Overdose Deaths

Rise in Overdose Deaths Driven by Drug Combinations

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Experts are sounding the alarm that a combination of prescription and/or recreational drugs now contribute to nearly three-quarters of overdose deaths in the United States. 

Reports of the use of fentanyl along with the animal tranquilizer xylazine make preventing substance use disorder and associated overdose deaths even more complicated, experts said during a webinar sponsored by the National Institute for Health Care Management. 

“Nearly 74% of all overdose deaths linked to cocaine now involve synthetic opioids, such as fentanyl,” said Cecelia Spitznas, PhD, a senior science policy analyst in the White House Office of National Drug Control Policy. “This type of combination drug use is part of a new trend driving the overdose rate, along with a growing use of xylazine, or ‘tranq.’” 

The Basics: Fentanyl

Fentanyl is a powerful opioid painkiller that’s stronger than morphine or heroin.

The White House declared the drug combinations as an emerging threat against the United States in April. 

In terms of overdose prevention, “if you yourself use any substance or if you know anybody who uses substances, here’s a couple of things that we like to encourage people to think about,” Shawn Westfahl, overdose prevention and harm reduction coordinator at Prevention Point Philadelphia, said during the webinar. Avoid using drugs alone. “Most people who die from opioid overdose die with nobody around them. We encourage people to use the buddy system and stagger their use.”

Westfahl also suggests that people using substances “go slow, go easy, especially if they inject. They can put more in; they can’t take it out. And we encourage people to avoid mixing in other drugs with opioids.”

Medically Assisted Treatment

Although equal access is a challenge, “the most important thing that we in the United States can do at this point in time to combat the substance use disorders epidemic, and that’s increasing access to evidence-based treatment, in particular … to medically assisted treatment,” said Doug Henry, PhD, vice president of psychiatry and behavioral health at Allegheny Health Network in Pittsburgh. 

Allegheny Health launched a program in 2020, for example, to increase access in medically assisted treatment in rural and underserved areas in West Virginia. Offering remote treatment “was really groundbreaking,” Henry said, especially in regions with certain geographic and population density challenges.

Getting people engaged in medically assisted treatment, and keeping them in treatment, “is hugely, hugely important,” Henry said. “These efforts have led to a reduction in opioid-related overdoses.” 

What’s Alarming the Experts

Henry agreed that drug combinations are adding to the challenge.

“The ongoing opioid epidemic and the emerging epidemic of combined molecules into deadly poisons are leading to an increased frequency of overdoses,” he said. He is seeing spikes in both of his professional roles – at Allegheny Health, a 14-hospital network in southwestern Pennsylvania and western New York, and at Highmark Health, the third largest Blue Cross Blue Shield insurance company in the United States, serving members primarily in West Virginia, western New York, Delaware, and Pennsylvania. 

Westfahl reported that 1,413 people died from drug overdoses in 2022 in Philadelphia, up from 1,276 overdose deaths in 2021, a 10% increase. Most of the 2022 deaths, 83%, involved opioids. Fentanyl and tranq remain major challenges for the population served by Prevention Point, he said. 

“We are seeing a huge spike [in fentanyl use] consistently increasing throughout the years,” he said.

What You Should Know About Opioids

In 2010, for example, fentanyl was involved in fewer than 10% of drug overdoses. Last year, fentanyl played a role in 96% of overdose deaths. 

The national picture is not much more encouraging, Spitznas said. About 25%, or 70 million Americans, used illicit drugs in 2022, national survey data reveal. More than 17%, or nearly 49 million Americans, reported past-year substance use disorder.

Marijuana led drug use among Americans 12 years and older. An estimated 62 million Americans used marijuana in 2022. Next, two of the most common drugs used are in categories such as hallucinogens and pain reliever misuse, each involving 8.5 million Americans. Also, nearly 5 million people misused prescription tranquilizers and sedatives.

In terms of deaths, there’s been a dramatic uptick blamed on synthetic opioids and fentanyl, climbing to just under 80,000 deaths in April 2023. Spitznas said the categories are not mutually exclusive because many drugs are used in combination. In addition, “we think both the heroin figure and the fentanyl figures are dramatic undercounts” in national surveys. 

“Fentanyl is often used in to contaminate certain substances, so it’s unlikely that people really, truly know if they are using heroin or they’re using fentanyl,” she said. Fentanyl and xylazine test strips, if available, can help determine what substances are present when someone is overdosing. 

Good and Bad News on Treatment

National data also shows that only about 24% of Americans 12 years and older who are classified as needing substance use treatment receive it. A silver lining can be seen in a breakdown by age group, Spitznas said. “We’re doing a little bit better in getting 12- to 17-year-olds in treatments.”

