The Fentanyl Phase of the Opioid Epidemic in Cuyahoga County, Ohio

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A new study shows data on the increase in fentanyl-related overdose death in one county in the state of Ohio at the midpoint of the opioid crisis – and reveals why the programs put in place in Ohio in 2015-2016 are still valuable and relevant in 2023.

According to data from the Centers for Disease Control (CDC), the opioid crisis unfolded in three waves. The first wave took place between 1999 and 2010 and was driven by an increase in prescription opioids and overdose deaths related to prescription opioids. The second wave took place between 2010 and 2013 and was driven by an increase in heroin use and heroin overdose. The third wave began in 2013 and was characterized by and increase in overdose deaths related to synthetic opioids, primarily fentanyl.

Experts indicate that we’re now moving into a fourth wave, driven by fentanyl, polysubstance misuse, co-occurring mental health disorders, and various consequences of the COVID-19 pandemic.

This article will focus on the third wave of the opioid crisis, with special attention to the change in the contours of the crisis that defined the difference between the second and third wave: the increase in overdose deaths related to synthetic opioids, and a relative and parallel decrease in overdose deaths related to heroin.

The Third Wave: The Impact of Fentanyl

Between 2010 and 2012, the limited availability of opioid pain relievers led to an increase in use of the illicit opioid, heroin. This is called the heroin phase of the opioid epidemic, which was followed by the illicitly manufactured fentanyl (IMF) phase of the opioid epidemic, which began in 2014.

Both phases of the opioid crisis hit Ohio hard.

In fact, Ohio is among the top 5 states in the nation for overdose deaths in the country, with the third most overdose deaths after California and Florida. In 2021, 5,405 people died of drug overdose, which was a 3.6 percent increase from 2020, and a 62 percent increase from 2015. Of those overdose deaths in 2021, data shows 4,209 – that’s 78 percent – involved fentanyl. That’s a slight increase from 2020, a 72 percent increase from 2019, and a 334 percent increase from 2015.

Those are the reasons we research, write, and publish articles about the opioid crisis in Ohio. The challenging situation keeps changing. With each change, individuals, families, and communities in Ohio experience harm in different ways. This default situation means policymakers and treatment providers like us must adapt, overcome, and help our patients manage, mitigate, or eliminate the harm caused by the opioid crisis to the best of our ability.

In this article – as we mention above – we’ll narrow our focus to one thing: the role of fentanyl in the opioid crisis between 2012 and 2016. We’ll also narrow our focus to one location: Cuyahoga County, Ohio.

This focus on fentanyl and Cuyahoga County possible because of a 2022 publication called “The Fentanyl Phase of the Opioid Epidemic in Cuyahoga County, Ohio, United States.”

About the Study: Fentanyl and Heroin in Cuyahoga County, Ohio

Cuyahoga County, with a population of 1.2 million, is the second most populous county in Ohio. Unfortunately, the citizens of Cuyahoga have experienced the negative effects of the opioid crisis firsthand. In 2020, overdose deaths totaled 549, with 416 attributed to fentanyl – that’s 76 percent of all overdose deaths.

That’s the current situation. This study we introduce above, however, is retrospective, meaning it looks back at data from the past. When reviewing data on opioid overdose fatalities, researchers noticed a spike in overdose deaths attributed to illicitly manufactured fentanyl (IMF) between 2015 and 2016.

Here’s what they saw:

  • IMF Deaths 2015: 370
  • IMF Deaths 2016: 666
That’s a 400% increase.

This caused them to go further back in the data in order to identify when heroin overdose deaths began to decrease, and IMF-related overdose deaths began to increase. To accomplish that goal, researchers compared heroin-related deaths in 2012 and 2016 with heroin and IMF-related deaths in 2016 in order to identify any common variables or trends.

