, West Virginia, and Wisconsin). U-47700 was present in 0.8 percent of deaths and found in five or more deaths only in Ohio, West Virginia, and Wisconsin.


Demographic characteristics of decedents were similar among overdose deaths involving fentanyl analogs and fentanyl. Most were male (71.7 percent fentanyl and 72.2 percent fentanyl analogs), non-Hispanic white (81.3 percent fentanyl and 83.6 percent fentanyl analogs), and aged 25–44 years (58.4 percent fentanyl and 60.0 percent fentanyl analogs).


Other illicit drugs co-occurred in 57.0 percent and 51.3 percent of deaths involving fentanyl and fentanyl analogs, respectively, with cocaine and confirmed or suspected heroin detected in a substantial percentage of deaths. Nearly half (45.8 percent) of deaths involving fentanyl analogs tested positive for two or more analogs or fentanyl, or both. Specifically, 30.9, 51.1, and 97.3 percent of deaths involving carfentanil, furanylfentanyl, and acetylfentanyl, respectively, tested positive for fentanyl or additional fentanyl analogs. This supports findings from other reports indicating that fentanyl and fentanyl analogs are commonly used with or mixed with heroin or cocaine. Nearly half of overdose deaths involving fentanyl and fentanyl analogs, however, did not test positive for other illicit opioids, suggesting that fentanyl and fentanyl analogs might be emerging as unique illicit products.


Forensic investigations found evidence of injection drug use in 46.8 percent and 42.1percent of overdose deaths involving fentanyl and fentanyl analogs, respectively. Approximately one in five deaths involving fentanyl and fentanyl analogs had no evidence of injection drug use but did have evidence of other routes of administration. Among these deaths, snorting (52.4 percent fentanyl and 68.8 percent fentanyl analogs) and ingestion (38.2 percent fentanyl and 29.7 percent fentanyl analogs) were most common. Although rare, transdermal administration was found among deaths involving fentanyl (1.2 percent), likely indicating pharmaceutical fentanyl. More than one third of deaths had no evidence of route of administration.


This is the first report on data from the State Unintentional Drug Overdose Reporting System (SUDORS), which tracks fatal opioid overdoses and is a component of the CDC’s ESOOS program. SUDORS makes it possible to use toxicology and death scene investigation data previously unavailable across states, to provide insights into specific substances and circumstances driving overdoses. This information can help uncover changes in the opioid epidemic and inform interventions.


The findings in this report are subject to at least five limitations. First, results are limited to 10 states and therefore might not be generalizable. Second, the presence of fentanyl analogs is underestimated because commonly used toxicologic testing does not include fentanyl analogs, some fentanyl analogs are difficult to detect, and specialized testing for fentanyl analogs varied across states and over time. Third, the route of fentanyl and fentanyl analog administration must be interpreted cautiously because the data do not link specific drugs to routes of administration and thus the precise route of administration of fentanyl or fentanyl analogs cannot be determined in overdose deaths involving multiple substances (e.g., heroin and cocaine) and routes (e.g., injection and snorting). Fourth, the combination of deaths with toxicologic confirmation of heroin with those with detection of morphine and death scene evidence suggesting heroin use might have resulted in misclassification of some deaths. Finally, the source of the fentanyl could not be definitively determined; however, only a small percentage of fentanyl deaths had evidence consistent with prescription fentanyl (e.g., transdermal use versus injection).


See the CDC Announcement


See the CDC Report


See also Medical Risk Law Report: Prescription Painkillers: Risks for Patients, Pharmacists, and Physicians


See also Medical Risk Law Report: Drugs, Dosage, and Damage: Physician Liability for Prescribing or Administering Medication


See the Medical Risk Law Blog: Pharmacy Owes Duty To Patient Not To Fill Excessive Prescriptions for Opioids


See the Medical Risk Law Blog: Opioid Pain Pill Abusers Switch to Heroin; Heroin Overdose Deaths Double