Even as fentanyl overdoses surge, few hospitals test for it

As more people are suffering overdoses due to fentanyl, hospitals are being pressed to do more to combat the threat ravaging communities across the country.

Federal authorities and health officials say fentanyl is driving the increase in overdose deaths nationally. More than 71,000 people nationwide died due to synthetic opioids in the United States in 2021, and almost all involved fentanyl, according to the U.S. Centers for Disease Control and Prevention. Deaths involving fentanyl and other synthetic opioids accounted for two-thirds of the nation’s fatal overdoses last year.

Philadelphia witnessed a record high in overdose deaths in 2021, and the vast majority are tied to fentanyl, The Philadelphia Inquirer reported this week. Minnesota reported a record number of overdose deaths last year, CBS reports. Massachusetts also suffered more overdose deaths in 2021 than in any other year, WBUR reports.

Still, hospitals are rarely testing for fentanyl and overdoses.

Only 5% of patients in hospital emergency departments for overdoses are tested for fentanyl, according to a study by researchers from Epic, the electronic health records giant, and the University of Maryland Center for Substance Abuse Research.

When patients are tested for fentanyl, more than 40% test positive, the research found.

Hospitals need to be testing regularly for fentanyl, says Dave Little, Epic's director of clinical informatics and a co-author of the study.

“It's really a question of awareness,” Little told Chief Healthcare Executive in an interview. “Fentanyl is a huge public health problem in this day and age.” (See excerpts of our conversation in this video. The story continues below the video.)

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When Epic and the University of Maryland began the study, Little said he expected that few hospitals would be testing for fentanyl. The researchers examined more than 315,000 emergency department overdose visits that occurred between 2017 and August 2022. He said there was little difference in testing in urban or rural hospitals.

“It's lower than we anticipated,” Little said. “It has been increasing slowly over time as awareness grows. But I can't say this was altogether unexpected.”

The high positivity rate among those who were tested for fentanyl was much more alarming.

When asked if he was surprised at so many testing positive, Little said, “I would even go so far as to say shocked.”

Fentanyl tests are not part of the standard toxicology screening hospitals typically run when dealing with a patient who has had an overdose. Hospitals typically test for what is often called the “federal five”: opiates, amphetamines, cocaine, THC and PCP. Because fentanyl is a synthetic opioid, doctors would need to put in a separate order for a fentanyl test, Little said.

“In a vast majority of cases, the fentanyl doesn't happen unless either the physicians specifically asks for the fentanyl to be tested or an organization has taken steps to incorporate fentanyl testing into their standard protocols,” he said.

More testing for fentanyl is happening, albeit slowly.

California recently became the first state in the country to pass a law requiring hospitals to test for fentanyl in all patients who have overdosed. California Gov. Gavin Newsom signed the legislation in August.

It’s critical to do more testing for fentanyl, Little said.

“For the well being of the entire public, we need to be doing fentanyl screenings routinely on patients who come into the emergency department,” he said. “It's also a question of awareness on behalf of the patients. A lot of the times when patients are exposed to fentanyl, they don't know that they were exposed to fentanyl. They didn't necessarily go out on the street looking for fentanyl.”

Many who suffer overdoses are unknowingly exposed to fentanyl when it is mixed with other drugs, health experts say. Some dealers are selling fake prescription pills that contain fentanyl, according to the Drug Enforcement Administration.

“A lot of the fentanyl exposures are unknown,” Little said. “And making that aware to the patient, you know, will hopefully change the practices of the patient.”

“Physicians need to be aware, the patients need to be aware of the public health system as a whole needs to be aware,” he said. “So I think awareness is the key to all of this in terms of why we need to be doing this testing.”

Increased fentanyl testing would also help law enforcement, and state and local health agencies, identify outbreaks or mass overdose events, Little said.

Hospital and health system leaders are going to need to make the issue a priority for fentanyl testing to become more widespread. Little said it’s unrealistic for emergency department physicians to lead the charge, because they are focused on treating a high volume of patients as quickly as possible.

“This is a huge public health issue. And the attention that needs to get needs to come from leadership,” Little said.

The most efficient way of doing more testing would be to incorporate the fentanyl test agent in the standard toxicology screen, Little said. He conceded that would require some recalibration and changes in the laboratory, but he said that would be the best solution in the long term. Another option would be to set up a fentanyl test order as part of the screening battery in the hospital’s electronic health record system.

Whatever method is chosen, Little said it’s clear hospitals should be testing more regularly for fentanyl.

In the spring, the DEA sent out a warning about a nationwide spike in mass overdose events related to fentanyl. Mass overdose events are described as three or more overdoses in the same location at about the same time. Mass overdose events were reported in cities such as Austin, Texas, Cortez, Colorado, Omaha, Nebraska, and St. Louis, Missouri.

“Fentanyl is killing Americans at an unprecedented rate,” DEA Administrator Anne Milgram said in April.

With fentanyl overdoses taking such a toll, Little said he feels driven to push for more testing in the health system.

“The healthcare system needs to be aware at all levels,” Little said.