Grappling with the Opioid Epidemic
Written by Kristi Mayo   

A GROUP OF MORE THAN 45 EXPERTS convened in Washington, DC July 18-19, 2019 to present the latest information on the ongoing threats from opioids and other emerging drugs. Hosted by the National Institute of Justice (NIJ), in partnership with the Forensic Technology Center of Excellence (FTCoE) at RTI International, the National Opioid and Emerging Drug Threats Policy and Practice Forum focused on forensic, public safety, and health responses to the epidemic.

A number of themes emerged from the panels of experts who spoke over the course of the two-day conference. These key points included backlogs and workforce shortages; the value of real-time data; and the importance of opening up communication between all of the public entities touched by the opioid epidemic—from law enforcement to forensic investigations, and from social workers to public-health professionals.

Analytical Preparedness

The transient nature of illicit drugs challenges law enforcement, laboratories, and public health agencies. It’s a simple fact that you can’t find something if you’re not looking for it. Unfortunately, the overdose risk of opioids puts pressure on public agencies to identify these substances in real time, even as they are evolving.

While real-time identification of new drugs isn’t exactly a reality, information-sharing and diligent testing can help get very close to that goal. At the forum in July, Emily Lockhart, senior forensic chemist with the DEA’s Special Testing and Research Laboratory, cited two programs at the DEA that assist laboratories with analytical preparedness: the Reference Materials Program, which supplies reference materials to all DEA laboratories; and the Emerging Trends Program, which issues a quarterly Emerging Threat Report through the National Drug Early National Warning System website (NDEWS), chemical analysis of novel materials, and ongoing monitoring of “substance unconfirmed” reports.

While these DEA programs look at the chemical analysis of the substances themselves, others are working to understand the body’s reaction to these drugs—and the implications of that on toxicology screens, as well as life-saving measures such as administration of naloxone. Dr. Michael H. Baumann with the Designer Drug Research Unit said that novel synthetic opioids are presenting a particular challenge.

“We have the rapid appearance of synthetic opioids that have not been approved for medical use, and we don’t know what they do. We have no idea the toxicology of this plethora of substances,” said Baumann. He added that because of the way they are metabolized, analogs may not show up on a drug screen unless the toxicologist is specifically looking for them.

Surveillance and Data Sharing

For some agencies, managing backlogs and increasing drug-testing capabilities will be key to tracking the continued spread of opioids and other emerging drug threats. In one case example, Dr. Jennifer AL Smith, director of the Department of Forensic Sciences (DFS) in Washington, DC, shared the experience of her agency’s move to begin in-house drug testing. Prior to Smith’s 2015 arrival as director at the lab, all of Washington DC’s drug evidence was being sent off for testing by the DEA. In all, only about 19% of all seized evidence was actually analyzed. Smith and other policymakers recognized that if the district had been able to test that other 81% of evidence, they would have been better able to track the emergence of new illicit drugs such as synthetic cannabinoids and fentanyl.

Working with DC Health, the laboratory received a joint grant from the Centers for Disease Control and Prevention (CDC) focusing on surveillance testing. “This is something I tell my colleagues: talk to the public health folks—you may be able to come and be a part of that public service,” said Smith.

By doing their own drug testing in their new in-house lab, DFS was able to develop actionable intelligence on emerging drugs. The agency now releases alerts that might be of interest to law enforcement, as a basic “be-on-the-lookout” notice for novel substances that have been detected in their laboratory. In one example, DFS released an alert in November 2018 on counterfeit oxycodone pills containing fentanyl. In February 2019, a factory in Pittsburgh, Pennsylvania was found where the pills were being manufactured. “This is the reason we push this information out in different ways,” said Smith.

Work as Partners

Throughout the two-day forum, it was made clear that the opioid epidemic is not a law enforcement issue as much as it is a public health issue. Identifying illicit drugs and arresting the people who possess them does not stop the underlying issue, which is addiction. Because of this, multiple approaches are needed—from laboratories to health care providers to social workers—to track and, ideally, prevent the spread of these drugs.

“The United States has an addiction epidemic with a fentanyl crisis,” said Thomas Synan with the Newtown (Ohio) Police Department.

RxStat, a drug surveillance system developed in New York in 2011, monitors in real time opioids and other drugs and their associated consequences. The system has developed into a partnership between 30 different agencies, from public health to public safety, and from city to state organizations. “All of them are looking at the same map at the same time with the same goal and trying to find ways we can reduce (overdoses),” said Chauncey Parker, director of the New York/New Jersey High-Intensity Drug Trafficking Area. “Always asking that question, What can we do to reduce overdoses and save lives?”

