Fentanyl

Below, the same pattern of fatal drug overdoses by substance is seen in the grams of drugs seized by Maine Drug Enforcement Agency (MDEA) task forces and the pounds of drugs seized by Customs and Border Protection (CBP). This indicates that fatal drug overdoses are related to the lethality and potency of substances in the illicit drug supply. MDEA heroin seizures peaked in 2019 dropping in 2020 and 2021. This same pattern is replicated in the CBP drug seizures nationally. Seizures of pharmaceutical drugs peaked in 2019 and also dramatically dropped in 2020 and 2021. Fentanyl seizures, much like drug deaths, peaked in 2017 dipped in 2018, and abruptly rose beginning in 2019 and continues through 2021. CBP drug seizures saw fentanyl sharply rise from 2017 to the present. In both MDEA and CBP data methamphetamine began sharply rising in 2018.

Nonpharmaceutical fentanyl and its analogs are synthetic opioids typically manufactured in China and shipped to drug cartels in Mexico for distribution throughout the United States. They are significantly more potent than other opioids—including oxycodone and heroin—however, the purity and concentrations of fentanyl is unknown to users both in their total supply or in their individual doses. Fentanyl is up to 25 times more potent than oxycodone and 50-100 times more potent than heroin. Some fentanyl analogs, such as carfentanil, are 100 times more potent than nonpharmaceutical fentanyl. Despite its potency, naloxone is still an effective medication that can potentially reverse an opioid overdose caused by fentanyl and its analogs if quickly administered by bystanders or public safety personnel. That is why it is important to #haveitonhand and #knowyouroptions.

Nonpharmaceutical fentanyl and its analogs are in the drug supply because it is cheaper and easier to create the chemical compounds needed to manufacture these synthetic opioids than it is to grow opium poppy plants and manufacture heroin from morphine. Fentanyl and its analogs also have a much greater potency than heroin and produce a much greater yield per kilogram than any other opioids. Heroin, by contrast, is a heavy and bulky product making it more difficult to ship and conceal during illicit distribution.

Fentanyl is frequently added to other opioids such as heroin. However, it is also added to stimulants such as cocaine and methamphetamine and other illicitly purchased substances such as marijuana and ecstasy/Molly (MDMA) to produce novel effects. This often occurs without the users’ knowledge. By adding even small amounts of fentanyl to a less potent drug, producers, dealers, and consumers can stretch their drug supply and increase their profits. The presence of opioids in the illicit drug supply is illustrated by the following animated chart of deaths from the illicit drug supply around the world from 1990 to 2019.

As mentioned above, fentanyl and its analogs are more lethal than pharmaceutical opioids and other illicit opioids, such as heroin, due to their potency and unknown purity and concentrations in the illicit drug supply or in individual doses. In some death investigations, users are found to have experienced a fentanyl overdose before the syringe is removed. That is why it is essential for bystanders to carry naloxone, call 9-1-1 in the event of an emergency, and understand how to respond to an opioid overdose. It is also essential that individuals to never use alone.

in addition to opioid users, stimulant users and persons using illicit street pharmaceuticals and marijuana unknowingly have consumed fentanyl and overdosed due to their supply being adulterated by these powerful synthetic opioids. Even for stimulant and psychedelic users, naloxone should be carried by bystanders and individuals should never use alone.

The drug deaths involving combinations of fentanyl with other illicit substances have been trending upwards over the past nine years. Fatal overdoses in Maine involving fentanyl and other key illicit substances mirror MDEA and CBP drug seizures with fentanyl related overdoses increasing dramatically in 2017 and methamphetamine related overdoses increasing nearly exponentially from 2018 to 2021. Additionally, since 2018 overdoses involving heroin have been decreasing corresponding with decreasing seizures of the drug both in Maine and nationally beginning in 2019 and continuing through the present.

The State of Maine is engaged in many novel and evidence-based substance-use disorder programs, the following harm reduction and investigative programs are currently or have the potential to, save victims of the fentanyl epidemic in Maine.

The Overdose Prevention Through Intensive Outreach Naloxone and Safety (OPTIONS) initiative ( https://knowyouroptions.me ) aims to improve the health of Mainers using substances through harm reduction strategies, helping them on the road to recovery, and dramatically reducing the number of fatal and nonfatal overdose deaths.

The OPTIONS liaison initiative embeds licensed behavioral health clinicians within local emergency medical services (EMS) and law enforcement agencies in every county across Maine. Liaisons work alongside their first responder counterparts to:

• Engage in post-overdose followup and help with referrals.
• Conduct proactive outreach with at-risk communities.
• De-escalate behavioral health crises when possible.
• Provide short-term counseling interventions when appropriate.

Each OPTIONS liaison serves the entire county in which they are located. As part of the OPTIONS liaison initiative, the Office of Behavioral Health and the Maine Center for Disease Control and Prevention is working to better integrate the varying levels of support services in each county. These services include Syringe Access Programs, naloxone distribution, Recovery Centers, medication for opioid-use disorder providers, and food and housing support among others.

To learn more about the OPTIONS program check out the link below.

On June 21, 2021, Governor Mills signed into law L.D. 1718, An Act to Establish the Accidental Drug Overdose Death Review Panel. The law establishes an Accidental Drug Overdose Death Review Panel to review a subset of deaths caused by accidental drug overdoses and to recommend to state, county, and local agencies methods of preventing deaths as the result of such overdoses, including modification or enactment of laws rules, policies, and procedures. The panel is made of up fifteen (15) individuals representing a number of state offices, law enforcement agencies, and impacted family members and persons in recovery.  The panel also will include one or more physicians who treat substance use disorder, an EMS representative, and a harm reduction specialist.  The panel is chaired by the state’s Director of Opioid Response and is staffed by the Rural Drug and Alcohol Research Team at the Margaret Chase Smith Policy Center at the University of Maine.