BACKGROUND: During the first decade of this century an opioid epidemic emerged, with prescription opioids – primarily oxycodone – the primary drugs of abuse. Following the re-formulation of oxycodone, the creation of Prescription Monitoring Programs, and legislative action in Florida and across the country, prescription drug poisonings declined dramatically between 2010 and 2013, then leveled off. Since 2010 heroin poisonings have risen rapidly. Additionally, since 2010 national fentanyl and fentanyl analog poisonings have risen rapidly. This study examines the relationship between heroin, fentanyl and fentanyl analog poisonings in Florida, and the origin and distribution patterns of these substances nationally.
METHODS: Heroin and fentanyl poisoning deaths were analyzed using Florida Medical Examiner Commission drug death data from 2007 through 2015. In 2015 many of Florida’s Medical Examiners voluntarily tested for and reported on illicit fentanyl analogs. This data was included in the analysis. Additionally, data from the DEA National Drug Threat Assessment Report, and National Drug Early Warning System reports were used to provide a more complete picture of the current epidemic.
RESULTS: Florida deaths deemed to have been caused by heroin decreased from 93 to 48 (-48%) between 2007 and 2010, then rose to 733 in 2015 (+1427%). Those caused by fentanyl remained stable between 2007 and 2010, but increased from 114 in 2010 to 705 in 2015 (+518%). Most of the fentanyl deaths were due to fentanyl analogs. Although testing for metabolites of fentanyl in Florida was not comprehensive, of those tests that were conducted in 2015, 65% of fentanyl analog deaths were attributed to acetyl fentanyl, 22% to beta-hydroxythiofentanyl and 13% to butyryl fentanyl. Nationally the primary source of heroin is Mexico. Heroin deaths are increasing, especially in the Northeast and Midwest states. The main source in these areas is South America. The primary source of West Coast heroin is Mexico. The primary source of fentanyl and fentanyl analogs is China, either directly to the US or through Mexico. The powder form is sold directly, mixed with heroin, sold as heroin, or pressed into pills sold as prescription drugs.
CONCLUSIONS: Although the number of deaths resulting from prescription opioids has decreased, the opioid epidemic is not over. The increases in heroin and fentanyl analog deaths are expected to continue. Increased public education, naloxone availability, access to treatment and other public health prevention efforts are needed to battle this epidemic.