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ACEP Now: Vol 33 – No 12 – December 2014

Is it a heroin overdose or something worse?

A new study in Annals of Emergency Medicine warns emergency physicians that what appears to be an increase in heroin overdoses is actually an increase in overdoses tied to acetyl fentanyl mixed into street drugs marketed as heroin.¹

“What’s frightening about this emerging street drug is that users may not be aware that they are ingesting it,” said lead author John Stogner, PhD, assistant professor in the department of criminal justice and criminology at the University of North Carolina in Charlotte. “A patient may report heroin use and have symptoms consistent with heroin overdose, but an emergency physician may find that the standard dose of [naloxone] doesn’t work. Larger or additional doses are necessary when acetyl fentanyl is responsible.”

Dr. Stogner said physicians should be aware that ELISA testing will not indicate acetyl fentanyl use and that gas chromatography–mass spectrometry is necessary to attribute an overdose to acetyl fentanyl.

Acetyl fentanyl is a fentanyl analogue with no recognized medical use. It is 5 to 15 times stronger than heroin. Users typically administer it intravenously as a direct substitute for heroin or pharmaceutical-grade opioids, although many are unaware that they aren’t consuming plain heroin. A user who injects pure acetyl fentanyl may suffer severe consequences because of its extraordinary potency. The substance is associated with euphoria, altered mood, drowsiness, miosis, cough suppression, constipation, and respiratory depression.²

“Clever and well-informed drug-distribution networks will likely take advantage of the legal loophole and profit by replacing or cutting a highly regulated drug with this less-regulated one. The significant potential for overdose of acetyl fentanyl necessitates more medical research and policy reform.”
–John Stogner, PhD

According to the study, novel psychoactive substances often quickly emerge as problematic substances. Typically, drug users become aware of these compounds before extensive information appears in criminological or medical journals. Therefore, experimentation often precedes the development of legal and clinical protocols, forcing law enforcement officers and emergency medicine professionals to react to situations for which they are unprepared.

A survey of emergency physicians by Lank and colleagues³ indicated that only 20 percent felt prepared to deal with acute, novel drug intoxication or overdose. In addition, relatively common novel drugs were completely unknown to more than half of the respondents, and all reported a desire for more information and training.

Acetyl fentanyl is not specifically regulated, although it qualifies as an analogue of fentanyl. Thus, it exists in a legal gray area: it is considered illicit for human consumption, but if a package is labeled “not for human consumption,” the product is technically legal. A large quantity of acetyl fentanyl would potentially be immune to regulation as long as it was titled, labeled, and stored as a product with industrial or nonhuman research purposes.

An acetyl fentanyl case may indicate that a dealer failed to appropriately dilute the compound prior to providing it to customers. “The authorities should be notified and advised that acetyl fentanyl or acetyl fentanyl–contaminated heroin may be on the streets,” Dr. Stogner said.

“Clever and well-informed drug-distribution networks will likely take advantage of the legal loophole and profit by replacing or cutting a highly regulated drug with this less-regulated one,” Dr. Stogner said. “The significant potential for overdose of acetyl fentanyl necessitates more medical research and policy reform.”

According to the Annals study, because of acetyl fentanyl’s smaller potential user base, it is not expected to become as widespread as other novel drugs such as synthetic cannabinoids.

Karen Appold is a medical writer in Pennsylvania.

References

1. Stogner JM. The potential threat of acetyl fentanyl: legal issues, contaminated heroin, and acetyl fentanyl “disguised” as other opioids. An. Emerg Med. 2014. Aug 7. [Epub ahead of print]
2. Acetyl fentanyl (N-(1-phenethylpiperidin-4-yl)-N-phenylacetamide), December 2013. Drug Enforcement Administration Web site. Available at: http://www.deadiversion.usdoj.gov/drug_chem_info/acetylfentanyl.pdf. Accessed September 25, 2014.
3. Lank PM, Pines E, Mycyk MB. Emergency physicians’ knowledge of cannabinoid designer drugs. West J Emerg Med. 2013;14:467-470.