Fentanyl: trend -spotting overview and focus on deaths

Jane MounteneyEMCDDA

2

Trendspotter - concept

• In depth information gathering

• On subject of concern, uncertainty

• One off and ad hoc

• Rapid reporting

3

Trendspotter methods

Multi source, multi-method, multi-disciplinary, triangulation:

• Literature review• Routine data collection• Electronic survey • MEETING• Expert presentations • Work groups • Analysis

4

2012 Fentanyl trendspotter study

AimTo increase our understanding of the illicit use and availability of fentanyl in Europe, in particular:

• extent and patterns of illicit fentanyl use• illicit production and diversion • harms and deaths linked with fentanyl use• responses

5

Impetus…for the study

• EWS signals - misuse of synthetic opioids on the rise• Fentanyl the most potent, dangerous • Estonia - long term reporting of serious problems, deaths • Accumulation of reports - Slovakia & Bulgaria, linked with heroin shortages• Outbreaks in Germany, Sweden

6

Sources of fentanyl(s) supply

• Illicitly manufactured fentanyls - limited to fentanyl and TMF

• Misuse of fentanyl-containing medicines, mainly transdermal patches

• Medical sources diverse -theft & diversion, overprescribing, doctor shopping, waste products.

• Internet

7

Seizures of medicinal fentanyl in last 3 years

Seizures of illicitly manufactured fentanyls in last 3 years

8

Diverse epidemiology/country situations…

• Some countries - no data • One off ‘events’ e.g. Portugal• Continuous low level noise• Outbreaks - linked with ODs and deaths - different types (prescribing, new lab)• Endemic, established problem (Estonia)

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DRD data key to understanding the epidemiology

• Epidemic curves

• Age/gender pyramids

• Deaths by fentanyl type

• Geographical distribution

Deaths in 2011 by type of fentanyl

0

2

4

6

8

10

12

14

16

18

20

1 2 3 4 5 6 7 8 9 10 11 12

Month

Num

ber Fentanyl

3 methylfentanyl, fentanyl3 methylfentanyl

15-19

20-24

25-29

30-34

35-39

40-44

50-54

60-64

-15 -10 -5 0 5 10 15 20 25 30 35

Ag

e ba

nd

Number of deaths

Female

Male

40

1 death

35

30

25

20 ? ? ? ?

15

10

5

12012201120102009

Num

ber of cas

es

2008200720062005

0

4

8

12

16

20

1 2 3 4 5 6 7 8 9 10 11 12

Months

Num

bers

of c

ases

ViljandiTallinn

Sillamäe

Narva

Lääne-Viru countyKohtla-Järve

Jõhvi

Ida-Viru countyHarjumaa

10

Deaths related to fentanyl – different epidemic curves

40

1 death

35

30

25

20 ? ? ? ?

15

10

5

12012201120102009

Num

ber o

f cas

es

2008200720062005

109 1 death87654

321

Source Special register. Communication Head of NFP38 cases in 2011, 21 cases in 2010 - tbc

201120102009

Num

ber

of c

ases

20082007

1 death

181716151413121110

987654

321

Progressive improvement in screening for fentanyl2006-08: 28% of DRD cases screened and Source:Kipke Poster 2011 and communication2009-10: 65% of DRD cases screened

Num

ber

of c

ases

2008200720062005200420032002 201120102009

1/4 of all DRD screnned. 5% positive

2/3 of all DRD screnned. 11% positive

Source 2011 Police data

1 death4

321

Source:Np-SAD J. Corkery communication

2001 2011201020092008200720062005200420032002

Estonia (650)Sweden (?59)

Germany (160)UK (50)

11

United Kingdom

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

>=65

-15 -10 -5 0 5 10 15 20 25 30 35

Age

ban

d

Number of deaths reported

Female

Male

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

>=65

-15 -10 -5 0 5 10 15 20 25 30 35

Age

ban

d

Number of deaths reported

Female

Male

15-19

20-24

25-29

30-34

35-39

40-44

50-54

60-64

-15 -10 -5 0 5 10 15 20 25 30 35

Ag

e ba

nd

Number of deaths

Female

Male

Germany

Estonia

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Estonia – share of fentanyl / 3MF Deaths in 2011 by type of fentanyl

0

2

4

6

8

10

12

14

16

18

20

1 2 3 4 5 6 7 8 9 10 11 12

Month

Num

ber Fentanyl

3 methylfentanyl, fentanyl

3 methylfentanyl

13

On going risks & considerations

• Threat from continued heroin shortages?

• Role of pharmaceutical industry in promotion of patches?

• Importance of not hindering appropriate medical pain management

• Economic crisis - palliative care increasingly likely to be outside hospital settings

• Environmental health risk - need for safe waste disposal

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Fentanyl a microcosm of complex modern day drug market

• Symptomatic of Europe’s growing synthetic opioid misuse problem

• Illicit component

• Misuse/diversion of medicines

• Designer drug, internet availability?

• …and environmental health implications

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Fentanyls 2013 update …

• Multiple reports of fentanyls (ODs & seizures) from Canada, US, Australia, EU..

• Fentanyls emerging as NPS e.g. Carfentanyl- EWS alert Feb 2013 - 70g seized in Latvia

(not under international control)

• Carfentanyl is 4000x more potent than morphine

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Fentanyls DRD updates …

We invite and welcome comments from experts on study and recent data

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Update 2013 reports

0

5

10

15

20

25

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

40

1 death

35

30

25

20 ? ? ? ?

Num

ber

of c

ases

15

10

5

12005 2006 2007 2008 2009 2010 2011 2012

0

10

20

30

40

50

Sweden: Toxicological analyses at the National Board of Forensic Medicine: positive for tramadol

UK: np-SAD data

Estonia