Fatal overdoses continued to decline in Massachusetts in the second quarter of 2018, but a new challenge has surfaced as deadly fentanyl gets mixed with cocaine, a drug now found in more overdose deaths than heroin, authorities said Friday.
The devastating and growing prevalence of fentanyl was the dominant message in the state’s latest quarterly report on opioid-related deaths, released Friday. Fentanyl — the illicit synthetic, not the drug doctors prescribe — was present in nearly 90 percent of overdose deaths.
“If you are using illicit drugs in Massachusetts, you really have to be aware that fentanyl is a risk no matter which drug you’re using,” said Dr. Monica Bharel, Massachusetts public health commissioner. “The increased risk of death related to fentanyl is what’s driving this epidemic.” Fentanyl is many times more potent than heroin.
“Pretty much all you can access in the Boston area is fentanyl. You’re not finding heroin anymore,” said Richard Baker, director of the mobile prevention team at Victory Programs, a treatment provider.
That means that a new population of drug users — those who use cocaine — are also in danger of opioid overdose, said Dr. Alex Walley, physician and researcher at Boston Medical Center’s Grayken Center for Addiction.
Some cocaine users may not know their drug has been cut with fentanyl, and unaccustomed to opioids, they are especially prone to overdose. Others are continuing a longstanding practice of mixing cocaine, a stimulant, with heroin, a depressant — except that now, instead of heroin, they’re using the much more potent fentanyl.
“The deadliness of doing that increases with the introduction of fentanyl,” Walley said.
“It’s been over a year since I’ve seen [a patient] who told me they used heroin and they didn’t have fentanyl in their toxicology screen,” he added. “Fentanyl is the rule when it comes to people using what they call heroin.”
Cocaine has surpassed heroin in tests of those who fatally overdosed, starting with the last quarter of 2017. That has prompted the state to alert treatment providers that cocaine users are also at risk of opioid overdose, and a new alert to all medical personnel is planned, Bharel said.
The last quarter of 2017 is also when opioid-related deaths overall started to decline. From April to June 2018, fatal opioid overdoses in Massachusetts fell for the third consecutive quarter — but chiefly among whites. Blacks, especially black men, continue to be hit hard: The rate of overdose deaths among blacks increased by 23 percent from 2016 to 2017, while whites and Hispanics saw slight decreases.
Overall, opioid-related overdoses in Massachusetts declined by 4 percent from 2016 to 2017. But in the first six months of 2018, there were a total of 1,017 confirmed and estimated opioid-related overdose deaths, a slight increase from the 975 in the first six months of 2017.
But this small increase may merely be an insignificant blip. Both long-term data and data from recent quarters indicate a trend of declining overdose deaths, said Ann Scales, spokeswoman for the Department of Public Health.
Massachusetts was one of only six states, including Rhode Island and Vermont, that recorded a decline in overdoses last year.
Baker, of Victory Programs, cautioned against complacency amid the declining death toll, because certain groups are still severely affected, especially minorities and people in the prime of life. Between January 2017 and June 2018, nearly two-thirds of overdose deaths occurred among people age 25 to 44.
“We have an epidemic among young, new users who aren’t able to access resources and information that some of our older users have,” Baker said.
Massachusetts’ health and human services secretary, Marylou Sudders, acknowledged the issue in a statement. “When you look at the trend lines over time, while the results of our efforts are having an impact, we must double down on our efforts to implement treatment strategies that meet the needs of the highest-risk individuals and communities,” she said.
Most people who die of overdoses have more than one drug in their system, and the medical examiner often cannot pinpoint which drug or drugs were responsible for the death. But the prevalence of different drugs found in the victims’ bodies provides insight into the changing forces in substance use.
In the first quarter of 2018, there were 477 opioid-related deaths in which the medical examiner was able to screen for drugs. Of these, 89 percent involved fentanyl, 43 percent cocaine, 42 percent benzodiazepines, and 34 percent heroin. In contrast, in 2014, fentanyl was present in only about 40 percent of those who overdosed.
“This quarterly report provides a new level of data revealing an unsettling correlation between high levels of synthetic fentanyl present in toxicology reports and overdose death rates,” Governor Charlie Baker said in a statement. “It is critically important that the Commonwealth understand and study this information so we can better respond to this disease and help more people.”
Friday’s report also showed that the number of people in Massachusetts who receive prescriptions for opioid painkillers fell more than 30 percent since the beginning of 2015.
While controlling opioid prescribing has been a big focus of the Baker administration, the report shows that prescribed drugs are playing an ever-smaller role in epidemic. In the first quarter of 2018, only 19 percent of those who died of opioid overdoses had prescription opioids in their bodies.
Due to a reporting error, a previous version of the story mischaracterized the change in mortality between the first six months of 2018 when compared with the first six months of 2017. There was slight increase in the number of opioid-related deaths.