Carfentanil came, killed, left.

The reason overdose deaths have fallen sharply in Ohio can be attributed to a singular cause: carfentanil has nearly vanished from Ohio’s illegal drug supply. The charts in this article will explain why.

It’s important to understand that carfentanil was responsible for essentially the entire surge in overdose deaths between the mid-2016 and mid-2017, a death spike that pushed Ohio from No. 5 in overdose death rates to No. 2. CDC mortality data showed a carfentanil-related overdose death rate that was 21 times of other states it studied. (See HRO’s stories  here and here.)

This type of mountainous variance between states is almost unheard of in any kind of data analysis, not just examinations or death rates or drug policies. Ohio’s catastrophic overdose death levels since 2016 had nothing to do with drug use — Ohioans use drugs at average rates —  or addiction or Mexican cartels or the other things commonly blamed. 

It was all carfentanil…and carfentanil was pretty much only in Ohio…and it pretty much happened without our state and local governments realizing the scope of what was happening. 

Carfentanil Mountain

When the media proclaimed in early 2017 that Dayton was the heroin overdose capital of the United States, the truth was otherwise. The overdoses were driven by carfentanil in cocaine. (See our story on “The Dayton Tragedy.”) Heroin had nothing to do with the increase.

In reality, what happened to Ohio was this: carfentanil came here hard and fast in the spring of 2016. The presence of carfentanil went from non-existent to deep into all Ohio’s major illegal drugs — heroin, cocaine, meth, pills (but not marijuana; fentanyl-laced marijuana is a myth) — with extraordinary swiftness, as the charts show will show.

Carfentanil killed 1,106 Ohioans in the 12 months studied by the CDC and about 2,000 over a 24-month period, HRO estimates. 

Carfentanil was largely an Ohio-only phenomenon. Even neighboring states — West Virginia, Kentucky — did not get ravaged by this potent fentanyl analog (sometimes used as a large animal tranquilizer). Neither did New Hampshire and other states that had suffered alongside Ohio from high rates of overdose deaths.

(Why Ohio and not other states? Harm Reduction Ohio has a theory on this which we have not confirmed.)  

For whatever reason, the presence of carfentanil peaked in the spring of 2017 and fell sharply and fast. The drug left Ohio nearly as quickly as it came. (It could but is unlikely to return anytime soon for reasons beyond the scope of this article.)

The charts below show what percentage of Ohio’s illegal drug supply and specific drugs contained carfentanil, as measured by all drugs tested at the state’s four crime labs since 2015. The data is based on drug confiscated by police in all 88 counties, then sent to the state crime labs for testing.

This big data set that is a good proxy the make-up of the state’s illegal drug supply as a whole. The Ohio Bureau of Criminal Investigation crime labs do gas chromatography–mass spectrometry tests on about 3,000 confiscated controlled substances every month. This covers about half of all drugs seized in Ohio. Local crime labs do the other half. (Harm Reduction Ohio has analyzed results provided by the crime labs in Cuyahoga County (Cleveland) and Montgomery County (Dayton) as well.)  

In technical terms, the chemical composition of Ohio’s illegal drug supply — as shown in the BCI crime lab data — is strongly correlated to overdose death In everyday words: Tell me what’s in 3,000 illegal drug samples tested by the state every month and I’ll tell you how many people died. In the mortality data, overdoses deaths are called “unintentional drug poisonings” for a reason. What’s in the drug supply is the primary determinant of death rates — not levels of use or access to treatment or arrests or the weather.

Fentanyl kills at higher rates than heroin, and carfentanil kills at multiples beyond fentanyl. The connection is direct and could be seen by your blind grandmother even if she’s deceased. That is, if you look.

HRO did two smaller studies with local crime labs in Cuyahoga County and Montgomery County that first alerted us to this “holy shit” effect from whenever carfentanil appeared in a drug supply. These smaller studies prompted us to expand our research to the statewide level. (HRO has encouraged state officials to consider this data, but, well…God grant us the serenity…)

Death starts before police find carfentanil

HRO started this research hoping that drug seizure data could predict and prevent increases in overdose death. Sadly, the opposite turned out to be true. Overdose deaths rise (or fall) about three months before what’s confiscated by law enforcement registers changes (for good or bad) in the drug supply. This time lag was true in both HRO’s two local studies and our ongoing analysis of state data. The likely reason new drug combinations reach users first and it takes a while for police to catch up. 

With that said, here’s why overdose deaths in Ohio have declined since the last 18 months. 

This chart should astound you. At its peak, carfentanil was in nearly 10% of all illegal drugs confiscated in Ohio. Not just heroin but cocaine, meth, fake pills, Ecstasy, etc. And the numbers even include marijuana seizures, even though Ohio’s marijuana supply is safe from fentanyl and its analogs.

