Missouri reflects the national trends, with most drug overdose fatalities related to opioids. Recent trends nationally show an overall decrease in death rates from opioids, including prescription opioids and heroin. Missouri deviated from this trend recently and for a brief time was the state with the largest absolute and percentage per year increase in opioid-related overdose fatality rates.

Rates per capita rose in 2018 over the previous year (18.3 percent and 3.1/100,000). This increase occurred despite an overall national decrease in U.S. opioid-related death rates in the same period.

When the data is disaggregated among counties, a clearer picture emerges. If St. Louis City and St. Louis County numbers are excluded from Missouri, overdose deaths decreased about 6 percent — better than the national average. However, in St. Louis City and the county, overdose deaths increased by 27 percent. The majority of these overdoses occurred in black males, with 90 percent of these deaths associated with fentanyl — compared to 78 percent of overdose deaths in 2017.

While the disparity is not surprising, the magnitude of the disparity is. The black community in North St. Louis City and the county face well-documented long-standing problems in access to care, health resources and trust of health care messaging. These results can guide future funding in more equitable and effective prevention, harm reduction and treatment.

The map in Figure 4 shows the crude opioid death rate per capita for each county in Missouri. St. Louis city has the highest opioid death rate in the state, followed by Jefferson and Franklin counties, which belong to the urban fringe areas that demonstrate the highest opioid mortality rates nationally. Jackson County, which includes Kansas City, has lower opioid death rates than some rural areas, much lower than found in St. Louis.

Brandon Costerison, of the St. Louis chapter of the National Council on Alcoholism and Drug Abuse (NCADA), states St. Louis is one of the top five urban regions in the country for opioid-related deaths. In explaining St. Louis’ high overdose rate, DEA’s National Drug Threat Assessment, December 2019, found that Chicago-based street gangs in St. Louis, with ties to the national Crips gang, are the main source of the area’s heroin.

Costerison cites second-hand sources that identify Omaha and Dallas as the main suppliers for Kansas City, with entirely different sources for their heroin. These five-year rates obscure some recent changes, especially the rise of deaths in rural areas. The number of opioid deaths rose 50 percent (from 12 to 24) in Boone County from 2017 to 2018. Stacy Huck, a staff member in the Boone-Callaway County medical examiner’s office, found most overdoses were either fentanyl or methamphetamine (meth) related. Boone County Police Sgt. Brian Leer said, “Meth [sic] used to be the drug we battled here. Meth labs dropped off when Mexican labs began producing methamphetamines. It’s fentanyl in heroin that is driving the overdoses now. Boone County has a problem with Gray Death (the street name for the gray-colored mix of heroin and varying amounts of fentanyl, fentanyl analogues and U-47700). The route is Chicago to St. Louis and then across Missouri. The stigma of heroin has gone away — it’s more accepted in the user world.”

Bill Callahan, head of St. Louis Division DEA, said, “Meth is still a big problem in western Missouri. We have some instances of meth with fentanyl contamination.”

In fact, the street slang term goofball now refers to a combination of methamphetamine and either heroin or fentanyl.

Accounting for Opioid Deaths

Missouri is a street drug state, not a prescription overdose state.

In 2018, Missouri providers wrote 63.4 opioid (fentanyl included) prescriptions per 100 persons, somewhat more than the national average rate of 51.4 per 100. There are a few outlier Missouri counties, including Dunklin, Butler, St. Francois and Howell, with opioid prescription rates from 2017 data over two-and-a-half times the national average. Dunklin County ranks the highest with 148.6 opioid prescriptions per 100 people. Only St. Francois County of the four counties listed above ranks within the top quarter of opioid overdose counties in the state, and Dunklin County has one of the lowest opioid overdose fatality rates in the state: 0.66 persons per 100,000 (one person died 2014-2018).

St. Louis City, with the highest rate of opioid deaths, ranks below the national average for opioid prescriptions: 42.5 per 100 persons. Evan Mobley of the Missouri DHHS advised caution about citing numbers of prescriptions written as the sole measure of controlled substance prescribing habits, without considering the duration of the prescription. Careful prescribing practices remain the best approach for providers.

Fentanyl is moving west

Toxicology laboratory reports gathered by the CDC demonstrate an increasing national rate of fentanyl overdoses (Figure 5). Toxicology laboratory reports show fentanyl death rates are highest in the eastern part of the country. Missouri is one of only nine states with a high rate (29 or more per 100,000 persons aged 15 or older in 2017) of fentanyl toxicology reports. All these states except Missouri are east of the Mississippi River. However, the highest growth rates in fentanyl reports are from toxicology labs further west. Missouri was one of eight states that had a growth rate in reports of 150 percent or more. All these states except three are west of the Mississippi River. Fentanyl analogue reports demonstrate a similar westward movement.

