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Epidemiology of fentanyl-involved drug overdose deaths: A geospatial retrospective study in Rhode Island, USA

https://doi.org/10.1016/j.drugpo.2017.05.029Get rights and content

Introduction

Since late 2013, the North American opioid overdose epidemic has been exacerbated by deaths involving prescription and illicitly manufactured fentanyl, a synthetic opioid analgesic (Gladden, Martinez, & Seth, 2016; US Drug Enforcement Administration, 2015). More recently, Australia has also reported a sharp increase in fentanyl overdoses among people who inject drugs (Latimer, Ling, Flaherty, Jauncey, & Salmon, 2016). The high potency of fentanyl means that only a miniscule amount (less than 2 mg, the equivalent of two grains of salt) can lead to overdose and death (Hess, Stiebler, & Herz, 1972). Difficult to distinguish from other drugs, illicitly manufactured fentanyl is an increasingly common adulterant in heroin and other illicit substances (US Drug Enforcement Administration, 2016). Sharp increases in fentanyl contamination in counterfeit prescription pills have also been observed (Centers for Disease and Control Prevention, 2016), increasing the risk of fentanyl overdose among persons seeking medications on the illicit market—representing a large and geographically widespread population. Consequently, fentanyl overdose risk now extends well beyond those regions previously impacted by heroin.

States in the US, including Maryland, Massachusetts, Ohio, and Florida, have all reported dramatic increases in fentanyl-related deaths (Peterson et al., 2016). Among six states that publish data on fentanyl fatalities, the number of fentanyl-involved deaths increased by over 350% between 2013 and 2014, from 392 to over 1400 (Gladden et al., 2016). In British Columbia, Canada, the number of drug overdose deaths involving fentanyl has sharply increased from 13 in 2012 to over 330 in just the first nine months of 2016 (British Columbia Coroners Service, 2016). A recent study involving clients of the Sydney Medically Supervised Injecting Centre in Australia found injection of fentanyl increased more than any other drug between 2013–2015, and the overall risk for fentanyl-related overdose was nearly 4.5 times higher than risk for overdose with other opioids (Latimer et al., 2016).

Despite the recent surge in fentanyl-related overdose deaths, there is a paucity of data regarding the characteristics, circumstances, and toxicology of fentanyl overdose decedents. Moreover, few studies have examined whether the geospatial distribution of fentanyl-related overdose deaths differs from that of non-fentanyl deaths. To inform more targeted and improved overdose prevention efforts, we conducted a detailed epidemiological and geospatial investigation of fentanyl-associated overdose deaths in Rhode Island, a state with the fifth highest rate of overdose mortality in 2015 (Rudd, Seth, David, & Scholl, 2016).

Section snippets

Methods

We conducted a retrospective review of accidental drug overdose deaths occurring in Rhode Island between January 1, 2014 and September 30, 2016. In accordance with state policy (Rhode Island Department of Health, 2015), cases were considered confirmed accidental drug-related overdose fatalities if: (i) the death was pronounced in Rhode Island; (ii) the final manner of death was deemed an accident by the medical examiner, and (iii) a drug is listed on the death certificate as the primary cause

Results

A total of 778 accidental drug overdose deaths in Rhode Island were observed during the study period. In total, 358 (46.0%) were attributable to acute fentanyl intoxication, increasing from 84 (35.0%) in 2014 to 138 (55.6%) during the first nine months of 2016 (P < 0.001). The total number and proportion of deaths attributable to acute fentanyl intoxication by month is shown in Fig. 1. We did not observe significant changes over time in the proportion of deaths involving injection drug use or

Discussion

This study shows that the number and proportion of overdose deaths involving fentanyl has increased rapidly and significantly in Rhode Island. Fentanyl is now the primary or contributing cause of death in over half of all overdose fatalities. Diverse population groups appear to be affected, with those who engage in injection drug use at particularly high risk of fentanyl overdose. Although fentanyl overdoses were somewhat more common in urban and suburban areas, geospatial analysis demonstrated

Author contributions

BDLM had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analyses. BDLM and TCG designed the study. BDLM conducted the literature review and drafted the manuscript. BDLM and MSK conducted the statistical analyses. JLY, PO, PB, NEAS, JDR, and TCG helped interpret the data and critically revised successive drafts of the manuscript for important intellectual content.

Funding

This study was supported in part by the Centers for Disease Control and Prevention, Prescription Drug Overdose Prevention for States [grant numbers RFA-CE15-1501]. BDLM is funded by a Henry Merrit Wriston Fellowship from Brown University.

Role of the funding source

The funders had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; nor in the decision to submit the article for publication.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention.

Acknowledgements

The Rhode Island Office of State Medical Examiners (OSME) provided the data. We would also like to thank Lauren Brinkley-Rubenstein, PhD, Alexandria Macmadu, ScM, Maximilian King, ScM, Elliott Liebling, BA, Benjamin Bouvier, and Jonathan Goyer for their assistance with data abstraction and OSME case file review.
Competing interests
The authors declare no conflicts of interest.

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