Here’s how they did it:

  • Retrieved records on overdose from the Cuyahoga County Medical Examiners’ Office (CCMEO) for the years 2012 and 2016.
  • Collected and analyzed the following procedural information:
    • Scene investigation
    • Toxicology report
    • EMS report
    • Police report
  • Collected and analyzed the following personal information:
    • Demographics: age, sex, race
    • Residence
    • Education
    • Occupation
    • Marital status
    • Veteran status
  • Additional general information:
    • Presence of others at the scene
    • Use of naloxone
    • Presence of drug paraphernalia
  • Medical information:
    • General medical history
    • Illicit drug use
    • Intravenous (IV) drug use
    • Previous detoxification treatment
    • Previous overdose
    • History of SUD treatment
    • History of incarceration
    • Periods of abstinence from drug use

Researchers divided the data into three groups:

  • 2016 IMF group: individuals who died in 2016 due to IMF-related overdose
  • 2016 heroin group: individuals who died in 2016 due to heroin-related overdose
  • 2012 heroin group: individuals who died in 2012 due to heroin-related overdose

When possible, researchers compared variables for all three groups. However, the main comparison in the study was between the 2016 IMF and 2016 heroin groups. The goal of the study was to identify any significant factors – demographics, social, medical, or otherwise – that distinguished the IMF group from the heroin group.

Let’s take a look at what they found.

Fentanyl and Heroin Overdose in Cuyahoga County, Ohio

Here are the baseline demographic and social characteristics of individuals who died of heroin-related overdose and fentanyl-related overdose in 2016, labeled below as IMF16 and Heroin16, respectively.

Overdose in Cuyahoga County, Ohio: Demographic Information

Total Deaths:

  • IMF16: 421
  • Heroin16: 92

Average Age:

  • IMF16: 41
  • Heroin16: 45

Age groups:

  • 18-34:
    • IMF16: 154
    • Heroin16: 26
  • 35-64:
    • IMF16: 252
    • Heroin16: 59
  • 65+:
    • IMF16: 15
    • Heroin16: 7


  • IMF16: 308 male/113 female
  • Heroin16: 70 male/22 female


  • White:
    • IMF16: 350
    • Heroin16: 79
  • Black:
    • IMF16: 60
    • Heroin16: 9
  • Hispanic:
    • IMF16: 11
    • Heroin16: 3
  • Other:
    • IMF16: 0
    • Heroin16: 1

Residential information:

  • Urban
    • IMF16: 190
    • Heroin16: 37
  • Suburban
    • IMF16: 112
    • Heroin16: 29
  • Exurban
    • IMF16: 70
    • Heroin16: 13
  • Rural
    • IMF16: 49
    • Heroin16: 13


  • High school or less
    • IMF16: 320
    • Heroin16: 66
  • College:
    • IMF16: 81
    • Heroin16: 19
  • Post-graduate
    • IMF16: 11
    • Heroin16: 1


  • Employed:
    • IMF16: 296
    • Heroin16: 57
  • Unemployed:
    • IMF16: 34
    • Heroin16: 9

Veteran Status:

  • IMF16: 31
  • Heroin16: 9

Marital Status:

  • IMF16: 248 never married/57 married/114 divorced
  • Heroin16: 45 never married/14 married/31 divorced

The first thing we’ll point out about this set of data is that it confirms the role of fentanyl in the overdose crisis in Ohio. In 2016, there were over four times as many deaths involving fentanyl than heroin. The presence of fentanyl in illicit drugs, even non-opioid drugs, is one of the main reason the overdose crisis is getting worse, rather than better.

We’re also attuned to several other demographic factors: three-quarters of deceased individuals in both categories had a high school education or less, around half in each category were never married, over 80 percent of deceased individuals were fully employed, around 84 percent were white, around 70 percent were male, and around 60 percent between 35-64 years old.

We can use all that information to assess overdose risk among our patients.

Additional Data: Location Details and Personal Histories in Cuyahoga County, OH

The data above help us create a profile of individuals in our care who may be at increased risk of overdose with fentanyl or heroin. This next set of data helps us complete that profile. One thing we notice here – and in the data above – is the remarkable amount of overlap in demographic characteristics between the three groups in the study.

While most studies look for differences between the groups they examine, the similarities we see in these groups do not mean this study is a failure. Actually, it means the opposite – and we’ll explain why in a moment.

For now, let’s have a look at the rest of the data, starting with the information collected at the overdose scene, and personal information on the overdose victims.

