Last Friday (3 January 2020) the Advisory Council on the Misuse of Drugs (ACMD) published a new report on the Misuse of Fentanyl (and Fentanyl analogues). As many readers will know, Fentanyl is a licensed medicine used for anaesthesia and pain management. Like morphine, heroin, codeine and other ‘opioid’ drugs, fentanyl and compounds with similar chemical structures (fentanyl analogues) may be subject to non-medical use (misuse). This may involve the diversion of licensed medicinal fentanyl or fentanyl analogues, or the use of illicitly manufactured material. These very potent compounds have already been implicated in large numbers of deaths amongst drug users in the United States (US) and Canada. There is an ongoing risk of illicit fentanyls increasingly infiltrating the illicit opioid market in the UK, with consequent increases in drug-related deaths that could be substantial.
The main reason that the ACMD has been looking into Fentanyl is that infiltration of fentanyls into the heroin supply chain in the United States and Canada has been responsible for substantial increases in drug-related deaths. The public health risk associated with the misuse of fentanyl and its analogues relates to the high potency of these substances. Compared to morphine, the amount of fentanyl required to produce the same pain killing (analgesic) effects is 50-100 times lower. Because of this, users face a high risk of accidental overdose leading to potentially fatal respiratory depression.
There has been growing evidence recently of a steady increase in the number of fentanyl-related deaths in the UK. In 2017, the National Crime Agency (NCA) reported heroin containing fentanyl seized in Yorkshire. There was also a heroin-related death in April 2017 where carfentanil was identified at post mortem. Following targeted testing in the North East of England, samples from further apparent heroin-related deaths were found to contain fentanyls. More recently, however, the majority of UK police forces have reported fentanyl-related deaths
- The risk to public health from fentanyls may be lower in the UK than in North America because there is a smaller population of people who have become habituated to strong opioids. There is, however, limited information available about diversion rates and misuse of pharmaceutical fentanyls in the UK.
- Episodes of fentanyl toxicity and deaths in the UK have been sporadic and have not approached the very high numbers seen in North America. However, rates of registered deaths involving fentanyls have recently increased and may be under-estimated because sufficiently detailed forensic analysis of drug causes is sometimes not carried out. Consequently, the role of a fentanyl in the death may not be recognised.
- There remains an ongoing risk of fentanyls and other new synthetic opioids increasingly infiltrating the UK heroin market and increasing rates of drug-related deaths. The long-standing UK generic control on fentanyls has proved to be robust and almost all ‘designer’ fentanyl variants being encountered are automatically controlled in the UK as Class A drugs. There are a small number that are not controlled, although these are largely of lower potency and carry a lower risk of overdose. Most fentanyl precursors are also controlled, with some exceptions.
The ACMD makes a number of recommendations:
- Research should be commissioned to study diversion and non-medical use of strong opioids to identify trends, drug products involved and populations at risk.
- Government departments should conduct a full review of international drug strategy approaches to fentanyl markets, in particular, the North American experience, and consider interdiction controls that can be applied to the UK situation.
- Ensure that health professionals are trained in the appropriate therapeutic use of strong opioids, as described in the ‘Opioids Aware’ resource and the forthcoming NICE guidance on management of chronic pain.
- Toxicology analysis of samples of all deaths related to drug poisoning should include analysis for fentanyl and fentanyl analogues as non-systematic screening hinders our capacity to understand trends in drug death.
- Toxicology reports from all deaths related to drug poisoning should include a clear statement as to whether fentanyl and/or its analogues were included in the testing. Importantly, it should be made explicit if fentanyl
and/or its analogues have not been tested for. This would enable meaningful monitoring of trends in fentanyl-associated deaths.
- Research should be commissioned to monitor the local and national prevalence of fentanyl and fentanyl analogues in:
i) drug seizures, including heroin preparations and counterfeit medicines
ii) non-fatal episodes of heroin toxicity requiring hospital treatment.
- Increased funding should be made available to the Defence, Science and Technology Laboratory Forensic Early Warning System (DSTL FEWS) programme to increase capacity to analyse un-adopted police and border force seizures.