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. 2018 Feb 1;133(2):142–146. doi: 10.1177/0033354917753119

The Rapid Escalation of Fentanyl in Illicit Drug Evidence in Allegheny County, Pennsylvania, 2010-2016

Kathleen E Creppage 1,2,✉, Joshua Yohannan 2, Karl Williams 2, Jeanine M Buchanich 3, Thomas J Songer 4, Stephen R Wisniewski 1, Anthony Fabio 1
PMCID: PMC5871138  PMID: 29389251

Abstract

Opioid overdose deaths in the United States quadrupled from 1999 (n = 8050 deaths) to 2015 (n = 33 091 deaths), and the number of deaths associated with synthetic opioids, such as fentanyl, increased from 3105 deaths in 2013 to nearly 20 000 deaths in 2016. Given this rapid increase, timely surveillance for drugs in circulation is crucial. However, current surveillance systems used to track drug overdoses do not detect new drugs in circulation quickly. We studied the change in the presence of fentanyl in “stamp bag” drug evidence in Allegheny County, Pennsylvania, from 2010 through 2016. Stamp bags are small wax packets with individual stamps that contain mixtures of drugs, most commonly heroin, that law enforcement officers seize and retain as legal evidence. The proportion of stamp bags determined to contain fentanyl or a fentanyl analog was 2.1% in 2014 and rose sharply to 17.1% in 2016. Monitoring the chemical makeup of drug evidence items could help public health authorities identify drug use trends in their jurisdictions.

Keywords: fentanyl, epidemiology, stamp bag, opioids, drug chemistry

The number of fatal opioid overdoses in the United States quadrupled from 8050 in 1999 to 33 091 in 2015.1 Major contributors to these deaths have been heroin and synthetic opioids, especially fentanyl, a legal Schedule II substance that is 20 to 50 times more potent than heroin,2,3 and its analog, acetylfentanyl,4 which is 80 to 100 times more potent than morphine5 and 5 to 15 times more potent than heroin.1,6-9 To quantify, deaths specifically involving synthetic opioids such as fentanyl increased from 3105 in 2013 to nearly 20 000 in 2016.9 Clusters of deaths have resulted from heroin adulterated with fentanyl or acetylfentanyl in the United States.2,3,5,10–12 The role of these drugs in US overdose deaths is increasing. Heroin prices have remained low since the late 1990s, and heroin has become more available than before. Fentanyl has increasingly been packaged with heroin, or even manufactured as counterfeit pills out of clandestine laboratories.12

Information on the circulation and use of these drugs, and the resultant mortality, comes from 2 government sources: public health and law enforcement. Public health information comes from the investigation of overdose deaths, such as death certificate information and toxicology data from medical examiners’ or coroners’ offices, which identify the specific drugs that contribute to individual overdose deaths. By monitoring these data over time, public health authorities can identify trends in the types of drugs that are contributing to these deaths.1,10 However, public health surveillance systems do not have a way to rapidly capture data on the use and circulation of fentanyl and its analogs. In 2015, 17% of death certificates did not identify specific drugs involved in overdose deaths.8

Law enforcement authorities use other systems to monitor trends in illegal drug circulation. One is the monitoring of drugs seized by law enforcement authorities.1,12-15 At the national level, the National Forensic Laboratory Information System (NFLIS) tracks trends in the circulation of illegal drugs. One report found a 426% increase in fentanyl submissions by the US Drug Enforcement Administration and law enforcement into NFLIS, from 1015 fentanyl submissions in 2013 to 5343 fentanyl submissions in 2014. This same study found that fentanyl deaths were fueling deaths from synthetic opioids.15