Overdose Scene Information and Personal Details

Presence of Drug Paraphernalia

  • IMF16: 290 (70%)
  • Heroin16: 60 (66.7%)
  • Heroin12: 81 (50.6%)

EMS Response:

  • IMF16: 407 (97.1%)
  • Heroin16: 85 (94.4%)
  • Heroin12: 152 (95%)

Naloxone Administration:

  • IMF16: 145 (34.6%)
  • Heroin16: 25 (27.5%)
  • Heroin12: 36 (22.5%)

History of Abstinence:

  • IMF16: 257 (66.1%)
  • Heroin16: 54 (60%)
  • Heroin12: 60 (37.5%)

Overdose/ER Visits:

  • IMF16: 116 (33.7%)
  • Heroin16: 13 (14.6%)
  • Heroin12: n/a

History of Detox/Rehab:

  • IMF16: 169 (48.1%)
  • Heroin16: 31 (34.4%)
  • Heroin12: 48 (30%)

History of Incarceration:

  • IMF16: 153 (36.7%)
  • Heroin16: 39 (43%)
  • Heroin12: 28 (17.5%)

While those numbers appear mismatched, the percentages are consistent across groups. The significant differences we see here are a larger percentage of individuals in in IMF16 group with a history of inpatient detoxification/SUD rehab/Overdose/ER visits, and more individuals with a history of incarceration in both 2016 groups compared to the Heroin12 group. The differences in Naloxone administration are the result of increased availability created by the implementation of harm reduction programs between 2014 and 2016. The other observable differences – such as the presence of absence of drug paraphernalia – do not affect our work as SUD treatment providers.

We have one more set of data to share from this study. This information is limited to individuals in the IMF16 group and speaks to the phenomenon of polysubstance misuse. Researchers noted whether each overdose victim had any history of prescriptions for drugs of misuse of disordered use, had participated in and medication-assisted treatment programs (MAT), or had a history of doctor shopping.

Prescription Drug Use Among IMF16 Group

Data collected from the Ohio Automated Rx Reporting System (OARRS) Prescription Drug Monitoring Database. “Doctor shopping” means an individual was flagged by either doctors or pharmacists for seeking more medication than allowed from more than one doctor or pharmacy/pharmacist.

  • Opioids: 89.4%
  • Benzodiazepines: 44.3%
  • Medication-assisted treatment (MAT): 19.1%
  • Doctor shopping: 22.5%

This data is also instructive: it shows the direct relationship of opioid prescriptions to subsequent overdose deaths and highlights the danger of simultaneous benzodiazepine and opioid use. It also begs a question: if only 20 percent of individuals received MAT, could we have saved the other 80 percent if we’d somehow managed to get them into an integrated, whole-person MAT program?

That’s a question we can’t answer, but we know that MAT works, which means we’ll keep offering it as the go-to treatment for opioid use disorder (OUD) among our patients – which brings us to the most important takeaway from this report.

All of the Above: Cuyahoga County Needs Ongoing Treatment, Awareness, and Harm Reduction Initiatives

We mention above that most studies look for differences between groups to generate useful data. Meaning, for example, that if data shows person with [X] characteristics is more likely to experience a fatal overdose than a person with [Y] characteristics, knowledge of those different characteristics can help us prevent overdose.

In this study, researchers found that there were no significant demographic or personal differences between the three groups: the profiles of individuals in the Heroin12, Heroin16, IMF12, and IMF16 groups mirrored one another with surprising consistency.

Why is this helpful?

It means that the programs and systems public health officials, community organizers, and treatment professionals like us here at Pinnacle Treatment Centers initiated in 2015 and 2016 are still relevant to the groups at risk in 2022 and 2023.

The Drug Enforcement Agency (DEA) will continue working to keep fentanyl off the streets and out of illicit drugs of misuse: that’s a big piece of solving this crisis, moving forward.

For our part, we’ll continue doing what we know works: offer integrated, whole person treatment for anyone with SUD, offer medication-assisted treatment (MAT) to people with OUD, and continue advocating for and supporting harm reduction measures in our communities.

With a comprehensive, collaborative, all-of-the-above, all-hands-on-deck approach, we know we can turn the tide on this public health crisis.

The materials provided on the Pinnacle Blog are for information and educational purposes only. No behavioral health or any other professional services are provided through the Blog and the information obtained through the Blog is not a substitute for consultation with a qualified health professional. If you are in need of medical or behavioral health treatment, please contact a qualified health professional directly, and if you are in need of emergency help, please go to your nearest emergency room or dial 911.