Tuesday, July 3rd, 2018

MEDICAL EXAMINER RELEASES ANNUAL

HEROIN AND FENTANYL OVERDOSE DATA
The Monroe County Office of the Medical Examiner today released annualized data
pertaining to 287 deaths directly attributable to the use of heroin, fentanyl, or
other related substances in 2017. These substance-use related deaths represent a
rapidly growing proportion of the total cases submitted to the laboratory for
toxicological analysis.

“Our office continued to see an increase in fatalities resulting from heroin, morphine,
fentanyl, or other analog substances in 2017,” said Dr. Nadia Granger, Monroe
County Medical Examiner. “In addition to the new six-month tracking report we
issued earlier this year, these annualized data can be helpful in assessing the full
scope of the impact that the nationwide opioid crisis is making in our region. I thank
our Office of the Medical Examiner staff who worked diligently to prepare this
comprehensive report to enhance public awareness.”

“The data presented in the Medical Examiner’s annual review reinforces the trends
we observed in the six-month report and also confirms what many of us already
know – the nationwide opioid crisis continues to take a devastating human toll
across our region,” said Dr. Michael Mendoza, Monroe County Commissioner of
Public Health. “Monroe County will continue to combat addiction through our Opioid
Action Plan, which includes expanded education, increased Narcan training, and a
first-of-its-kind advisory panel comprised of local medical experts. We have been
tireless in our fight against opioids and we will not rest until the tide begins to turn.”

The data presented in this report refer only to those individuals for whom the
cause of death was solely attributed to the substances involved. It does not
include deaths wherein these substances were present, but the cause of death was
attributed to some traumatic injury (e.g., driving under the influence of drugs
leading to a fatal crash). It also does not include cases attributed to overdose on
prescription opioids in the absence of heroin/morphine or fentanyl/analogs.

Upon entry into the body, heroin is rapidly metabolized to morphine through an
intermediate (6-monoacetylmorphine, 6-MAM). Detecting 6-MAM helps
differentiate heroin from pharmaceutical morphine, but its absence does not
preclude it. Thirty-two of the 287 deaths involved morphine that could not
necessarily be attributed to heroin. Fentanyl and analogs are typically sold on the
street as heroin or cocaine, often in preparations or mixtures with those

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compounds. Fentanyl analogs are a growing class of novel psychoactive
substances (NPS) that are structurally related to fentanyl, and first appeared in
the illicit drug market within the last few years. Laboratory testing for these
analogs began in 2015-2016.

Table 1. Total number of Monroe County Office of the Medical Examiner deaths
attributed to heroin/morphine and/or fentanyl, fentanyl analogs, or U-47700.

Year Total Number of Heroin/Fentanyl Percent of Cases

Deaths Investigated
2011 11 1.2%
2012 30 3.1%
2013 67 6.8%
2014 95 9.1%
2015 85 8.2%
2016 206 19.9%
2017 287 22.7%

Of the 287 total deaths, 220 occurred in Monroe County, while 67 occurred in
surrounding counties that contract for autopsy services with the Office of the
Medical Examiner (Table 2). It should be noted that the deaths occurring outside
of Monroe County likely do not represent the total number of
heroin/morphine/fentanyl related deaths occurring in those counties, as not all
cases from those counties were submitted to the Monroe County Office of the
Medical Examiner.

Table 2. Number of deaths related solely to overdose from heroin/morphine and/or

fentanyl, fentanyl analogs, or U-47700, organized by county where the death occurred.

Number of Deaths
County of Death 2011- 2014 2015 2016 2017
2013
Monroe 78 81 69 169 220
Allegany 0 0 2 0 1
Chemung 11 2 3 0 0
Genesee 0 3 2 0 19
Livingston 3 3 1 8 15
Ontario 4 2 3 0 1
Orleans 1 1 0 9 7
Steuben 4 3 2 13 10
Wayne 0 3
Wyoming 7 0 2 7 11
Yates 0 0 1 0 0

The majority of the decedents (66%) were white males (Table 3, Table 4). The
race/ethnicity distribution was consistent with previous years (Table 3). It reflects
the opioid crisis’ impact irrespective of ethnic heritage. The sex distribution of the
decedents was also consistent with prior years.

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 Table 3. Race/ethnicity distribution among heroin/morphine and fentanyl/analogs
deaths from 2014-2016.

