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Fatal overdoses from counterfeit pharmaceuticals, particularly pills found to contain fentanyls, more than doubled in recent years, the CDC reported.

Among more than 100,000 recent overdose deaths in the U.S., the percentage caused by pills disguised as legitimate pharmaceutical products increased from 2.0% in the third quarter of 2019 to 4.7% in the last quarter of 2021.

The proportion of those deaths involving illicitly manufactured fentanyls jumped to 93.0% from 72.2%, while illicit benzodiazepines also rose to 5.3% from 1.4%. Fake fentanyl was the sole drug involved in 41.4% of counterfeit pill-related deaths, compared with 19.5% of overdose deaths without evidence of counterfeit pill use.

Western states drove the increase in deaths with evidence of counterfeit pill use, with a rise from 4.7% to 14.7% across the study period, whereas percentages remained below 4% elsewhere, reported Julie O'Donnell, PhD, of the CDC, and colleagues in .

"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 [Xanax]), is complicating the illicit drug market and potentially contributing to [overdose] deaths," O'Donnell and colleagues wrote.

And it may unintentionally expose new populations to highly potent drugs.

"Counterfeit pills often contain illicitly manufactured fentanyls (IMFs), illicit benzodiazepines (e.g., bromazolam, etizolam, and flualprazolam), or other illicit drugs, and can increase overdose risk because the pills might expose persons to drugs they did not intend to use," they added.

The findings come against a backdrop of an overall increase in drug overdose death rates involving fentanyl, methamphetamine, and cocaine from 2016 through 2021, as previously reported by the CDC without respect to counterfeit status.

Prevention and education efforts "that are tailored to persons most at risk, and include outreach to those who do not frequent traditional harm reduction services, might be most successful," they wrote.

Effective messaging by public health entities might include highlighting the dangers of pills obtained and taken without a prescription, as well as encouraging drug product testing, O'Donnell and colleagues added.

Data examined for the study came from jurisdictions participating in CDC's State Unintentional Drug Overdose Reporting System (SUDORS), which included 29 states and the District of Columbia from July 2019 to December 2021, with an additional five states reporting data during 2021. Jurisdictions entered information about unintentional and undetermined intent overdose deaths from death certificates, post-mortem toxicology reports, and medical examiner and coroner reports.

As for means of drug use, smoking was the most common non-ingestion route among deaths with evidence of counterfeit pill use (39.5%) and was highest in western jurisdictions (55.1%).

More than half of deaths with evidence of counterfeit pill use involved counterfeit oxycodone, either alone (55.2%) or with counterfeit alprazolam (3.9%), researchers reported.

Decedents with evidence of counterfeit pill use were younger than those without such evidence (57.1% vs 28.1% under age 35) and more were Hispanic or Latino (18.7% vs 9.4%, respectively). Additionally, a higher percentage of deaths with evidence of counterfeit pill use were in people with a history of prescription drug misuse compared with those without such evidence (27.0% vs 9.4%).

Deaths involving oxycodone and alprazolam combined involved people of the youngest average age (26 years).

"Counterfeit pills have been marketed toward younger persons, who might have more recently started using drugs and have lower tolerance," O'Donnell and colleagues wrote. "Younger persons might also exhibit more risk-taking behaviors than do older persons, and engage less with harm reduction services."

"The higher percentage of Hispanic decedents could reflect the younger age of this population and the demographics of western states where evidence of counterfeit pill use was more common; nonetheless, it might still have implications for access to and use of prevention messaging materials and harm reduction services," they added, such as tailoring these messages and services to address potential engagement, language, or other barriers.

Limitations of the study included that analyses might not be generalizable beyond jurisdictions that were included, and that documentation of counterfeit pill use is likely underestimated, the researchers noted.

Furthermore, the definition for evidence of counterfeit pill use included pills found or reported to be at the overdose scene, and some overdose deaths might be included as having evidence of such use even if the decedent did not use the pills.

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