July 30, 2018

TO: 
Medical Providers and First Responders

FROM:
Sara H. Cody, MD, Health Officer Director 
Toni Tullys, MPA, Behavioral Health

Health Advisory Opioid Overdose Deaths in Santa Clara County Due to Fentanyl

In 2017, the County of Santa Clara Medical Examiner’s Office verified 16 deaths in the County due to fentanyl overdose, an increase from 11 fentanyl-related deaths in 2016. Most of these cases involved fentanyl in combination with other drugs such as heroin, other opioids, benzodiazepines, methamphetamine, and cocaine. Between 2016 and 2017, the Medical Examiner has verified deaths due to fentanyl and analogs of fentanyl such as acryl fentanyl, acetyl fentanyl, butyryl fentanyl, furanyl fentanyl, cyclopropyl fentanyl, methoxyacetyl fentanyl, and 4-ANPP. Earlier this month, the US Centers for Disease Control and Prevention (CDC) issued a health update regarding the rising number of national opioid-related deaths and reports of street drugs contaminated with fentanyl and carfentanil, two synthetic opioids that are extremely potent and particularly dangerous when used illicitly. Fentanyl and carfentanil carry high risk of overdose and death and can be challenging to reverse with naloxone, often requiring extra doses. Street drugs may be laced with fentanyl or can consist entirely of fentanyl while being sold as another drug. In addition to reports of fentanyl-laced “crack” cocaine and oxycodone tablets in San Francisco, there have been reports by law enforcement, medical providers, and people who use drugs of such street drug contamination in the County of Santa Clara. The full CDC alert can be found at https://emergency.cdc.gov/han/han00413.asp.

Any street drug has the potential of being laced with a powerful opioid such as fentanyl; therefore, any person using street drugs should have access to naloxone. Naloxone is a short-acting opioid antagonist that is sprayed intranasally or injected to reverse an overdose. Per California law (AB635 and AB1535) naloxone is not a controlled substance, can be prescribed by any licensed healthcare provider, and can be administered by witnesses as a first aid measure. It is covered by Medi-Cal, Valley Health Plan, and most private health plans and can also be furnished by pharmacists registered to do so without a prescription. It is also available at no cost to people who inject drugs from the County’s Needle Exchange Program and to others through the County’s Behavioral Health Services.

Actions Requested of Santa Clara County Clinicians: 

1. Counsel patients to avoid purchasing drugs on the street and warn them of the possibility of fentanyl contamination.
2. Consider testing for fentanyl in patients presenting with symptoms of opioid overdose, particularly if they did not intend to take an opioid. Note: Request fentanyl specifically as it is not detected with routine toxicology testing.
3. Ensure that patients who use street drugs (any drugs, not just opioids) have naloxone. Prescribe naloxone for your patients, or direct them to the resources below.
4. Refer patients who need addiction treatment. See resources below for treatment referral information.
5. Treat synthetic opioids such as fentanyl or carfentanil as hazardous materials. Handling should be only by trained professionals with appropriate personal protective equipment due to extremely high toxicity. See https://www.dea.gov/divisions/hq/2016/hq092216.shtml.

Resources: 

• CA Poison Control (800-222-1222) will answer public and provider questions regarding overdoses or symptoms.
• Treatment Referrals:
  • Medi-Cal and uninsured, contact Santa Clara Valley Behavioral Health Services Gateway: (800) 488-9919
  • Insured, please contact insurance carrier’s member services
• Naloxone can be prescribed by any licensed health care provider, furnished by registered pharmacists, or obtained from the County Substance Use Treatment Services or Needle Exchange Program
  • Central Valley Clinic: 2425 Enborg Lane, San Jose (408) 885-5400
  • Alexian Health Clinic: 2101 Alexian Drive - Suite A, San Jose (408) 272-6577
  • South County Clinic: 90 Highland Ave, San Martin (408) 852-2420
  • Needle Exchange Program http://www.sccnex.org  
• Opioid prescribing guidelines at https://www.cdc.gov/drugoverdose/prescribing/guideline.html

 

***Santa Clara County Public Health Department is moving to an email system to send out health alerts, advisories, and updates. These notifications provide official guidance from the Santa Clara County Health Officer to inform clinicians about important public health issues, such as communicable disease outbreaks. To receive these emails, please sign up at http://eepurl.com/dqocab. Note: if you are part of a hospital or health system in Santa Clara County, you might already receive these emails from your administrator.***

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