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Invited Commentary
Public Health
November 8, 2019

Our Response to Opioid Overdose Deaths Must Be as Nimble as Illicit Opioid Markets

Author Affiliations
  • 1University of Massachusetts, School of Criminology & Justice Studies, Lowell
JAMA Netw Open. 2019;2(11):e1914634. doi:10.1001/jamanetworkopen.2019.14634

Overdose deaths involving synthetic opioids other than methadone, which include fentanyl, increased almost 47% from 2016 to 2017.1 According to data from the National Forensic Laboratory Information System, seizures of fentanyl increased by nearly 7-fold from 2012 to 2014, with more than 80% of fentanyl seizures in 2014 concentrated in 10 states, with Ohio and Massachusetts in the top 5.2 Clearly, fentanyl and other synthetic opioids (FOSOs) have become regionally entrenched throughout the United States, most notably in Appalachia, New England, and the mid-Atlantic.3 Markets for FOSOs west of the Mississippi River have remained relatively stable; in 2019, there were 2199 overdose deaths involving opioids in California—a rate of 5.3 deaths per 100 000 persons, which is lower than the national rate of 14.6 deaths per 100 000 persons.4 Ohio reported a rate of 39.2 deaths per 100 000 persons and Massachusetts reported a rate of 28.2 deaths per 100 000 persons for the same reporting period.4

Hot spots for FOSO overdose death (ie, Appalachia, New England, and the mid-Atlantic) evidence considerable variability in spatial overlap when examining incidence of overdoses and drug seizures. These hot spots are contingent upon product variability, ie, the presence or absence of street heroin, fentanyl, and/or diversification of new synthetic opioids such as carfentanil (which, incidentally, was a contributing factor in many of the fatal overdoses in Ohio for 2017).3 Zibbell et al5 highlight the unprecedented pace for fentanyl overdose deaths from 2014 to 2017 by integrating overdose mortality data from Ohio’s Vital Statistics System with state crime laboratory data from Ohio’s Bureau of Criminal Investigation; their findings demonstrate a significant association between law enforcement drug seizures and overdose deaths.

Notwithstanding common reporting biases associated with health-related and criminal justice administrative data, the demand for improved and continual surveillance of FOSO markets remains critical across both public health and public safety sectors. The opioid epidemic is currently in its third wave; the inherent variability of FOSO markets requires a proactive rather than a reactive response, which has been the standard practice of the last 2 heroin epidemics. This third wave is inherently different. Markets for FOSOs are predicated on a business model defined by a fluid organization of illicit synthetic opioid entrepreneurship. While traditional drug trafficking organizations and nation-states play a major role in FOSO distribution and transportation, a significant number of independent actors also dominate FOSO markets owing to their significant profit margins. Therefore, FOSO markets are highly jurisdictional in structure, diverse in product, and profitable.

Moving forward, local communities must be as nimble and innovative as FOSO markets themselves. Zibbell et al5 highlight this reality by calling for a genuine commitment in data-driven decisions stemming from strong public health and public safety partnerships.

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Article Information

Published: November 8, 2019. doi:10.1001/jamanetworkopen.2019.14634

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Palacios WR. JAMA Network Open.

Corresponding Author: Wilson R. Palacios, PhD, University of Massachusetts, School of Criminology & Justice Studies, Health and Social Sciences Bldg, 113 Wilden St, Room 489, Lowell, MA 01854 (wilson_palacios@uml.edu).

Conflict of Interest Disclosures: None reported.

Centers for Disease Control and Prevention National Center for Health Statistics. Wide-ranging online data for epidemiologic research (WONDER). http://wonder.cdc.gov. Accessed October 12, 2019.
Centers for Disease Control and Prevention. CDC health advisory: increases in fentanyl drug confiscations and fentanyl-related overdose fatalities. https://emergency.cdc.gov/han/han00384.asp. Published October 26, 2015. Accessed October 12, 2019.
Pardo  B, Taylor  J, Caulkins  JP, Kilmer  B, Reuter  P, Stein  BD.  The Future of Fentanyl and Other Synthetic Opioids. Santa Monica, CA: Rand Corporation; 2019. doi:10.7249/RR3117
National Institute on Drug Abuse. California Opioid Summary. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/california-opioid-summary. Updated March 2019. Accessed October 14, 2019.
Zibbell  JE, Aldridge  AP, Cauchon  D, DeFiore-Hymer  J, Conway  KP.  Association of law enforcement seizures of heroin, fentanyl, and carfentanil with opioid overdose deaths in Ohio, 2014-2017.  JAMA Netw Open. 2019;2(11):e1914666. doi:10.1001/jamanetworkopen.2019.14666Google Scholar
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