In Pennsylvania, fentanyl has gradually replaced heroin as the drug that contributes the most to these deaths. In 2015, the most common drugs in fatal overdoses were heroin and fentanyl.16 In Allegheny County, Pennsylvania, 1053 of 3374 (31.2%) people who died of a drug overdose between 2008 and 2017 had fentanyl in their bodies as evidenced by toxicology.17 In this part of the country, small packages called stamp bags are used for illicit drug sales (Figure 1). The word “stamp” refers to the graphic logo sometimes placed on the wax bag by drug dealers to show the contents or origin of the bag. Stamp bags are recovered during undercover purchases, drug seizures, or seizures at the scene of a fatal or nonfatal overdose. In Allegheny County, Pennsylvania, roughly 1000 unique stamps were found among stamp bags collected as drug evidence in 2016. Stamp bags in Allegheny County contain powdered drugs (not pills or patches), often with bulking agents or other drugs. For example, heroin may be found mixed with cocaine or methamphetamine.

Figure 1.

Figure 1.

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Example of recovered stamp bags as part of drug evidence in Allegheny County, Pennsylvania, 2010-2016. Stamp bags are small wax packets that contain mixtures of drugs, most commonly heroin, that are often seized by law enforcement officers and retained as legal evidence. Laboratory-tested bags in this study all had a stamp. Unstamped bags were not included in this analysis. Figure was obtained with permission from the Allegheny County Medical Examiner Office.

We studied the number and percentage of laboratory-tested, seized stamp bags containing fentanyl, fentanyl analogs, and heroin in Allegheny County from 2010 through 2016 and explored the value of using stamp bags to monitor trends in the circulation of these drugs locally.

Methods

Data Sources

We compiled laboratory test results of stamp bags from the drug chemistry laboratory of the Allegheny County Office of the County Medical Examiner (OCME) in Pittsburgh, Pennsylvania. All stamp bags in the database were seized as evidence by law enforcement authorities. Drug evidence must be submitted for testing by using proper protocols described in the evidence submission manual for the OCME.18 If an agency suspects that a stamp bag contains a certain drug, the name of the drug should be specified upon submission. Only stamp bags that are linked to an open, active law enforcement case are tested. Drug chemistry testing is performed exclusively in the Allegheny County Drug Chemistry laboratory of the OCME. Our analysis did not include toxicology from human samples; as such, it was expedited and approved by the University of Pittsburgh Institutional Review Board.

Sampling

Seized stamp bags can be single bags or large batches of bags. At the laboratory, technicians sort through the batch obtained by a seizure. Bags in a batch are initially sub-itemized by stamp, color, and other characteristics (eg, suspected drug). A single batch of stamp bags could contain 2 or more groups (eg, 1 group of white powder bags with a unique stamp, 1 group of brownish powder with a unique stamp). Because of resource constraints, not all bags are tested. A single bag is randomly selected from each group of bags and tested by a technician. Gas chromatography–mass spectroscopy is used to confirm the identity of any controlled substances that are present.

Dataset

We used a dataset consisting of drug chemistry results of stamp bags that were tested in the laboratory from 2010 through 2016. We grouped the types of drugs found in the bags into the following 6 categories, which are not mutually exclusive: (1) any heroin (presence of any heroin or heroin hydrochloride, with or without other drugs); (2) heroin alone (heroin was the only controlled substance present; other nondrug substances may have been used to bulk or dilute in the bag, but no other drugs were present); (3) any fentanyl (any fentanyl was present; analogs may have been present but were not counted as fentanyl, with or without drugs); (4) fentanyl alone (fentanyl was the only controlled substance present; other nondrug substances may have been used to bulk or dilute in the bag, but no other drugs were present); (5) heroin and fentanyl only (only these 2 drugs were present); and (6) any fentanyl analogs (acetylfentanyl, furanylfentanyl, butyrylfentanyl, 4-methoxy butyrylfentanyl, trans-3-methylfentanyl, cis-3-methylfentanyl, and carfentanil, with or without other drugs). Fentanyl analogs were not categorized as fentanyl and do not necessarily appear in bags with fentanyl. These groups are not mutually exclusive; the use of “any” fentanyl, for example, means that other drugs could be present in stamp bags including fentanyl analogs. We calculated descriptive statistics of these bags by drug and year by using Microsoft Excel and SAS version 9.4.19

Results

The laboratory tested 16 594 stamp bags from 2010 through 2016, of which 15 932 (96.0%) contained any heroin, 15 216 (91.7%) contained heroin alone, 752 (4.5%) contained any fentanyl, 201 (1.2%) contained fentanyl alone, 463 (2.8%) contained only heroin and fentanyl, and 109 (0.7%) contained fentanyl analogs. The proportion of heroin declined slightly over time (Table).

