Fentanyl
There ’ s someThing in The heroin
Claire Gilbert , Tony Margetts , Gilda Nunez , Bryony Sedgwick and Tim Allison describe their response to the emergence of fentanyl and carfentanil in their local area
Hull and the East Riding have been at the centre of a cluster of drug-related deaths from the end of 2016 to the end of May 2017 that appear to be due to fentanyl and particularly carfentanil , one of the 40-plus analogues of fentanyl in illicit heroin . Carfentanil is so powerful it is only licensed for use in animals ( eg to tranquilise elephants ); an amount less than 1 / 2000th of a grain of salt ( 1 microgram ) is biologically active in humans and approximately 1 / 1000th of a grain of salt ( 2 micrograms ) can be lethal . This is a brief account of that event , how we responded at East Riding Public Health , and key learning points .
The first death potentially related to fentanyl / carfentanil was in September 2016 – we cannot be sure as it is not part of the standard toxicology screen routinely tested for in the UK and was not tested at the time . Numbers of deaths started to rise and remained well above typical rates until the end of May .
We sent out a request for information and a drugs worker in the local prison , HMP Hull , reported that clients believed the heroin was being cut with fentanyl or Xanax ( a benzodiazepine ) and witnessed people ‘ going over ’ ( overdosing ) as a result . In addition , pharmacists undertaking harm reduction training in East Riding reported users describing a change in how the heroin felt – that they were getting a quick strong hit . Benzodiazepines would be a concern , but were unlikely to be killing people so quickly .
Evidence from North America raised concerns over possible fentanyl / carfentanil as a cause of drug-related deaths . The first case of carfentanil was found in April , and the test was used retrospectively where possible for previous post-mortems . One pharmacist said ‘ they are all saying “ there is something in the heroin ”’, and this became the title of our harm reduction leaflet which was distributed widely ( see above , right ). We issued a warning to local treatment services , needle exchanges and prisons , and raised awareness through the local media . Humberside Police issued a separate additional warning .
A meeting was held between the coroner , Hull and East Riding Public Health , the police , and the toxicologist , and toxicology reports were released to East Riding Public Health . Our investigations are ongoing and inquests are yet to be held on the most recent deaths .
There were 31 deaths attributed to accidental opiate overdoses between September 2016 and May 2017 in East Riding and Hull ; 35 per cent had evidence of standard fentanyl and 45 per cent had carfentanil . Two cases ( 6 per cent ) alarmingly had evidence of carfentanil but no heroin . The people most at risk were men , average age 39 , long-term users , using alone . There were a disproportionate number who were homeless , living in shelters or
recently discharged from policy custody . This raises the possibility that those using a new or different dealer may be most at risk .
Death appeared to happen very quickly , shown by how the deceased were found ( eg still holding the needle ) and biological measures ( relatively low free total morphine / free morphine suggesting a rapid death ). Of the 31 , only four people ( 13 per cent ) survived long enough to make it to hospital , none of whom survived due to severe brain injury , and naloxone appeared to be ineffective . It is unclear whether , if given very quickly , very high doses of naloxone may work . In one case , a user was admitted to hospital following using heroin , had taken the entirety of one kit of naloxone in the community and started a second and recovered . He died a few days later following a further hit .
Our work would suggest there are indicators that should alert an area to the possibility of fentanyl or carfentanil overdoses and lessons from our recent experience . These are :
• Listen to current drug users from prisons , needle exchanges and elsewhere – they might spot the change in the drug supply early .
• Be alert to changes in the drugs market – police intelligence and treatment services reported a greater availability of heroin , at a lower price and higher strength during this cluster .
• Work with your partners , in our case the coroner ’ s court , Humberside Police , treatment services , prisons , pharmacists and public health .
• The very high potency of carfentanil has implications for emergency services , who may need to take extra precautions to avoid contact with the substance .
• Watch out for features that suggest fentanyl and carfentanil and consider testing for it at post-mortem – sudden death , unusual spike in deaths , high total / free morphine ratios , lower morphine toxic levels than you might expect .
• Raise awareness of risks to users , eg through a leaflet ( above ).
• Consider availability of naloxone and need for higher doses .
Dr Claire Gilbert is public health registrar , Tony Margetts is substance misuse manager , Dr Tim Allison is director of public health , Gilda Nunez is a public health officer and Dr Bryony Sedgwick is a foundation doctor in East Riding
10 | drinkanddrugsnews | December / January 2018 www . drinkanddrugsnews . com