Primary Care Corner with Geoffrey Modest MD: 2 CDC Reports on Spread and Toxicity of Fentanyl

By Dr. Geoffrey Modest

A couple of brief reports on opiates in the community.

1. MMWR reported that there was an outbreak of poisonings in people in San Francisco taking a counterfeit Norco (a combo of hydrocodone and acetaminophen, but with a sinister name) See http://www.cdc.gov/mmwr/volumes/65/wr/mm6516e1.htm?s_cid=mm6516e1. 7 cases were reported, with some differences in the apparent composition of the counterfeit drug: all had fentanyl (a potent synthetic opioid, 100x that of morphine, and a full m-opioid receptor agonist. fentanyl has high lipophilicity, allowing it to enter the CNS rapidly. It is not marketed as an oral pill, so its presence in pill form confirms its being illicit); some had promethazine (used for nausea/vomiting, motion sickness, and it may potentiate the opiate high), some trace amounts of cocaine and several with no detectable hydrocodone.

Details:

• The illicit drugs appeared very similar to the real thing, including the inscription “M367”
• Patients present to the ER with lethargy, bradypnea, unresponsiveness

So, just an alert. There has been an increase in these illicit/counterfeit products over the past few years, with fentanyl often being part of the problem. And this counterfeiting seems to be more sophisticated, with pills that look pretty much identical to the legal drugs.

2. Another DEA alert on fentanyl (see http://emergency.cdc.gov/han/han00384.asp ) which also highlights the increased street prevalence of products containing illicit fentanyl or acetyl-fentanyl (at this time, most of the fentanyl-related overdoses are from illicit/manufactured drug, not diverted pharmaceutical fentanyl). Fentanyl is often mixed with heroin to increase the high, but sometimes sold alone as a highly potent drug (sometimes with street name “China White”).

A few points:

• Drug seizures by the DEA have found dramatic increases in fentanyl: from 618 in 2012 to 945 in 2013 to 4,585 in 2014
• >80% of the drug seizures were in 10 states, from highest to lowest:
  • Ohio (1245)
  • Massachusetts (630)
  • Pennsylvania (419)
  • Maryland (311)
  • New Jersey, Kentucky, Virginia, Florida, New Hampshire, Indiana (all between 133 to 238)
• It often takes more than one dose of naloxone to revive a patient with a fentanyl overdose.

So, perhaps the most important issues are the increasing availability of fentanyl on the streets, and its high potency means that we may need to use more than one dose of naloxone to revive a patient. And, when we give naloxone to patients to have at home, we need to advise them/their supports that it may take more than one dose.