Our country and community are in crisis. As of January 2020, 49 U.S. states have reported fentanyl-laced counterfeit pills, with deaths attributed to such pills in 38 states. This is an increase from the 22 states reporting deaths related to fentanyl-laced counterfeit pills in April 2018. In 2021, Nashville saw more than 700 deaths due to fentanyl overdose, a 15% increase over 2020. 

The collision of the opioid epidemic and the coronavirus pandemic has escalated the already-increasing rate of overdose deaths and the disruptions in care. Further exacerbating the problem: the lurking emergence of novel psychoactive substances (NPS), more commonly known as designer drugs, which are developed to have effects similar to commonly prescribed pharmaceuticals, such as fentanyl or alprazolam, and are sold on the street as prescription medications or illicit drugs.

These synthetic compounds, like illicitly manufactured fentanyl, are unregulated, highly dangerous, and if left unidentified, threaten to spread through the community like wildfire. One way to fight back against this ongoing crisis is to identify use of these drugs by testing for them in urine or saliva specimens.

Drug testing often carries a negative connotation, with results too often being used punitively. However, testing has far greater capabilities and implications – for assessment of medication adherence, as a guidepost for providers, and when used strategically, as a tool for tracking substance use trends. With so much at stake for community health, it begs the questions: What separates the numerous available testing technologies, and what is the impact for those tested and our larger community?

Testing starts with considering two key factors: the individual being tested, and what they’re being treated for. Methodology, testing components, analysis, and ultimately treatment all flow from these questions. Yet frequently, the end user and even their purveyor of care are unaware of the options at their disposal, what exactly to test for, and what the implications of those choices are – for both the individual receiving treatment and the community at large. 

Two types of drug tests are used today, by medical professionals, treatment clinics, businesses, and more:

• Presumptive: These test for a smaller array of drugs and deliver more rapid results. What is often associated with the general public’s idea of a drug test, these are quick, easy, and cheap but cannot detect many substances, including designer drugs.
• Definitive: These are innovative, complex tests that require more expertise and more time to identify what’s in the specimen, and they provide specific and actionable results. These can detect designer drugs, but few labs offer the advanced technology to process the tests. 

The bottom line is that there is no “standard” drug test, and what is determined to be medically necessary to perform is dependent on each unique treatment scenario. Though both testing methods have their place, too often the medical field relies on the rapid results of the less expensive presumptive tests over the in-depth portrait that definitive tests can provide.

The root cause isn’t malice but rather misunderstanding. There is a knowledge gap on the differences between presumptive and definitive test methods and the nuances they can provide in their results, particularly on recently ingested substances and the dangers of drug interactions and synthetic drugs. Lack of understanding regarding the differences in limitations between these two methodologies can leave providers unaware of which drug compounds to test for and how they can impact treatment.

Also present is the urge to say “it’s not happening here” about widespread synthetic drug or NPS use, an assumption as dangerous as it is incorrect. This increases the risk for non-prescribed substance use to potentially go unnoticed, and new designer drugs continue to pop up faster than we can address them, spread unabated, and ravage our community. 

Far from a punitive measure, testing is a tool within the scope of medical practice that helps with risk mitigation and lifesaving treatment. With a rotating door of designer drug compounds in our community – many with the potential to be deadly – lives hang in the balance.

Our best path forward is widespread understanding among the medical community and the public on testing and how it can be utilized. At minimum, understanding and implementation of definitive testing technology helps providers develop clearer treatment plans and spotlight occurrences of NPS use. It also allows us to view the city- and statewide trends – determining what new drugs are circulating, charting their journey throughout our community, and deploying resources to confront them before they cause more harm. 

Education and conversation around testing can transform care and, ultimately, save lives.

Dr. Joshua Schrecker, Pharm.D., is the director of Clinical Affairs at Aegis Sciences Corporation.