A Cluster of Fentanyl-Laced Heroin Deaths in 2015 in Melbourne, Australia

Abstract

The prevalence of opioid use in therapeutic and recreational settings has steadily increased throughout the western world. The addition of fentanyl into heroin products can produce potentially dangerous consequences, even to opioid tolerant individuals who may be unaware of such additions. Following an observed spike of heroin-fentanyl related deaths in Melbourne, Australia, a study was undertaken to determine the prevalence of these cases. All reportable deaths occurring in Victoria during 2015 and submitted to the toxicology laboratory were analysed using LC-MS-MS to confirm the combination of the heroin marker 6-acetylmorphine and/or morphine, and fentanyl. Over 4,000 coronial cases in 2015 underwent toxicological analysis for these drugs, there were nine cases identified that involved fentanyl-laced heroin. There was no specific mention of fentanyl use in any of these cases. All occurred within 2 months and in two distinct locations. The first four deaths occurred within 3 days of each other, in neighboring suburbs. The ages ranged from 25 to 57 years with an average of 40 and median of 37 years, and consisted of eight males and one female. The average and median femoral blood concentration of fentanyl was 18 and 20 ng/mL (range: <1-45 ng/mL), and morphine 140 and 80 ng/mL (range: 20-400 ng/mL), respectively. All nine cases had 6-acetylmorphine detectable in blood. Urine analysis was also performed where available. A syringe, powder and spoon found at the scene of one case were also analysed and found to be positive for both heroin and fentanyl, which supported the likelihood of fentanyl-laced heroin. This is the first reported case series of fatalities involving heroin and fentanyl outside of North America in published literature. These findings may help inform public health and prevention strategies serving to decrease the potential for such fatalities in the future.

Recent trends in heroin and pharmaceutical opioid‐related harms in Victoria, Australia up to 2018

“…Monitoring of these trends by opioid‐type and dosage will continue to be important to assess any new opioid‐related intervention—for example, to monitor what happens in 2020 when Victoria becomes the first Australian jurisdiction to implement mandatory real‐time prescription monitoring , which may have unintended consequences such as a shift toward illicit markets . The rise of heroin and the possibility of illicit fentanyl gaining traction in Australia is driving the urgency toward addressing acute overdose harms—to lower the cost and broaden the distribution of opioid overdose reversal drug, naloxone and to make opioid agonist treatments more flexibly available .…”

One single large intramuscular dose of naloxone is effective and safe in suspected heroin poisoning

“…Evidence of heroin exposure relied on patient history rather than laboratory confirmation. There are some reports of fentanyl and its analogues being sold as heroin within Australia; however, evidence suggests this is not common . Furthermore, this was a retrospective analysis of data recorded in a patient's chart that has subsequently been extracted.…”

Hitting the Jackpot – development of gas chromatography–mass spectrometry (GC–MS) and other rapid screening methods for the analysis of 18 fentanyl‐derived synthetic opioids

“…Though principally associated with the United States, the global significance of these synthetic opioids within forensic casework has been highlighted through a number of toxicological reports in which fentanyl‐laced heroin has been implicated in fatalities in Canada and Australia . Though fentanyl and its analogues have been principally combined with heroin ( 8c ) or are being sold in combination with U‐47700 as “fake Norco” (a formulation of acetaminophen and hydrocodone), it has also been detected in street samples of cocaine ( 7 ), and even purportedly sold as 3′,4′‐methylenedioxymethamphetamine (MDMA, 3 ) – which potentially may have more serious implications to wider drug using communities . The development of simple, sensitive methods for the screening of fentanyl and its analogs at trace level in complex mixtures is therefore crucial for public health protection.…”