FEATURE
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.
Building Capacity
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
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Spring 2020 LAB MATTERS 5