Missouri was one of 14 states to have more than 200 reports of the non-fentanyl synthetic opioid U-47700 in 2017, and had the fourth highest rate of growth in U-47700 (pink) reports: 854 percent increase from 2016 to 2017, behind only South Carolina, Illinois and Michigan.

One reason for the east-to-west gradient in fentanyl-related overdose rates is the regional monopolies that control access to heroin, which offer only the type of heroin their distributor can supply. Powder heroin, available in Eastern states, is relatively easy to combine with fentanyl.

Black tar heroin, a dark, sticky opium-like substance predominant in western states, is difficult to mix with fentanyl. Kevin Wandler, MD, Chief Medical Officer at Advanced Recovery Systems, stated, “I have not yet heard stories of people lacing black tar heroin with fentanyl. But the market is changing: toxicology lab reports demonstrate that fentanyl is increasingly found in more western states. This march westward is now playing out in Missouri.

Missouri’s at-risk demographic

One of the major driving forces for the use of fentanyl, both knowingly and unknowingly, is the heroin market in the U.S. In several ways, the opioid crisis is founded on economic distress within communities across Missouri. Without any adulteration, the average retail price of pure heroin has significantly increased. Synthetic opioids, both fentanyl and analogues, are available at a far cheaper price than street heroin as they are cheaper to manufacture. By adding cheap synthetic opioids, the price per milligram of the final product has almost halved from 2010 to 2014.

The decrease in prices for fentanyl-adulterated heroin and the increased opioid potency, which can vary significantly among opioid batches, equate to more users, more demand and more danger for each user. In recent years, the heroin market has expanded from the inner-city domain to towns and rural locations, which puts most of Missouri at risk.

The social conditions that correlate with the increased use of illegal drugs – poverty, both rural and urban, unemployment, and homelessness – are expected to persist and may get worse in the current pandemic. Economic constraints may reduce access to addiction treatment, which is of primary importance in reducing opioid deaths.

One new and unknown factor in Missouri is the new medical marijuana law 19 CSR 30-95 passed in 2018. Bill Callahan, head of DEA’s St. Louis District, said, “Marijuana is not necessarily a gateway drug, but it is a gateway to a culture shift because you’re running with a different group of people.”

Speaking of teenagers’ ability to make decisions, Callahan said, “The brain is not fully developed.” Thus, as Callahan sees it, there may be more exposure to different drugs once a young person becomes acquainted with a new group of people who will expose them to new and dangerous drugs, including fentanyl and analogues.

Opioid deaths continue to rise in Missouri

In early 2020, when the Chinese government shut down activity in and around Wuhan due to the COVID-19 virus, the illicit opioid supply chain was disrupted. Yet the communists acted quickly to promote economic recovery. A South Central Drug Task Force officer found that “heroin/fentanyl continue to be available in the area for roughly the same prices.” The officer noted unusually high numbers of Narcan use in some rural Missouri counties.

We queried two county medical examiner offices who noted a year-on-year increase in opioid-related deaths. The St. Louis County Medical Examiner’s Office reports preliminary opioid-related deaths for the first five months in 2020 were up 17 percent from the year before (112 deaths in 2019 and 131 in 2020). Because of short-staffing (and an increase in overdose cases), it is difficult keep current with data entry and these preliminary 2020 totals are expected to rise.

Outstate areas are also on track to equal or exceed overdoses totals of previous years. The Boone County Medical Examiner’s office, which performs examinations for Boone and Callaway counties, has preliminary data showing opioid deaths are increasing. Boone and Callaway counties have already had respectively nine and three cases of known opioid deaths for the first half of 2020, with a further 34 and 11 cases pending final assignment of cause of death. Boone and Callaway are on track to outpace the 2014-2018 annual averages of 13 and 4 fatalities, respectively.

“The drug supply is in chaos,” said Brandon Costerison of NCADA, summarizing the situation for the illicit drug user in Missouri. “Due to social distancing, those users may be using alone at home, and people don’t know to check on them.”

In the era of COVID, narcotic addicts who overdose are dying alone at home.

Reprinted with permission, Missouri Medicine, the Journal of Missouri State Medical Association.

About the authors

• William V. Stoecker, MD, MS, MSMA member since 1984, practices at S&A Technologies and The Dermatology Center, Rolla, and the Department of Dermatology, University of Missouri-Columbia Health Sciences Center, Columbia.

• K. Taylor Bosworth is in the Departments of Biological Sciences and Psychological Science, Missouri University of Science and Technology.

• Fred Rottnek, MD, MAHCM, is Professor and Director of Community Medicine, Department of Family and Community Medicine and Program Director, Addiction Medicine Fellowship at Saint Louis University School of Medicine, St. Louis.