Multiple Fentanyl Overdoses — New Haven, Connecticut, June 23, 2016

Probably not a substantial claim: may not pass S3 (load-bearing).

The one patient with a negative urine cocaine screen, patient A, acknowledged past cocaine use.

“The one patient with a negative urine cocaine screen (patient A) acknowledged past cocaine use.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Actions of multiple partners led to the arrest 4 days later of three persons allegedly responsible for the illicit fentanyl sales.

“Actions of multiple partners led to the arrest 4 days later of three persons allegedly responsible for the illicit fentanyl sales.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Community opioid treatment programs and providers collaborated with the EDs to provide rapid access to treatment for patients with opioid use disorders.

“In addition, community opioid treatment programs and providers collaborated with the EDs to provide rapid access to treatment for patients with opioid use disorders.”

May combine two claims.

The absence of other opioids such as heroin, methadone, or oxycodone in serum, with only one patient D positive for hydrocodone, was consistent with patient reports that most were not habitual opioid users.

“The absence of other opioids, such as heroin, methadone, or oxycodone, in serum (only one patient [D] was hydrocodone positive) was consistent with reports by the patients that most were not habitual opioid users.”

May combine two claims.

Within 6 hours, seven additional patients arrived at the York Street Campus ED and one more at the St. Raphael ED; these included two pronounced dead on arrival and four critically ill requiring endotracheal intubation and ICU admission.

“Within 6 hours, seven additional patients arrived at the York Street Campus ED and one more at the St. Raphael ED; these patients included two who were pronounced dead on arrival and four critically ill patients requiring endotracheal intubation and ICU admission (Figure).”

May combine two claims.

Serum samples from hospitalized patients analyzed at UCSF demonstrated fentanyl levels of 0.5-9.5 ng/mL; postmortem levels in the first two patients who died were 11 ng/mL for patient E and 13 ng/mL for patient I.

“Serum samples from the hospitalized patients analyzed at UCSF demonstrated fentanyl levels of 0.5–9.5 ng/mL (Table 2) (therapeutic range for analgesia = 0.6–3.0 ng/mL) (4); postmortem levels in the first two patients who died were 11 ng/mL (patient E) and 13 ng/mL (patient I).”

May combine two claims.

Some patients required naloxone doses exceeding 4 mg, and several patients who were alert after receiving naloxone subsequently developed respiratory failure.

“Some patients required doses of the opioid antidote naloxone exceeding 4 mg (usual initial dose = 0.1–0.2 mg intravenously), and several patients who were alert after receiving naloxone subsequently developed respiratory failure.”

May combine two claims.

All patients had clinical signs of opioid overdose and received at least one dose of naloxone from EMS.

“All of the patients had clinical signs of opioid overdose and received at least one dose of naloxone from EMS (Table 1).”

May combine two claims.

The white powder was determined to be fentanyl and included trace amounts of cocaine.

“The white powder was determined to be fentanyl, a drug 50 times more potent than heroin, and it included trace amounts of cocaine.”

May combine two claims.

The patients represented four geographic clusters and were transported by EMS crews responding to bystander 911 calls.

“The patients represented four geographic clusters (i.e., at least one other victim found in the same vehicle or parking lot, or in the same house or an adjacent house), and were transported by EMS crews responding to bystander 911 calls.”

May combine two claims.

Two of the three intubated patients suffered acute kidney injury and pulmonary or gastrointestinal hemorrhage; one, patient K, died 3 days later from multisystem organ failure.

“Two of the three intubated patients suffered acute kidney injury and pulmonary or gastrointestinal hemorrhage, one of whom (patient K) died 3 days later from multisystem organ failure.”

May combine two claims.

Postmortem toxicology screens identified fentanyl as a cause of death for patients E and I, both of whom arrived in the ED in cardiac arrest.

“Postmortem toxicology screens identified fentanyl as a cause of death for patients E and I, both of whom arrived in the ED in cardiac arrest.”

May combine two claims.

On June 23, 2016, a white powder advertised as cocaine was purchased from multiple street sources and used by an unknown number of persons in New Haven, Connecticut.

“On the evening of June 23, 2016, a white powder advertised as cocaine was purchased off the streets from multiple sources and used by an unknown number of persons in New Haven, Connecticut.”

May combine two claims.

Nine patients were admitted to the hospital, including four to the intensive care unit; three required endotracheal intubation, and one required continuous naloxone infusion.

“Nine patients were admitted to the hospital, including four to the intensive care unit (ICU); three required endotracheal intubation, and one required continuous naloxone infusion.”

May combine two claims.

The urine toxicology screens suggest that most patients were cocaine users but not chronic opioid users, and as such would likely not have received training in identification or treatment of opioid overdose.

“The urine toxicology screens suggest that most patients were cocaine users, but not chronic opioid users, and as such, would likely not have received any training in the identification or treatment of opioid overdose.”

Probably not a substantial claim: may not pass S2 (checkable).

A collaborative and timely multi-organization response can mitigate the consequences of an extraordinary public health event.

“A collaborative and timely multi-organization response can mitigate the consequences of an extraordinary public health event.”

May combine two claims.

Norfentanyl was not detected in postmortem testing of patients E and I, presumably because death occurred before metabolism of fentanyl to norfentanyl.

“norfentanyl was not detected in postmortem testing of patients E and I, presumably because death occurred before metabolism of fentanyl to norfentanyl.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

Many users might be unaware that their expected substance of choice might be substituted by or adulterated with high doses of fentanyl.

“In addition, many users might be unaware that their expected substance of choice might be substituted by or adulterated with high doses of fentanyl.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The therapeutic range for fentanyl analgesia is 0.6-3.0 ng/mL.

“(therapeutic range for analgesia = 0.6–3.0 ng/mL) (4)”

• cites [4] Peng, 1999, A review of the use of fentanyl analgesia in the management of acute pain in adults., Anesthesiology sourceNot checked — no full text of the source

May combine two claims.

The swift coordinated multiagency response likely limited the impact of this outbreak, and the resultant strengthening of community partnerships has the potential to further limit opioid-related morbidity and mortality in communities.

“The swift coordinated multiagency response likely limited the impact of this outbreak, and the resultant strengthening of community partnerships has the potential to further limit the morbidity and mortality related to opioids in communities.”

May combine two claims.

Effective communication and timely, coordinated, collaborative actions of community partners reduced the harm caused by this event and prevented potential subsequent episodes.

“Effective communication and timely, coordinated, collaborative actions of community partners reduced the harm caused by this event and prevented potential subsequent episodes.”

May combine two claims.

This outbreak was unique in representation of fentanyl as cocaine to an opioid-naïve population, which resulted in an outbreak of fatal and nonfatal overdoses.

“this outbreak was unique in representation of fentanyl as cocaine to an opioid-naïve population, which resulted in an outbreak of fatal and nonfatal overdoses.”