To Treat Overdose Patients Now, Hospitals Must Test for More Kinds of Drugs

Most hospitals typically test people for drugs that drove overdoses 15 to 20 years ago. We need a national system for expanded testing to help patients get the treatment they need today

A gloved hand holding urine testing strips with brightly colored squares

Hospitals link people to treatment in their time of greatest need. That includes drug overdoses, which now kill more than 100,000 people in the U.S. every year.

However, the standard hospital urine drug tests often do not detect fentanyl, which today is the leading cause of fatal overdoses, or other “synthetic” substances. Expanded urinalyses that could detect them can be time-consuming and cost-prohibitive.

But if hospital drug screens fail to detect these drugs, people will likely not be fully diagnosed. Without an opioid-positive urine test, they may not be accepted into an opioid treatment program. Or their treatment may not be covered by insurance. Without clear identification of all the substances involved in their visit, patients may be less likely to remain in treatment, even if they are accepted.

Most hospitals, however, are still testing for the drugs driving previous drug crises, such as heroin and cocaine, and have little concrete data about the drugs to which their patients are now being exposed. In fact, in the second quarter of 2022, only 5 percent of hospitals included fentanyl in their standard drug screen. One year later, this percentage had only increased to approximately 14 percent, while testing for opiates (natural opioids like heroin) remained at about 50 percent. That’s a decade into an overdose crisis driven by fentanyl that has claimed more than a million American lives.

The overdose crisis is in constant flux, and users are often unaware of the drugs to which they have been exposed. Changes in drug composition can alter the symptoms seen in emergency departments and can change patients’ treatment needs. Drug use and overdose are often very individualized. Therefore, America’s hospitals must have access to expanded urinalyses to understand all the drugs to which their patients have been exposed.

The University of Maryland’s Center for Substance Use, Addiction, and Health Research (CESAR), where we work, has been piloting a new approach, the Emergency Department Drug Surveillance (EDDS) system, with federal and state funding. We currently offer 50 hospitals across the U.S. the opportunity to submit anonymous urine specimens at no cost to the hospitals for expanded urinalyses. We look for many more substances than local hospitals can routinely test for; we use the results to identify patient exposure to specific drugs and to track new patterns of drug use that may be emerging in the population.

Our program could serve as the first phase of a national system to inform hospitals about the drugs to which their patients have been exposed, as well as the role of multiple drugs, or polysubstance use, in overdoses. Hospitals have already used our findings to update their urine drug test panels. For example, EDDS has documented patient exposure to drugs such as fentanyl and xylazine across the U.S. Two hospitals in Baltimore added fentanyl to their standard drug screens in 2019 after participating in EDDS and have since found fentanyl to be the most frequently detected drug in 70 percent or more of specimens tested each year.

In addition, California and Maryland have passed legislation requiring all of their hospitals to include fentanyl in urine drug screens to diagnose patient drug exposure. This is an important step, but as we stressed earlier, illicit drugs are constantly changing. EDDS was able, for example, to detect the animal tranquilizer xylazine in urine specimens from hospitals in Florida, Georgia, South Carolina, Tennessee and Maryland. The drug most likely to be found in addition to xylazine was fentanyl, detected in 85 percent of the xylazine-positive specimens. Xylazine can worsen the life-threatening effects of opioids by causing dangerously slowed breathing and low blood pressure.

EDDS researchers believe that it is essential to launch a true nationwide system to provide hospitals with expanded urine testing at regular intervals and support physicians interested in conducting more in-depth research. We now have a proven method for doing this. More states should follow the lead taken by California and Maryland and require every hospital to include fentanyl in diagnostic drug screens. New drugs such as xylazine should also be added to urine drug screens in states where they are an identified part of the illicit drug market.

Most specimens positive for drugs such as fentanyl and xylazine are also positive for at least one other drug on standard hospital urine screens. While these results may provide adequate information for physicians to treat the immediate medical condition, they don’t ensure that hospitals can link patients to the substance use treatment they need to start a successful recovery. The EDDS system has laid the foundation for a nationwide system, but more work still needs to be done.

With nearly 300 Americans a day dying of overdoses and a nonfatal opioid overdose occurring approximately every three minutes, it is imperative that a system for collaborating with hospitals to conduct expanded urinalyses be fully funded by the federal government. A centralized system like this can regularly collect drug use information that can then be disseminated in a practical and useful manner, and support work with local physicians to conduct more in-depth research, as well as inform health policy. Other tools, such as urine test strips for xylazine and fentanyl, could also support a cost-effective approach to expanding hospital testing abilities and monitoring drug use trends.

Without these kinds of resources, we will forever play catch-up, striving to identify emerging drugs and keep up with the illicit drug market. And patients will continue to miss opportunities for treatment and recovery. 

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.

The views presented here are those of the authors and do not necessarily represent the official views of the CESAR funding agencies, any other federal or state of Maryland agencies, or the participating hospitals.

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