By Melanie Padgett Powers, writer
During the May 23 session “Innovative Laboratory Surveillance Projects for Drug Overdose: Successes, Challenges and Future Directions” at the 2023 APHL Annual Conference, experts explained how public health laboratories can create biosurveillance programs for non-fatal drug overdoses.
These programs involve partnering with hospital emergency departments, where hospital staff collect urine specimens from patients who survive drug overdoses. The samples are de-identified — meaning the patients are anonymous to the laboratory staff — and shipped or delivered to the state public health laboratory for testing.
Fentanyl drives overdose deaths
There have been three waves of the opioid overdose epidemic in the US, explained Desiree Mustaquim, PhD, MPH, senior health scientist at the Centers for Disease Control and Prevention (CDC). The first wave started in the late 1990s with an increase in prescription overdose deaths. Following this, around 2010 there was an increase in heroin overdose deaths, and then starting about 2013, there was a large increase in synthetic opioid deaths, mostly from fentanyl, she said.
Preliminary data predict that there were 109,680 overdose deaths in the US in 2022. While that is a slight increase from 2021, Mustaquim said, it appeared the number of overdose deaths might be leveling off.
“Fentanyl continues to be the main driver,” she said. “Co-involvement on multiple substances also continues to be a major problem. The drug supply is incredibly complex, and it is constantly evolving. So, those three things are indicators as to why laboratory surveillance is incredibly important in this space.”
Public health laboratories can apply for funding for these biosurveillance programs through the CDC Overdose Data to Action (ODA) program. CDC announced an expansion of the ODA program this year with two new funding opportunities, one designed for states and one designed specifically for localities and territories. Both awards will support five-year cooperative agreements.
To analyze the samples, public health laboratories are using high-resolution mass spectrometry, which is more sensitive and more accurate. In Minnesota, laboratory scientists also analyzed benzodiazepine dropper bottles submitted by law enforcement. The results of six bottles showed multiple types of benzodiazepines but only two that were consistent across the six bottles, said Rosie Rushing, MS, research scientist at the Minnesota Department of Health Public Health Laboratory. The bottles also had traces of delta-9 THC (found in cannabis), methamphetamine and synthetic cannabinoids.
“So, depending on how these bottles were used to either transport or store previous material could impact the future components or drugs that were put into these dropper bottles, and people could be using them without even knowing what was in them,” Rushing said.
The dropper findings support the urine sample results, which often show multiple substances as well. In fact, Rushing said, in one of the more complex urine samples there were 23 unique substances.
One of the emerging drugs is xylazine, a non-opioid animal tranquilizer that can be fatal to humans. In April 2023, the Biden administration designated fentanyl associated with xylazine as an emerging threat. However, individuals may not know they are being exposed to xylazine; drug producers may be adding it to other drugs to enhance drug effects or to increase street value by increasing their weight, according to the CDC.
Hospital partnerships important
These biosurveillance systems rely on participation of hospital emergency department staff. Experts said this makes the development of the partnership between the hospital and public health laboratory critically important.
The South Carolina public health laboratory staff found it helpful to partner with the South Carolina Hospital Association and to get program buy-in directly from hospital CEOs, said Beth Bair, MS, chemistry division director at the public health laboratory of the South Carolina Department of Health and Environmental Control.
Through those efforts, 41 hospitals in 28 South Carolina counties agreed to participate. Over the past three years, 30 of the hospitals actually sent in samples, with samples coming from 12 hospitals a month on average. Recently, the laboratory received over 400 samples in one month for the first time; the average is 370 a month.
The laboratory initially tested for 21 compounds, mostly fentanyl analogs. Staff have added to that every year based on what drugs were emerging or suspected in the state. Now, they test for more than 40 compounds, which takes up a lot of time.
The speakers stressed that one of the critical components is what the laboratories do with all that data. South Carolina has created an online data dashboard that is expected to go public soon.
“We’ve worked really hard on finding meaningful ways to present this data because we really want this data to be impactful,” Bair said. “We want it to be useful for the people who are actually going out and targeting treatment and prevention efforts to address this epidemic.”
Melanie Padgett Powers is a freelance writer and editor specializing in health care and public health.