Race 2014 2015 2016 2017

Caucasian 87.4% 80.0% 89.3% 88.9%
African American 7.4% 17.6% 8.7% 9.1%
Asian 1.0% 1.2% -- 0.7%
a
Other 2.2% 1.2% 1.9% 1.4%
b
Hispanic 1.0% 4.7% 8.7% 8.0%
a
Other includes but is not limited to Native American.
b
Hispanic/Non-Hispanic identification is independent of race identification.

Table 4. Sex distribution among heroin/morphine and fentanyl/analogs deaths from

2011-2016.

Year(s) Male Female

2011-13 79.6% 20.4%
2014 74.7% 25.3%
2015 74.1% 25.9%
2016 76.2% 23.8%
2017 74.6% 25.4%

In 2017, the ages of the victims of heroin/morphine/fentanyl/analogs overdose

ranged from <20 to 82 years with a median age of 38 years (Figure 1). Median ages
for 2014, 2015, and 2016 were 36, 36, and 35, respectively. The 2017 deaths
represent a 39% increase from 2016, and a 3.4-fold increase from 2015. The crisis
has escalated steadily since it began in mid-2012 (Figure 2). For nearly every age
group between 20-59, 2017 represented the highest number of heroin/fentanyl
deaths ever witnessed by this office, with a marked increase since 2015. The
opioid crisis affects people of all ages.

Figure 1. Age distribution and total heroin/morphine and fentanyl/analogs deaths by

year(s). Data for 2011-2013 are presented in aggregate.

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Variable monthly rates of heroin/fentanyl fatalities are likely due to changing
availability, potency and/or composition of drugs on the street. The availability of
heroin and heroin substitutes varies by region. Additionally, the fentanyl analogs
included in street heroin preparations vary regionally and over time. In early-mid
2017, furanyl fentanyl, acetyl fentanyl, and U-47700 were the most common
compounds detected. By mid-2017, U-47700 had all but disappeared, and para-
fluoro(iso)butyryl fentanyl became common. Beta-thiohydroxy fentanyl also began
to be detected.

The dynamic and frequently changing NPS drug market presents unique and
growing challenges for toxicological testing. The Office of the Medical Examiner is
watching these developments carefully and continues to adapt testing methodology
to detect these new threats to public health.

Heroin, fentanyl/analogs, ethanol (alcohol) and cocaine are frequently encountered

together in postmortem cases (Table 4). Among the 287 cases described herein,
there was both a mean and median of 2 of these four substances that were listed
as direct contributors to the cause of death. Although heroin preparations vary, it
is generally not possible to establish whether cocaine and fentanyl/analogs were
contained in the same mixture or merely utilized concurrently. However, the public
should be cautioned about the risks of taking multiple drugs and/or combining
drugs with alcohol—as well as the fact that illicit drugs may contain unknown
mixtures of compounds and produce unexpected or exaggerated effects.
Benzodiazepines are another class of compounds that are frequently detected in
opioid overdose deaths. Other common findings of drugs contributing to these
overdose deaths are presented in Table 4.

Table 4. Number of 2017 cases for which common substances were listed in the cause
of death.

Compound / Drug Number of Cases Percent of Heroin/Morphine/Fentanyl Overdose

Class Deaths
Fentanyl/Analogs 261 90.9%
U-47700 12 4.2%
Heroin 96 33.4%
Morphine 32 11.1%
Cocaine 141 49.1%
Alcohol 61 21.3%
Benzodiazepines 50 17.4%
Prescription Opioidsa 32 11.1%
Amphetaminesb 7 2.4%
Mitragynine 6 2.1%
Cyclobenzaprine 5 1.7%
Gabapentin 5 1.7%
a
Note: these data do not include deaths attributed to prescription opioids in the absence of heroin/morphine or
fentanyl/analogs. Prescription opioids include buprenorphine, hydrocodone, methadone, oxycodone, and tramadol.
b
Includes amphetamine, methamphetamine, and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy)

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 Figure 2. Number of heroin/morphine and fentanyl/analogs deaths by month, 2011-
2017.

Average Deaths/Month
2011 1
2012 2
2013 6
2014 8
2015 7
2016 17
2017 24

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Media inquiries, contact:

Director of Communications Jesse Sleezer at (585) 402-8019
Department of Communications at (585) 753-1080

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