It was in the 1980s that physicians first explored the use of narcotics/opioids for the treatment of pain associated with non-terminal illnesses, including chronic and “mild to moderate” pain. In 2012, opioid prescriptions for outpatients were common, and some states had as many as 143 opioid prescriptions for every 100 people. Today, more than 6 out of 10 drug overdoses involve an opioid. The CDC states that 91 Americans die every day from an opioid overdose. This situation has been called “the opioid crisis” and the “opioid epidemic.” It is a public health emergency.
The landscape is characterized by new trends in both the drugs involved and drug user demographics. Current data indicates that prescription opioids are not the main problem. In fact, from 2015 to 2016, prescription opioid overdoses decreased from 17,539 to 16,800. The decrease in prescription overdose may indicate that efforts to reduce over-prescribing may be working. Or, drug users may be abandoning high cost prescription opioids for illicit drugs.
While prescription opioid overdoses have been decreasing, the incidence of heroin overdose has tripled. The incidence of fentanyl overdose has increased 196%, and the incidence of overdose due to non-methadone synthetic opioids has increased by 72%. Fentanyl is available both legally by prescription, and illegally from illicit sources. It is frequently combined with or sold as other drugs such as heroin, cocaine, and alprazolam. Fentanyl is 100 times more potent than morphine, and 50-100 times more potent than heroin. Even more dangerous are the fentanyl analogs, carfetanil(yl) sufentanil, acry and acetyl fentanyl, and furanyl fentanyl, to name a few. Sufentanil is 1000 times more potent than morphine, and carfentanil – sometimes called elephant tranquilizer – is 10,000 times more potent than morphine. Opioid abuse now spans nearly all demographics. In fact, NCHS Data Brief in 2017 disclosed that the age group with the most rapid rise in opioid overdose is adults ages 55-64 years. Some of the greatest increases in heroin related deaths have been among women, privately insured, and those with higher incomes – demographic groups that historically have had low rates of heroin abuse.
Laboratory professionals can help fight this crisis by providing relevant testing, and billing for the testing appropriately. Most hospitals are ill equipped to test for the synthetic opioid analogs. For many hospitals, the drug testing capabilities consists of an immunoassay based urine drug screen. These screens can detect many of the “classic” drugs of abuse like morphine (heroin), cocaine, amphetamines, PCP, and benzodiazepines. These screens do not differentiate individual drugs in a drug class, and they can’t detect fentanyl or fentanyl analogs, even with high degrees of cross-reactivity. As our Vice President of Laboratories expressed it to me, “our emergency rooms are full of overdose patients with negative drug screens.” Unfortunately, the culprit drug is not identified until a medical examiner orders forensic toxicology. More comprehensive and confirmatory testing like mass-spectrometry based testing provides more accurate information.
Mass spectrometers are not cheap, and many laboratory professionals are challenged with obtaining funding for them. The challenge is not lessened by the bad taste left in Medicaid’s mouth by code-stacking when billing for drug testing in the pain management patient population. This practice was, unfortunately, exploited by some physicians running office-based drug testing labs. Large multi-drug LCMS based panels were used in routine monitoring of pain management testing but instead of billing per panel, the test was billed by drug (analyte) in the panel. This practice led to CMS scrutinizing the use of mass spec testing alone and recommending the limited immunoassays. Laboratory professionals have the responsibility to advocate for the appropriate use of this powerful testing, and fortunately we are doing that – the Academy of AACC in collaboration with American Academy of Pain Medicine just released guidelines for the use of laboratory tests in monitoring pain management patients. We need to be trusted to do the right test, at the right time, for the right patient.
Forensic pathologists and toxicologists also face big challenges related to the opioid crisis. Forensic toxicologists are challenged to keep up analytically with synthetic and novel drugs entering the market while dealing with the pressure of limited budgets and client frustration with long turnaround times. Forensic pathologists are challenged by the sheer volume of overdose-related deaths. The National Academy of Medical Examiners (NAME) limits the number of autopsies to 325/pathologist/year. There are currently only around 500 board certified forensic pathologists in the US and the future doesn’t look great – only 3% of graduating medical students choose to enter pathology and only 7% of those will enter forensic pathology.
–Sarah Riley, PhD, DABCC, is an Assistant Professor of Pediatrics and Pathology and Immunology at Washington University in St. Louis School of Medicine. She is passionate about bringing the lab out of the basement and into the forefront of global health.