by Melanie Padgett Powers, writer
The opioid epidemic remains a public health emergency in the United States, with more than 67,000 drug overdose deaths in 2018. Opioids—mostly synthetic versions—were involved in 70% of those deaths. In fact, from 1999 to 2018, almost 450,000 people died from an overdose involving an opioid, according to the US Centers for Disease Control and Prevention (CDC).
Forensic and crime laboratories provide data on fatal opioid overdoses, but a sole focus on fatalities omits valuable data that could be used to protect communities. This data includes the drugs used in a specific region, those drugs most likely to cause overdoses and which combinations of drugs cause overdoses more frequently.
Amy Miles, director of forensic toxicology at the Wisconsin State Laboratory of Hygiene, said public health has done a good job of characterizing fatal overdoses. “But at that point it’s almost too late [for the community], and usually they’ve switched to something else by the time we’ve figured out what’s trending.”
Public health laboratories, in concert with other stakeholders, play a vital role in battling this crisis by contributing their analytical capabilities and knowledge of public health surveillance systems. To further develop this role, APHL convened the Opioids Biosurveillance Task Force in early 2019 (see sidebar). With some planning, public health laboratories can test specimens from non-fatal overdoses, capitalizing on current partnerships with hospitals, which treat most of these cases. Laboratories may need to invest in more equipment, hire staff and form new partnerships, but the benefits of strengthening public health interventions to reduce drug use will outweigh the costs.
Opioids biosurveillance is already underway in the Minnesota Department of Health’s Response Network for Chemical Threats (LRN-C) laboratory. Building upon capabilities developed as part of the LRN-C and using its surge capacity, the Minnesota laboratory is able to leverage resources to support a biosurveillance program for drugs of abuse, according to Jason Peterson, MS, the LRN-C laboratory’s chemical threat preparedness coordinator.
In 2017, Minnesota began to see an increase in overdoses from synthetic cannabinoids and synthetic cathinones, known as “k2/spice drugs” or “bath salts.” One of the health department’s medical directors asked the LRN-C laboratory if it would accept clinical samples to detect drugs causing these non-fatal overdoses. At the time, the laboratory did not have the reference materials to identify the drugs. Instead, it gathered samples and sent them to a private laboratory for testing. This experience demonstrated the need—and potential—of in-house testing and spurred the laboratory to begin building its internal capacity.
That same year, LRN-C personnel began working on drug detection. Led by a top analyst, the Minnesota Drug Overdose and Substance Use Pilot Surveillance Activity (MNDOSA) project was initiated to track drug overdose morbidity in the state. Some employee requirements and duties were changed and the laboratory had to allocate and optimize an instrument for drug testing, removing it from other projects.
But the addition of biosurveillance to LRN-C team responsibilities has not changed the staff’s work dramatically. The analysts already knew how to test for compounds in clinical specimens and they can use the same instrumentation. Although it takes time to optimize the instruments to detect various drug analytes, the knowledge transfers. According to Peterson, “Instead of looking for LRN chemical threat agents, we’re looking for commonly misused drugs.”
As Peterson explained, thousands of people are affected by overdoses every day. Laboratory staff knew they could provide useful information about the drugs harming communities in their state. “The LRN is designed to respond to chemical emergencies, and overdoses are clearly a national chemical emergency,” he said.
Testing for opioids in public health laboratories became more robust after CDC partnered with two companies to develop traceable opioid material (TOM) kits, said Jennifer Liebreich, MPH, APHL’s manager of environmental health. Reference materials included in the kits contain the latest opioid compounds and fentanyl analogs in alignment with emerging threat reports from the US Drug Enforcement Administration (DEA). Kits can be ordered, free of charge, by any US laboratory. Having consistent standards throughout the network provides confidence in the accuracy of identifying these novel compounds.
In Rhode Island, all hospitals are actively contributing to non-fatal overdose surveillance in the state. The LRN-C laboratory, with the help of funding received through the CDC Cooperative Agreement for Emergency Response: Public Health Opioid Crisis Response Grant, implemented a confirmatory opioids panel in early 2019. By June 2019, the laboratory had asked all hospitals to send urine samples from overdose patients. The laboratory has since added a fentanyl panel using TOM kits.
