Fentanyl misuse in the UK: will we see a surge in deaths?BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1564 (Published 09 April 2018) Cite this as: BMJ 2018;361:k1564
All rapid responses
As highlighted in the editorial, the fentanyl analogue carfentanil is of particular concern due to its very high potency. The Office for National Statistics released the latest figures on deaths related to drug poisoning in England and Wales on 6 August 2018, showing carfentanil was first mentioned on death certificates in 2017 and accounted for 27 deaths.(1) We had an increase in drug-related deaths in Hull and the East Riding in early 2017 and conclude that the presence of carfentanil needs to be actively considered and tested for to prevent further deaths.
The time lag between an individual death occurring and an accurate report of the cause highlighted by Ian Hamilton’s rapid response is a real challenge to identifying changes in local death rates. We were able to identify and respond due to real time contact from the coroner’s office when a suspected drug-related death occurred rather than waiting until inquest findings which can be many months later. In addition, close working with the toxicology laboratory, police and intelligence from local services was crucial to our identifying changes in the local drug market and mounting a quick response. We received reports from HM prison and pharmacists involved in needle exchange services, both reporting that users described a change in the local heroin supply.
It is not widely appreciated that standard post-mortem fluid screening for fentanyl does not detect the more potent analogues, as this requires more sophisticated analysis, and reports of deaths from fentanyl or fentanyl analogues do not always make this clear. Similarly, tests for fentanyl analogues are not widely available in most emergency departments. The University Hospitals of Leicester NHS Trust provide approximately 25% of post-mortem toxicology testing across the UK(2) including for Hull and the East Riding, and have been screening for fentanyl as part of standard testing for over 10 years. When the rise in the number of suspected drug-related deaths in early 2017 could not be explained by standard tests, they began testing for new psychoactive substances including carfentanil and applied the tests retrospectively.(2) There were 15 deaths where evidence of carfentanil was found in our area.
Three of the deceased in our area survived long enough to be admitted to hospital but suffered irreversible hypoxic brain injury. The European Monitoring Centre for Drugs and Drug Addiction describes three individuals reported to them across Europe with acute intoxication and confirmed exposure to carfentanil, all of whom survived. They advise that higher and additional doses of naloxone may be required to fully reverse poisoning in some cases.(3) This is an important finding for community provision of naloxone and emergency department management of acute intoxication.
Harm reduction messages were distributed locally, especially through needle exchanges and publicity via the local media. Staff at the East Riding Partnership Drug & Alcohol Services have reported that users are forthcoming in passing on information about changes in the drug market to services, many users learn harm reduction messages from their peers, and users report that they know to try a small amount initially or smoke a substance first in an attempt to avoid overdose.
Close working between the coroner’s office, local authority public health, toxicologists, police, staff and users from services such as needle exchange services, prisons and treatment services and are all vital to identify and respond to changes in the drug market. We need to actively consider the potential presence of carfentanil and other synthetic fentanyl analogues in drug-related deaths.
Tony Margetts and Gilda Nunez (East Riding Public Health); East Riding Partnership Drug and Alcohol Services; Hull City Council; University Hospitals of Leicester NHS Trust Forensic Toxicology Service; HM Coroner Office Hull
1. Office for National Statistics. Statistics bulletin: Deaths related to drug poisoning in England and Wales: 2017 registrations, 2018. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri... [Accessed 13 August 2018].
2. Hikin L, Smith PR, Ringland E, et al. Multiple fatalities in the North of England associated with synthetic fentanyl analogue exposure: Detection and quantitation a case series from early 2017. Forensic Sci Int 2018;282:179–83. Available at: doi:10.1016/j.forsciint.2017.11.036. [Accessed 22 May 2018].
3. European Monitoring Centre for Drugs and Drug Addiction 2017. EMCDDA-Euopol Joint Report on a new psychoactive substance: methyl 1-(2-phenylethyl)-4-[phenyl(propanoyl)amino]piperidine-4-carboxylate (carfentanil). Available at: http://www.emcdda.europa.eu/publications/joint-reports/carfentanil_en [Accessed 22 May 2018].
Competing interests: No competing interests
We won't know how many lives will be claimed by Fentanyl as there is a significant time lag between an individual death and an accurate report of the cause. The Home Office is aware of this problem and says it is trying to address it. However this is one of many problems we have in trying to understand how many people lose their lives due to drug use. People who develop problems with drugs and as result die also have a range of physical comorbidities which make a definitive cause of death difficult to pin down. Coroners are human and may well spare the surviving family and friends by recording a death as due to respiratory failure rather than due to an opiate such as Fentanyl. There is also some evidence that gender bias may be at play with predominantly male coroners reluctant to investigate untoward deaths in females.
But the problem seems to start before this point, we know that toxicology reports are not routinely requested and even when they are they either lack sophistication or can be inconclusive, particularly if multiple drugs are involved which is the norm for people who develop problems with drugs.
All of these factors impede our collective understanding of drug related mortality and as with Fenatnyl being quick enough to respond to emerging problem drugs, equally a lack of timely mortality data can create unjustified panic.
Competing interests: No competing interests