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Heroin and fentanyl in Washington state

Opioids are a class of drugs that bind to opioid receptors and have opioid-type effects similar to the classic compound morphine. There are many types of opioids and they differ in important ways including how strong the drug is, how quickly it takes effect, and how long it lasts. Heroin is a drug long used internationally and in Washington State, despite associated negative health outcomes and its status as a Schedule 1 drug (illegal in the United States). Fentanyl is a synthetic opioid used medically for severe pain and during surgery. It is a schedule 2 drug and can be prescribed or dispensed for medical purposes. Over the last two decades fentanyl has also been manufactured illicitly, initially occasionally, and since approximately 2014 with much greater frequency. "Fentanyl" can be an umbrella term, including fentanyl itself as well as various analogues of fentanyl, some of which are legal. While all fentanyls are generally more potent than heroin, potency varies widely.

According to the CDC, in 2015 synthetic opioids other than methadone (mostly fentanyl) surpassed heroin among drug overdose deaths in the U.S. As of 2020 fentanyl, suspected to be almost entirely illicit, is the most common drug detected in fatal drug overdoses in many cities and states. In Washington State fentanyl-involved drug overdose deaths are increasing, and preliminary data from the WA State Department of Health indicate that in recent months they have become common than heroin deaths and those involving commonly prescribed opioids. On this page we provide a detailed analysis of drug-caused deaths involving fentanyl to provide some insights into use in Washington State. The supply of fentanyl appears to be increasing. Although there have been media reports of fentanyl being directly shipped via package delivery services, most of the fentanyl in the US is reportedly coming from Mexico via regular criminal drug shipment routes. We examine evidence from law enforcement seizures below. The data (crime lab and death) do not distinguish between legal and illegal fentanyls.

The data are complex and imperfect, including issues regarding drug identification and inconsistencies over time. We provide detailed descriptions of data sources and data issues at the bottom of this page.

Statewide opioid deaths by subtypes

As a reference point, we present overall opioid-involved drug poisoning data for the state. Similar to national trends from the CDC and others, we compare opioid-involved drug poisonings involving heroin, commonly prescribed opioids, and other synthetic opioids, the most common of which are fentanyl and its anologues. Pharmaceutical opioids have declined somewhat in recent years as heroin has increased and starting in 2016 other synthetic opioids started increasing.

Press the "Death rates" button to see rates per 100,000 residents, and the "Percent of opioid deaths" to see what percentage of all these deaths involved each of the three main subtypes. As noted above, specification of opioids into subtypes in death certificate data has improved over the years. Thus, part of the increase in the share of opioid deaths involving heroin is due to better documentation of heroin by medical examiners. Many opioid deaths involve multiple opioids, and so these rates and percentages are not mutually exclusive.

Data sources: Washington State Department of Health (deaths), state Office of Financial Management (population)

Distribution across the state

The maps below allow you to compare the spread of heroin deaths versus those drug poisonings involving the synthetic opioids category.

Select which type of death rate maps you wish to see:

See death rates by county See death rates by Accountable Community of Health
Data sources: Center for Health Statistics, Washington State Department of Health (deaths), Washington State Office of Financial Management (population)
Data sources: Center for Health Statistics, Washington State Department of Health (deaths), Washington State Office of Financial Management (population)
Data sources: Center for Health Statistics, Washington State Department of Health (deaths), Washington State Office of Financial Management (population)
Data sources: Center for Health Statistics, Washington State Department of Health (deaths), Washington State Office of Financial Management (population)

Co-ingestants: Drug pairs involved in opioid deaths

Drug poisonings involving opioids often involve more than one type of opioid, and often involve other substances as well. In the graphic below, we present the percentage of all opioid poisonings involving the pair of drugs or drug categories listed (ignoring the presence of all other drugs). See our major drug deaths page for more about this data visualization. Fentanyls are again represented in the "Other synthetic opioids" category. The time trends in the first graphic above show a clear increase in heroin deaths after 2010, and in fentanyl deaths after 2015. We provide two co-ingestant matrices, for 2016-2018 and for a period 10 years before, to allow comparison of the types of drugs present in opioid deaths before and after apparent major changes in the predominate type of opioids. The rows and columns are ordered from largest to smallest proportion of drug deaths, that is alone or in combination.

