Doctors share how the Emergency Department Drug Surveillance (EDDS) system has positively impacted their practice

Very few overdose patients are currently tested for fentanyl in U.S. hospitals’ emergency departments. However, thanks to a new bill Maryland Governor Wes Moore recently signed into law, all hospitals in the state will need to begin testing for fentanyl in their toxicology screens on October 1, 2023.

A few Maryland hospitals are already ahead of the curve, having spent the last few years working with the Emergency Department Drug Surveillance (EDDS) system, developed by the University of Maryland’s Center for Substance Use, Addiction & Health Research (CESAR), to get insight into the use of fentanyl and other drugs in their communities.

There are two types of EDDS programs that CESAR is currently collaborating with 51 of the nation’s hospitals on: National EDDS and Maryland EDDS (MD-EDDS). Both programs use de-identified hospital electronic health records to safely and securely analyze information on their patients’ drug exposure, and also analyze urine samples from the hospitals for the presence of fentanyl and other substances.

For the national EDDS program, funded by the Office of National Drug Control Policy, hospitals submit up to 150 de-identified urine samples to be retested for the presence of approximately 500 different substances—synthetic opioids like fentanyl included. With MD-EDDS, funded by the State of Maryland’s Opioid Operational Command Center, hospitals are given fentanyl dipsticks to test 50 patients’ already collected urines for fentanyl exposure. This month, MD-EDDS received an additional $476,000 in support from the State of Maryland's Opioid Operational Command Center to continue the project for another year and to retest samples of urine specimens submitted by participating hospitals for over 500 drugs.

“EDDS analyses of objective toxicology results makes it possible for the first time to understand the wide range of substances a patient has been exposed to,” said Dr. Eric Wish, the principal investigator of the EDDS systems and former director of CESAR. “Doctors and hospital administrators throughout Maryland and other parts of the country have used EDDS findings to update their testing protocols and to connect patients to appropriate treatment and other services."

EDDS test results help to address a few of the unique challenges facing hospitals today. For example, patients who test positive on a standard opiate test are typically referred by doctors to a drug treatment program. But, the standard opiate test does not detect synthetic opioids like fentanyl. So, unless a patient is tested for fentanyl specifically, opioid exposure could be overlooked, a potentially life-saving referral to treatment never made, and an opportunity to encourage patients to engage in harm reduction behaviors—like carrying the opioid overdose reversal drug, naloxone—missed.

This possibility was raised by Dr. Zachary Dezman, a collaborating ED physician in Baltimore and Assistant Professor with the University of Maryland School of Medicine, after working with CESAR’s EDDS system.

“The high prevalence of fentanyl and the high rate of false negative opiate tests were major findings,” Dr. Dezman said. “We found 83% of persons coming to my emergency department for complaints of withdrawal or intoxication or seeking treatment were positive for fentanyl exposure. Only 4% of patients suspected they had been exposed to fentanyl; the remainder thought they had used heroin or another street drug … [and] about half of those exposed to fentanyl were negative on the standard hospital opiate screen. In fact, fentanyl became the most common positive result once it became part of the standard drug screen at the University of Maryland Medical Center (UMMC) and UMMC Midtown campus.”

In an interview with NBC Nightly News—about how she helped establish California’s “Tyler Law” requiring hospitals in her state to test for fentanyl in their standard drug test panels—Dr. Roneet Lev, an EDDS collaborator and the director of operations of the Scripps Mercy Emergency Department in San Diego, said she sees patients surprised to hear about their fentanyl-positive tests “all the time, every single day.”

“We realized that we were having a fentanyl problem as outlined by EDDS data and medical examiner data, and we embarked on a quest to find out what it would take to add that to our drug screens in the hospital,” Dr. Lev, who began participating in CESAR’s national EDDS program in 2021, recalled. “If you are selected to be able to work with CESAR on data, it's an honor. It helps you locally, and it helps the nation.”

For Dr. Michael Moss, a collaborating emergency medicine physician in Salt Lake City, it was the presence of other types of drugs being used in his community that was a major national EDDS takeaway.

“Though we have a good idea of drug use in our area from clinical experience, having the actual data helps us collaborate with other state agencies and partners in identifying where to focus our efforts. For instance, the data reminds us that methamphetamine is just as much of a problem for us in Utah as opioids,” said Dr. Michael Moss, Utah Poison Control Center’s Medical Director.

Sridhar Rao Gona, a Pharmacy Informatics Researcher at Meritus Medical Center in Hagerstown, has also had a positive experience working with CESAR via its MD-EDDS program.

“The fentanyl dipstick testing revealed that 20% of the patients who had tested positive for one or more drugs in the hospital's standard screen also tested positive for fentanyl. This finding was surprising and concerning,” said Gona, a Pharmacy Informatics Researcher and MD-EDDS collaborator at Meritus Medical Center in Hagerstown. “The data also revealed that fentanyl use was not limited to a specific demographic or age group, emphasizing that this issue affects a broad spectrum of patients in our community.”

EDDS collaborators also noted that their participation in EDDS programs added little day-to-day responsibilities to their already-full workloads.

“After we completed the IRB and data transfer agreements, the project required minimal additional work for our Emergency Department team,” Dr. Moss explained. “Our campus data science group pulls new data quarterly to update our trends.”

Dr. Dezman echoed Dr. Moss’s thoughts, describing working with CESAR’s EDDS team as being “as straightforward as it was productive.”

“Their team made every effort to work with our institutional review boards to obtain appropriate permission to study subjects and respect their privacy. They were able to coordinate the procurement of samples in such a way as to fit the research work within the constraints of a busy inner-city emergency department,” Dr. Dezman said. “I would encourage physicians who treat patients with substance use disorders to reach out to the EDDS team. Substance use is always changing, and medicine must change to address the problems our patients face. We cannot treat a problem if we don’t detect it.”

CESAR’s new Director, Dr. Jessica Magidson, is “excited about the EDDS research, which supports CESAR’s mission of conducting timely scientific studies that can improve patient care and access to effective treatment.”

 

Image provided by iStock

Urine collection vial and printout of test results