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The Deadly Rise of Carfentanil: What You Need to Know
In recent years, there has been a disturbing trend in the world of drug use – the rise of carfentanil. This synthetic opioid is 100 times more potent than fentanyl and a staggering 10,000 times stronger than morphine. With just a tiny amount capable of causing overdose or even death, carfentanil poses a serious threat to public health.
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Uncovering the Dark Classics in Chemical Neuroscience: The Deadly Power of Carfentanil
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Detection of Illegally Manufactured Fentanyls and Carfentanil in Drug Overdose Deaths — United States
Summary:
Illegally manufactured fentanyls, including carfentanil, have been a major contributor to the rising number of drug overdose deaths in the United States. In this blog article, we will delve into the issue of detecting these dangerous substances in overdose cases and explore the potential risks associated with their widespread availability online.
Abstract:
The opioid crisis in the United States has reached unprecedented levels, with illegally manufactured fentanyls and carfentanil playing a significant role in the epidemic of drug overdose deaths. Detecting these potent substances in overdose cases is crucial for understanding the scope of the problem and identifying potential sources of supply. This blog article will examine the current methods used for detecting fentanyls and carfentanil in toxicology screenings, as well as the challenges faced by law enforcement and public health officials in combating their proliferation.
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Introduction
In 2013, illegally manufactured fentanyl and fentanyl analogs (IMFs) entered the U.S. illegal drug supply as adulterants of or replacements for white powder heroin in the Northeast and have now replaced heroin as the dominant opioid in the United States (1). Introduction of IMFs led to a sharp rise in overdose deaths, likely because of their high potency and rapid onset of effects (2,3). In 2023, approximately 72,000 drug overdose deaths, or nearly seven in 10, were estimated to involve fentanyl, which is primarily illegally manufactured.*,† Provisional data project a decrease in overdose deaths in 2023 compared with the number in 2022, the first decline since 2018; the decrease appears to have continued into 2024.§ However, recent reemergence of carfentanil,¶ a fentanyl analog 100 times more potent than fentanyl (4), which had largely disappeared after carfentanil-involved overdose death outbreaks during 2016–2017 (5,6), might threaten this progress. Data from CDC’s State Unintentional Drug Overdose Reporting System (SUDORS) were analyzed to describe recent trends in detection of IMFs and carfentanil among overdose deaths in the United States.
Methods
Data on unintentional and undetermined intent drug overdose deaths obtained from death certificates, coroner and medical examiner reports, and postmortem toxicology reports were entered into SUDORS.** These data were entered by 49 states and the District of Columbia (DC) (jurisdictions) funded through the Overdose Data to Action in States cooperative agreement.††
Statistical Analyses
Numbers of all overdose deaths and numbers and percentages of overdose deaths with IMFs§§ detected that occurred during January 2021–June 2024 were calculated overall and by quarter (Q1 = January–March, Q2 = April–June, Q3 = July–September, and Q4 = October–December) for all jurisdictions combined and for each U.S. Census Bureau region.¶¶ Because data for January–June 2024 are preliminary, incomplete, and have not undergone full quality control measures,*** only percentages of overdose deaths with IMFs detected are presented for this period.††† Numbers of overdose deaths with carfentanil detected overall, and with carfentanil co-detected with illegally manufactured fentanyl (IMF; excluding fentanyl analogs),§§§ during January 2021–June 2024 were tabulated by 6-month period. All trend analyses included 46 jurisdictions (45 states and DC).¶¶¶ The number of overdose deaths with carfentanil detected during January 2023–June 2024 was tabulated by state among 50 jurisdictions (49 states and DC).**** Analyses were performed using SAS software (version 9.4; SAS Institute). This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.††††
Results
Overdose Deaths with IMFs Detected
During January 2021–December 2023, a total of 251,089 unintentional and undetermined intent drug overdose deaths occurred in 46 jurisdictions, including 188,082 (74.9%) with IMFs detected. Overdose deaths with IMFs detected increased 4.9%, from 60,674 in 2021 to 63,674 in 2022 and were stable from 2022 to 2023 (63,734) (Figure 1). However, during 2023, overdose deaths with IMFs detected peaked in Q2 at 16,814, declined 4.7% in Q3 to 16,019, and declined another 11.2% in Q4 to 14,229. The number of deaths with IMFs detected was 7.8% lower during the second half of 2023 (30,248) than during the second half of 2022 (32,802). Overall fatal drug overdose trends were similar to trends in deaths with IMFs detected during 2021–2023; during 2023, overdose deaths peaked in Q2 and declined thereafter.
