When a call came in from the county coroner, it was never good news. Every once in a while, her work included a shock big enough to share with the public health team where I served as Medical Director. This was the case that Monday afternoon. Two teenage deaths, likely from opioid overdoses, likely the first time they had tried opioids. The illicit drugs in this case looked like prescription oxycodone.
What chemical is in these pills? Fake opioids recovered from the home where an overdose death occurred. Photo courtesy of Dr. Michelle Jorden, Santa Clara County Medical Examiner. August 2019
But these were not Percocet. These pills were not pharmaceutical medications. They were not a brand name, or generic, or prescribed, or stolen from the medicine cabinet for a Friday night party. These particular fake pills contained lethal doses of a fentanyl-like compound, created in a clandestine lab miles away, packaged to look like prescription oxycodone. Counterfeit pills containing a host of fentanyl analogs [pdf] are now the leading cause of overdose death in the US.
A false friend is more dangerous than an open enemy
-Francis Bacon
We don’t know what these fake pills all look like, how they are packaged, and what buyers believe they are purchasing, as the issue of fake or counterfeit drugs is just now being recognized [pdf] and addressed. In the US, more than 40,000 people die from opioid overdose each year. I am a co-author of a recent report that predicts [pdf] COVID-19 may lead to tens of thousands of additional overdose deaths. A recent news analysis found a 30-40% rise in overdose in the first half of 2020.
Upstream harm reduction
Harm reduction is an approach to drug use that attempts to minimize the potential for death or serious morbidity among people who use drugs. Harm reduction attempts to identify the safest way for people to use a drug, eliminating as many potential adverse outcomes as possible. Needle exchange minimizes needle sharing and decreases the transmission of HIV and Hepatitis. Supervised injection sites provide a modicum of medical support for people with drug dependence to reduce the chance of overdose death. Medication-Assisted Treatment/Therapy/Recovery provides opioid cell receptor activation to eliminate withdrawal symptoms but not enough activation for euphoria, or getting high, allowing patients to regain function and purpose in their life.
Fake pills
First, we must resist the urge to call these pills and drug products by their brand name, or even their common chemical name. These pills are not percs or oxy, or even true fentanyl. Calling these products by their brand or common names leads users to believe they contain the expected chemicals. They do not. These pills and products contain adulterated chemical compounds, close analogs of known pharmaceutical chemicals. But make no mistake, they are fake, and only by calling them fake can we overcome the complacent use.
Overdose contact tracing
Second, we need a rapid public health response, contact tracing similar to efforts used to trace measles or the COVID-19 cases. Opioid overdose tracing could coordinate with the coroner, law enforcement, EMS, and local medical services. Together this opioid overdose tracing team could obtain and test the pills/products used in the overdose, identify others who may have been exposed, other buyers, family, and friends.
Will people answer questions? Not likely if they come from law enforcement, which is why public health and medical care providers must be involved. We are in a crisis with tens of thousands dying from opioid overdoses. If we implement an all-hands-on-deck approach, people will answer. The purpose is not to identify the dealer. The purpose is to identify potential users and warn them of the lethality of the substance they have. Opioid overdose contact tracing could save lives.
Anonymous analysis
Third, we need a method for quickly identifying the current drugs circulating in the community and notifying the public of their active ingredient and potency. Anonymous analysis for fake opioid and benzodiazepine drugs could determine active ingredient and potency based on morphine milligram equivalent (MME) [pdf] dose and benzodiazepine potency.
Imagine, a new shipment of fake pills comes into town. The distributor puts five pills in an envelope with their own unique code, such as ABC123DEF, and drops them in the mail. Once received at the lab, the pills are analyzed for active ingredients and potency. The results are posted online, in the newspaper, and shared with public health, Emergency Services, and local hospitals.
ABC123DEF = Active ingredient – para-fluoro-butyrylfentanyl
Average potency each pill – 100 MME
Potency information provides the dealer with an understanding of the drug being pedaled. The dealer and the buyer will know the potency and the cash value of the drug. Users will know the amount to take for the desired effect. New users will be able to judge the risk of overdose.
So, why would a drug dealer use anonymous analysis? They may not, but drug dealers do not want their buyers to die of an overdose, if for no other reason than a business loss. Knowing the active ingredient and potency may provide value to their customers. Buyers will want to know potency to maximize their desired effect and minimize accidental overdose. Dealers may use their potency as a marketing tool. Savvy users will demand to know the contents of their purchase. Experimenters may only take pills for which they know the content.
Today’s dealers often lead sophisticated businesses with high tech shipping, handling, and distribution. Mailing a few pills to a lab won’t be difficult. And the public is ready for a shift in thinking that might keep people from dying.
Changing the way we think
With thousands of new fake opioid overdose deaths, it is time for a new approach. Overdose contact tracing and potency reporting will require a change in the way we think about opioid and substance use. Law enforcement and public health and medical providers will need to get in a room together. Upstream harm reduction will require clinical changes in treatment availability, public health messages to decrease stigma, and policy changes that create laws to support upstream harm reduction. And everywhere we will need a culture change that accepts substance use as a clinical disorder rather than a moral failure.
Yes, people will need to learn a new taxonomy: Morphine Milligram Equivalent (MME), the active ingredient, potency, para-fluorofentanyl, etc. This language can be included in public health messaging [pdf], opioid prescriptions, clinical settings, and school education programs. Dealers, users, emergency medical services, families, and friends, even law enforcement will need to understand this comprehensive harm reduction effort aims to save lives, not catch the bad guys. We can catch the bad guys another day.
Harm reduction has faced challenges at every step, with naysayers declaring it enables and even encourages drug use. Perhaps. But often, harm reduction provides a person suffering opioid dependence and addiction the opportunity for one more day. And one more day may be the first step on the path to recovery.
Jack Westfall