“The statewide surveillance system implemented in Rhode Island is still unique in its scope,” said Ewa King, PhD, director of Rhode Island’s state health laboratories. “The Rhode Island Department of Health exercised its regulatory authority to mandate the submission of biological specimens (urine samples) to the state laboratory, but it was the relationships with individual hospital laboratories that made it work.”
All LRN-C laboratories can also get involved in opioid biosurveillance, even if they don’t conduct testing in-house, Liebreich said. For example, laboratory outreach coordinators can alert hospitals to drugs recently identified in overdose patients and discuss procedures for sample submission to the laboratory.
Beyond LRN-C Laboratories
LRN-C laboratories are not the only public health laboratories involved in the opioid crisis. The forensic laboratory at the Wisconsin State Laboratory of Hygiene is one of a handful of US forensic laboratories housed in a public health laboratory, rather than a law enforcement agency. The laboratory recently began to implement an opioid biosurveillance program, analyzing specimens from impaired drivers while also receiving reports of fatal overdoses from medical examiners.
“We consider ourselves the bookend,” Miles said. “I think the US has focused on one side of it or the other. It’s rare for us to have that continuous examination of opioids—or any other drug of abuse, for that matter.” Now, the US is playing “catch-up” to improve its knowledge of overdoses and their causes, she said.
Because forensic laboratories analyze specimens from impaired drivers, results can point out emerging drug trends in a particular community. In Wisconsin, positive tests for PCP have highlighted a new drug threat in the community. “We know if we’re seeing it in our drivers, it’s probably been in the population before we actually saw it.”
The Wisconsin laboratory had also been exploring Neonatal Abstinence Syndrome (NAS) testing (see sidebar), but the project was put on hold due to the coronavirus pandemic. “We thought it would be a natural fit to have the forensic section test the blood spots from newborns—not as a way to formulate any charges, but to get a better understanding of the exposure of neonates to drugs of abuse,” Miles said.
Challenges, but Progress
One of the major challenges for opioid biosurveillance is also a common one: funding. But federal grants are becoming available. Minnesota was one of 14 LRN-C laboratories participating in a three-year Overdose Data to Action (OD2A) cooperative agreement from CDC’s National Center for Injury Prevention and Control (NCIPC) in collaboration with their state health departments. OD2A builds prevention and surveillance capacity targeting the drug overdose epidemic, according to Grant Baldwin, PhD, MPH, director of the NCIPC’s Division of Overdose Prevention. The funding supports innovative surveillance strategies. Other laboratories, including Minnesota, employed a federal grant to purchase new equipment through the CDC Public Health Crisis Surge Support Program.
In Wisconsin, the laboratory strengthened its partnership with the state’s Division of Public Health, which provided the funding for its opioid biosurveillance program.
Often, a state’s public health and forensic laboratories don’t know that the other exists. “They don’t realize that we have the same instrumentation; a lot of times public health laboratories could take some of the burden off forensic laboratories and vice versa,” Miles said. “We didn’t have all the right people at the table at first, and now we’re starting to realize who we need there. It’s getting better, but we still have a long way to go.”
Another challenge for biosurveillance programs is building relationships with hospitals. Public health laboratories rely on hospital emergency departments to supply them with the samples needed to complete testing. This is where reinforcing partnerships is paramount. Laboratories need to emphasize that patient privacy and confidentiality will be upheld. Additionally, hospitals need to understand the value that opioid biosurveillance programs bring to public health and make arrangements to potentially increase hospital staff responsibilities.
In Minnesota, epidemiologists from the state health department’s health promotion and chronic disease group are the liaisons. They communicate directly with medical toxicologists at local hospitals, which have established processes for submitting routine specimens through their newborn screening programs. They can use these same processes to ship collected samples from non-fatal overdoses to public health laboratories for drug testing.
But new for hospitals is the need to develop a process for collecting specimens from non-fatal overdose cases and train emergency room physicians and nurses on when and how to collect them. Hospitals also need to add a code to their emergency medical record system that marks the specimen for collection and shipment. Without it, clinicians will need to make a note in the chart and the hospital will have to create a system for gathering that information.