Another kind of system that is ideal for public health and public safety partnerships is prescription drug monitoring programs (PDMPs). According to Dr. Chris Delcher, an epidemiologist and associate professor at the University of Kentucky’s Department of Pharmacy Practice and Science, nearly 2 million health professionals are registered to use state-based PDMPs, and health professionals made more than 460 million PDMP queries in 2018. That was a 56% increase from 2017 and a 651% increase from 2014. And in Florida, 73.6% of law enforcement reported using the state’s PDMP in an investigation.

Another key example of a program working as a partnership between multiple stakeholders is the Drug Monitoring Initiative (DMI). New Jersey State Trooper Adam Polhemus, a founding member of the DMI, said the program took an all-hazards, all-threats approach to gathering data on emerging trends and drug activity trends. It includes crime-related data sets on drug seizures, lab results, law enforcement Narcan deployments, drug arrests, shooting, and gun recovery; and health and human services-related data sets on EMS Narcan deployments, drug-related emergency room visits, toxicology, PMPs, addiction treatment admissions, and urinalysis results from corrections and probation.

While the program began in New Jersey, Polhemus said there are eight other states that have adopted the DMI program, and there are 34 other states that have expressed interest. “We have a tool kit and online training coming in the fall that will allow those entities to do so,” said Polhemus.

Another effort discussed at the forum was NPS Discovery, a website operated by the Center for Forensic Science Research and Education that works to rapidly disseminate information on emerging drugs. Utilizing surveillance from seized drugs at the border and mail ports of entry, postmortem databases, and biological information from mass overdose outbreaks, the website posts real-time trend reports, emerging trends and outbreak reports, analytical monographs, and more.

A program from the DEA, the National Forensic Laboratory Information System (NFLIS), collects and disseminates results of forensic analyses and other related information from local, regional, and national entities. As of February 2019, NFLIS-Drug contains the drug-analysis data from 50 state laboratory systems and 104 local or municipal labs. The DEA has recently expanded the NFLIS program to include public and private toxicology laboratories (NFLIS-Tox) and medical examiner and coroner offices (NFLIS-MEC).

“Our office was individually calling medical examiners’ offices to get death reports because we had seen a news report or heard of an aggregated death or clusters of death,” said DeMia Pressley, DEA program officer. “That can be time consuming. We were hoping that with these two new data collections, we would have a means of an ongoing dataset so we could get to this process for emergency scheduling much faster.”

Yet another resource is the National Drug Early Warning System (NDEWS). This project monitors emerging drug-use trends and encourages information-sharing in three ways: 1) The NDEWS Network, a virtual community of more than 1,500 experts from a variety of fields, along with concerned citizens, who share information on emerging drugs and drug trends; 2) Sentinel Community Sites, ranging in size from a city to a county to an entire state, where epidemiologists monitor and provide regular updates and annual reports; and 3) HotSpot Studies, where experts work together to identify a trend or question of concern, research it, and provide information on all available data and existing research that is available.

The Need for Forensic Pathologists

Opening the panel discussion on the need for more forensic pathologists and medicolegal investigators in the United States, Dr. Jonathan L. Arden, 2019 president of the National Association of Medical Examiners (NAME) did not mince words.

“Since forensic pathology was established, there has been a critical shortage of forensic pathologists,” said Arden. “That has not changed except to get worse over the years. We have now reached a point of being on the cusp of an existential crisis of forensic pathology.”

Arden described medical examiners and coroners as standing on the front lines of emerging threats like the opioid crisis. And yet the demand for these professionals is far outpacing their supply. According to Arden, there are currently 400-500 full-time forensic pathologists working in the United States. Based on NAME accreditation standards, the estimated number of forensic pathologists needed to deal with the current opioid epidemic is closer to 1,200-1,500.

The reason for the shortage? “Crushing student debt burden,” said Arden. Government salaries are half of private-sector salaries. Plus, entering the medical-examiner field requires an extra year of training with reduced earnings compared to the private sector… all with the same student debt load.

MJ Menendez, a member of the NAME Strategic Planning Committee, listed a number of steps that could be taken to attract more people to the field of forensic pathology, including visa waivers, fellowships, and loan forgiveness. She also made an impassioned plea before the forum. “I come to these meetings over and over again, and since 2003 we have made no progress on these issues,” she said. “That is because somehow… the fact of the fundamental problem being so prevalent and serious—it hasn’t made it into people’s souls. What I want you to do today is decide whether you are going to take this message into your soul. It is going to take every one of us, taking at least one step out to talk to a policymaker or legislator, a funder, a public authority, to change this problem.”

Online Archives Coming Soon

The archived webcast of the 2019 National Opioid and Emerging Drug Threats Policy and Practice Forum will be made available on the Forensic Technology Center of Excellence website soon. You can find the full agenda, speaker bios, and more here.

About the Author

Kristi Mayo is the editor/publisher of Evidence Technology Magazine.


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