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**DEPARTMENT OF HEALTH & HUMAN SERVICES** Substance Abuse and Mental
Health Services Administration

Center for Mental Health Services

Center for Substance Abuse Prevention

Center for Substance Abuse Treatment

Rockville, MD 20857

June 2, 2006

Number range CHAPTERDear Colleague:

A combination of street drugs-- taken together -- is having a lethal
effect in a number of communities across the country. The root cause of
these deaths appears to be the addition of fentanyl -- a powerful
narcotic analgesic -- to heroin or cocaine being sold on the street.
Fentanyl, prescribed most often by physicians to treat patients with
severe or chronic pain, is 50-100 times more powerful than morphine.

You may have been reading and hearing about clusters of drug-related
deaths in Philadelphia, Chicago, St. Louis, and, most recently, Detroit.
In just one week, an estimated 33 individuals in the Detroit area are
reported to have died after using this fatal mix of drugs; the same drug
combination may have been responsible for over 100 deaths in the same
region since last September. As an individual involved in the public
health, you need to be aware of this new "killer drug combination," and
you need to be prepared to alert patients, clients, and others in order
to help save lives.

When used illegally, particularly in combination with a drug such as
heroin or cocaine, or when used in excessive amounts, fentanyl can
result in irregular heart beat, the inability to breathe, and death. In
some cases, heroin or cocaine users are aware they are purchasing this
dangerous combination of drugs; in other cases, the buyer is not aware
that he or she is purchasing this potentially lethal drug combination.
The current situation highlights the need to be vigilant in your
community for the possible introduction of this potent drug mixture into
circulation on the street, and to help educate individuals with whom you
come in contact.

As professionals individuals involved in substance abuse treatment and
prevention, you have many tools at your disposal right in your community
to help prevent overdoses and deaths, and to help identify and rapidly
treat overdoses. The appended fact sheet can be reproduced and
distributed as you believe most appropriate and effective. We hope you
will work with your local health authorities to bring this critical
information to first responders, emergency room personnel, street
substance abuse workers, drug treatment facilities, local health care
providers, the recovery community, and the public at large. At the very
least, please get the word out to your own networks of patients and
colleagues about this dangerous drug combination and how to treat its
effects.

SAMHSA can provide additional information to you on this emerging area
of substance abuse concern. Please contact Kenneth Hoffman, M.D, M.P.H.,
at 240-276-2701 or <Kenneth.Hoffman@samhsa.hhs.gov>. Let us know what
you are doing in your community. Together, we can reduce the danger
associated with this new, often lethal street drug cocktail.

Sincerely yours,

H. Westley Clark, M.D., J.D., MPH. CAS, FASAM. Director

Center for Substance Abuse Treatment

Enclosure

> **Fact Sheet: Heroin Fentanyl**

**THE ISSUE**

-   An outbreak of overdoses and deaths involving fentanyl combined with
    heroin or cocaine has been reported in a number of urban areas in
    the United States, including, among others, Chicago (IL), Detroit
    (MI), Philadelphia (PA), and Camden (NJ).

-   The majority of overdoses and deaths related to fentanyl in
    combination with heroin or cocaine that are now being reported do
    not appear to be from the misuse of prescription-grade fentanyl.

-   These reports have led to local Drug Enforcement Administration and
    Centers for Disease Control and Prevention investigations as well as
    local--and national -- health information efforts to alert first
    responders, hospital emergency rooms, health care providers, and the
    community about this new public health problem.

**WHAT IS FENTANYL**

-   Fentanyl, a schedule II prescription narcotic analgesic, is roughly
    50-80 times more potent than morphine. This medication is used to
    manage both pain during surgery and for persons with chronic
    moderate to severe pain who already are physically tolerant to
    opiates.

-   However, fentanyl also can be produced in clandestine laboratories
    in powder form and mixed with or substituted for heroin.

**PREVENTING OVERDOSES**

> Persons using heroin or cocaine, or in treatment/recovery from such
> use need to know that:

-   The potency of street-sold heroin or cocaine is amplified markedly
    by fentanyl.

-   One may not know that the heroin or cocaine has been cut with
    fentanyl.

-   Because the potency of the drug purchased on the street is not
    known, and because the inclusion of fentanyl may not be disclosed,
    ANY use -- even a reduced dose -- can result in overdose or death.

-   The effects of an overdose occur rapidly, particularly with this
    potent combination of drugs. Critical treatment minutes can be lost
    because emergency room personnel may not be aware that fentanyl is
    not detected in standard toxicology screens.

**DETECTING AND TREATING OVERDOSES**

-   Fentanyl-related overdoses can result in sudden death through
    respiratory arrest, cardiac arrest, severe respiratory depression,
    cardiovascular collapse or severe anaphylactic reaction.

-   Routine toxicology screens for opiates will **not** detect fentanyl.
    Some labs can test for fentanyl when specifically requested.

-   Because these drugs, in combination, can be lethal if action is not
    taken promptly, suspected overdoses should be treated rapidly with a
    naloxone injection, 0.4-2 mg IV, SC or IM every 2 to 3 minutes which
    should rapidly reverse symptoms related to a narcotic overdose.
    Naloxone can also precipitate immediate narcotic withdrawal symptoms
    as overdose symptoms are reversed. If there is no response after 10
    minutes, a different diagnosis should be considered.