Improving Public Health Interventions
Although building an opioid surveillance system may require several steps, the resulting data analysis can inform public health efforts. For example, messaging can alert drug users about more dangerous drugs entering the area.
“By knowing the potential potency of the drug they are choosing to consume, the hope is that users will use less or avoid the substance altogether. Then they won’t be at as much of a risk for an overdose,” Peterson said. “If you don’t know what you’re fighting against, if you don’t know what drugs are in your community, you have no idea what messaging you’re supposed to give people outside of ‘don’t do drugs.’”
However, public health laboratories are in a unique position to fill an unmet need of conducting testing in non-fatal overdose cases. “This can help public health practitioners and law enforcement target evidence-based interventions to save lives,” Baldwin said. In addition, public health laboratories can work to develop standardized testing algorithms and methods to produce results that are comparable across the country.
The opioid biosurveillance programs have already generated useful community-specific data. In Minnesota, testing confirmed that methamphetamine was more widespread than heroin and fentanyl. Tests also showed that some people had more than 20 different drug analytes in their body, showing extensive poly-substance use.
To continue to learn more about newly surfacing drugs, Minnesota has regular conference calls with partners such as the US Customs and Border Protection and areas deemed High Intensity Drug Trafficking Areas, or HIDTAs. These calls alert the laboratory to newer street drugs such as kratom, which is legal in many states but has not yet been scheduled by the DEA.
“People believe there are opioid-like medicinal uses for it and that it’s less dangerous than traditional opiates,” Peterson said. “Initially, we didn’t have kratom in our toxicology panel. That was one of those instances where we got information, expanded our testing capabilities and then went back to suspected exposures and were able to detect it.”
In Rhode Island, King pointed to several important questions: What drug combinations are responsible for fatal overdoses? Do non-fatal overdoses differ in some way from fatal overdoses? Are fentanyl analogs still a problem? Because both the LRN-C and forensic toxicology laboratories are part of the Rhode Island State Health Laboratories, data can be compared relatively easily.
In the Phoenix, Arizona area, epidemiologist Kate Goodin, MS, MPH, used drug testing analysis to work directly with the community. Her department worked with the DEA to learn about drug use activity in various communities.
She then developed heat maps showing increased density of fatal overdoses to educate local leaders. “A lot of that was a call to action,” she said. “It showed it wasn’t just an urban core issue, which is some of the stigma.”
(Goodin was epidemiology and data services program manager at the Maricopa County Department of Public Health in Arizona last year. She is now director of surveillance systems and informatics at the Tennessee Department of Health.)
Reliable partners can include community organizations with a stake in the opioid epidemic—such as those that focus on criminal justice, homelessness and mental health. The harm reduction community is also actively engaged in epidemic response efforts through provision of needle exchange and safe injection site services. For example, Maricopa County has an intervention program called MOSAIC that provides incarcerated men and women intensive life-skills training. The program focuses on people who have histories of substance abuse. This partnership led to a new program in which Goodin’s department tracked volunteers who had recently been released from jail in order to collect data related to drug use.
According to Goodin, because they’re not toxicologists, epidemiologists have a learning curve when interpreting the data. But that’s where solid partnerships with the public health laboratory come in.
“You need them to understand how you determine what someone is ingesting based on laboratory results,” Goodin said. “That’s not always a one-to-one correlation. There’s a lot of human biology involved.”
Goodin hopes the APHL task force’s Model Biosurveillance Strategy resource provides an easy introduction into the topic for epidemiologists. “It can be intimidating to learn a new area,” she said. “It’s hard when you don’t even know the right questions to ask.”
Public health laboratories can fill a gap in public health surveillance for drug misuse and overdoses. Although the extent of the opioid crisis varies from state to state, they have the knowledge and instrumentation for effective overdose surveillance. Said King, “These programs provide factual, laboratory-based characterization of the non-fatal overdoses that will help devise more effective public health approaches to prevent irreversible, fatal overdoses.”