The Monroe County Office of the Medical Examiner released annualized data pertaining to 287 deaths directly attributable to the use of heroin, fentanyl or other related substances in 2017.
These deaths related to substance use represent a rapidly growing proportion of the total cases submitted to the laboratory for toxicological analysis.
“Our office continued to see an increase in fatalities resulting from heroin, morphine, fentanyl or other analog substances in 2017,” said Nadia Granger, medical examiner. “In addition to the new six-month tracking report we issued earlier this year, these annualized data can be helpful in assessing the full scope of the impact that the nationwide opioid crisis is making in our region.”
“The data presented in the medical examiner’s annual review reinforces the trends we observed in the six-month report, and also confirms what many of us already know — the nationwide opioid crisis continues to take a devastating human toll across our region,” said Michael Mendoza, commissioner of public health. “Monroe County will continue to combat addiction through our opioid action plan, which includes expanded education, increased Narcan training and a first-of-its-kind advisory panel comprised of local medical experts.”
The data presented in this report refer only to individuals whose cause of death was solely attributed to the substances involved. It does not include deaths where substances were present, but the cause was attributed to some traumatic injury. It also does not include cases attributed to overdose on prescription opioids in the absence of heroin/morphine or fentanyl/analogs.
Upon entry into the body, heroin is rapidly metabolized to morphine through an intermediate (6-monoacetylmorphine, 6-MAM). Detecting 6-MAM helps differentiate heroin from pharmaceutical morphine, but its absence does not preclude it. Of the 287 deaths, 32 involved morphine that could not necessarily be attributed to heroin. Fentanyl and analogs are sold on the street as heroin or cocaine, often in preparations or mixtures with those compounds. Fentanyl analogs are a growing class of novel psychoactive substances that are related structurally to fentanyl, and first appeared in the illicit drug market within the last few years. Laboratory testing for these analogs started in 2015-16.
Of the 287 deaths, 220 occurred in Monroe County; 67 occurred in surrounding counties that contract for autopsy services with the medical examiner’s office. The deaths occurring outside of Monroe County likely do not represent the total number of heroin/morphine/fentanyl-related deaths occurring in those counties, as not all cases from those counties were submitted to the Monroe County Office of the Medical Examiner.
The majority of the deceased (66 percent) were white males. The race/ethnicity distribution was consistent with previous years. It reflects the opioid crisis’ impact irrespective of ethnic heritage. The sex distribution of the deceased was consistent with prior years.
In 2017, the ages of the victims of heroin/morphine/fentanyl/analogs overdose ranged from younger than 20 to 82, with a median age of 38 years. Median ages for 2014, 2015 and 2016 were 36, 36 and 35, respectively. The 2017 deaths represent a 39 percent increase from 2016, and a more than threefold increase from 2015. The crisis escalated steadily since it started in 2012. For nearly every age group between 20 and 59, 2017 represented the highest number of heroin/fentanyl deaths ever witnessed by this office, with a marked increase since 2015. The opioid crisis affects people of all ages.
Variable monthly rates of heroin/fentanyl fatalities are due to changing availability, potency and/or composition of drugs on the street. The availability of heroin and heroin substitutes varies by region. Additionally, the fentanyl analogs included in street heroin preparations vary regionally and over time. In early 2017, furanyl fentanyl, acetyl fentanyl and U-47700 were the most common compounds detected. By mid-2017, U-47700 had all but disappeared, and para-fluoro(iso)butyryl fentanyl became common. Beta-thiohydroxy fentanyl also started to be detected.
The dynamic and frequently changing NPS drug market presents challenges for toxicological testing. The medical examiner’s office is watching these developments, and continues to adapt testing methodology to detect these new threats to public health.
Heroin, fentanyl/analogs, ethanol and cocaine frequently are encountered together in postmortem cases. Among the 287 cases, there was a mean and median of two of these four substances that were listed as direct contributors to the cause of death.
Although heroin preparations vary, it is generally not possible to establish whether cocaine and fentanyl/analogs were contained in the same mixture or merely utilized concurrently. However, the public should be cautioned about the risks of taking multiple drugs and/or combining drugs with alcohol, as well as the fact that illicit drugs may contain unknown mixtures of compounds and produce unexpected or exaggerated effects. Benzodiazepines are another class of compounds that are frequently detected in opioid overdose deaths.