Notes from the Field: Overdose Deaths with Carfentanil and Other Fentanyl Analogs Detected - 10 States, July 2016-June 2017.

Fentanyl and fentanyl analogs are increasingly involved in opioid overdose deaths, and new fentanyl analogs continue to be identified (). Carfentanil, the most potent fentanyl analog detected in the United States, is intended for sedation of large animals and is estimated to have 10,000 times the potency of morphine (). It has recently been reported in an alarming number of deaths in some states. Ohio reported nearly 400 carfentanil-involved deaths during July–December 2016, and Florida reported >500 such deaths for all of 2016 (,).

CDC funds 32 states and the District of Columbia (DC) to abstract detailed data on opioid overdose deaths from death certificates and medical examiner and coroner reports through the State Unintentional Drug Overdose Reporting System (SUDORS). Twelve states began reporting in August 2017, and 20 states and DC will begin reporting in August 2018.* CDC analyzed trends in overdose deaths testing positive for carfentanil and other fentanyl analogs during July 2016–June 2017 in 10 SUDORS states (Kentucky, Maine, Massachusetts, New Hampshire, New Mexico, Ohio, Oklahoma, Rhode Island, West Virginia, and Wisconsin). States abstract data on all substances (both opioids and nonopioids) that contributed to death, as well as all substances for which the decedent tested positive.

During July 2016–June 2017, among 11,045 opioid overdose deaths, 2,275 (20.6%) decedents tested positive for any fentanyl analog, and 1,236 (11.2%) tested positive for carfentanil. Fourteen different fentanyl analogs were detected. Among overdose deaths with fentanyl analogs detected, the analogs were determined by medical examiners or coroners to have contributed to the death in >95% of deaths. During the first half of 2017, the number of deaths with any fentanyl analog detected (1,511) nearly doubled, compared with the number during the second half of 2016 (764); deaths with carfentanil detected increased 94%, from 421 to 815. The proportions of deaths with any fentanyl analog or with carfentanil detected nearly doubled during this period.

Ohio reported the largest numbers and most substantial increases in deaths with any fentanyl analog detected, including carfentanil (Figure). The number of carfentanil deaths in Ohio initially peaked in September 2016 (86 deaths), decreased during October 2016–February 2017, and peaked again in April 2017 (218 deaths). Changes in the number of deaths with any fentanyl analog detected mirrored changes in deaths with carfentanil detected, except during October 2016–February 2017, when deaths with carfentanil decreased. During this period, the number of deaths with any fentanyl analog detected instead increased, mainly driven by acrylfentanyl (202 deaths) and furanylfentanyl (192 deaths). The number of deaths with carfentanil present in other states followed a similar pattern, with peaks occurring slightly after those in Ohio. During the first half of 2017, seven states reported detecting carfentanil in overdose deaths, compared with three during the second half of 2016; the number of counties in which overdose deaths with carfentanil present occurred increased from 54 to 77.

FIGURE

Number of overdose deaths with carfentanil and any fentanyl analog detected* — Ohio and nine other SUDORS states, July 2016–June 2017

Abbreviation: SUDORS = State Unintentional Drug Overdose Reporting System.

* “Any fentanyl analog” includes carfentanil, so the categories are not mutually exclusive.

Kentucky, Maine, Massachusetts, New Hampshire, New Mexico, Oklahoma, Rhode Island, West Virginia, and Wisconsin.

In 2015, CDC issued a nationwide public health advisory about increases in fentanyl-related overdose deaths in multiple states (), and in 2016 issued an update to that advisory to warn about increasing availability of fentanyl and fentanyl-related substances being pressed into counterfeit pills, and the potential for broad distribution across the United States (). In response to findings in SUDORS data, on July 11, 2018, CDC issued a second update highlighting the emerging prevalence of fentanyl analogs contributing to opioid overdose deaths (). Growing outbreaks associated with fentanyl analogs are occurring at a time when sharp increases in fentanyl overdose deaths are already straining the capacity of medical examiner and coroner offices and public health departments. The increasing array of fentanyl analogs highlights the need to build forensic toxicological testing capabilities to identify and report emerging threats and to enhance capacity to rapidly respond to evolving drug trends. The highly potent nature of many analogs, particularly carfentanil, might warrant multiple administrations of the effective opioid overdose reversal medication naloxone.