The early period, 2006-2008, was approximately the peak of prescription-type opioid deaths, so among the classes of drugs shown here methadone and other commonly prescribed opioids (hydrocodone, oxycodone, etc.) are the two most prominent types. Antidepressants were also commonly present, while methamphetamine was relatively rare. The synthetic opioid category appeared without any other drug category presented in 2% of all opioid deaths, and was never paired with heroin. The drug categories presented here accounted for over 96% of drug poisonings involving opioids (the rest likely involved the "Other and unspecified narcotics" code [T40.6]).

In contrast, in the most recent period (click the 2016-2018 button), the drug classes presented account for nearly 99% of opioid deaths (due in part to better specification of the type of opioid involved), and heroin is now the most common drug class. Other synthetic opioids has moved up to fourth most common, with 8% of opioid deaths involving just this class with no other drug type presented here, 5% of opioid deaths in combination with other commonly prescribed opioids, and 2% in combination with heroin. The most common pair is heroin with methamphetamine (19%). As we examine further below, the synthetic opioids are less commonly found with methamphetamine.

Data source: Washington State Department of Health

Heroin versus fentanyl

In the next few analyses, we revise the underlying data to separate out heroin without fentanyl, fentanyl without heroin, and heroin and fentanyl together. First, we examine time trends for both crime lab submissions and deaths. For both, we look at instances where one drug is identified but not the other and instances where both are identified, all regardless of the presence of any other substance. For crime lab cases, this does not necessarily mean the two drugs were mixed together, just that they were seized together and submitted under the same case number. For deaths, again, we are using the broader other synthetic opioids category. Click on the button to view the number of cases, rates (per 100,000 state residents), and percentage of all opioid cases.

Data sources: Washington State Department of Health (deaths), Forensic Laboratory Services Bureau, Washington State Patrol (cases), state Office of Financial Management (population)

For heroin, and opioids in general, there are generally far more cases of the drug seized than there are of deaths involving the drug. The opposite is true for fentanyl. While acknowledging the broader "synthetic opioids" definition, there appear to be more deaths than there are cases involving fentanyl submitted by law enforcement agencies in the state (at least until 2019). Click on the most prominent series (heroin) to better view this above. The reason for this is unknown. One theory is that it is related to where/how drugs are bought and sold and that synthetic opioids may be sold in less public ways.

Heroin deaths versus fentanyl deaths versus those with both: Demographics

As seen above, fentanyl has become much more prominent in the last few years. To explore potential differences in the people who are being affected by heroin and/or fentanyl, we examine information available consistently in the death certificates for the three groups above: heroin without fentanyl, fentanyl without heroin, and fentanyl and heroin together (all with or without any other substance). We concentrate on the most recent three years of data. The racial categories--Caucasian, African American, Native American or Alaska Native, and Asian or Pacific Islander--are mutually exclusive categories, with Hispanic a separate dimension. All, as well as female gender, are as reported by the death certifier (coroner or medical examiner) and may not match the decedent’s self-identification.

Decedants who died of drug poisonings involving synthetic opioids without heroin were 53% more likely to be female than those with both heroin and synthetics, but note that the latter proportion is somewhat unstable as there are only 35 such deaths. That small group was more likely to be African American or Native (as identified by the certifier, which is generally underreported) than the other two groups. Deaths involving synthetics but not heroin were 1.8 times as likely to be Hispanic than deaths involving heroin but not synthetics.

Data source: Washington State Department of Health

Heroin deaths versus fentanyl deaths versus those with both: Co-ingestants

Below we present a table of the number and percentage of deaths in each of our non-overlapping categories that involve the other co-ingestants highlighted above. Again, this combines deaths for 2016-2018, but note the small number of deaths involving heroin and other synthetic opioids.

