Drug Overdose Deaths with Evidence of Counterfeit Pill Use

Abbreviations: IMF = illicitly manufactured fentanyl; SUDORS = State Unintentional Drug Overdose Reporting System.
*Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Utah, Vermont, Virginia, Washington, and West Virginia. Arkansas, Illinois, Louisiana, Pennsylvania, and Washington reported deaths from counties that accounted for ≥75% of drug overdose deaths in the respective state in 2017, per SUDORS funding requirements; all other jurisdictions reported deaths from the full jurisdiction. Jurisdictions were included if complete data (including medical examiner or coroner reports for ≥75% of deaths) were available for all of January–December 2021. Analysis was restricted to decedents with an available medical examiner or coroner report.
^†Missing values were excluded from calculations of percentages. Percentages might not sum to 100% because of rounding.
^§Analysis included some, but not all, of the jurisdictions in each U.S. Census Bureau region. Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Iowa, Kansas, Michigan, Minnesota, Nebraska, Ohio, and South Dakota; South: Arkansas, Delaware, District of Columbia, Georgia, Kentucky, Louisiana, Maryland, North Carolina, Oklahoma, Virginia, and West Virginia; West: Alaska, Arizona, Colorado, Nevada, New Mexico, Oregon, Utah, and Washington.
^¶A drug was considered involved if it was listed as a cause of death on the death certificate or in the medical examiner or coroner report. Percentages sum to >100% because drug categories are not mutually exclusive.
**Fentanyl was classified as likely illicitly manufactured using toxicology, scene, and witness evidence. For the 8% of deaths involving fentanyl that had insufficient evidence for classification as illicit or prescription, fentanyl was classified as illicit because the vast majority of fentanyl overdose deaths involve illicit fentanyl. All fentanyl analogs except alfentanil, remifentanil, and sufentanil, which have legitimate human medical use, were included as IMFs.
^††IMFs were the only drugs listed as cause of death by medical examiners or coroners on the death certificate. Ethanol was not considered a drug for this analysis; some deaths included as IMFs only involved ethanol.
^§§Drug entries coded as heroin were heroin and 6-acetylmorphine. In addition, morphine was coded as heroin if detected along with 6-acetylmorphine or if the scene, toxicology, or witness evidence indicated presence of known heroin adulterants or impurities (including quinine, procaine, xylazine, noscapine, papaverine, thebaine, or acetylcodeine), injection, illicit drug use, or a history of heroin use.
^¶¶Drug entries coded as prescription stimulants were amphetamine (in the absence of methamphetamine), armodafinil, atomoxetine, dextroamphetamine, levoamphetamine, lisdexamfetamine, mephentermine, methylphenidate, modafinil, and propylhexedrine. Also included as prescription stimulants were brand names and metabolites of these drugs.
***Drug entries coded as illicit benzodiazepines were 4'-chloro deschloroalprazolam, adinazolam, alpha-hydroxyetizolam, bromazolam, clonazolam, delorazepam, deschloroetizolam, diclazepam, etizolam, flualprazolam, flubromazepam, flubromazolam, metizolam, nitrazolam, nordiclazepam, and pyrazolam.
^†††Limited to IMF-involved deaths among jurisdictions with toxicology reports available for ≥75% of deaths during this period (resulting in the same 35 jurisdictions) and to deaths with an available toxicology report (deaths with evidence of counterfeit pill use: 2,258; deaths without evidence of counterfeit pill use: 37,352; and overall: 39,610).
^§§§Includes history of prescription opioid or prescription benzodiazepine misuse.
^¶¶¶Includes history of IMF, heroin, cocaine, or methamphetamine use.
****Only noningestion routes of drug use are presented because the counterfeit pill definition depended largely on scene or witness evidence of pill use. SUDORS guidance is to endorse evidence of ingestion when pills are found or reported to be used, if no indication of use by another method (e.g., crushed for snorting). Therefore, evidence of ingestion would be falsely elevated among decedents with evidence of counterfeit pill use. The percentage of deaths with no route of use evidence would be falsely elevated for the same reason; therefore, that information is not presented. Evidence of injection, smoking, and snorting are not mutually exclusive; a death could have evidence of more than one of these routes.
^††††For SUDORS, a potential bystander is defined as a person aged ≥11 years who was physically nearby either during or shortly preceding a drug overdose and potentially had an opportunity to intervene or respond to the overdose. This definition includes any persons in the same structure (e.g., same room or same building, but different room) as the decedent during that time; a family member who was in another room during the fatal incident would be considered a potential bystander if they might have had an opportunity to provide lifesaving measures (e.g., naloxone administration), if adequate resources were available, and if they were aware that an overdose event could occur. Persons in different self-contained parts of larger buildings (e.g., a different apartment in the same apartment building) would not be considered potential bystanders.
^§§§§Criteria used to define evidence of counterfeit pill use are related to this circumstance; therefore, it might be overrepresented in deaths with evidence of counterfeit pill use.

