Atlanta—Public health officials are sounding an alarm about the increase in counterfeit pill availability in the United States and the related historically high levels of drug overdose deaths.

In an article in Morbidity & Mortality Weekly Report, the CDC reported that evidence of counterfeit pill use in overdose deaths more than doubled from July 2019 to September 2019 and October 2021 to December 2021 and tripled in western U.S. states.

The CDC researchers pointed out that people who died with evidence of counterfeit pill use, compared with those without such evidence, tended to be younger, more often Hispanic or Latino, and more frequently had a history of prescription drug misuse and drug use by smoking.

“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,” the authors wrote.

The article noted that the quarterly percentage of deaths with evidence of counterfeit pill use more than doubled from 2.0% during July 2019 to September 2019 to 4.7% during October 2021 to December 2021 and more than tripled in western jurisdictions (from 4.7% to 14.7%). “Illicitly manufactured fentanyls [IMFs] were the only drugs involved (i.e., caused death) in 41.4% of deaths with evidence of counterfeit pill use and 19.5% of deaths without evidence,” according to study authors.

As for those who died, they were:

• Younger (57.1% vs. 28.1% were aged <35 years)
• More often Hispanic or Latino (18.7% vs. 9.4%)
• More frequently had a history of prescription drug misuse (27.0% vs. 9.4%).

The most common noningestion drug use route among deaths with evidence of counterfeit pill use (39.5%) was smoking, the article added.

“Drug overdose deaths are at historically high levels in the United States, with a preliminary estimate of more than 105,000 deaths in 2022,” according to the CDC team. “The proliferation of counterfeit pills, which are not manufactured by pharmaceutical companies, but are typically made to look like legitimate pharmaceutical pills (frequently oxycodone or alprazolam), is complicating the illicit drug market and potentially contributing to these deaths.”

The report advised that counterfeit pills often contain IMFs, illicit benzodiazepines (e.g., bromazolam, etizolam, and flualprazolam), or other illicit drugs. Those can increase overdose risk because the pills might expose users to drugs they did not intend to ingest, the researchers pointed out.

The information came from death certificates, postmortem toxicology reports, and medical examiner and coroner reports. Quarterly percentages of overdose deaths with evidence of counterfeit pill use were calculated among 30 jurisdictions, with complete data for July 2019 to December 2021.

The CDC stated that evidence of counterfeit pill use included:

• Pills found at the overdose scene that were identified as counterfeit (e.g., by witnesses, law enforcement, medical examiners, or coroners)
• Pills that tested positive for drugs other than what they appeared to contain, pills appearing as oxycodone with no oxycodone detected on postmortem toxicology, or pills appearing as alprazolam with no alprazolam detected
• Unmarked pills
• A witness report that the decedent used pills, but none of the drugs detected by toxicology testing are available in legitimate pill form.

Among 54,768 overdose deaths from January 2021 to December 2021 in 35 jurisdictions, 2,437 (4.4%) had evidence of counterfeit pill use, according to the report. “More than one-half (55.8%) of overdose deaths with evidence of counterfeit pill use occurred in western jurisdictions compared with 16.3% of deaths without evidence of counterfeit pill use,” according to the researchers.

While the highest percentages of deaths with evidence of counterfeit oxycodone use (both alone and with counterfeit alprazolam) were in western jurisdictions, one-half of deaths with evidence of counterfeit alprazolam use only were in southern jurisdictions. “His finding suggests that exposure to different types of counterfeit pills and drugs might vary by region. Prevention and education materials that incorporate local drug seizure data and information about regional drug markets might be particularly effective at highlighting relevant counterfeit pill types and reducing deaths,” according to the researchers.

A substantial proportion of deaths with evidence of counterfeit pill use involved only IMFs. The report suggested that access to fentanyl test strips and drug-checking services could help raise awareness of the contents of illicit pills and having naloxone available could lower risk.

Of special interest to pharmacists, the CDC noted, “The higher percentage of decedents with prescription drug misuse history among deaths with evidence of counterfeit pill use, compared with those without such evidence, could indicate a transition from using prescribed medications to obtaining pills illicitly. Discontinued access to prescription drugs might increase overdose risk and negative health outcomes.”

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

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