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Prince Accidentally Overdosed on Fentanyl

The official autopsy report followed weeks of speculation


The Midwest Medical Examiner’s Office in Minnesota released its autopsy report on Prince today, saying the singer died accidentally of “fentanyl toxicity.” Prince self-administered the drug, a powerful opioid painkiller, the report said.

That report came just hours after the Associated Press (AP) quoted an anonymous law enforcement source saying that Prince died of an opioid overdose, though the source did not name the drug.

The media and Prince’s legions of admirers have been waiting since his death on April 21 for the autopsy results. It is not unusual for toxicology results to take weeks to be finalized. The date of the “injury” was listed as unknown. Prince was 57.

Other details of the autopsy report, signed by medical examiner Dr. A. Quinn Strobl, reduce the megastar to the stature of the merely human: He stood 5 feet 3 inches tall and weighed 112 pounds. His clothing, at the time of his death, consisted of a black cap, black shirt, grey undershirt, black pants, black boxers and black socks.

Fentanyl in the Spotlight

Opioid deaths have nearly quadrupled since 1999, according to the Centers for Disease Control. Officials suspect that a significant proportion of the rising death toll is due to a surge in illegally made fentanyl, which is increasingly used to heighten the effects of other drugs, like heroin. Fentanyl-laced heroin killed Oscar-winning actor Philip Seymour Hoffman in February 2014. He was 46.

We physicians have few alternatives for patients who have already tried non-steroidal anti-inflammatory medications and acetaminophen without relief.

— Dr. Mitchell H. Katz

The New York Times reported in March that fentanyl is also being sold by itself. It is “up to 50 times more powerful than heroin and up to 100 times more potent than morphine,” the newspaper said, adding that  a tiny bit can be fatal.

Doctors began using fentanyl in the 1960s as an intravenous pain reliever; its illicit use is mostly through needles but, like heroin, the drug can also be smoked or snorted, according to the U.S. Drug Enforcement Administration.

A California addiction specialist was scheduled to meet with Prince on April 22  and Prince’s representatives called on the doctor April 20, saying he “was dealing with a grave medical emergency,” the Star Tribune of Minneapolis reported previously.

The newspaper attributed the information to a prominent Minneapolis attorney, William Mauzy, who was hired by Dr. Howard Kornfeld of Recovery Without Walls in Mill Valley, Calif. Kornfeld “could not clear his schedule” to get to [Prince’s studio residence] Paisley Park on April 20, but set up a meeting with the legendary musician that was to take place April 22, the Star Tribune said. Kornfeld sent his son, Andrew, to explain the treatment program; Andrew Kornfeld took a red-eye flight Wednesday night. He was at Paisley Park when the singer was found dead the morning of Thursday, April 21, the paper said.

Shortly after Prince’s death, a law enforcement source confirmed that Prince was given a shot of Narcan, a drug that reverses the effects of an opioid overdose, during an emergency landing of his plane in Moline, Ill., on April 15. He was on his way back to Minnesota after performing two shows in Atlanta. At home the next day, he hosted a dance party at Paisley Park but did not perform.

On May 1, AP reported that Prince’s personal chef Ray Roberts noticed he “wasn’t himself probably the last month or two.” Roberts had cooked for Prince nearly every day for almost three years and said he saw no signs of a drug problem. But Prince was “sick a lot” with sore throats and upset stomachs, and often requested smoothies and fresh juices in place of his regular meals, the AP quoted Roberts as saying.

Unlike many other star musicians, Prince was known for his avoidance of drugs. But he may have been in pain; Sheila E., his ex-fiancee and former drummer, told ABC’s Good Morning America that he had hurt his hips while performing in past years with stunts like jumping off risers in high heels.

A Scourge of Drug Deaths

“The United States is in the midst of a drug overdose epidemic,” the Centers for Disease Control (CDC) says on its website. More Americans died from overdoses in 2014 than in any other year on record, and more than three out of five of those deaths — a total of 28,000 – involved an opioid, the agency says.

Those fatalities include deaths from prescription painkillers such as oxycodone, hydrocodone and morphine as well as heroin and other illegal opioids. Percocet, which TMZ reported was the cause of Prince’s alleged overdose on the airplane, is a combination of acetaminophen (Tylenol) and oxycodone. The CDC estimates that 19,000 people, or 52 per day, died from prescription opioids in 2014.

Many opioid users become addicted to the drugs after an illness or injury results in chronic pain. The 2012 National Health Interview Study revealed that 11.2 percent of adults report having daily pain. And the treatment of chronic pain has been fraught with complexity for both patients and their doctors.

Urine Testing Included in Recommendations

On March 15, the CDC revised its guideline for prescribing opioids for chronic pain outside of palliative care or treatment for cancer.

“This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death,” the CDC wrote.

Among its 12 recommendations are some that seem obvious, and not particularly helpful:Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient,” and “discuss with patients known risks” of opioid therapy.

Others are more specific, even surprising: Before starting chronic pain patients on opioids, doctors should do urine drug testing and consider renewing those tests “at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs,” the CDC said.

It also recommended that physicians prescribe immediate-release opioids instead of extended-release/long-acting opioids; prescribe the lowest effective dose for the shortest time possible for acute pain; consider offering patients naloxone (Narcan) when they have a history of overdose, a history of substance use, higher opioid dosages or also use benzodiazepine (Valium, Xanax) and review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data.

Doctors have responded to the recommendations.

‘Little Relief in Sight’

“Four of five persons newly initiating heroin use now report starting with a prescription opioid, a near complete reversal since prior to 2000,” wrote Dr. Yngvild Olsen in an April 21, 2016 JAMA editorial on the new CDC guidelines. “Despite multiple, laudable efforts across the country aimed at curbing the opioid epidemic, there seems to be little relief in sight.”

The recommendation on acute pain — to prescribe low doses for the minimum number of days necessary — is clearly an attempt to keep patients from falling into long-term use, yet it’s complicated, wrote Dr. Mitchell H. Katz, in a separate JAMA editorial.

“The care of such patients is challenging, because whatever you believe about the efficacy of opioids for chronic pain, you cannot tell a patient who says that his pain is relieved by opioids that it is not,” he wrote. Even when their patients have not yet tried opioids, “we physicians have few alternatives for patients who have already tried non-steroidal anti-inflammatory medications and acetaminophen without relief.”

Officials suspect that a significant proportion of the rising death toll is due to a surge in illegally made fentanyl, which is increasingly used to heighten the effects of other drugs, like heroin. Fentanyl-laced heroin killed Oscar-winning actor Philip Seymour Hoffman in February 2014. He was 46.

Other Facts About Opioids

Statistics reported by the CDC include the following:

  • The most common drugs involved in prescription opioid overdose deaths include methadone, oxycodone (such as Percocet and OxyContin) and hydrocodone (such as Vicodin)
  • Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids
  • Of those who died from prescription opioid overdose between 1999 and 2014, overdose rates were highest among people aged 25 to 54 years.
  • As many as one in four people who receive prescription opioids from their doctors long-term for noncancer pain struggles with addiction.

 

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