Whether to accept and eat candy is a widely known quandary children face. It’s the predictable cautionary tale to avoid strangers. But what happens when every day, seemingly innocent candy exchanges become a real threat? At Kindergarten Meet the Teacher Night, my 5-year-old daughter accepted a piece of candy from another little girl, put it in her mouth, and then tried to hide it from me because she knew I wouldn’t want her eating candy I didn’t buy her. What should be a harmless childhood rite of passage at best, or an inconvenient sugar high at worst, suddenly has the potential to be deadly.
In September of 2022, the United States Drug Enforcement Administration (DEA) seized 15,000 “rainbow fentanyl” pills in New York City concealed in a LEGO box, and 40% of them contained lethal doses.1 That same month, the Pasadena Police Department seized more than 300,000 fentanyl pills, included among them were the rainbow fentanyl pills. And in Wethersfield, CT, two men were arrested attempting to sell rainbow fentanyl pills hidden in Nerds candy boxes and Skittles candy bags. The undercover DEA agents found thousands of brightly colored fentanyl pills hidden in candy boxes inside the dealer’s car.
Whether the rainbow fentanyl pills are being pushed to children or not, they are made to look like something a child may want to try. According to New York’s Special Narcotics Prosecutor Bridget G. Brennan, “Using happy colors to make a deadly drug seem fun and harmless is a new low, even for the Mexican cartels. Fentanyl is already involved in more than 80% of overdose deaths in the city. If you take any drug sold on the street or through the internet, regardless of its medicinal markings or festive appearance, you risk your life.”1 The jury is still out on whether a drug dealer would give away their product for free just to target children, as this would negatively impact their profit and bottom line. Some believe the rainbow pills are a tactic by cartels to avoid detection by law enforcement.
To not get caught up in the “why” debate, lets instead focus on what we know with certainty is plaguing our communities daily — odorless, colorless, and tasteless fentanyl, concealed in fake oxycodone pills, cocaine, heroin, ecstasy, methamphetamine, and others. Drug dealers have figured out that illicitly produced fentanyl is cheap and easy to manufacture. In addition, fentanyl is highly potent and addictive, which is why we’re seeing an increase in fentanyl contamination of the street drug supply. It is being added to many different drugs to turn recreational users into addicted customers. In some cases, individuals are not even aware they have taken fentanyl, and those that are, are playing a very dangerous game.2 From April 2021 to April 2022, synthetic opioids like fentanyl, were responsible for nearly 90% of reported deaths, according to the latest Centers for Disease Control and Prevention (CDC) data.3 Fast forward to September 2022, where now fake oxycodone pills have evolved into pills disguised as candy.
The case for fentanyl testing
Being in the drug testing field, I am acutely aware of the dangers associated with opioid use. As a result of the evolving fentanyl contamination issue, two questions come to mind:
If someone unknowingly takes fentanyl and they are lucky enough to wake up in an emergency department (ED) post-treatment, how does the hospital, patient, and/or the patient’s family know that fentanyl was the reason for this overdose? The patient may admit to using whatever drug they thought they purchased but won’t know that the added fentanyl is what sent them to the ED, unless testing is performed.
Thinking even more broadly, how does a community know its drug supply is contaminated with fentanyl? While “drug checking” test strips at the point-of-use exist to test the drugs themselves and potentially prevent fentanyl overdoses, many states consider them to be contraband.4 Therefore, these test strips are illegal in many cases, even though they can save lives and community resources dedicated to overdose-related emergency incidents.
Identifying whether fentanyl is present in a community serves as a warning sign—not only at the community level, but at the individual patient level, as well. To support drug policies and rehabilitation efforts, a community must know fentanyl is present and is an ongoing, active threat.
Treatment of substance use disorders and identification of fentanyl contamination start with a laboratory test. There are several types of laboratory tests available to detect the presence of fentanyl with different sample types depending on the test. For example, several laboratory diagnostics manufacturers offer urine drug screening and serum toxicology which is performed via immunoassay methods on automated chemistry and dedicated drug testing analyzers. Rapid urine drug testing, which is considered point-of-care testing, also is available as cups, strips, and cartridges, and is manually performed and interpreted. Additionally, there is oral fluid testing to screen for the presence of fentanyl. Regardless of the screening method, it is always recommended that laboratories confirm preliminary results with a confirmatory method such as liquid chromatography followed by tandem mass spectrometry (LC-MS/MS).
Drug screening for fentanyl, and specifically norfentanyl (the major metabolite of fentanyl) serves a vital purpose as the first line of defense in combating this fentanyl contamination crisis. Since fentanyl is primarily excreted as metabolites, with only ~10% of the drug remaining unchanged in urinary excretion, it is imperative the screening assay detects norfentanyl. This helps reduce the risk of false negatives.5 It is simply not enough to offer just any fentanyl-specific screening test. Laboratories must offer a fentanyl-specific test that demonstrates excellent sensitivity and specificity for detection of fentanyl and excellent cross-reactivity with norfentanyl.
If test strips are not available to test the drug itself and if laboratories aren’t testing patient samples for fentanyl, there is no way for physicians, patients or anyone else involved to know of its presence. This lack of information could hinder a patient’s treatment plan, including a patient’s ability to secure space in a treatment facility, for example.
Conclusion
Fentanyl drug screening provides that critical level of awareness needed to help facilitate proper treatment, prevent overdoses or recurrent overdoses, guide public health initiatives, and ultimately save lives—not just on Halloween, Thanksgiving, or Christmas—but on any day of the year. It is imperative that collective community resources such as hospital systems, laboratory diagnostics companies, government or local/state agencies, treatment centers, police or sheriff’s departments and other organizations work together to help put an end to this “hidden” epidemic. Empowered laboratories offering fentanyl testing deliver vital test results, enabling actionable efforts that drive towards a safer and healthier population.
References
- Trafficker-quantities of “rainbow fentanyl” arrive in New York. DEA. Accessed October 25, 2022. https://www.dea.gov/press-releases/2022/10/04/trafficker-quantities-rainbow-fentanyl-arrive-new-york.
- Fentanyl: What you need to know - national coalition against prescription drug abuse. National Coalition Against Prescription Drug Abuse. Published December 1, 2021. Accessed October 25, 2022. https://ncapda.org/fentanyl/?gclid=EAIaIQobChMIssyzlprW-gIVF47ICh1KBg-PEAAYAiAAEgKggvD_BwE.
- Products - vital statistics rapid release - provisional drug overdose data. Cdc.gov. Published October 12, 2022. Accessed October 25, 2022. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
- Facher L. Fentanyl test strips could help save lives. In many states, they’re still illegal. STAT. Published September 8, 2022. Accessed October 25, 2022. https://www.statnews.com/2022/09/08/fentanyl-test-strips-could-help-save-lives-in-many-states-theyre-still-illegal/.
- Huhn AS, Hobelmann JG, Oyler GA, Strain EC. Protracted renal clearance of fentanyl in persons with opioid use disorder. Drug Alcohol Depend. 2020;214(108147):108147. doi:10.1016/j.drugalcdep.2020.108147.
