Synthetic Opioid Use Up Almost 800% Nationwide

Kelli Whitlock Burton

June 14, 2022

Synthetic opioid use increased by almost 800% over 7 years, new research shows

The results of a national urine drug test (UDT) study come as the US is reporting a record-high number of drug overdose deaths — more than 80% of which involved fentanyl or other synthetic opioids and prompting a push for better surveillance models.

Researchers found that UDTs can be used to accurately identify which drugs are circulating in a community, revealing in just a matter of days critically important drug use trends that current surveillance methods take a month or longer to report.

The faster turnaround could potentially allow clinicians and public health officials to be more proactive with targeted overdose prevention and harm-reduction strategies such as distribution of naloxone and fentanyl test strips.

Dr Steven Passik

"We're talking about trying to come up with an early warning system," study author Steven Passik, PhD, vice president for scientific affairs for Millennium Health, San Diego, California, told Medscape Medical News. "We're trying to find out if we can let people in the harm reduction and treatment space know about what might be coming weeks or a month or more in advance so that some interventions could be marshalled."

The study was published online June 3 in JAMA Network Open.

Call for Better Surveillance

More than 100,000 people in the US died of an unintended drug overdose in 2021, a record high and a 15% increase over 2020 figures, which also set a record.

Part of the federal government's plan to address the crisis includes strengthening epidemiologic efforts by better collection and mining of public health surveillance data.

Sources currently used to detect drug use trends include mortality data, poison control centers, emergency departments, electronic health records, and crime laboratories. But analysis of these sources can take weeks or more.

Dr Rebecca Jackson

"One of the real challenges in addressing and reducing overdose deaths has been the relative lack of accessible real-time data that can support agile responses to deployment of resources in a specific geographic region," study co-author Rebecca Jackson, MD, professor and associate dean for Clinical and Translational Research at Ohio State University in Columbus, told Medscape Medical News.

Ohio State researchers partnered with scientists at Millennium Health, one of the largest urine test labs in the US, on a cross-sectional study to find out if UDTs could be an accurate and speedier tool for drug surveillance.

They analyzed 500,000 unique urine samples from patients in substance use disorder (SUD) treatment facilities in all 50 states from 2013-2020, comparing levels of cocaine, heroin, methamphetamine, synthetic opioids, and other opioids found in the samples to levels of the same drugs from overdose mortality data at the national, state, and county level from the National Vital Statistics System.

On a national level, synthetic opioids and methamphetamine were highly correlated with overdose mortality data (Spearman ρ = 0.96 for both). When synthetic opioids were co-involved, methamphetamine (ρ = 0.98), heroin (ρ = 0.78), cocaine (ρ= 0.94), and other opioids (ρ = 0.83) were also highly correlated with overdose mortality data.

Similar correlations were found when examining state-level data from 24 states and at the county level upon analysis of 19 counties in Ohio.

A Changing Landscape

Researchers said the strong correlation between overdose deaths and UDT results for synthetic opioids and methamphetamine are likely explained by the drugs' availability and lethality.

Penn Whitley

"The most important thing that we found was just the strength of the correlation, which goes right to the heart of why we considered correlation to be so critical," lead author Penn Whitley, BA, senior director of bioinformatics for Millennium Health, told Medscape Medical News. "We needed to demonstrate that there was a strong correlation of just the UDT positivity rates with mortality — in this case, fatal drug overdose rates — as a steppingstone to build out tools that could utilize UDT as a real-time data source."

While the main goal of the study was to establish correlation between UDT results and national mortality data, the study also offers a view of a changing landscape in the opioid epidemic.

Overall, UDT positivity for total synthetic opioids increased from 2.1% in 2013 to 19.1% in 2020 (a 792.5% increase). Positivity rates for all included drug categories increased when synthetic opioids were present.

However, in the absence of synthetic opioids, UDT positivity decreased for almost all drug categories from 2013 to 2020 (7.7% to 4.7% for cocaine; 3.9% to 1.6% for heroin; 20.5% to 6.9% for other opioids).

Only methamphetamine positivity increased with or without involvement of synthetic opioids. With synthetic opioids, meth positivity rose from 0.1% in 2013 to 7.9% in 2020. Without them, meth positivity rates still rose, from 2.1% in 2013 to 13.1% in 2020.

The findings track with an earlier study showing methamphetamine-involved overdose deaths rose sharply between 2011 and 2018.

"The data from this manuscript support that the opioid epidemic is transitioning from an opioid epidemic to a polysubstance epidemic where illicit synthetic opioids, largely fentanyl, in combination with other substances are now responsible for upwards of 80% of OD deaths," Jackson said.

In an accompanying editorial Jeffrey Brent, MD, PhD, clinical professor in internal medicine at the University of Colorado School of Medicine and Stephanie T. Weiss, MD, PhD, staff clinician in the Translational Addiction Medicine Branch at the National Institute on Drug Abuse note that as new agents emerge, different harm reduction strategies will be needed, adding that having a real-time tool to identify the trends will be key to preventing deaths.

"Surveillance systems are an integral component of reducing morbidity and mortality associated with illicit drug use. On local, regional, and national levels, information of this type is needed to most efficiently allocate limited resources to maximize benefit and save lives," Brent and Weiss write.

The study was funded by Millennium Health and the National Center for Advancing Translational Sciences. Full disclosures are included in the original articles, but no sources reported conflicts related to the study.

JAMA Netw Open. Published online June 3, 2022. Full text, Editorial

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