Drug Outbreak Testing Service (DOTS)

I wanted to get this information out as soon as I saw it. It is a service that offers free testing for drug outbreaks that are occurring more frequently as the pendulum swings to more acceptance of using various intoxicants.  This is a valuable service because many of these outbreaks occur so rapidly and with an unknown compound that leads to a sudden burst of morbidity and mortality and the medical systems in some towns are ill equipped to identify the offending agent.  I have posted about an epidemic of synthetic cannabinoids that required an intensive effort to look identify the compound being used.

This service offers rapid testing for up to 240 prescription and primarily nonprescription street drugs.  In their first paper on methodology at the references below they describe the rationale and procedure.  To qualify as a DOTS site, there has to be an identifiable outbreak of intoxicant use that cannot be identified locally.  That site needs to be able to submit 20 identified urine samples for testing.  In the following references the patterns of detected drugs vary considerably by site and level of sophistication necessary to identify the compounds.  For example, the King County DOTS samples yielded bufotenine, cathinine, alpha-PVP, mitragynine/7-hydroxy mitragynine, and U-47700 - compounds that are unlikely to be picked up in standard testing even at most substance use treatment centers.  Their assays also have sensitivity enough to pick up compounds like fentanyl that may be missed with lower sensitivity assays.

A brief discussion of the sample sites is required.  Comparing the toxicology data shows considerable variation across the sites.  The first sample was from an emergency department (ED) at the University of Maryland looking at the question of agitated patients and suspecting the use of cathinones or Bath Salts.  There were only 8 samples submitted.  There was more evidence that fentanyl may have been involved but there were a wide variety of compounds noted including diphenhydramine.  The King County Medical Examiner samples were from 20 people who had died of drug overdoses. Fifteen of the 20 samples contained methamphetamine and 14/20 contained fentanyl or analogues.  None of the 20 sample contained 10 or more compounds showing a high degree of polysubstance use in this sample.  The Montgomery County Maryland site is 20 samples from an outpatient clinic treating uninsured or publicly insured patients. The majority (75%) contained THC with 6/20 containing cocaine and 3/20 containing methamphetamine.  The Recovery Research Network submitted 23 samples from patients who were all in voluntary outpatient treatment.  The samples show a high degree of polypharmacy with 35% containing 10 or more drugs and 91% containing 5 or more drugs.   Aspenti Health submitted 20 samples on outpatients and their interest was in detecting possible fentanyl use.  12/20 samples were positive for fentanyl even though the lab results from the originating facility were b=negative due to a higher detection limit on their assay.  90% were positive for buprenorphine and 53% contained naloxone.

All together there are 91 samples from the 5 sites.  There is a lot of information contained in that data.  There is more detailed toxicology here that is available on most reports that I have reviewed, although data is generally not presented well in electronic health records.  I have included the data form the King County Medical Examiner's Office because it is the most complex and because this appears to be a publicly funded document with no copyright constraints.  Click to enlarge the graphic.

 
This is the way the data is presented from all 5 sites.  Major drug categories are color coded across all of the sites and there are row and column sums.  Interesting observations can be made in the data, but incident and sampling heterogeneity precludes any scientific conclusions.  One of the first things I noticed was the low frequency of psychiatric medications 26/91 were on antidepressants. One sample contained haloperidol and there were no samples containing quetiapine - a medication commonly used in residential treatment centers for insomnia. This could mean that much of the psychiatric comorbidity in the sample was not addressed.  The autopsy samples contained the fewest antidepressants.  Despite the recent concerns about gabapentin it was found in 13 of 91 samples and 4/20 autopsy specimens.

The greatest totals were for THC (50/91) and fentanyl and fentanyl metabolites (46/91).  The fentanyl was overrepresented in the autopsy specimens where 11/20 were positive and the Recovery Research Network sample where 19/20 were positive for fentanyl.  More  concerning 5 or those samples were also positive for buprenorphine indicating that patient may have been on MAT for opioid use disorder (OUD).  A similar pattern exists in the Aspenti Health sample where  11/20 were positive for both fentanyl and buprenorphine.  That is not to say that MAT for OUD is not indicated, but it probably reflects that fact that a significant number of drug users are not risk averse and do not consider MAT as a way to help them avoid the risks of OUD.  It is consistent with a recent story I heard about a number of OUD patients leaving a residential treatment facility because they heard that fentanyl was available in that community.  Many of those patients were on buprenorphine at an appropriate maintenance dose.

In may last look at the DEA schedule of controlled substances it contained about 330 compounds and I am sure that number has grown by now.  DOTS tests for 240.  If you have an outbreak in your community and the sources are not clearly known and little toxicology is available - it might be worthwhile to give them a call.  This is a valuable service to provide insight into what intoxicants may be responsible.

Being an undergrad chemistry major, this project also lead me to think about why every metropolitan area with a university or college having a chemistry major and access to GC/Mass Spectrometry should not have similar testing services.  These departments could be subsidized or reimbursed for the testing, incentivized for quality, and train the next generation of analytical organic chemists all in the same process.



George Dawson, MD, DFAPA


References:

1:  DOTS Bulletin A Pilot Study of the National Drug Early Warning System (NDEWS) University of Maryland, College Park Drug Outbreak Testing Service July 2018. Issue 6 DOTS Web Site