Compared to the 25% of younger teens receiving treatment, “we’re doing really poorly in getting 18- to 25-year-olds into treatment,” she said. The figure is a little more than 16%. “And across the board, we need to get more people into treatment.”

Providing naloxone is a priority, Spitznas said. The FDA approved the first over-the-counter nasal naloxone spray in March. The agency also approved a second agent to reverse opioid overdoses called nalmefene in May.

If a person is overdosing on both fentanyl and tranq, the opioid reversal agents can treat the effects of fentanyl. But xylazine, or tranq, is not an opioid. It’s a veterinary medicine that causes prolonged sedation, and the FDA has not approved its use in humans. 

“One way to think about this is that naloxone can restore breathing. You may not have a rapid return of consciousness when there’s fentanyl and xylazine together. But as long as breathing returns, that is a good thing,” Spitznas said. “That is why we’re recommending continuing with naloxone as well as calling 911 and getting emergency services.”

Treatment for combination overdoses may not ease withdrawal symptoms. “People dependent on xylazine may experience an extreme withdrawal, even if they receive medications for opioid use disorder,” Spitznas said. There is no medication available for xylazine withdrawal, she said. 

As Overdose Deaths Soar To Record Highs, FDA Approves New Painkiller 1,000x MORE Powerful Than Morphine

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Purdue Pharma and other pioneers of powerful opioid painkillers probably felt a twinge of regret on Friday when the FDA approved a powerful new opioid painkiller that’s 10 times stronger than fentanyl  – the deadly synthetic opioid that’s been blamed for the record number of drug overdose deaths recorded in 2017 – and 1,000 times more powerful than morphine, ignoring the objections of lawmakers and its own advisory committee in the process.

After all that trouble that purveyors of opioids like Purdue and the Sackler family went to in order to win approval –doctoring internal research and suborning doctors to convince the FDA to approve powerful painkillers like OxyContin despite wildly underestimating the drug’s abuse potential – the agency might very well have approved those drugs any way? And opioid makers might have been able to avoid some of the legal consequences stemming from this dishonesty, like the avalanche of lawsuits brought by state AGs.

What’s perhaps even more galling is that the FDA approved the drug after official data showed 2017 was the deadliest year for overdose deaths in US history, with more than 70,000 recorded drug-related fatalities, many of which were caused by powerful synthetic opioids like the main ingredient in Dsuvia, the brand name under which the new painkiller will be sold.

Dsuvia is a 3-millimeter tablet of sufentanil made by AcelRx. It’s a sublingual tablet intended to provide effective pain relief in patients for whom most oral painkillers aren’t effective. The FDA’s advisory committee voted 10-3 to recommend approval of the drug, a decision that was accepted by the FDA on Friday. The agency justified its decision by insisting that Dsuvia would be subject to “very tight” restrictions.

“There are very tight restrictions being placed on the distribution and use of this product,” said FDA Commissioner Scott Gottlieb in a written statement Friday regarding his agency’s approval of Dsuvia. “We’ve learned much from the harmful impact that other oral opioid products can have in the context of the opioid crisis. We’ve applied those hard lessons as part of the steps we’re taking to address safety concerns for Dsuvia.”

Still, some of the agency’s actions looked to critics like attempts to stifle internal criticism. For example, the agency scheduled the advisory committee vote on a day where the chairman of the committee, who was opposed to approval, could not attend – while circumventing its normal vetting process, despite the fact that the member in question had notified the agency of his unavailability months beforehand.

But the FDA rejected any and all criticisms related to Dsuvia being sold as a street drug by insisting that the risk of diversion (when doctor-prescribed drugs are illicitly sold on the black market) was low because the drug would only be prescribed in hospital settings, and wouldn’t be doled out at pharmacies. But critics said that, given its potency, Dsuvia would “for sure” be diverted at some level. They also rejected the FDA’s argument that Dsuvia satisfied an important need for pain treatment: offering rapid, effective relief for obese patients or others lacking easily accessible veins.

While a niche may eventually be found for Dsuvia, “it’s not like we need it…and it’s for sure, at some level, going to be diverted,” said Dr. Palmer MacKie, assistant professor at the Indiana University School of Medicine and director of the Eskenazi Health Integrative Pain Program in Indianapolis. “Do we really want an opportunity to divert another medicine?”

Fortunately for Dsuvia’s manufacturer, AcelRx, these public health risks pale in comparison to the enormous profits that the company stands to reap from sales. The company anticipates $1.1 billion in annual sales, and hopes to have its product in hospitals early next year.

It goes without saying that cancer patients and others suffering from life threatening illnesses have a legitimate need for effective pain relief. But when the FDA says Dsuvia is needed in the hospital setting, it probably isn’t telling the whole story. Because, as the Washington Post pointed out, the medication’s development was financed in part by the Department of Defense, which believes Dsuvia will be an effective treatment for emergency pain relief on the battlefield – like when a soldier gets his legs blown off after accidentally stepping on an IUD.

