Tuesday, July 3rd, 2018 MEDICAL EXAMINER RELEASES ANNUAL HEROIN AND FENTANYL OVERDOSE DATA The Monroe County Office of the Medical Examiner today released annualized data pertaining to 287 deaths directly attributable to the use of heroin, fentanyl, or other related substances in 2017. These substance-use related deaths 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 Dr. Nadia Granger, Monroe County 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. I thank our Office of the Medical Examiner staff who worked diligently to prepare this comprehensive report to enhance public awareness.” “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 Dr. Michael Mendoza, Monroe County 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. We have been tireless in our fight against opioids and we will not rest until the tide begins to turn.” The data presented in this report refer only to those individuals for whom the cause of death was solely attributed to the substances involved. It does not include deaths wherein these substances were present, but the cause of death was attributed to some traumatic injury (e.g., driving under the influence of drugs leading to a fatal crash). 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. Thirty-two of the 287 deaths involved morphine that could not necessarily be attributed to heroin. Fentanyl and analogs are typically sold on the street as heroin or cocaine, often in preparations or mixtures with those MEDICAL EXAMINER RELEASES OVERDOSE DATA 1 of 5 compounds. Fentanyl analogs are a growing class of novel psychoactive substances (NPS) that are structurally related to fentanyl, and first appeared in the illicit drug market within the last few years. Laboratory testing for these analogs began in 2015-2016. Table 1. Total number of Monroe County Office of the Medical Examiner deaths attributed to heroin/morphine and/or fentanyl, fentanyl analogs, or U-47700. Year Total Number of Heroin/Fentanyl Deaths 11 30 67 95 85 206 287 2011 2012 2013 2014 2015 2016 2017 Percent of Cases Investigated 1.2% 3.1% 6.8% 9.1% 8.2% 19.9% 22.7% Of the 287 total deaths, 220 occurred in Monroe County, while 67 occurred in surrounding counties that contract for autopsy services with the Office of the Medical Examiner (Table 2). It should be noted that 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. Table 2. Number of deaths related solely to overdose from heroin/morphine and/or fentanyl, fentanyl analogs, or U-47700, organized by county where the death occurred. County of Death Monroe Allegany Chemung Genesee Livingston Ontario Orleans Steuben Wayne Wyoming Yates 20112013 78 0 11 0 3 4 1 4 7 0 Number of Deaths 2014 2015 2016 81 0 2 3 3 2 1 3 69 2 3 2 1 3 0 2 0 0 2 1 169 0 0 0 8 0 9 13 0 7 0 2017 220 1 0 19 15 1 7 10 3 11 0 The majority of the decedents (66%) were white males (Table 3, Table 4). The race/ethnicity distribution was consistent with previous years (Table 3). It reflects the opioid crisis’ impact irrespective of ethnic heritage. The sex distribution of the decedents was also consistent with prior years. MEDICAL EXAMINER RELEASES OVERDOSE DATA 2 of 5 Table 3. Race/ethnicity distribution among heroin/morphine and fentanyl/analogs deaths from 2014-2016. 2017 Race 2014 2015 2016 Caucasian 87.4% 80.0% 89.3% 88.9% 9.1% African American 7.4% 17.6% 8.7% 0.7% Asian 1.0% 1.2% -a 1.4% Other 2.2% 1.2% 1.9% b Hispanic 1.0% 4.7% 8.7% 8.0% a Other includes but is not limited to Native American. b Hispanic/Non-Hispanic identification is independent of race identification. Table 4. Sex distribution among heroin/morphine and fentanyl/analogs deaths from 2011-2016. Year(s) 2011-13 2014 2015 2016 2017 Male 79.6% 74.7% 74.1% 76.2% 74.6% Female 20.4% 25.3% 25.9% 23.8% 25.4% In 2017, the ages of the victims of heroin/morphine/fentanyl/analogs overdose ranged from <20 to 82 years with a median age of 38 years (Figure 1). Median ages for 2014, 2015, and 2016 were 36, 36, and 35, respectively. The 2017 deaths represent a 39% increase from 2016, and a 3.4-fold increase from 2015. The crisis has escalated steadily since it began in mid-2012 (Figure 2). For nearly every age group between 20-59, 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. Figure 1. Age distribution and total heroin/morphine and fentanyl/analogs deaths by year(s). Data for 2011-2013 are presented in aggregate. MEDICAL EXAMINER RELEASES OVERDOSE DATA 3 of 5 Variable monthly rates of heroin/fentanyl fatalities are likely 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-mid 2017, furanyl fentanyl, acetyl fentanyl, and U-47700 were the most common compounds detected. By mid-2017, U-47700 had all but disappeared, and parafluoro(iso)butyryl fentanyl became common. Beta-thiohydroxy fentanyl also began to be detected. The dynamic and frequently changing NPS drug market presents unique and growing challenges for toxicological testing. The Office of the Medical Examiner is watching these developments carefully and continues to adapt testing methodology to detect these new threats to public health. Heroin, fentanyl/analogs, ethanol (alcohol) and cocaine are frequently encountered together in postmortem cases (Table 4). Among the 287 cases described herein, there was both a mean and median of 2 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. Other common findings of drugs contributing to these overdose deaths are presented in Table 4. Table 4. Number of 2017 cases for which common substances were listed in the cause of death. Compound / Drug Class Fentanyl/Analogs U-47700 Heroin Morphine Cocaine Alcohol Benzodiazepines Prescription Opioidsa Amphetaminesb Mitragynine Cyclobenzaprine Gabapentin Number of Cases 261 12 96 32 141 61 50 32 7 6 5 5 Percent of Heroin/Morphine/Fentanyl Overdose Deaths 90.9% 4.2% 33.4% 11.1% 49.1% 21.3% 17.4% 11.1% 2.4% 2.1% 1.7% 1.7% a Note: these data do not include deaths attributed to prescription opioids in the absence of heroin/morphine or fentanyl/analogs. Prescription opioids include buprenorphine, hydrocodone, methadone, oxycodone, and tramadol. b Includes amphetamine, methamphetamine, and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) MEDICAL EXAMINER RELEASES OVERDOSE DATA 4 of 5 Figure 2. Number of heroin/morphine and fentanyl/analogs deaths by month, 20112017. Average Deaths/Month 2011 1 2012 2 2013 6 2014 8 2015 7 2016 17 2017 24 ### Media inquiries, contact: Director of Communications Jesse Sleezer at (585) 402-8019 Department of Communications at (585) 753-1080 MEDICAL EXAMINER RELEASES OVERDOSE DATA 5 of 5