Abbreviations: IMF = illicitly manufactured fentanyl; NA = not applicable; SUDORS = State Unintentional Drug Overdose Reporting System.
*Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Utah, Vermont, Virginia, Washington, and West Virginia. Arkansas, Illinois, Louisiana, Pennsylvania, and Washington reported deaths from counties that accounted for ≥75% of drug overdose deaths in the respective state in 2017, per SUDORS funding requirements; all other jurisdictions reported deaths from the full jurisdiction. Jurisdictions were included if complete data (including medical examiner or coroner reports for ≥75% of deaths) were available for all of January–December 2021. Analysis was restricted to decedents with an available medical examiner or coroner report.
^†Categories are mutually exclusive: counterfeit oxycodone without counterfeit alprazolam, counterfeit alprazolam without counterfeit oxycodone, both counterfeit oxycodone and alprazolam, or unspecified counterfeit pill type (e.g., witness reported that the decedent used "counterfeit pills" but did not indicate the type of pharmaceutical pills mimicked).
^§Missing values were excluded from calculations of percentages. Percentages might not sum to 100% because of rounding.
^¶Analysis included some, but not all, of the jurisdictions in each U.S. Census Bureau region. Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, Pennsylvania, Rhode Island, and Vermont; Midwest: Illinois, Iowa, Kansas, Michigan, Minnesota, Nebraska, Ohio, and South Dakota; South: Arkansas, Delaware, District of Columbia, Georgia, Kentucky, Louisiana, Maryland, North Carolina, Oklahoma, Virginia, and West Virginia; West: Alaska, Arizona, Colorado, Nevada, New Mexico, Oregon, Utah, and Washington.
**A drug was considered involved if it was listed as a cause of death on the death certificate or in the medical examiner or coroner report. Percentages sum to >100% because drug categories are not mutually exclusive.
^††Fentanyl was classified as likely illicitly manufactured using toxicology, scene, and witness evidence. For the 8% of deaths involving fentanyl that had insufficient evidence for classification as illicit or prescription, fentanyl was classified as illicit because the vast majority of fentanyl overdose deaths involve illicit fentanyl. All fentanyl analogs except alfentanil, remifentanil, and sufentanil, which have legitimate human medical use, were included as IMFs.
^§§IMFs were the only drugs listed as cause of death by medical examiners or coroners on the death certificate. Ethanol was not considered a drug for this analysis; some deaths included as IMFs only involved ethanol.
^¶¶Drug entries coded as heroin were heroin and 6-acetylmorphine. In addition, morphine was coded as heroin if detected along with 6-acetylmorphine or if the scene, toxicology, or witness evidence indicated presence of known heroin adulterants or impurities (including quinine, procaine, xylazine, noscapine, papaverine, thebaine, or acetylcodeine), injection, illicit drug use, or a history of heroin use.
***Drug entries coded as prescription stimulants were amphetamine (in the absence of methamphetamine), armodafinil, atomoxetine, dextroamphetamine, levoamphetamine, lisdexamfetamine, mephentermine, methylphenidate, modafinil, and propylhexedrine. Also included as prescription stimulants were brand names and metabolites of these drugs.
^†††Drug entries coded as illicit benzodiazepines were 4'-chloro deschloroalprazolam, adinazolam, alpha-hydroxyetizolam, bromazolam, clonazolam, delorazepam, deschloroetizolam, diclazepam, etizolam, flualprazolam, flubromazepam, flubromazolam, metizolam, nitrazolam, nordiclazepam, and pyrazolam.
^§§§Counterfeit pills that often contain IMFs or other illicit drugs are frequently marked with "M-30" to mimic legitimate oxycodone 30-mg pills. Pills marked M-30 found at the overdose scene or reportedly used by the decedent were defined as counterfeit oxycodone pills if no oxycodone was detected by postmortem toxicology testing.

Authors and Disclosures

Julie O'Donnell, PhD¹, Lauren J. Tanz, ScD¹, Kimberly D. Miller, MPH¹, Amanda T. Dinwiddie, MPH¹, Jessica Wolff, MPH¹, Sasha Mital, PhD¹, Rochelle Obiekwe, MPH^1,2 and Christine L. Mattson, PhD<sup>1

1</sup>Division of Overdose Prevention, National Center for Injury Prevention and Control, CDC; ²Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee.

Corresponding author
Julie O'Donnell, irh8@cdc.gov.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Sidebar

Summary

What is already known about this topic?

Counterfeit pill availability in the United States is increasing; drug overdose deaths are at historically high levels.

What is added by this report?

Evidence of counterfeit pill use in overdose deaths more than doubled from July–September 2019 to October–December 2021, and tripled in western U.S. states. Decedents with evidence of counterfeit pill use, compared with those without such evidence, were younger, more often Hispanic or Latino, and more frequently had a history of prescription drug misuse and drug use by smoking.

What are the implications for public health practice?

Overdose prevention messaging that highlights the dangers of pills obtained illicitly or without a prescription, encourages drug product testing by persons using drugs, and is tailored to persons most at risk (e.g., younger persons) could help prevent overdose deaths.