FEATURE
APHL Helps Close the Gaps
in Information
For every fatal overdose there are many
nonfatal overdoses. Without laboratory
data on those who leave the emergency
room alive, the US is fighting the
rapidly evolving opioid epidemic with
incomplete information.
APHL’s Opioid Biosurveillance Task
Force was created to close this gap. The
task force—an interdisciplinary team of
epidemiologists, national health officials
and scientists from commercial, forensic
and public health laboratories—aims to
help states institute testing programs
for biological specimens (primarily
urine samples) taken from individuals
who present at hospital emergency
departments with symptoms of opioid
overdoses.
The primary focus of the Task Force
is to provide guidance to jurisdictions
developing model surveillance
systems for use in tracking non-fatal
opioid overdoses at the state level. To
accomplish this, it has been hard at
work compiling a comprehensive Model
Biosurveillance Strategy resource, which
will include:
• Recommended testing platforms,
generally employing tandem mass
spectrometry
• Calibration and quality control
standards, including those available
free-of-charge through CDC
• Safety procedures for working
with drugs, especially fentanyl and
analogs.
• Staffing requirements
• Guidance on ascertaining legal
authority for access to overdose
patient specimens.
Opioid biosurveillance is also used in
assessing neonatal exposure to opioids
in utero through laboratory testing.
This testing may help identify cases
of Neonatal Abstinence Syndrome
(NAS), a constellation of signs and
symptoms of drug withdrawal. APHL
task force members collaborated with
the Council of State and Territorial
Epidemiologists (CSTE) to develop the
NAS case definition, which outlines
the criteria needed for surveillance of
this syndrome. During the coming year,
the Task Force plans to explore issues
associated with NAS.
With input from Task Force members,
APHL created a toolkit to help
laboratories gain US Drug Enforcement
Administration registration, sponsored
a webinar on the safe handling of
fentanyls in the laboratory and helped
jumpstart the development of opioid
surveillance data systems for public
health laboratories.
To assist laboratories in developing
opioid biosurveillance programs,
APHL also offers travel scholarships to
vendor trainings and national biannual
LRN-C Technical Meetings, where staff
can receive training (Due to travel
restrictions associated with the ongoing
COVID-19 pandemic, these meetings and
trainings have been postponed).
— Gynene Sullivan
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.
8 LAB MATTERS Spring 2020
PublicHealthLabs
@APHL APHL.org