Heroin, no synthetic opioids Other synthetic opioids, no heroin Heroin & other synthetic opioids
Drug categoryN%N%N%
Other common opioids10411.5%9421.9%720.0%
Alcohol11212.3%5512.8% 411.4%
Barbiturates20.2%51.2% 12.9%
Deaths, 2016-201890742935

As noted above, drug poisonings involving heroin without synthetic opioids are more likely to also involve methamphetamine (47%) than deaths involving synthetic opioids without heroin (11%). Those dying with synthetic opioids but not heroin appear to be more likely than those with heroin and not synthetics to also have other commonly prescribed opioids besides methadone or benzodiazepines mentioned on the death certificate. Those dying with synthetic opioids but not heroin appear to be about a third less likely to also have methadone present. For the small group of deaths involving both heroin and synthetic opioids, what stands out is the relatively common presence of benzodiazepines.

Another way to view differences in co-ingestants is using a Venn diagram to show combinations. We collapse methadone and other common natural and semi-synthetic opioids into a single "common Rx opioids" category; combine alcohol, benzodiazepines, and barbiturates into a single "ABB" category of central nervous system depressants; and do not include the presence of antidepressants in order to minimize the number of possible combinations. We present diagrams for the two largest groups, not the small heroin and synthetics group. Note that "None of these" could mean just heroin/synthetics, or could mean heroin/synthetics plus antidepressants or other drug categories not included here.

For synthetic opioids without heroin, 44% of deaths involve none of the other drugs listed. For deaths involving heroin but not synthetic opioids, 28% had none of these other drug types present. As noted in the table above, there are also large differences in the presence of methamphetamine, alone or in combination with other drug categories.

Data source: Washington State Department of Health
Data source: Washington State Department of Health

Data notes

Drug-caused deaths are based on individual-level death certificate data from the state Department of Health. We restrict analysis to drug poisonings (based on ICD-10 codes X40-X44, X60-X64, X85, and Y10-Y14 as the underlying cause of death) involving Washington residents who died in Washington. This common definition excludes cases where alcohol poisoning or alcoholism, carbon monoxide poisoning, etc., was coded as the underlying cause of death. Alcohol deaths are thus drug poisonings also involving alcohol. As of this writing, completed death data are available through 2018. (However, the state's review and confirmation of potential opioid cases, conducted from 1999 through 2015, has been eliminated from defining opioid deaths.) Many drug deaths involve multiple drugs, and identifying the single drug out of many that resulted in death is impossible. Thus, these deaths are best described as drug poisonings involving the drug or category of drugs specified.

Identification of heroin (ICD code T40.1) as a contributing cause of death is difficult and has improved over time, due in part to the state Department of Health working with local coroners and medical examiners to improve testing and reporting. This paper describes some of the difficulties (see sidebar). Identification of fentanyl analogues in the early years of illicit fentanyl distribution may have been incomplete due to lack of familiarity with specific chemicals as well as changes in laboratory testing and reporting procedures.

Following the lead of the CDC, among opioids we focus on deaths specifically involving heroin (T40.1), methadone (T40.3), other commonly-prescribed natural and semisynthetic opioids (oxycodone, codeine, morphine, etc.; T40.2), and other synthetic opioids (T40.4), most prominent among them being fentanyl and fentanyl analogues. There is no ready way to identify fentanyl deaths other than using this ICD code, which may catch deaths involving other synthetics such as pethidine and tramadol. The increase in recent years of the number of deaths involving this code, however, indicates that most of them involve one of the fentanyls. In our data, a random sample of 100 drug poisonings with this code found that 79 indeed involved a fentanyl. The remaining cases included 12 deaths involving tramadol, 5 involving buprenorphine, 1 each with meperidine and U-47700, and 2 were improperly coded and did not belong in this category.

Identification of methamphetamine deaths is based on searching written information saved in the electronic death certificates for relevant words containing "meth" and/or "thamphet", including innumerable misspellings of methamphetamine. This written information ("literals") is available back to 2003. All other drug categories are based on coding of contributing causes of death to specific ICD T-codes.

Crime lab cases are the results of the Washington State Patrol’s Forensic Laboratory Services Bureau chemistry testing of samples submitted by law enforcement. While the data provide important insights into the supply of drugs, in part due to the use of precise chemical testing which indicates exactly which substance is present, they also have numerous important limitations, which we describe elsewhere. As with toxicology testing in deaths, identification of novel synthetic opioids may have lagged behind availability of such substances.