Overdose Deaths with IMFs Detected, by U.S. Census Bureau Region
Northeast, Midwest, and South. From 2021 to 2022, the number of deaths with IMFs detected increased 4.1% in the Northeast (from 15,269 to 15,900), 2.1% in the Midwest (from 13,825 to 14,119), and 3.6% in the South (from 25,631 to 26,543). Subsequently, from 2022 to 2023, the number of deaths with IMFs detected decreased 3.2% in the Northeast (to 15,397), 7.8% in the Midwest (to 13,022), and 2.8% in the South (to 25,789). Declines were sharpest in the second half of 2023: compared with the second half of 2022, deaths with IMFs detected decreased 11.2% in the Northeast (8,245 to 7,323), 16.1% in the Midwest (7,160 to 6,008), and 10.5% in the South (13,492 to 12,077).
West. In the West Region, the percentage of overdose deaths with IMFs detected increased from 48.5% during Q1 2021 to 66.5% during Q2 2024. The number of overdose deaths with IMFs detected increased 19.5% from 2021 (5,949) to 2022 (7,112) and increased 33.9% from 2022 to 2023 (9,526), representing a 60.1% increase from 2021 to 2023. However, the number of deaths with IMFs detected decreased 13.0% in late 2023, from 2,588 in Q3 to 2,252 in Q4.
Overdose Deaths with Carfentanil Detected
Carfentanil was detected in 513 overdose deaths during January 2021–June 2024 (Figure 3). The number of overdose deaths with carfentanil detected was low during January 2021–June 2023 (≤30 per 6-month period). However, deaths with carfentanil detected increased 503.4% from 29 during January–June 2023 to 175 during July–December 2023, and increased at least another 36.0% to at least 238 during January–June 2024,§§§§ representing a total increase of 720.7% from the first half of 2023 to the first half of 2024. The average number of deaths with carfentanil detected sharply increased from 3.3 per month during January 2021–June 2023 to 34.4 per month during July 2023–June 2024. Among deaths with carfentanil detected during July 2023–June 2024, 86.9% had IMF co-detected. During January 2023–June 2024, carfentanil was detected in at least one overdose death in 37 states and at least 20 deaths in eight states, all east of the Mississippi River (Figure 3).
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IMFs entered western U.S. drug markets later than other regions, likely because of challenges mixing fentanyl into the black tar heroin that was more common in the West (1). Recent increases in counterfeit pills containing IMFs, particularly in the West, have helped IMFs infiltrate the market, increasing overdose risk (8). Consistent with more recent proliferation into western markets, the West experienced recent large increases in the number and percentage of deaths with IMFs detected, approaching 70% in early 2024. If the West is similar to other regions where deaths plateaued when ≥70% of overdose deaths had IMFs detected, this region might soon experience a lasting plateau or decrease in overdose deaths as the drug supply approaches potential saturation with IMFs.
Although still rare, overdose deaths with carfentanil detected increased approximately sevenfold starting in mid-2023. Because carfentanil is 100 times more potent than fentanyl (4), overdose deaths could substantially increase if carfentanil further infiltrates the drug supply, as evidenced by previous outbreaks (5,6). The geographic spread (37 states) and substantial codetection with IMF (87%) are markedly different from what was observed during the emergence of carfentanil in overdose deaths during 2016–2017, in which outbreaks were localized, and <25% of deaths had fentanyl co-detected (5,6). The potential mixing of carfentanil into fentanyl products as an adulterant raises concern that its presence might be unknown to persons using drugs, reminiscent of the way that fentanyl was first introduced as an adulterant of heroin
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Limitations
The findings in this report are subject to at least three limitations. First, depending on the analysis, 46 or 50 jurisdictions were included; thus, results might not be generalizable to the entire United States. Second, postmortem toxicology testing lacks standardization across and within jurisdictions and might result in differential carfentanil detection. Finally, 2024 data are preliminary; not all overdose deaths that occurred have been reported to SUDORS yet. These limitations likely underestimate overdose deaths with carfentanil detected. Therefore, the increases in deaths with carfentanil detected are likely larger than those presented in this report.
Implications for Public Health Practice
Reductions in unintentional and undetermined intent drug overdose deaths overall and with IMFs detected described in this report coincide with provisional estimates showing projected decreases in overdose deaths nationally in 2023 and into 2024. †††††† Importantly, most overdose deaths in the United States still have IMFs detected. In the West, deaths increased into 2023 as the percentage with IMFs detected approached levels similar to those seen in the rest of the country. Efforts focused on preventing deaths involving IMFs, including carfentanil and other analogs, such as maintaining and improving distribution of risk reduction tools, increasing access to and retention in treatment for substance use disorders, and preventing drug use initiation, might result in sustained decreases in overdose deaths.
Acknowledgments
Jurisdictions participating in CDC’s Overdose Data to Action (OD2A) program and providing data to the State Unintentional Drug Overdose Reporting System, including state and jurisdictional health departments, vital registrar offices, and medical examiner and coroner offices; CDC OD2A-States team, Division of Overdose Prevention, National Center for Injury Prevention and Control, CDC.
