26 - The Crisis Within the Crisis: Fentanyl Abuse and COVID-19

¹Rutgers NJ Medical School, Newark, NJ, USA. ²Quest Diagnostics, Secaucus, NJ, USA

Purpose
More than 750,000 people in the U.S. have died from a drug overdose since 1999, with nearly 400,000 deaths involving prescribed or illicit opioids. The 12-month rolling count of provisional overdose deaths associated with non-methadone synthetic opioids (likely fentanyl) has increased every month since January 2015 (5,766) through December 2019 (36,509). Although overall overdose deaths began to plateau or even decrease in recent years, the COVID-19 pandemic appears to be reversing these trends. To help prevent the spread of COVID-19, there was widespread adoption of virtual telemedicine visits and recommendations to postpone preventive medical services during stay-in-place orders. During that time, overdose-related deaths progressively increased, especially related to illicit synthetic opioids and heroin: nationally, suspected overdose submissions to the Overdose Mapping Application Program (ODMAP) in 2020 rose by 18% in March, 29% in April, and 42% in May, based on a 30-day rolling mean comparison to these months in 2019. Tracking national laboratory drug monitoring data can help yield early signals to our country’s re-emerging drug abuse problem. To better understand how the drug epidemic is interacting with the COVID-19 pandemic, we investigated changes in the results of prescription drug monitoring fentanyl tests after large-scale implementation of stay-at-home measures in the United States during the COVID-19 pandemic.
Methods
We analyzed changes in prescription urine drug monitoring testing patterns and results at a national reference clinical laboratory, comparing data for fentanyl positivity obtained before and during the pandemic. De-identified results from all medMATCH specimens with clinician-provided prescribed drug information performed from January 1, 2019 through May 16, 2020 were selected for potential inclusion. medMATCH reports indicated whether the prescribed drug(s) specified by the ordering provider, or other drugs, were detected in a specimen. The pre-pandemic “baseline” time period included specimens tested January 1, 2019, through March 14, 2020. The “during COVID-19” time period included specimens tested March 15 to May 16, 2020; the week starting March 15 was the first full week after a national emergency was declared on March 13.
Positivity for fentanyl was defined as the presence of a positive result for any fentanyl product not listed as prescribed by the ordering clinician. Analysis of all UDT results included either presumptive immunoassay screening tests, with confirmation of positive results by quantitative definitive mass spectrometry, or tests performed directly by quantitative definitive mass spectrometry. Quantitative confirmation analysis was performed to rule out false-positive presumptive screening results.
Results
Clinical drug monitoring declined rapidly during stay-at-home orders, starting the week beginning March 15, 2020. There were 310,709 specimens in this study. The weekly clinical drug monitoring test volume fell approximately 71% from the mean during the baseline period to the trough (the week starting April 5), and then rose in subsequent weeks. Test volume in the final week of the study had doubled from the trough but was still 42% below the mean baseline weekly test volume.
During COVID-19, positivity for non-prescribed fentanyl increased (by 35%; P<0.01) compared to the baseline period. Significant increases in non-prescribed fentanyl positivity were demonstrated for males, females, and all age groups 25 years and above. The increase in non-prescribed fentanyl positivity during COVID-19 remained significant in a multivariable model controlling for various independent risk factors (AOR 1.55, 95% CI 1.43-1.67). Specimens from substance use disorder (SUD) facilities (adjusted odds ratio [AOR] 4.90, 95% CI 4.55-5.27) and medication assisted treatment (MAT) patients (AOR 4.33, 95% CI 4.08-4.59) had the strongest associations with non-prescribed fentanyl positivity. The combination of non-prescribed fentanyl with other drugs also increased during the pandemic. Specifically, positivity for non-prescribed fentanyl increased by 89% among patients positive for amphetamines (P<0.01); 48% for benzodiazepines (P<0.01); 34% for cocaine (P<0.01); 39% for opiates (P<0.01); and 4% for heroin.
Conclusions
Our findings indicate that not only has drug testing decreased since the start of the pandemic, non-prescribed positivity for fentanyl, one of the drugs most responsible for the overdose epidemic in recent years, has greatly increased. Perhaps even more troubling, the data suggest that use of fentanyl drug combinations is increasing as well. The COVID-19 pandemic appears to have created an environment of increased risk for those prone to drug misuse, which includes increased stress, isolation, removal of access to treatment, and a decrease in clinical drug monitoring. In these times of crises, we must maintain extra vigilance and not lose ground in our continued efforts to combat our nation’s drug abuse crisis. We need to continue employ opioid abuse risk management strategies including drug testing, the only objective measure of what drugs or substances a patient is taking.