In an article in the April 2018 issue of the American Journal of Public Health, four researchers at the Centers for Disease Control and Prevention’s Division of Unintentional Injury Prevention report that the CDC’s methods for tracking opioid overdose deaths have over-estimated the number of those deaths due to prescription opioids, as opposed to heroin, illicitly manufactured fentanyl, and other illicit variants of fentanyl. They called the prescription opioid overdose rate “significantly inflated.”

Fentanyl is a synthetic opioid categorized as a prescription opioid. But, in the outpatient setting, it is predominantly prescribed as a time-release transdermal patch, not suitable for nonmedical users. Occasionally, it is prescribed as a lozenge, a nasal spray, or a small film that can be placed within the corner of one’s mouth, usually to cancer patients in extreme pain. These forms of the drug don’t lend themselves to being converted into a form suitable for nonmedical users wishing to snort or inject the drug. The injectable form of fentanyl is almost exclusively used in the hospital setting, both as an anesthetic agent and to control severe pain in patients who are critically ill or in the postoperative recovery room. Over the past several years, the underground market has been flooded by illicitly manufactured fentanyl and its variants, often moved into the country in a powdered form through the mail.

The authors of the AJPH article state, “Traditionally, the Centers for Disease Control and Prevention (CDC) and others have included synthetic opioid deaths in estimates of ‘prescription’ opioid deaths. However, with IMF (illicitly manufactured fentanyl) likely being involved more recently, estimating prescription opioid–involved deaths with the inclusion of synthetic opioid–involved deaths could significantly inflate estimates.” They suggest that under a new “conservative” definition—excluding deaths involving synthetic opioids like fentanyl—the 32,445 prescription opioid-involved deaths that the CDC estimated occurred in 2016 would be revised down to 17,087.

The authors point out that the exact drugs involved in overdose deaths are not identified in 20 percent of death certificates, and the number of deaths due to diverted (stolen, smuggled, or sold by dealers) prescription opioids is unknown. They also note that multiple drugs are involved in over half of their reported cases of prescription opioid overdoses—although other centers report multiple drugs involved in over 90 percent of overdoses. Because of this, they say, even that reduced estimate is likely inaccurate.

In December 2017, the CDC reported that overdose deaths due to fentanyl have been increasing at a rate of 88 percent per year since 2013, and now make up the largest component of opioids responsible for overdose deaths.

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