Only 5% of ER overdose visits are tested for fentanyl despite a high positivity rate, Epic study finds

Despite fentanyl being among the leading causes of overdose deaths, few patients are screened for the substance in emergency rooms, a new study finds.

The analysis was conducted by Epic and the University of Maryland’s Center for Substance Abuse Research (CESAR). The team used Cosmos, which contains de-identified Epic data on 162 million patients, to analyze more than 315,000 emergency department (ED) overdose visits from 2017 to mid-2022. 

The group looked to see how often toxicology screenings, which can inform treatment and public health data, were performed and what substances are tested for. Routine toxicology screens typically test for cocaine, amphetamines, marijuana, phencyclidine (PCP) and natural opiates like heroin or morphine. Synthetic opioids like fentanyl require a separate test.

Three-quarters of all drug overdose deaths in 2020 involved opioids, and the vast majority of those were synthetic. Yet Epic and CESAR found that despite a slight rise in fentanyl testing over the years, only 5% of visits are currently tested—the highest testing rate since 2017. Of those screened, more than 40% are positive. 

By comparison, the latest analysis revealed, nearly half of ED visits were tested since 2017 for opiates despite a declining positivity rate, currently at about 14%. 

"We need to know precisely how people are struggling so that we can help them before their lives are on the line,” Dave Little, M.D., director of clinical informatics at Epic and co-author of the study, said in a press release.

Prior to the latest analysis, CESAR published several studies on fentanyl toxicology locally in Baltimore. It also received funding to expand the Emergency Department Drug Surveillance system, which collaborates with dozens of hospitals to track local drug use availability based on de-identified patient drug test results.

"Our earlier, limited, region-specific research on this topic suggested a lack of fentanyl screening across the country," Eric Wish, Ph.D., director at CESAR and co-author on the latest study, said in the press release. "Because Cosmos data is both vast and representative of the U.S. population, it makes it possible to quickly observe this kind of nationwide challenge and inspire data-driven interventions."

That’s why Wish approached Epic; health records are a “goldmine of information,” he told Fierce Healthcare. It was “counterintuitive” to discover that so few are getting tested for fentanyl, given what is known about fentanyl’s role in overdoses today, Wish said.

The exact number of people who overdose on fentanyl and intentionally took the substance is unknown. “We don’t know the whys, and we don’t know the numbers, but what we do know is that a lot of fentanyl overdoses are occurring in patients who did not intend to take fentanyl,” Little told Fierce Healthcare. A growing number of street drugs are contaminated with it unbeknownst to many users. 

Physicians may not be aware that fentanyl is not a part of the routine screen, Little said. And not all providers have easy access to fentanyl testing. While some hospitals that have a chemical analyzer can get rapid fentanyl test results, clinics do not have the same capacity, according to one expert

Providers may also worry about costs associated with ordering an additional test, Jackie Gerhart, M.D., Epic’s vice president of clinical informatics, told Fierce Healthcare. All labs that include urine fentanyl screens are covered by government payers, she said, but patients who do not know their out-of-pocket cost may request that physicians not order them. Epic hopes public health authorities will cover the costs “because it’s a public health problem,” Gerhart said. 

For now, Epic will be upgrading its software to ensure that a fentanyl test order is placed automatically alongside a standard toxicology screen, Little said. Epic has also presented the latest findings to agencies like the Office of National Drug Control Policy and the Centers for Disease Control and Prevention. Apart from action at a federal level, Little said, the issue could also be addressed state by state: In August, California passed legislation to require general acute hospitals conducting urine drug tests to include fentanyl.

The study’s authors wrote that to improve tracking of drug use and interventions and treatment, EDs should consider including fentanyl testing in toxicology screening. Routinely testing for it can inform fentanyl contamination tracking efforts. And not only is it important for patients to be aware if they ingested fentanyl, it’s also key knowledge to have for a referral to a substance use disorder treatment provider. 

“You want the most accurate information being passed along,” Little said.