Table.

Number and percentage of laboratory-tested stamp bagsa that contained heroin, fentanyl, or fentanyl analogs, Allegheny County, Pennsylvania, 2010-2016b

Drug Total (N = 16 594) No. (%) 2010 (n = 1865) No. (%) 2011 (n = 1531) No. (%) 2012 (n = 1616) No. (%) 2013 (n = 2316) No. (%) 2014 (n = 3042) No. (%) 2015 (n = 3170) No. (%) 2016 (n = 3054) No. (%)
Any heroinc 15 932 (96.0) 1809 (97.0) 1495 (97.6) 1549 (95.9) 2257 (97.5) 2981 (98.0) 3013 (95.0) 2828 (92.6)
Heroin aloned 15 216 (91.7) 1790 (96.0) 1488 (97.2) 1535 (95.0) 2245 (96.9) 2908 (95.6) 2802 (88.4) 2448 (80.2)
Any fentanyle 752 (4.5) 0 0 0 0 64 (2.1) 230 (7.3) 458 (15.0)
Fentanyl alonef 201 (1.2) 0 0 0 0 8 (0.3) 67 (2.1) 126 (4.1)
Heroin and fentanyl onlyg 463 (2.8) 0 0 0 0 56 (1.8) 122 (3.8) 285 (9.3)
Any fentanyl analogsh 109 (0.6) 0 0 0 0 0 45 (1.4) 64 (2.1)
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aStamp bags are small wax packets that contain mixtures of drugs, most commonly heroin, that are often seized by law enforcement officers and retained as legal evidence. Laboratory-tested bags in this study all had a stamp.

bData source: Allegheny County Office of the Medical Examiner, Drug Chemistry Unit.

cLaboratory test indicated the presence of any heroin (presence of any heroin or heroin hydrochloride, with or without drugs).

dLaboratory test indicated the presence of heroin alone (heroin was the only controlled substance present; other nondrug substances may have been used to bulk or dilute in the bag, but no other drugs were present).

eLaboratory test indicated the presence of any fentanyl (any fentanyl was present; analogs may have been present but were not counted as fentanyl; with or without other drugs).

fLaboratory test indicated the presence of fentanyl alone (fentanyl was the only controlled substance present; other nondrug substances may have been used to bulk or dilute in the bag, but no other drugs were present).

gLaboratory test indicated the presence of heroin and fentanyl only (only these 2 drugs were present).

hLaboratory test indicated the presence of 1 or more fentanyl analogs (acetylfentanyl, furanylfentanyl, butyrylfentanyl, 4-methoxy butyrylfentanyl, trans-3-methylfentanyl, cis-3-methylfentanyl, and carfentanil with or without other drugs).

The proportion of tested bags containing fentanyl or its analogs increased from 2010 to 2016. By 2016, fentanyl was found in 458 of 3054 (15.0%) tested bags, and 126 of 3054 (4.1%) tested bags contained fentanyl alone. Fentanyl analogs did not appear in stamp bags until 2015 (45/3170 tested bags in that year; 1.4%), but the presence of fentanyl analogs increased from 45 of 3170 (1.4%) tested bags in 2015 to 64 of 3054 (2.1%) tested bags in 2016 (Figure 2).

Figure 2.

Figure 2.

