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Polysubstance Crisis Calls for All-Hands-on-Deck Response
Fentanyl is ubiquitous and deadly, as evidenced by the fact it’s associated with two-thirds of the nation’s overdose deaths in 2021. Today, more and more, it is found in combination with other drugs, making drug use more dangerous than ever.
The quantity of fentanyl seized by US Customs and Border Patrol has more than tripled since 2020 and is increasingly being found in illicit drug supplies and pills. Counterfeit pills increase the risk of unintentional overdoses because they can be difficult to distinguish from authentic pharmaceutical products. In November 2022, the US Drug Enforcement Administration (DEA) issued a public safety alert stating that 60% of fentanyl-laced fake prescription pills analyzed in 2022 contained a potentially lethal dose of fentanyl, up from 40% in 2021.
But fentanyl typically is not acting alone. The recent Millennium Health Signals Report, a focus on fentanyl, clearly demonstrates that the current substance use crisis is one of polysubstance use. In this analysis of over 4.5 million definitive urine drug test (UDT) results, over 83% of people testing positive for fentanyl also tested positive for one or more additional substances; about 30% were positive for one additional drug, over 43% were positive for 2-3 additional drugs, and nearly 10% were positive for 4 or more additional drugs. Given that these additional drugs, i.e., methamphetamine, cocaine, fentanyl analogues, prescription opioids, and others, are dangerous in their own right, it’s not surprising that the Centers for Disease Control and Prevention (CDC) data confirm that most overdose deaths involve multiple substances.
Polysubstance use complicates efforts to reverse overdose and treat opioid use disorder. Naloxone remains our most effective opioid overdose reversal agent, and methadone, buprenorphine, and naltrexone are effective medications for opioid use disorder. But all face challenges in those intentionally or unintentionally using multiple substances, especially non-opioid drugs like methamphetamine, and newer agents like xylazine. The tools and treatments available may not fully address the potent drug combinations behind today’s drug overdoses. National Institute on Drug Abuse Director Nora Volkow, MD, has made these challenges a priority—and the agency is working on fentanyl vaccines, drugs for stimulant use disorder, and other treatments.
Definitive urine drug testing (UDT) can also help, as it allows clinicians to obtain a clear picture of what a patient is using to better inform the development of the patient’s treatment plan. Many individuals may not even know they are using multiple drugs in tainted drug supplies,and there is no Clinical Laboratory Improvement Amendments-waived point-of-care test for fentanyl or many of the other emerging deadly drugs. Therefore, the need for definitive urine drug testing may be more warranted than ever, by providing the runway for clinicians to compassionately discuss appropriate risk-mitigation strategies with these patients, including harm-reduction approaches.
It is important that we engage all available resources in the fight against the current polysubstance use crisis, as we’re fighting a lethal enemy. Only together, and well-armed, can we save those suffering in its grip.
Angela Huskey, PharmD, CPE, is chief clinical officer for Millennium Health, a San Diego, California-based specialty laboratory.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Addiction Professional, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
References
Millennium Health. Millennium Health Signals Report, Vol. 5. Millennium Health. 2023.
National Institute on Drug Abuse. Nora’s Blog. National Institutes on Health.
