Hospitals don’t routinely test for fentanyl — it’s time to add to the ‘federal five’

A 14-year-old boy presented unresponsive to a children’s hospital after a presumed fentanyl overdose. His urine drug screen was negative in the emergency department, including opiates. While in the ICU on a ventilator he was kept sedated with a fentanyl drip, a common ICU medication. Unfortunately, he was declared brain dead, passed and his family never received the definitive answer they desperately wanted as to why their son died. 

Within a short time after this case, the children’s hospital included fentanyl in all their urine drug screens.  

Fentanyl is now the number one cause of death for Americans ages 18-45; more than COVID-19 or suicide. Illicit fentanyl is the driver of more than 100,000 drug overdoses in the United States in a 12-month period. This potent drug, 100 times stronger than morphine, has been found in combination with 37 percent of heroin drug poisoning deaths, 40 percent of cocaine overdose deaths and 25 percent of methamphetamine of overdose deaths. It has been found in counterfeit pills that look like hydrocodone, oxycodone, alprazolam, vaping products and marijuana. Any drugs purchased outside a pharmacy are at risk for fentanyl contamination.  

Given that fentanyl is the drug most associated with death, it should be included in drug toxicological testing. The drugs that are part of a standard rapid urine drug screen include the “federal five”: amphetamines, cocaine, marijuana, opiates, and phencyclidine (PCP). These five categories were established by the Substance Abuse and Mental Health Services Administration’s (SAMHSA) division of workplace programs. Synthetic opioids such as fentanyl, oxycodone and methadone do not show up in an opiate drug screen and require a separate test.  

It is time for the “federal five” to become the “federal six.” 

The ability to measure the presence of fentanyl in patients is available in real-time, within an hour, at all hospitals that have a chemical analyzer. Chemical analyzers are large, expensive machines that are part of any hospital lab, even in rural settings. They are responsible for common lab tests such as a complete blood count (CBC) and blood chemistry panel. To identify fentanyl, there are several FDA-cleared substances that can be used in chemical analyzers. Those substances cost, on average, 75 cents per test. There is no excuse for hospitals not to include fentanyl as part of a drug screen. If there is routine reporting for PCP, why not include fentanyl?  

Unfortunately, to this date, there is no FDA-cleared point of care urine strip test for fentanyl that is part of a multi-drug panel. That means doctor offices and clinics do not have the capacity for rapid fentanyl test results. Fentanyl strips that are commonly promoted are used to test drug products, not human specimens.   

A positive urine drug test for fentanyl can make a difference. A positive test warns the provider, the patient who may not be aware their drug contained fentanyl and friends who may have used drugs together. It also leads to a prescription for naloxone to someone who does not necessarily use opioids, connects people to addiction treatment and can be a strong motivator for the patient to change. The fentanyl test result available in a hospital setting can help in an outpatient setting that does not have this testing capacity.   

The San Diego Prescription Drug Abuse Task Force has embarked on a fentanyl testing project; creating a tool kit and requesting all hospitals to include fentanyl in their urine drug screens. Within 10 months of the start of the project, 15 out of 24 hospitals started to include fentanyl, making it the standard of care for the community. On Feb. 14, State Sen. Melissa Melendez (R) introduced Tyler’s Law, legislation that will require all hospitals in California to include fentanyl in hospital urine drug panels.   

The nation’s hospitals should not wait for legislative mandates to advocate for fentanyl drug tests today. Testing will not solve the fentanyl crisis, but it will engage the medical community with data and could save lives in the process. 

Roneet Lev, MD, is a former chief medical officer of the White House Office of National Drug Control Policy. She is board certified in emergency and addiction medicine, and currently practices emergency medicine at Scripps Mercy Hospital in San Diego.