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Number of laboratory-tested stamp bags that contained fentanyl or fentanyl analogs and percentage of tested stamp bags with fentanyl, Allegheny County, Pennsylvania, 2010-2016. Stamp bags are small wax packets that contain mixtures of drugs, most commonly heroin, that are often seized by law enforcement officers and retained as legal evidence. Laboratory-tested bags in this study all had a stamp. Any fentanyl indicates any fentanyl was present; analogs may have been present but were not counted as fentanyl, with or without drugs. Fentanyl alone indicates fentanyl was the only controlled substance present; other nondrug substances may have been used to bulk or dilute in the bag, but no other drugs were present. Fentanyl analogs indicates the presence of acetylfentanyl, butyrylfentanyl, 4-methoxy butyrylfentanyl, trans-3-methylfentanyl, cis-3-methylfentanyl, and carfentanil, with or without other drugs.

Discussion

To our knowledge, this is the first public health analysis to describe stamp bag contents and track changes in the presence of illicit fentanyl. Although the proportion of stamp bags that tested positive for heroin in Allegheny County was relatively stable from 2010 to 2016, the number of stamp bags that tested positive for both heroin and fentanyl, fentanyl alone, or any fentanyl analogs increased. The combination of heroin and fentanyl in stamp bags did not exist in 2010, but this combination accounted for 9.3% of tested bags by 2016. This finding is consistent with local and national reports of drug activity during the past few years.1,12,13,20

Monitoring drug evidence can provide data on drugs in circulation that may not be available from typical public health surveillance systems, such as drug overdose mortality and toxicology data from medical examiners’ or coroners’ offices. Mortality data lag about 18 months. Also, many opioids are combined into groups for International Classification of Diseases, Tenth Revision, reporting, which results in lost information about opioid deaths.21 Drug evidence data are usually available more quickly than public health data. In Allegheny County, drug evidence data for stamp bags seized during 2017 were already processed and available.

Unlike toxicology data from medical examiners’ or coroners’ offices, data from drug evidence can provide information on many unique drugs in their original chemical form, before they are metabolized in the body. Some potentially dangerous drugs, such as U-47700, are not always identified in the toxicology testing process or are not reported on the death certificate. Although toxicology testing is an excellent tool, the detection of opioids and their analogs can be difficult, depending on which assay or test is used and how the results are interpreted. For example, synthetic opioids are not detected by some commercial serum assays and urine testing.22 Chemical testing of the drugs, on the other hand, identifies all substances.

Limitations

This study had several limitations. First, these findings represent a sample of all stamp bags submitted to the laboratory; the total quantity of bags submitted to the laboratory was not recorded until 2015 and, therefore, was not available. Every stamp bag cannot be tested. Bags that were linked to active law enforcement cases were prioritized, meaning that bags were not tested if criminal charges were not filed. In addition, we did not report on other substances found in the bags beyond fentanyl and its analogs, which could be important for identifying other drugs of concern.

Conclusions

Stamp bags can provide valuable insight into the illegal drug trade. A stamp bag monitoring system can serve as a complementary form of surveillance for other public health and law enforcement systems. For example, stamp bag data can be combined with prescription drug monitoring and mortality data to answer questions about how and where people are seeking drugs. In addition, these data are available in near-real time and can serve as an early warning of illegal drugs that are currently available for purchase and used at the local level. Although this brief report describes drugs found in stamp bags, data on other drug evidence can provide information about other trends in illicit drug use (eg, illegal pills). The methodology for examining drug evidence can be explored and expanded for public health across the United States. Law enforcement and public health officials might consider how data on drug evidence can inform educational campaigns, resource allocation, and prevention strategies. First responders can benefit from information on drugs in circulation and can also be prepared with naloxone in the event of overdose.

Acknowledgments

The authors acknowledge the staff of the Drug Chemistry Unit and the law enforcement entities that contributed to this work through data collection and testing. The authors also acknowledge the Dean of the University of Pittsburgh School of Public Health for support for this project.

Footnotes

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors declared no funding with respect to the research, authorship, and/or publication of this article.

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