Top Ten Drugs Tied to Overdose Deaths

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Deaths from drug overdose in the United States increased by 54% from 2011 to 2016 — with opioids, benzodiazepines (benzos), and stimulants the most commonly used drug classes involved, a new report released today by the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS), shows.

The report notes that there were 41,340 drug overdose deaths in 2011 vs 63,632 such deaths in 2016.

Although the opioid oxycodone was the most cited drug in overdose death records in 2011, heroin took the top spot from 2012 to 2015.

The story around fentanyl may be even more troubling. The rate of overdose deaths involving it or one of its analogs doubled each year from 2013 through 2016, when it finally took the lead in becoming the most mentioned drug. In 2016, 29% of all overdose deaths involved fentanyl (n = 18,335).

In addition, the stimulant cocaine was the second or third most cited drug in the overdose death records throughout the entire study period.

The CDC’s list of the 10 most frequently mentioned drugs also included the opioids methadone, morphine, and hydrocodone; the benzos alprazolam and diazepam; and the stimulant methamphetamine.

Of all 10 drugs, only methadone was associated with a decreasing overdose death rate from 2011 to 2016.

“While the ranking changed from year to year, the top 10 drugs involved in overdose deaths remained consistent throughout the 6-year period,” note the investigators, led by Holly Hedegaard, MD, NCHS.

“This report identifies patterns in the specific drugs most frequently involved in drug overdose deaths…and highlights the importance of complete and accurate reporting in the literal text on death certificates,” they write.

The data were published online in the December 12 issue of the National Vital Statistics Reports.

Rise in Overdose Death Toll

An NCHS report released last year showed the age-adjusted rate of US drug overdose deaths increased dramatically from 1999 (6.1 per 100,000 population) to 2016 (19.8 per 100,000).

Although several previous studies on drug overdoses have used National Vital Statistics System-Mortality (NVSS-M) information, this data is coded using the International Classification of Diseases, Tenth Revision (ICD-10); and these ICD-10 codes focus on broad drug categories rather than on individual drugs, note the investigators.

In answer to this, the NCHS and the US Food and Drug Administration “collaboratively developed methods to search the literal text from death certificates to identify mentions of specific drugs and other substances, and to search contextual terms to identify involvement of the drug(s) or substance(s) in the death,” the researchers write.

They defined “literal text” as written information from the medical certifier on cause or circumstances related to a death.

For the current report, they examined NVSS-M data from 2011 through 2016. These data were linked to electronic files containing death certificate information.

In addition to the top 10 drugs involved in overdose deaths, drugs that held the number 11 through number 15 ranking throughout the 6-year study period included diphenhydramine, acetaminophen, citalopram, carisoprodol, oxymorphone, tramadol, amitriptyline, clonazepam, gabapentin, and amphetamine.

Threefold Increase in Heroin Deaths

The involvement of heroin in overdose deaths rose threefold from 4571 deaths in 2011 to 15,961 deaths in 2016. This made it the second-most mentioned drug in 2016, behind fentanyl.

Mentions of cocaine increased from 5892 overdose deaths in 2014 to 11,316 deaths in 2016, giving it that year’s number 3 ranking.

The fourth most mentioned drug in overdose deaths in 2016 was methamphetamine. Its 6762 related deaths signified a sharp increase from the 1887 related deaths in 2011.

“An analysis of trends…showed that, for several drugs, the age-adjusted rate of drug overdose deaths increased considerably within a relatively short period,” the investigators write.

Heroin, cocaine, and methamphetamine all showed significant increasing trends for age-adjusted rates of drug overdose deaths between 2011 and 2016 (1.5 vs 5.1 per 100,000 population; 1.6 vs 3.6 per 100,000; and 0.6 vs 2.1 per 100,000, respectively; all, P < .05).

Fentanyl showed a significant increasing trend between 2013 and 2016 (0.6 vs 5.9 per 100,000; P < .05).

The only decrease for a specific drug came from methadone, which was mentioned in 4545 overdose deaths in 2011 vs 3493 deaths in 2016 (1.4 vs 1.1 per 100,000). Still, it was the eighth most mentioned drug in 2016.

For the 2016 top 10 drugs, “the proportion of deaths involving both the referent drug and at least one other concomitant drug ranged from 50% for methamphetamine to 96% for alprazolam or diazepam,” the researchers report.

Finally, drugs most frequently recorded in unintentional overdose deaths in 2016 were fentanyl, heroin, and cocaine. The most frequently cited drugs in suicide by overdose were oxycodone, diphenhydramine, hydrocodone, and alprazolam.