Lab Matters Spring 2020 | Page 20

FROM THE BENCH Connecticut Improves Opioid Surveillance by Expanding Testing By Susan Isch, division director, Chemical Sciences, Connecticut Department of Public Health Katherine A. Kelley Laboratory The Connecticut Department of Public Health Laboratory (CT PHL) has been working with the US Centers for Disease Control and Prevention (CDC) and other public health laboratories throughout the country for the past two years to investigate, develop and expand testing in support of the opioid crisis. In the absence of approved and/or FDA cleared methodologies, it was necessary to establish and validate a robust protocol that would provide data and support to our partners. Early identification of emerging drugs in the Connecticut drug supply and providing data for the analysis of trends in drug prevalence in impacted populations are paramount in building a successful program. Chemists Damien Drobinski and Hien Diep analyze blood and urine for the presence of opioids and other illicit drugs utilizing a Sciex 5500+ Triple Quadrupole Mass Spectrometer. Photo: Mark Harkins In response to the significant rise in overdoses and deaths from prescription drug opioids and opioid overdoses in the state, CT PHL, in partnership with the CT Department of Public Health (DPH) Office of Injury and Violence Prevention, has initiated a pilot biosurveillance project. Starting the Conversation Initial validation efforts were focused on identifying specific drugs in blood using the Liquid Chromatography Tandem Mass Spectrometer utilized for our Laboratory Response Network for Chemical Threats (LRN-C) preparedness activities. The platform was set up to detect 25 drugs of concern in blood and had no capability for the identification of unknown or non-targeted compounds. Data generated was to be used for surveillance purposes only. This method required the samples be prepared using solid phase extraction (SPE) and was relatively labor intensive. In April 2019, utilizing funding from the CDC Cooperative Agreement for Emergency Response: Public Health Opioid Crisis Response procured by the Connecticut Department of Public Health (DPH) Office of Injury and Violence Prevention, CT PHL purchased a Sciex Quadrupole Time-of-Flight Mass Spectrometer (TOF-MS). This enabled staff to develop a robust and effective method on an instrument dedicated entirely to opioid testing. The Next Step After meeting with local emergency room personnel and other public health professionals, it was determined that urine would be easier to procure and beneficial in the identification of non-targeted/unknown compounds. Prior to specimen collection, CT PHL validated a laboratory-developed method for the identification of 35 selected prescription, metabolites and illicit drugs in urine. CT PHL began receiving specimens as part of the pilot study to test for opioids and other drugs of abuse on January 2. This testing includes a comprehensive list of 35 targeted opiates and opioids, including fentanyl, in addition to cocaine, cannabinoids, methadone and some commonly prescribed prescription drugs (e.g., benzodiazepines) of abuse. This new method utilized a dilute-and-shoot preparation eliminating the need for SPE. However, the method does require an enzyme hydrolysis step which is necessary to break down potentially interfering glucuronidated metabolites. A more detailed validation procedure was conducted for this platform to allow testing for direct patient care in addition to providing surveillance data. This newly validated method also has considerable potential for identifying emerging, novel and/or not yet fully characterized drugs of concern. CT PHL plans to expand testing to include blood and develop a more comprehensive list of targeted drugs reported utilizing the traceable opioid materials (TOM) Kits facilitated by CDC’s LRN-C. These reference materials provide more than 150 opioid standards, including more than 100 fentanyl analogues and are free of charge to public health and other US-based laboratories. Procuring standards and reference materials has been one of the challenges in developing methods, and the availability of these kits will be instrumental in addressing the growing number of possible illicit drugs and fentanyl analogs. Building capacity and capability on multiple platforms will only enhance future testing and provide more information to health care providers and public health professionals. In the near future, CT PHL and the Office of Injury and Violence Prevention hope to expand this limited pilot study and provide testing for more health care facilities throughout Connecticut. n 18 LAB MATTERS Spring 2020 PublicHealthLabs @APHL