Prince's death from an overdose of the powerful opioid fentanyl is another example of the national opioid epidemic driven by prescription painkillers.
"This was a man in his 50s who may have been struggling with pain and took a very potent opioid analgesic and died accidentally from an overdose," said Dr. Barbarajean Magnani, pathologist-in-chief at Tufts Medical Center who read a one-page autopsy report released Thursday. "Celebrities bring it to our attention, but we see this every day. We have to re-examine the way we're treating pain."
Prescription opioid overdoses reached nearly 19,000 in 2014, the highest number on record. Total opioid overdoses surpassed 29,000 that year when combined with heroin, which some abusers switch to after becoming hooked on painkillers.
Autopsy results released Thursday show Prince died of an accidental overdose of fentanyl, but did not indicate whether the drug had been prescribed to him by a physician. The 57-year-old singer was found dead April 21 at his Minneapolis-area estate. Investigators have been reviewing whether Prince was prescribed drugs in the weeks before his death.
WHAT IS FENTANYL?
Fentanyl is a synthetic opioid, 50 times more potent than heroin, that's responsible for a recent surge in overdose deaths in some parts of the country. It also has legitimate medical uses.
Doctors prescribe fentanyl for cancer patients with tolerance to other narcotics. It comes in skin patches, lozenges, nasal spray and tablets. Because of the risk of abuse, overdose and addiction, the Food and Drug Administration imposes tight restrictions on fentanyl; it is classified as a Schedule II controlled substance.
Some pharmaceutical fentanyl is illegally diverted to the black market. But most fentanyl used illicitly is manufactured in clandestine labs. The U.S. Drug Enforcement Administration has tied fentanyl seizures to Mexican drug-trafficking groups. On the street, fentanyl is sold alone as powder, added to heroin or made into counterfeit OxyContin pills. Users don't always know when they're taking fentanyl, increasing the risk of fatal overdose.
The DEA issued a nationwide alert about fentanyl overdose in March 2015. More than 700 fentanyl-related overdose deaths were reported to the DEA in late 2013 and 2014. Since many coroners and state crime labs don't routinely test for fentanyl, the actual number of overdoses is probably much higher.
WHAT IS A LETHAL DOSE?
It's tricky with opioids like fentanyl. Anyone who takes prescription opioid painkillers for a long time builds up a tolerance to the drugs. A dose that could kill one person might provide medicinal pain relief to another.
Experts in medical toxicology say it's important to know how much opioid medication a person has been using before a death to know how to interpret post-mortem blood levels. Pill bottles and medical history may become crucial evidence.
DOES PAIN TREATMENT LEAD TO ADDICTION?
Prince had a reputation for clean living, and some friends said they never saw any sign of drug use. But longtime friend and collaborator Sheila E. has told the AP that Prince had physical issues from performing, citing hip and knee problems that she said came from years of jumping off risers and stage speakers in heels.
Becoming tolerant to opioid painkillers may lead some patients to seek stronger drugs from their doctors. Some users — whether they start as recreational users or legitimate pain patients — become addicted, experiencing an inability to control how much they take, so they use much more than is prescribed or seek out drugs on the black market.
With good management, however, opioids can offer relief to people with only a small risk of addiction, according to a 2010 review of the available studies.
WHAT WAS ALREADY KNOWN ABOUT PRINCE?
Questions about Prince's health surfaced April 15, when his plane made an emergency stop in Moline, Illinois. The Associated Press and other media reported, based on anonymous sources, that Prince was found unconscious aboard the aircraft, and first responders gave him a shot of Narcan, an antidote used to reverse suspected opioid overdoses.
WILL PRINCE'S DEATH CHANGE ANYTHING?
Prince's death will intensify efforts to educate doctors and patients about the risks of opioids, said Dr. Paul Wax, executive director of the American College of Medical Toxicology, an organization conducting research on how overdoses strain hospital emergency departments.
"The epidemic spares no one," Wax said. "It affects the wealthy, the poor, the prominent and not prominent. That's the nature of an epidemic."
WHO IS THE MEDICAL EXAMINER?
Dr. A. Quinn Strobl, who has been the chief medical examiner at the Midwest Medical Examiner's Office since late 2009, performed the autopsy on Prince herself. Her office is the official coroner for 19 counties in Minnesota, including Carver County, where he was found dead.
Strobl has been a practicing forensic pathologist since she finished her fellowship in 2005 and is board-certified in anatomic, clinical and forensic pathology.
According to a 2009 (Minneapolis) Star Tribune article, Strobl is a native of Philadelphia who attended Penn State and the University of Pittsburgh School of Medicine. She considered going into family practice and surgery, and decided being a medical examiner was a good mix of the two.
"I interact directly with the family. I deliver the diagnosis, and I answer a wide spectrum of questions," she told the newspaper. "I don't deliver the bad news. Hopefully, I deliver answers."
Associated Press writers Michael Tarm in Chicago and Amy Forliti in Minneapolis contributed to this report.