In this June 6, 2017, file photo, a reporter holds up an example of the amount of fentanyl that can be deadly after a news conference about deaths from fentanyl exposure, at DEA Headquarters in Arlington, Va. Credit: Jacquelyn Martin / AP

Rare drugs designed to mimic the opioid fentanyl are showing up more often in urine samples from Penobscot County than any other county in the nation, according to a recent study. The findings are concerning to the authors, they said, since they come at a time when the fentanyl analogs are frequently being added to methamphetamine, creating a deadly combination.

In the study, published in the Drug and Alcohol Dependence journal, the authors analyzed 300,000 urine drug tests from July 15, 2019, through March 12, 2020. Health professionals from all 50 states submitted urine samples to Millennium Health LLC, a commercial laboratory based in San Diego, to have them tested as part of patients’ routine care. The vast majority — 295,647 — had not been prescribed fentanyl for medical purposes.

The study’s authors, who are all employees of Millennium Health, found that, of those patients testing positive for fentanyl without a fentanyl prescription, 40.55 percent had at least one fentanyl analog detected in their system, showing that copycat fentanyl is “absolutely infiltrating” the market for illicit substances, said Joseph Stanton, associate director of clinical affairs at Millennium Health and one of the study’s authors.

Fentanyl analogs are usually produced in clandestine laboratories and, while they are chemically similar to fentanyl, they were specifically engineered to skirt U.S. law, though the U.S. later banned them. China is the “principal source” of fentanyl analogs, which has routed the drugs through the mail and Mexico, according to the U.S. Drug Enforcement Administration.

Some drug dealers mix fentanyl analogs with other drugs, such as heroin, cocaine and methamphetamine. Mixing is cheaper for dealers because it takes only a small amount of a fentanyl analog to produce a high. However, it’s far riskier for users who don’t always know what they are getting, evidenced by the fact that, in Maine, the average drug overdose death in 2019 involved three drugs. Different analogs have different potencies, and they are not all well understood or well studied.

One well-known analog, however, is carfentanil, which, at 100 times the potency of fentanyl, was originally designed to sedate large animals such as elephants and moose. About 20 micrograms of carfentanil, which is less than a grain of salt, is enough to kill someone.

Of the no-prescription, fentanyl-positive urine samples in the study, the counties that saw the highest positivity rates for more frequently found analogs such as carfentanil and acetyl fentanyl were in Kentucky and Ohio.

But the greatest percentage of urine samples showing traces of the least frequently found fentanyl analogs came from residents living in Penobscot County. Of those Penobscot County samples, 11.36 percent tested positive for at least one of seven rare analogs, such as acryl fentanyl.

For Dr. Noah Nesin, chief medical officer for Penobscot Community Health Care in Bangor, the data was startling. “To have Penobscot County at the top of the list is distressing and a possible explanation as to why our overdose rates remain higher than the rest of the state,” he said. PCHC does not send samples to Millennium Health.

In its other studies, Millennium Health can see methamphetamine use has been growing quickly in Maine — placing the state 10th nationally for its methamphetamine positivity rate among urine samples processed by Millennium Health. Maine has the fifth highest positivity rate in the nation for fentanyl, based on the laboratory’s data. And for the number of samples showing a combination of methamphetamine and fentanyl, Maine ranks sixth, said Eric Dawson, the laboratory’s vice president of clinical affairs.

Combined with the recent evidence showing a high prevalence of rare fentanyl analogs in Penobscot County, it paints “a very concerning picture of the state of Maine and that county specifically as it relates to those users,” said Eric Dawson, vice president of clinical affairs at Millennium Health and a study author. “As you start adding these things, you add to the risk of overdose.”

Neither Dawson nor Stanton know why the rare analogs appeared in Penobscot County in the eight months prior to the pandemic.

Neither did Marcella Sorg, director of the Rural Drug and Alcohol Research Program within the University of Maine. But the results were not a surprise to her.

“I suppose that’s unusual, but Maine has had fentanyl analogs present in the population since late 2012,” she said.

In 2017, acryl fentanyl was involved in the drug death of one person in Maine, according to Sorg’s analysis of drug-related deaths that year. Butyryl fentanyl, another lesser-found analog, helped kill two people. Cyclopropyl fentanyl killed eight. And furanyl fentanyl, which the Millennium Health study didn’t detect in its review, contributed to the deaths of 32 people in Maine that year. Maine has seen a variety of fentanyl analogs show up in the overdose data since.

“Different analogs seem to peak at different times. It’s tough to get a real sense of why that may be,” Stanton, with Millennium Health, said. But the authors hope that knowing more about the ever-changing makeup of the drugs in an area will help local providers and others have more informed conversations with people who are using drugs and enhance efforts to reduce overdoses, they said.

Sorg also questioned whether the study’s sample size was large enough to protect against Penobscot County rising to the top of the list by chance. It is reasonable to assume that if the lesser-known analogs are in Penobscot County, they are also elsewhere in Maine, she said. Or, it’s possible Millennium Health tested Penobscot County samples at a particularly troublesome time.

“They may have just happened to hit it when a bad batch showed up in the drug supply,” she said.

Dr. Mark Publicker, an addiction specialist based in Portland who uses Millennium Health, agreed that the analogs may be common throughout the state. As for Penobscot County’s ranking, “that may be a function of how many providers use Millennium, which may be greater than other areas in the state,” he said.

The study does not reveal how many samples per county Millennium Health received. Because it is a private company, it doesn’t disclose specific data about its customer base, Dawson said. But the company only analyzed counties where at least 10 samples tested positive for fentanyl, and 181 counties across 30 states met that bar. The lab detected the rarer group of fentanyl analogs in 56 counties across 16 states.

“Our data is limited to samples being sent to our lab from health care practitioners. It may not reflect the general population of users, but what we see for Maine is concerning,” Dawson said.

What is clear to Sorg from the study is that fentanyl analogs are widely available. Based on the study, “You see a real wide range of geography, and I’d say it’s just widely distributed,” she said.

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Erin Rhoda

Erin Rhoda

Erin Rhoda is editor of Maine Focus, a journalism and community engagement initiative by the Bangor Daily News.