Why it's so hard to track the powerful opioid fentanyl

In the wake of the deaths of 14 people in the Sacramento area who ingested a counterfeit brand name medication laced with the powerful opiate fentanyl, Los Angeles County health officials have advised area doctors to be on the alert for the drug. L.A. officials think fentanyl misuse is a problem, but they don't know for sure because it's difficult to monitor.

Fentanyl is typically used to treat advanced cancer pain, because it's up to 100 times more powerful than morphine. But it's sold illegally for its heroin-like effect, and is often mixed with other drugs. A tiny amount can lead to an overdose or death.

L.A. County averaged 40 fentanyl-related deaths between 2011 and 2013 and reported 62 deaths in 2014, according to the county coroner's office. But those numbers don't tell the full story, explains Dr. Gary Tsai, medical director and science officer for the county Department of Public Health's Substance Abuse Prevention and Control unit.

While fentanyl-related deaths increased in 2014, "that doesn't distinguish between a fentanyl overdose as a result of misuse, or someone who died and required an autopsy and happened to be on fentanyl," says Tsai. He adds that while fentanyl is not as commonly prescribed as other opioids, it's "also not so rare as to suggest that all of those 'fentanyl-related' deaths were due to misuse."

There are several reasons why fentanyl overdoses have proved challenging to track, according to Substance Abuse and Prevention Control.

First, doctors treating overdose victims are mainly looking for the better-known opioids, like Vicodin. And when they check for drugs, standard tests often miss fentanyl. A special lab analysis is often necessary, and doctors – especially in busy ER's – don't always think of that. Another problem is that not all hospitals are set up to conduct the special lab analysis.

All of this is complicated by the fact that illegally manufactured fentanyl may be mixed with heroin or counterfeit pills that look like normal prescription medications, so people may not be aware that they're exposing themselves to the drug.

The rise in fentanyl use has health officials particularly worried, given its tremendous potency. To try to get a handle on the problem, the state has asked all local hospitals to report suspected fentanyl overdoses. State officials have also asked providers to test for fentanyl when ordering drug screening in cases of suspected overdose.

Meanwhile, L.A. County and state health officials are working with the county coroner’s office and poison control to establish a more robust surveillance system to track fentanyl-related deaths, according to Tsai.

Law enforcement officials in L.A. are also keeping a close eye on fentanyl. At this point, Southern California is still primarily a transit point for smugglers distributing fentanyl to other parts of the country, said Tim Massino, spokesman for the L.A. office of the Drug Enforcement Administration.

Fentanyl smuggling in the region is "definitely on the increase over the past couple of years, but it's not like we're seizing fentanyl every day, like we are with every other substance," he said.

But the agency is aware that the situation could change quickly, and Southern California could become a destination rather than just a transit point, said Massino.

Going back to the beginning of last year, there have been a handful of seizures in L.A. and Orange Counties of fentanyl or acetyl fentanyl, a fentanyl analog, he said. Acetyl fentanyl is very similar chemically to fentanyl. It is up to five times more powerful than heroin, according to the CDC.

In some cases, law enforcement officials seized pills that looked like legal prescription drugs, such as Vicodin or oxycodone, and found they contained fentanyl or acetyl fentanyl, said Massino.

This past January, officials seized more than 5,000 pills of apparently legal medications in the Anaheim area that turned out to contain fentanyl, he said. In June 2015, DEA agents seized 13 kilograms of acetyl fentanyl, and in Jan. 2015, an L.A. County task force seized 12 kilograms of fentanyl, added Massino.