Let’s look at the major drugs up close. 

This may be the most important chart.

Cocaine is a far more popular than heroin or meth. Plus, its users don’t expect fentanyl, much less carfentanil, to be in what they consume. They generally have no opioid tolerance, so they’re killed by much tinier doses than regular opioid users. In addition, it’s unlikely that naloxone was around to revive them and, even it was, it’s less likely to be used because you wouldn’t normally expect an opiate overdose to occur from cocaine use.

We hate to say we told you so but…

Harm Reduction Ohio was shouting early and alone about fentanyl-laced cocaine, even before we knew much of that was carfentanil. Most public health officials were clueless about — or did not understand the importance of — what was happening until long after the change had occurred.

The result was cocaine users were not properly warned about the life-threatening danger they faced, although the risk was clear in the mortality data (i.e., who was dying and why). The silence and inaction contributed to the tragedy shown in the net chart: cocaine-fentanyl overdose deaths exceeded heroin-fentanyl overdose last year while policy makers remained myopically focused on opiate use.

A chart we did in September illustrates. 

And meth?

Harm Reduction Ohio started warning about fentanyl-laced meth a year ago, encouraging the state to publish data on meth-fentanyl related deaths. (Cocaine-fentanyl and heroin-fentanyl deaths are released as they are reported, but meth deaths are not.) It was clear meth deaths (almost certainly meth-fentanyl deaths) were rising fast but the state was slow in saying so.

Now we know. The “good” news is that fentanyl/carfentanil did not make it as deeply into Ohio’s meth supply as it did into our cocaine supply. However, carfentanil and fentanyl still killed 500+ Ohioans during carfentanil’s 18- to 24-month reign of overdose terror. 

Carfentanil peaked at 1.5% of the meth supply. A little carfentanil can kill a lot of people. Still, compared to cocaine, which had a carfentanil peak of 8.4%, meth users escaped a catastrophic level of death.

Let’s not forget heroin

 Fentanyl and carfentanil was (and is) still most common in the heroin and opiate supply. Carfentanil in opiates killed at lower rates — not numbers, but rates — probably because regular opiate users often have heroic levels of opiate tolerance.

This chart shows the percentage of confiscated drugs containing heroin or only a fentanyl (including carfentanil). In other words, if police seized something that had any amount of heroin or had no heroin but contained only fentanyl or an analog, it was considered to be marketed as heroin and is included in these numbers.

Carfentanil is the big story of the last two years, but it’s not the whole story. Fentanyl and other analogs remain common and are related to overdose death at various levels. (Each analog carries a different level of risk.)

This chart shows the level of fentanyl adulteration in Ohio’s illegal drug supply and the role carfentanil within that adulteration. 

The peak number — 10.7% vs. 9.8% in the chart above — is a little higher because in this chart we excluded marijuana (because fentanyl/carfentanil-laced marijuana is a myth) and this chart shows fentanyls in the at-risk drug supply rather than the entire supply.

Note that fentanyl (of any kind) has fallen about 25% from its peak. However, all drugs are not created equal. The presence of a fentanyl (i.e., any kind) is almost unchanged in the heroin supply, but it has fallen about 80% in the cocaine and meth supplies. In other words, cocaine and meth in Ohio are much, much safer than a year ago. That’s very good news. 

The result will be that cocaine-fentanyl/carfentanil overdose deaths should fall dramatically. Ditto meth-fentanyl/carfentanil deaths. And, when the final numbers are in, heroin-carfentanil deaths should be down while all heroin-fentanyl/not carfentanil deaths will likely be about the same. 

Ain’t that the truth

When you read this article in The New York Times about Montgomery County’s success in reducing overdose death, don’t believe it. Local officials could not influence overdose death rates because they didn’t understand that carfentanil, not high levels of use, was the variable driving overdose death. 

By making drugs illegal, government has created an unregulated market for heroin, cocaine, meth and other drugs. Unlike markets for tobacco, alcohol and legal marijuana which governments can influence, government has no influence on product safety in drug markets, except generally pushing it to be more dangerous. (See Iron Law of Prohibition. Carfentanil is a pure expression of this economic phenomenon.) 

Drug markets may be illegal markets, but they are still markets. Safety levels of what people consume is the primary determinant of death levels. Drug users are not to blame at the epidemiological level. Carfentanil came, killed and left.  

— Dennis Cauchon, President, Harm Reduction Ohio

Dennis Cauchon was a national reporter at USA TODAY for 27 years. He took a buyout and formed Harm Reduction Ohio in 2016. You can email him here. He wrote the above article last night in 78 minutes. If you see typos, tell him! 

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