Suspected Counterfeit M-30 Oxycodone Pill Exposures and Acute Withdrawals Reported from a Single Hospital — Toxicology Investigators Consortium Core Registry, U.S. Census Bureau Western Region, 2017–2022

Discussion

Consultations for exposure to and acute withdrawal from suspected counterfeit M-30 pills increased during 2017–2022 at hospital A, from three in 2017 to 209 in 2022. Approximately two thirds of exposures occurred among patients aged 15–34 years. The majority of patients with suspected counterfeit M-30 exposure who were admitted to a hospital were admitted to an intensive care unit. Ingestion and inhalation were common routes of administration, and additional substances, including amphetamine/methamphetamine, benzodiazepines, and cocaine were frequently detected with fentanyl. These findings suggest that additional efforts are needed to prevent and reduce harm from use of counterfeit pills, especially among youths and young adults.

These findings are consistent with a broader trend that has been observed nationally and regionally. Overdose deaths with evidence of counterfeit pill exposure increased from 2.0% to 4.7% during July 2019–December 2021 in the United States, largely driven by a tripling in western jurisdictions (1). Further, 57.1% of decedents were aged <35 years, and 39.5% reported inhalation as the route of administration (1).

In this report, approximately one in three (31.2%) suspected counterfeit M-30 pill exposures occurred through ingestion. Persons who ingest pills might believe they are using a legitimate prescription drug. Unsuspected exposure to IMF is concerning because of its high potency and the possibility of rapid overdose (4). IMF-related overdoses involving ingested pills might require naloxone drip infusion or extended observation because of delayed, recurrent toxicity, as fentanyl continues to be gradually absorbed (5). In this analysis, approximately one in five patients with ingestion exposure was administered a naloxone drip infusion.

Evidence that some persons purposefully use counterfeit pills with IMF exists. The majority of persons accessing syringe service programs in Washington reported knowing their pill contained IMF.^¶¶ Some reports suggest that persons using drugs in the West might be shifting from injecting heroin to intentionally inhaling counterfeit pills with IMF because of cost, convenience, difficulties with injection, and reduced stigma (6). These findings are likely part of a larger nationwide shift toward inhaling or smoking IMF and away from injecting IMF (7).

In this study, detection of substances other than fentanyl was common. Co-exposure can mask opioid-related signs, complicating treatment. Further, sympathomimetic signs might appear after naloxone administration with stimulant co-exposures, and sedation could persist after naloxone administration with benzodiazepine co-exposures, both potentially requiring further medical intervention (8,9).

Approximately two thirds of exposures involved persons aged 15–34 years. Overdose deaths involving IMF among those aged 10–19 years sharply increased across 31 states during July 2019–December 2021, with evidence of counterfeit pills among one quarter of deaths (10). Easy access to counterfeit pills through sources such as social media*** might be increasing exposure to IMF and risk of overdose death among youths and young adults (10).

Limitations

The findings in this report are subject to at least six limitations. First, descriptions of the drug products used are based on patient self-report and were not verifiable. Second, in July 2018, hospital A implemented changes in laboratory methodology to improve detection of fentanyl in patient specimens; this improvement in detection could account for some of the increase in cases identified during the study period. Third, less severe cases are unlikely to require a medical toxicology consultation, biasing results toward more severe or complex clinical presentations. Fourth, data within the ToxIC Core Registry on outcome, beyond clinical death, have improved over time but were limited during the study period. Fifth, hospital A outpatient addiction medicine services were discontinued in March 2022; after this date, patients experiencing acute withdrawal might have been more likely to be referred for a medical toxicology consultation, accounting for some of the increase in cases identified in this analysis. Finally, data were from a single site and are not generalizable.

Implications for Public Health Practice

Linking persons treated in hospitals for an overdose to evidence-based substance use treatment,^††† and increasing outreach and linkage to care among youths and young adults who use diverted prescription pills (i.e., pills obtained without legitimate prescription) or who purposefully use IMF, could help prevent and minimize further harm associated with exposure to counterfeit pills. Other critical actions include improving access to harm reduction tools, such as fentanyl test strips to reduce unintentional exposure to IMF, and naloxone to reverse opioid overdose.^§§§ CDC recently launched support for surveillance activities through the Overdose Data to Action Program to provide laboratory testing of biologic specimens from patients with signs and symptoms of overdose, as well as testing of drug products and paraphernalia, to detect and track substances involved in drug overdoses. These data can help communities identify, tailor, and scale-up drug overdose prevention programs and policies.^¶¶¶ Increased awareness among clinicians, public health and public safety officials, and community-based organizations is needed to implement prevention strategies to reduce overdoses involving counterfeit pills.