Missouri’s fentanyl poisonings rise to record levels

The death total would be much higher if not for a record number of naloxone antidote doses distributed in the state. The intense naloxone delivery effort, led by the University of Missouri-St. Louis Addiction Science team, resulted in a reduction in the number of opioid deaths in St Louis City, the first such decline in years.

Authors William V. Stoecker, MD, Colin L. Smith, BS, and Elizabeth Connors, LCSW, explain why the respiratory response to drugs containing illicit fentanyl varies so widely.

William V. Stoecker, MD, MS, is at S&A Technologies and the Dermatology Center, Rolla, Missouri and in the Department of Dermatology, University of Missouri Health Sciences Center, Columbia, Missouri.  Colin L. Smith, BS, is at the Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, Missouri. Elizabeth Connors, LCSW, MSW, CRADC, is at the Missouri Institute of Mental Health, University of Missouri-St. Louis, St. Louis Missouri.

Missouri Medicine, the peer-reviewed, award-winning medical journal of the Missouri State Medical Association, reaches 4,500 physicians and medical organizations and libraries statewide and around the nation. In publication since 1904, Missouri Medicine is indexed by Index Medicus, MEDLINE, PubMed, PubMed Central, ProQuest, and Scopus.

This publication will republish the articles with permission in a multi-part series.

Missourians are dying of fentanyl poisoning at an unprecedented rate. We identified growth areas in Missouri for fatal fentanyl encounters in rural and western counties. Though the deaths occur for a multitude of reasons, a growing trend adds to the surge in fentanyl fatalities: poisonings from counterfeit pills. The tablets are often labeled with brand names for alprazolam or oxycodone, but may contain only fentanyl at a dangerous level. Teenagers find counterfeit pills all too easily via social media. Believing they have found an easy way to obtain a quick high or relief of minor pain and anxiety, they take the pill alone in their bedroom, with no possibility of reversing a fatal fentanyl dose. There is a wide range of respiratory depression from illicit drugs containing fentanyl. We reviewed the physiologic respiratory response to drugs containing fentanyl that varies with genetics and the unpredictable amount of fentanyl contained in illicit drugs.

Several Trends Drive Increase in Fentanyl–Related Deaths

In this article, we document the increase in fentanyl–related deaths in Missouri with new statistics. This report updates a previous report on fentanyl in Missouri. The most important trend accounting for fentanyl–related deaths is the increased fentanyl content in illicit drugs. We spoke with Tom Van De Berg, MD, Medical Examiner for Greene County, about the increase in opioid–related deaths there from 62 in 2020 to 101 in 2021. He stated: “Last year it really shot up for us. There is so much of it on the street.”

This persistent rise of fentanyl–related deaths in America began in 2014. Ben Westhoff, author of Fentanyl Inc., stated of fentanyl: “It’s so cheap to produce and it’s so powerful, that drug dealers began realizing it was a way to increase their profits.”

Part I of this update on illicit fentanyl reports a record–breaking total of fentanyl fatalities in Missouri and a new pattern for those deaths. Dealers now deliver fentanyl to virtually any town in Missouri. A recent fatal case due to ingestion of just one–half of a counterfeit pill typifies a growing trend.

Later we will document the critical change in fentanyl manufacturing—from a finished Chinese product to a Mexican product made from basic Chinese chemicals. Missouri statistics on narcotic prescriptions and significant harm reduction efforts will complete this two–part update on fentanyl in Missouri.

Missouri Opioid Fatalities in 2021: Rural Rates Rise; St. Louis City and County Decline

The result of the heavy influx of fentanyl–contaminated drugs from Mexican cartels, manufactured from basic Chinese chemicals, is apparent in recent statistics for opioid–related fatalities in Missouri. Provisional data from the Bureau of Health Care Analysis and Data Dissemination, Missouri Department of Health and Senior Services (MO DHSS), give a total of 1,581 opioid overdose deaths for Missouri residents in 2021. This represents a significant increase from the 1,375 fatalities recorded in 2020.

Figure 1 shows the opioid death rate per 100,000 for counties that recorded five or more deaths from provisional data available May 20, 2022. Counties not reporting data or with four or fewer deaths are shown in gray. St. Louis City still leads the state in opioid death rates at 86 per 100,000 population, followed closely by Dent County, which had 83 per 100,000 population (12 opioid deaths in Dent County, population 14,421). In descending order, the six counties that follow the top two counties, with opioid fatality rates between 45–69 deaths per 100,000 population, are Crawford, Washington, Phelps, St. Francois, Jefferson, and Warren. This data from 2021 demonstrates a rise in fatalities for many counties outside the urban fringes, especially along the Interstate–44 corridor.

St. Louis City and County demonstrated a fall in opioid death rates from 2020 to 2021—the first decline observed in these areas in years. The growth rates were high in some western counties such as Jackson and Greene counties, although both have a far lower opioid fatality rate than St. Louis City and even lower than many rural counties. Overall, the Interstate–44 corridor is the predominant pattern observed in counties with the highest opioid death rates and the highest percentage increases in Missouri opioid fatalities.

Fatal drug overdose statistics presented here represent all fatalities from opioids and are taken from ICD–10 coding for drug overdose deaths on death certificates and combined with available toxicology data. The opioid drug category includes both natural and synthetic opioids. The latter category includes fentanyl, fentanyl analogs, and other synthetic narcotics such as U–47700. This drug is known as “pink,” “pinky,” or “U4” and is associated with an increasing number of fatal opioid overdoses.

These fatal overdose totals are preliminary and subject to death–certificate reporting error. A combination of drugs (e.g., opioids and methamphetamines) sometimes contributed to fatal outcomes. Nora Volkow, MD, of the National Institute on Drug Abuse (NIDA) stated: “Unfortunately, comprehensive toxicological testing is not performed in many cases, or the results are not recorded on death certificates, so the reported numbers of fatal opioid overdoses and overdoses due to fentanyl might not capture the full scope of the epidemic.”