Community Overdose Surveillance: Fentanyl Involvement in Overdose Deaths in Rural Michigan

Background and purpose: The overdose epidemic remain one of the most pressing public health issues, with more than a half million deaths in the US over the past decade and over 100,000 deaths in 2021. Fentanyl remains the primary drug linked to most overdose deaths and recent trends in national overdose data suggest sharp increases in deaths associated with synthetic stimulants, cocaine, and methamphetamine. While historical trends suggest opioids and stimulants alternate in periods of use, it is unclear the extent to which polydrug co-use or contamination with fentanyl impact drug overdose mortality in rural areas. It is important to understand polydrug combinations involving fentanyl and methamphetamine in rural areas given the higher use of this psychostimulant and the relatively low availability of evidence-based treatment. The purpose of this study is to describe toxicology results from overdose deaths in 11 rural counties in a state with relatively high rates of overdose mortality. A secondary aim of this paper is to explore predictive factors (i.e., place of death; syringes at the scene, and other paraphernalia) of a fentanyl-involved death when controlling for demographics and other drugs.

Methods: Data were obtained from the Mid-Michigan Medical Examiner Group to examine postmortem toxicology results from overdose deaths that occurred between January 1, 2018, and December 31, 2020 in 11 rural counties. Data from death certificates provided sociodemographic information while toxicology data provided detection on all substances present at the time of death. Among 107 deaths that occurred over the three-year period we examined the detection of fentanyl, heroin, prescription opioids, cocaine, methamphetamine, and benzodiazepines. Binary logistic regression modeling was also performed.

Results: Most decedents were male (72.9%), White (96.3%), non-military (96.3%), employed (29.0%), never married (27.1%), and had a mean age of 47 years old. The place of death most often reported was the decedent’s residence (69.2%), follow by ER/Outpatient (12.1%), other residence (11.2%), and Other (7.5%). Approximately 38.3% of deaths were reported to have a syringe(s) present and nearly 64.0% had other paraphernalia present. Fentanyl was overwhelmingly the most common substance detected and a 94% increase during the three-year period to present in 70% of all the deaths in these counties in 2020. Among the deaths where cocaine was detected, 69% also contained fentanyl, and in deaths where methamphetamine was detected, 77% also contained fentanyl. Our binary logistic regression model indicated that dying of a fentanyl-involved overdose was nearly four times greater (OR = 3.8; 95% CI=2.2-12.6) when syringe(s) were found at the scene of death.

Conclusion and Implications: The lack of a “safe supply” is driving overdose increases, as people who use illicit opioids have shifted from prescription medications, to heroin, to heroin (and potentially other substances) contaminated with fentanyl. Drug checking can provide people who use drugs the ability to identify the presence of fentanyl in unregulated drugs. Being aware if fentanyl is present is a powerful overdose prevention tool and allows people to implement appropriate harm reduction strategies to reduce the risk of an overdose.