The Emerging Role of Toxic Adulterants in Street Drugs in the US Illicit Opioid Crisis

Abstract

Drug overdose deaths in the United States are a substantial public health issue. The number of annual reported drug overdose deaths increased roughly 3-fold, from 23 500 in 2002 to 70 200 in 2017. Of even greater concern, during this same period, the number of opioid-related overdose deaths increased 4-fold, from 11 900 in 2002 to 47 600 in 2017. From 2016 to 2017, rates of opioid-related overdose deaths rose from 42 400 to 47 600, an increase of 12%. Also during this period, death rates associated with cocaine and psychostimulants increased by 34.4% (from 3.2 to 4.3 per 100 000 population) and 33.3% (from 2.4 to 3.2 per 100 000 population), respectively, likely contributing to the rise in overall drug overdose deaths. On the other hand, the number of overdose deaths related to either prescription opioids (which include buprenorphine, codeine, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, and tramadol) or heroin did not increase. Estimates based on provisional data for 2018 from the Centers for Disease Control and Prevention (CDC) explain these findings. Of an estimated 48 000 overall opioid-related overdose deaths in 2018, 28 400 deaths involved nonmethadone synthetic opioids, the most common of which was illicitly manufactured fentanyl. This trend is concerning because illicitly manufactured drugs commonly contain additional pharmacologically active components. These components are added during the illicit manufacturing process to either increase the bulk of the product or enhance the potency of the primary active component, are known as adulterants or cutting agents, and can themselves be toxic. In this Executive Perspective, we review data on the opioid crisis and describe recent US and global trends in the role of toxic adulterants and other pharmacologically active components in illicitly manufactured street drugs. We also highlight the role of toxic adulterants in opioid-related overdose deaths, chronic illicit drug abuse, and other public health issues. Finally, based on the information provided, we propose that clinicians increase attention to the potential role of toxic adulterants when evaluating and treating patients involved in drug abuse, overdose death, and addiction and that future public and personal health responses to the opioid epidemic emphasize building awareness and knowledge about the presence and dangers of toxic adulterants. In this way, we can further highlight the need to aggressively decrease the supply of illicitly manufactured drugs.