Fentanyl-Associated Overdoses and Deaths Among Illicit Drug Users — Fulton County, Georgia, 2015

BACKGROUND:  Fentanyl is a potent synthetic opioid that can be added to illicit drugs without the user’s knowledge, resulting in overdose or death. In May 2015, Hospital A in Fulton County contacted the Georgia Department of Public Health to report an increase in emergency department (ED) patients with illicit-drug overdoses and fentanyl-positive urine tests in 2015. We investigated to characterize fentanyl-associated overdoses and fatalities among illicit drug users to guide prevention efforts.

METHODS:  We defined a case of fentanyl-associated drug intoxication as acute illicit-drug intoxication and a fentanyl-positive urine test not caused by prescribed fentanyl among patients presenting to Hospital A ED during May 5–July 31, 2015. We reviewed Hospital A records to identify those meeting case criteria, and obtained medical examiner (ME) data to identify fentanyl-positive unintentional illicit-drug deaths during January 1–July 31, 2014, and the same timeframe in 2015.

RESULTS:  During January 1–July 31, 2015, ME data revealed 100 unintentional illicit-drug–overdose deaths in Fulton County; 40 (40%) were fentanyl-positive. By comparison, 2/65 (3%) deaths were fentanyl-positive during the same timeframe in 2014. Among the 40 fentanyl-positive deaths of 2015, 70% also tested positive for heroin, 10% for cocaine, 3% for amphetamines, and 13% for multiple drugs; 5% tested negative for other drugs. Hospital A record review identified 94 cases, 73% male. Age range was 18–64 years (median: 36 years). Sixty-seven (71%) required ambulance transport to the ED; 27 (29%) received naloxone, an opioid reversal agent, before ED presentation. On presentation, 41 (43%) had altered mental status, including 11 (12%) who were obtunded or comatose; 9 (10%) required intubation. Sixty-four (68%) patients were discharged, and 30 (32%) were admitted for further treatment, 7 (7%) requiring ICU admission; none died. None reported intentional fentanyl use, although 60% admitted illicit-drug use before presentation. In addition to fentanyl, patient urine drug tests were positive for cocaine (18%), amphetamines (13%), and other opiates (6%); a total of 60% were positive for multiple drugs, and 3% for fentanyl only.

CONCLUSIONS:  Fentanyl-associated overdoses and deaths among persons who use illicit drugs sharply increased in Fulton County during 2015 and involved contamination of multiple illicit drugs, particularly heroin, but also cocaine and amphetamines. Research to understand knowledge of fentanyl risk and education about fentanyl-contaminated–drug lethality might prevent fentanyl-related overdoses among illicit-drug users. Improving naloxone availability to emergency response personnel and those in contact with at-risk persons might prevent overdose deaths.