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Fentanyl, heroin, and cocaine are the leading culprits in drug-related overdose deaths in the United States, although methamphetamine—the fourth most common cause of overdose deaths nationally—tops the list in many southern and western states, including Texas, Louisiana, Washington, and California, according to a new report from the Centers for Disease Control and Prevention (CDC). Collectively these four drugs accounted for 96.3% of overdose deaths in 2017. This study and others call for increased vigilance on the part of clinical labs and other authorities to effectively identify and track the paths of these illicit drugs

CDC analyzed data from the 2017 National Vital Statistics System mortality files, examining trends according all 10 U.S. Department of Health and Human Services (HHS) regions. “Deaths from drug overdose remain a significant public health concern in the United States,” the authors noted, citing a triple increase in age-adjusted rates of drug overdose deaths over the last 20 years, from 6.1 per 100,000 in 1999 to 21.7 per 100,000 in 2017.

Several drug classes were among the top 15 drugs involved in overdose deaths: opioids, benzodiazepines, stimulants, the antihistamine diphenhydramine and the anticonvulsant gabapentin. Fentanyl metabolites, precursors, and analogs accounted for 27,299 or nearly 39% of 70,237 overdose deaths in 2017, followed by heroin (22.8%), cocaine (21.3%) and methamphetamine (13.3%). The top three drugs predominated in HHS Regions 1-5, which range from Minnesota in the north to Mississippi in the south, extending to the East Coast from Maine to Florida.

CDC cited methamphetamine as the top drug leading to overdose deaths in HHS Regions 6 (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas) and 8–10 (westernmost parts of the United States).

In all 10 regions, six drugs—alprazolam, cocaine, fentanyl, heroin, methadone, and oxycodone—ranked among the 10 drugs linked to overdose deaths, though not always in the same order. “These regional differences in the drugs most frequently involved in drug overdose deaths mirror findings from studies and data sources related to drug use,” wrote the researchers.

There are several reasons why fentanyl overdoses are more prevalent in the East, Bryce Pardo, an associate policy researcher at RAND Corp., told CLN Stat. “First, parts of Appalachia and the Midwest were overexposed to prescription opioids. Heroin then came later. But the explanation that makes the most sense to me is that fentanyl started showing up as an additive to heroin,” he said. Pardo recently authored a study on synthetic opioids deaths that underscored the growing use of fentanyl in the United States.

Pardo suspects that the counterfeit pill phenomenon will allow fentanyl to spread farther west. “We’re already seeing increasing supply/death indicators out west, including increases in fake pills,” he noted.

Methamphetamine’s proliferation out west seems to follow some underlying historical patterns, he continued. “Meth’s resurgence decades ago was traced to the beatnik culture and biker gangs out west,” Pardo said. “One could also probably point to other cultural factors like long-haul truckers, who used meth to keep them alert on the job.”

The ability of home labs to produce meth also may have contributed to its popularity out west, although now, the drug seems to be making its way farther east, Pardo said.

Labs can help tackle this problem on several fronts, according to Pardo. In areas where entangle is prevalent, labs “will need to improve how they detect fentanyl in fluids, post mortems, or drug seizures. Quantifying fentanyl in drug seizures—especially in nonopioid drugs like cocaine—will be increasingly important,” he suggested. Knowing how fentanyl presents itself in drugs would also help increase transparency in markets and alert users about possible fentanyl contamination in the drug supply.

Clinical labs should also be aware of the proliferation of analogs, making sure they have the necessary equipment and are up to date on their referent libraries, Pardo said. With respect to methamphetamine, labs along with law enforcement and public health authorities need to keep an eye out for the emergence of novel synthetic stimulants like cathinones. “These drugs are also made in China and can be imported, so we’ll want to see if dealers start making the same decisions to move from methamphetamine from Mexico to other stimulants that can be imported from China,” Pardo elaborated.