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Biography of an epidemic:
Fentanyl overdose in Chicago
Harold Pollack
Greg Scott
Sandra Thomas
Opiate overdose as a general health risk
Fentanyl as a specific risk
Maps of Chicago
Implications for harm reduction
Opiate OD
• OD is a leading cause of premature death
among injection drug users (IDU) in industrial
– Several studies report incidence of 1-2 percent/year
among street IDU.
– Up to 45% of reported deaths in IDU cohort studies.
Risk-factors for OD
• Toxicological features of ingested drugs
– Variable purity of street heroin plays a role.
– Poly-substance use (alcohol, cocaine)
– Additives/adulterants
• Hazardous circumstances of use
• Loss of tolerance
Risk-factors for fatal OD
• Injecting alone
• Chosen dose/mixture of substance injected
• Reluctance of onlookers/shooting partners to
summon help, particularly given possible police
• Improper/ineffective/lame intervention by lay
– Mechanical stimulation common
– Reluctance to provide rescue breathing
– Injection of ineffective/harmful substances (milk,
Loss of tolerance
• Known risk factor for fatal OD.
– Release from hospitalization, detox, drug substance
abuse treatment, or incarceration are key pathways.
• Strang et al. (BMJ, 2003) followed 137 consecutive
IDU admitted to inpatient detox followed by a
(roughly 28-day) inpatient treatment at National
Addiction Center, Maudsley Hospital, London.
– 5/137 patients died during the next year, all from OD.
– All 5 had successfully completed at least detox phase of
– 4 of the 5 were evaluated as successfully completing the
full inpatient treatment program.
OD in Chicago
• Chicago area home to estimated 45,000 IDU.
– Huge confidence interval on the 45,000.
• Research team identifying and mapping all
Chicago OD deaths, and relating locations to
location of new prevention interventions.
• Search of individual death certificates 19992007.
• Current detailed microdata 1999-2003.
• 2004-2007 data now entering the nonfictional
Fatal OD in Chicago 1999-2003
Gender and Ethnicity
(age 18-64)
Hispanic Female
Hispanic Male
Non-Hispanic Black Female
Non-Hispanic Black Male
Non-Hispanic White Female
Non-Hispanic White Male
OD as % of all
accidental deaths
OD is common among street IDU
• CDC-funded Chicago survey of street IDU
– 63% Shoot alone
– 50% report observing at least 1 fatal OD
– 41% report having attempted a rescue
– 50% have suffered at least on non-fatal OD, with
loss of tolerance playing a key role.
• 30% of self-reported cases within 1 week of release from
• 15% of self-reported cases within 1 week of release from
Slide courtesy of Greg Scott
Of the 50% Non-Fatal ODs …
• The term “revived” inherently vague
– 33% revived by medical professional
– 44% revived by a fellow injector
– 9% revived by a non-injecting peer/relative
– Of the 53% revived by laypersons:
• 80% by manual stimulation
• 19% by administration of non-recommended substance
(e.g. milk, crack)
• 1% by injection of appropriate medication
Slide courtesy of Greg Scott
Naloxone interventions
• Beginning in 2002, Chicago Recovery Alliance
(CRA), city’s largest syringe exchange, began
Naloxone distribution program to address OD.
• Key program ingredients
OD education/awareness
Training of IDUs and shooting partners in first responses
Distributing Naloxone (“Narcan”)
Anecdotal reports of approximately 500 OD “reversals.”
• Program penetration in south and west Chicago,
with weaker program penetration far from CRA
syringe exchange sites.
Overall Pattern 1999-2004
• High and stable, slightly declining OD
incidence across Chicago.
• Some evidence of more rapid declines
among white male users in CRA served
Then something happened…
Something happening…
Apparent explanation
• Use of Fentanyl as an adulterant/ additive
and by itself.
• Illustrative brand names illustrate one public
health challenge:
– Flat line, lethal injection, DOA.
– Sold as “China White” for many years
• Fatal OD incidence roughly doubled, though
the excess OD incidence attributable to
fentanyl remains unclear.
– As noted, many deaths elsewhere…
Fentanyl noted
Among OD cases
June-December 2004
January-June 2005
July-December 2005
January-June 2006
July-December 2006
January-March 2007
July-December 2006
Would Naloxone bring some
• Yup…
• Let’s go to the ethnography.
– Greg Scott’s field notes.
Thus the need for evaluation
• Syringe exchange hard to evaluate well, given
cultural politics of HIV and needle provision,
broader political climate.
• Naloxone/OD seem less politically visible and
• Interventions at early phase, and can therefore
be explicitly tracked.
– Chicago, Boston, parts of New York, LA,
Albuquerque, NM.
• Evaluation more likely to improve
implementation of complex interventions.
Policy lessons
• Policy and intervention failures predated
Fentanyl epidemic and still remain after
Fentany problem has abated.
– E.G. Methadone maintenance waiting list of
600 people throughout this story.
• There is some self-limiting dimension to
new threats such as Fentanyl.
More policy lessons
• “You can’t easily regulate what you prohibit”
– Need for law enforcement response, informed by user
– Effective law enforcement requires informal contacts,
and some degree of selective targeting or intensity of
supply-side enforcement.
• Users adapted to new threat—with a lag.
• Necessity and limitations of harm reduction
• Opiate OD is a (surprisingly) prevalent threat to life and
• Successful OD prevention will straddle traditional
boundaries between “harm reduction,” and other forms of
– Syringe exchanges were largely implemented outside formal
systems of substance abuse treatment and medical care.
– Key OD risk-factors and (missed) opportunities for intervention arise
in medical care/substance abuse treatment.
• Finding politically feasible strategies to promote and
evaluate OD prevention will bring high payoffs unrealized in
syringe exchange debate.