Lab Matters Spring 2020 - Page 7

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 PublicHealthLabs @APHL Spring 2020 LAB MATTERS 5