While synthetic opioids are now the leading cause of death for Americans under age 45, fentanyl is not usually detected in routine toxicology screenings, and typically a test for it must be ordered separately, according to the briefing shared with Healthcare IT News.

Positivity rate for fentanyl soars

The team used deidentified Cosmos data from Epic's EHR – a HIPAA-defined limited data set of more than 149 million patients from 172 Epic organizations serving patients in all 50 states. Looking at 315,000 emergency department overdoses that occurred between 2017 and August 2022, the researchers learned how infrequent toxicology screening for fentanyl is at the ER.

"In this study, we had the unique opportunity to confirm this finding in many more hospitals. 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," said Dr. Eric Wish, director at CESAR and coauthor of the study, in a prepared statement.

Examining lab results for 15 drug categories, the researchers found that, while opiates are consistently tested for nearly half of the time, the opioid positivity rate has decreased from 25.2% in 2018 to 13.5% in 2022.

When tested for, the positivity rate of fentanyl is more than three times greater than opiates – 41.7%, compared to 13.5 % as of first quarter 2022 – according to the announcement. 

Tracking the shift from heroin at the ER

The decline in opiate positives may indicate a shift from heroin use to fentanyl use, given the 18-fold increase in overdose deaths related to synthetic opioids, the researchers surmise in the briefing.

In May, the CDC reported that overdoses involving fentanyl and other synthetic opioids were up 23% from 2020 to 2021, surpassing 71,000.

At the emergency room, providers often immediately administer naloxone in any suspected overdose to try and save the patient's life, not waiting for toxicology screening results to come back, Dr. Dave Little, director of clinical informatics at Epic and coauthor of the study, said in a prepared statement.

"We need to know precisely how people are struggling so that we can help them before their lives are on the line," he added. 

In the briefing, the researchers recommend emergency departments review standard drug-testing panels and consider including fentanyl testing in toxicology screening. 

"Comprehensive toxicology screenings are critical to both lifesaving treatments in the ED and effective public health efforts in the community," Little continued in the statement.

Other tools can also help ER departments better assess overdose patients. According to David Bucciferro, vice chair of the HIMSS Electronic Health Record Association and cochair of its Opioid Crisis Task Force, on a recent HIMSSCast, getting "clinically pertinent information" into the EHR could help emergency and other departments better assess overdose patients when they arrive.

Wish indicated that better electronic tracking could improve patient care. 

"Our findings highlight the need for a centralized overdose surveillance system and a nationwide standard for toxicology screenings in overdose treatment in order to track drug epidemics. This will give medical personnel the information they need to accurately diagnose and treat overdoses and other related problems and improve patient outcomes," he said in the statement.