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New data on drug overdose record the earliest days of the deadly western expansion of fentanyl

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A rigorous attempt to track the overdose of deaths in the US and the drugs that caused them provides a snapshot of a fentanyl epidemic at the point of a westward shift.

A study released by the Centers for Disease Control and Prevention on Friday shows the synthetic opioid cutting a strip of death and destruction in the Northeastern United States and the industrialized Midwest in 2017. That year, fentanyl became the drug most frequently mentioned as the cause of fatal overdoses in all five regions east of the Mississippi River, as well as in the adjacent region with Iowa, Missouri, Kansas and Nebraska.

The picture was very different in the western states of the country, where fentanyl was hardly registered as a cause of death. Instead, methamphetamine was the drug most frequently associated with overdose deaths in 2017.

Nationally, fentanyl played a role in almost 4 of the 10 fatal overdoses in 2017, more than any other medicine. For every 100,000 Americans, there were 8.7 fentanyl-related deaths that year, according to the CDC's National Center for Health Statistics study.

Fentanyl, a drug that is at least 10 times more potent than morphine, is "phenomenally cheap per dose," according to a recent Rand Corp. report on the future of synthetic opioids. Widely used by cartels and drug dealers to increase the potential of other drugs, it was cited as a cause of death – sometimes only in combination with other drugs – in 27,299 fatal overdoses across the country in 2017.

Those deaths caused by fentanyl were closely concentrated in the northeastern, mid-Atlantic and higher mid-western states of the country. Only 1,769 overdoses associated with fentanyl – less than 7% of the national total – were recorded in the & # 39; s regions with Louisiana, Arkansas, Texas, Oklahoma, Colorado, Wyoming, the Dakotas and all states moving from there to the west extend.

It is suspected that illegal fentanyl penetrated New England the earliest and most difficult in the US. In 2017, that region had a fentanyl overdose mortality rate of 22.5 per 100,000 – about 15 times higher than the prevailing rate in the western United States.

Experts say that the picture has already begun to change. In 2018 and the first months of 2019, evidence of the western diffusion of fentanyl began to grow.

Fentanyl "was rare for a minute on the west coast," said Dr. Daniel Ciccarone, physician and medical anthropologist at UC San Francisco, investigating trends into illegal drug use. "That is no longer true. We are now in the murder fields. & # 39;

While the plague of fentanyl strengthened its hold on Western states, it could herald a new chapter of the opioid epidemic, he warned.

"The opioid epidemic is maturing," Ciccarone said.

The current public health crisis can be traced back to the 1990s, when doctors began to prescribe opioid narcotic drugs with the encouragement of drug manufacturers.

By 2010, access to prescription pills was restricted because doctors wrote fewer prescriptions, abuse-resistant formulations reached pharmacies and efforts to prevent the diversion of pain killers to the black market were stepped up. Those who were addicted to opiates responded with an increase in heroin use, triggering the second wave of the epidemic.

Then, in 2013, cheap and deadly fentanyl began to reach American shores from Chinese laboratories and launched a third wave of the opioid epidemic. A fourth wave could see the uptake of fentanyl spread throughout the country, partly fueled by its wider use in drugs such as cocaine and methamphetamine, Ciccarone said.

The synthetic opioid, which can cause death in a non-opioid user at doses of just 2 milligrams, has already been seen in various Western drugs. In addition to being cut into cocaine and methamphetamine, it is squeezed into counterfeit pills that look like exact replicas of prescription anesthetic and anxiety medications. Ultimately, fentanyl is expected to find its way to heroin in the West.

The new study, who used death certificates to collect geographical patterns of drug use, discovered that methamphetamine was named in the West in 2017 as a factor in 5,241 fatal overdoses. Heroin was generally the second most mentioned drug on death certificates there.

Why fentanyl slowly reached the western states is a subject of debate and research.

Experts suggest that geographical differences in the uses of drug suppliers and users may explain regional inequality in 2017. Illegal fentanyl is largely used by drug distributors to increase the volume or increase the potency of other drugs, in particular heroin. That seems relatively simple with the white powdered form of heroin circulating throughout the eastern United States and the Midwest.

But cartels operating in the western states tend to sell heroin in a form similar to sticky black or brown tar, which is less susceptible to the addition of fentanyl.

"We don't exactly understand why powder doesn't go west," said Bryce Pardo, an expert from Rand Corp. on the illegal trade in drugs. But the fact that it did not protect the region, at least temporarily, against the deadly grip of fentanyl, he added.

That barrier can come down.

In January, California first aid doctors and health officials from the provinces documented a result of obvious fentanyl overdoses. In the Fresno, Chico and Madeira provinces – all connected by Highway 99 – three died and 16 people were treated and released after they had sniffed what they thought was cocaine.

Fentanyl also appears in the form of counterfeit pills that are sold as the prescribed pain killers oxycodone and hydrocodone, as well as the anti-anxiety medicine Xanax. And last year, researchers from the Food and Drug Administration dismantled a network of counterfeiters in Northern California, fake Xanax and Percocet pills were found to be used with Chinese chemicals and equipment.

Meanwhile, the Phoenix division of the Drug Enforcement Agency reported in August that the seizure had taken place more than 1.13 million illegally produced fentanyl pills between October 2017 and September 2018. That was an increase of 380,000 such pills the previous year.

Finally, the behavior of drug users has changed in a way that creates a potential opening for fentanyl in the West. In parts of the East and Midwest, a practice called & # 39; goofballing & # 39; or & # 39; speedballing & # 39; – where drug users combine heroin with stimulants such as methamphetamine or cocaine – become a popular way to achieve a more intense high.

The trend has reached the west coast. In June 2017, experts described a increase in heroin use among meth users in King County in Washington.

"If it happens in Seattle, it happens here in San Francisco," Ciccarone said.

While drug distributors cut fentanyl into all the drugs that form a goofballer's cocktail, fatal overdoses can increase. For people who generally do not use opioids and have not developed tolerance, the result of a double exposure to fentanyl can be a rapid death.

A database of drug death in California suggests that the increased presence of fentanyl is already being felt in the state. In 2018, fatal opioid overdoses associated with fentanyl grew to 743 from 429 in 2017, representing nearly one third of the state's 2,311 opioid-related deaths.

"Fentanyl is still rising – we haven't seen that cycle peak yet," Ciccarone said. But if current trends continue, he said, the outcome would be & # 39; terrible & # 39; can be.

It is a terrible warning that is confirmed by a report from Rand Corp.

"As soon as fentanyl gains a foothold, it seems to sweep through a market within a few years," concluded Pardo and his team of Rand researchers. “The American synthetic opioid problem is not yet really national in nature. Some regions to the west of Mississippi have been less affected to date. Those areas must be seen as a high risk of an aggravating problem. "

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