Fentanyl use in Montana driving spike in overdose deaths

Officials attribute the continuing trend to the highly potent synthetic opioid.

Deaths by drug overdose in Montana continue to rise.

Nearly 200 people in Montana died due to drug overdoses in 2021, the last year that comprehensive data is available, according to the state’s health department. That’s nearly 40 more lives lost than in 2020 and 80 more than in 2017.

Yellowstone County, the state’s most populous, had the highest number of fatal overdoses, followed by Missoula County.

Neither autopsies nor toxicological testing are performed on every person who dies from an overdose, according to Jon Ebelt, a spokesperson from the Montana Department Public Health and Human Services, so even those numbers could be an undercount.

Health care practitioners, law enforcement agencies and others attribute the increase to the proliferation of fentanyl, a synthetic opioid that, according to the Centers for Disease Control and Prevention, can be up to 50 times more potent than heroin and 100 times stronger than morphine.

And there’s no sign of the trend slowing. During the first quarter of 2023 year, Yellowstone County reported 41 calls related to opioid overdoses, followed by Missoula County with 32 and Cascade County with 28, according to a report from the state’s emergency medical services. Across the state in 2022, there were 1,041 opioid overdose-related 911 responses by EMS agencies, an average of 87 per month, up from 76 per month the year prior.

And Narcan, an over-the-counter nasal spray that reverses overdose effects, has become a household name. Clinics and local health departments around Montana are training the public on its use, and advocates and officials are encouraging people to carry Narcan if they believe they might know someone using opioids.

For years in Montana, methamphetamine has been the drug most gravely impacting communities. A public health department report from August 2020 determined that the number of deaths, hospitalizations and emergency room visits related to methamphetamine had all increased substantially since 2015. Crime related to methamphetamine use also increased.

Montana also suffers from an alcohol-induced death rate far greater than the national average. The alcohol-induced death rate in 2019 for adults over the age of 25 was 30.9 per 1,000 residents, compared with 17.3 per 1,000 nationally, and 18% of high-school students in Montana reported engaging in binge drinking, 4% higher than their national peers. 

But the arrival of fentanyl, a cheaper and more potent opioid, has created a new crisis. While methamphetamine and alcohol are still more prevalent, the rate of deaths from opioid-related drug overdoses in Montana nearly tripled between 2017-2018 and 2019-2020, according to the state Department of Public Health and Human Services. Nikki Russell, who struggled with substance abuse for nearly a decade and now serves as a peer mentor for Montana Peer Network — a statewide nonprofit that helps people struggling with addiction — said it felt like things changed overnight.

“It felt quick. I absolutely feel like I turned a corner and there [fentanyl] was,” Russell said. “I was hearing about one [overdose] after another after another.”

For example, the Northwest Montana Drug Task Force, responsible for covering six counties, including Lincoln, Lake and Flathead, equaling roughly 17,600 square miles, made 56 fentanyl-related arrests in 2022 and removed more than $2 million in illicit drugs from communities. Throughout Montana, there were 488 opioid seizures by law enforcement in 2021, nearly double the number in 2017, according to the Montana Board of Crime Control.

Ka Mua, a nurse practitioner at Ideal Option, which operates nine clinics across Montana that provide medication-assisted treatment to treat opioid dependence, said she has seen a significant rise in the use of fentanyl among patients in the last 18 months.

Among the many risks posed by fentanyl, according to Mua, is that the symptoms of withdrawal — intense nausea, fever or debilitating muscle aches — can start much quicker and be much more intense than with other opioids.

More than half of patients at Ideal Option clinics across the state test positive for at least two substances, and 24% test positive for three or more. That circumstance, called polysubstance use, often reveals that people don’t know how their drugs are getting cut or mixed. It’s not uncommon, then, for people to think they are taking one drug but to learn later that it was laced by illegal manufacturers with fentanyl, which is partly why the overdose risk is so high, Mua said.

According to research from the American Journal of Public Health, 61% of fatal overdoses nationally in 2021 that involved methamphetamine also included opioids such as heroin or fentanyl.

There’s “no way to measure the correct dose of fentanyl as a street drug,” Russell said.

“At the time when I was using substances, it was a dangerous road, but I could kind of see where I was going, even though I was, so to speak, lost,” Russell said. “What’s happening right now is that people are literally walking down that path in the dark. They have no idea what is going to be laced, what is going to be a dose that could kill you.” 

THE ROLE OF LAW ENFORCEMENT

Steve Holton has worked for the Ravalli County Sheriff’s Office for more than 25 years, and he’s been the sheriff for six. While substance use is nothing new in the Bitterroot Valley, he said, the pervasiveness of drugs and the impact substance use is having on the community is notably different.

“Fentantyl is definitely on the rise, even down here,” Holton said. “We’re seeing a lot of distribution. It’s super easy to get. It’s super pure. There was a time when our problem was methamphetamine labs, and that is simply not the case anymore.”

Although the number of fatal overdoses in Ravalli County is low — according to the public health department, six people died in 2021 — Holton said those numbers don’t adequately reflect the threat of the drug crisis in the community.

All deputies in the sheriff’s office carry Narcan, and Holton said access to naloxone — the generic name for the medication — has prevented many overdoses from resulting in death. But he cautions that people shouldn’t assume that low fatalities means overdoses are uncommon.

“People tend to have a that-can’t-happen-here attitude,” Holton said. “I don’t think people understand just how prevalent the dangerous drugs are in Ravalli County.”

It’s not uncommon for law enforcement officials in Montana to be some of the first on the scene for a drug-related health crisis. Montana comprises more than 147,000 square miles and in 2020 had 1,676 sworn police officers and 103 law enforcement agencies. Some of those agencies work together to serve as part of the state’s six drug task forces.

That’s a lot of area to cover with few people. Such remoteness makes responding to possible overdoses or investigating the origin of drugs in the community difficult, Holton said. Emergency calls “are a long ways away from each other, so to get people the help they need, law enforcement is often the answer,” he said.

REDUCING STIGMA

A compelling and growing body of research, including from the National Institute of Health, shows that criminalization of drug use prevents people from seeking treatment, which can push people struggling with addiction even further to the margins of society.

As a result, there has been an increasing effort nationally to reduce the prominence of traditional law enforcement in moments of mental health crises, including for people who may be using drugs. Missoula and Flathead counties, for example, have both created programs within their police departments that pair mental health counselors with law enforcement officers.

Community organizations are stepping up across the state, too. Safe syringe exchanges, like those offered by Missoula’s Open Aid Alliance, and medication-assisted treatment clinics are becoming more common. Those interventions are considered part of harm-reduction practices, a school of thought that aims to reduce the stigma around drug use. 

Advocates say public health interventions such as needle exchanges reduce some of the potential harm that drug use can cause. People struggling with addiction, they maintain, should feel comfortable seeking treatment and support. Russell added that the stigma around substance abuse, especially in rural communities, often discourages the people she works with from joining support groups, seeking help or taking advantage of existing resources.

The Montana State Legislature is doing work of its own to reduce the number of opioid-related drug overdoses in the state. A bill signed into law in May exempts fentanyl testing strips from the list of illegal drug paraphernalia so that people can better avoid unknowingly consuming the powerful opiate when they are using other substances.

Fentanyl’s hold on communities in Montana, experts agree, has forced something of a reckoning in how society can best help drug users prevent overdoses.

“If somebody’s not alive, how can they recover?” Russell said.