Millennium Health, San Diego, California.
University of Kansas School of Medicine, Kansas City.
JAMA Netw Open. 2019 Apr 5;2(4):e192851. doi: 10.1001/jamanetworkopen.2019.2851.
Drug overdose deaths continue to increase, despite the leveling off of prescription opioid use and policy changes limiting opioid prescribing. Illicit fentanyl is the leading cause of drug overdose death, and it is important to characterize the emerging combination of other illicit drugs with fentanyl, which increases the risk of overdose.
To determine whether rates of the combination of nonprescribed fentanyl with cocaine or methamphetamine have changed in urine drug test (UDT) results through time.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study of UDT results from January 1, 2013, through September 30, 2018, included patient specimens submitted for UDTs by health care professionals as part of routine care. Patients were selected from health care practices across the United States, including substance use disorder treatment centers, pain management practices, primary care practices, behavioral health practices, obstetrics and gynecology practices, and multispecialty groups. The UDT analysis used liquid chromatography-tandem mass spectrometry to detect benzoylecgonine (cocaine metabolite), methamphetamine, fentanyl, and norfentanyl. Specimens from individuals reported to have been prescribed fentanyl were excluded. A convenience sample approach was used to randomly select 1 million unique patient UDT specimens from Millennium Health's UDT database for further analysis. Each specimen had associated cocaine, methamphetamine, and fentanyl UDT results.
Medically necessary UDT to detect benzoylecgonine (cocaine metabolite), methamphetamine, fentanyl, and norfentanyl, ordered by a health care professional as part of routine patient care.
Rates of nonprescribed fentanyl positivity among cocaine- or methamphetamine-positive UDT results, quantified through time.
In a sampling of 1 million unique patients' UDT specimens analyzed for cocaine and fentanyl (median [interquartile range] age, 44 [19-69] years; 55.0% women), positivity rates for nonprescribed fentanyl among the cocaine-positive results increased significantly, from 0.9% (n = 84) (95% CI, 0.7%-1.1%) in 2013 to 17.6% (n = 427) (95% CI, 16.1%-19.1%) in 2018, a 1850% increase (τ = 0.78; z = 9.45; P < .001). In the same sampling of 1 million specimens, positivity rates for nonprescribed fentanyl among the methamphetamine-positive results also increased significantly, from 0.9% (n = 29) (95% CI, 0.6%-1.2%) in 2013 to 7.9% (n = 344) (95% CI, 7.1%-8.7%) in 2018, a 798% increase (τ = 0.72; z = 8.75; P < .001).
An increasing number of UDT results positive for cocaine or methamphetamine were also positive for nonprescribed fentanyl. This provides additional insight into recently reported increases in cocaine- and methamphetamine-related overdoses. Stimulant users who may be opioid naive are at a heightened risk of overdose when exposed to fentanyl. Clinicians need to be aware that patients presenting for treatment of suspected drug overdose or substance use disorder may have been exposed, knowingly or unknowingly, to multiple substances, including the combination of stimulants and opioids.
尽管处方类阿片使用量趋于平稳，政策也对限制阿片类药物的使用进行了调整，但药物过量死亡人数仍在继续增加。非法芬太尼是药物过量死亡的主要原因，了解其他非法药物与芬太尼混合使用的情况非常重要，因为这会增加药物过量的风险。
确定非处方芬太尼与可卡因或甲基苯丙胺联合使用的比率是否随时间在尿液药物检测（UDT）结果中发生变化。
设计、设置和参与者：本研究为一项回顾性队列研究，对 2013 年 1 月 1 日至 2018 年 9 月 30 日期间通过 UDT 检测的患者标本进行分析，包括医疗保健专业人员为常规患者护理而提交的患者标本。患者是从美国各地的医疗保健机构中选择的，包括药物滥用治疗中心、疼痛管理诊所、初级保健诊所、行为健康诊所、妇产科诊所和多专科团体。UDT 分析采用液相色谱-串联质谱法检测苯甲酰爱康宁（可卡因代谢物）、甲基苯丙胺、芬太尼和去甲芬太尼。排除报告有芬太尼处方的患者样本。采用便利抽样方法，从 Millennium Health 的 UDT 数据库中随机选择 100 万个独特患者 UDT 标本进行进一步分析。每个标本都有相关的可卡因、甲基苯丙胺和芬太尼 UDT 结果。
医疗保健专业人员为常规患者护理而检测苯甲酰爱康宁（可卡因代谢物）、甲基苯丙胺、芬太尼和去甲芬太尼的 UDT，这是一种必需的检测。
可卡因或甲基苯丙胺 UDT 阳性结果中非处方芬太尼阳性率的时间变化。
在对 100 万个独特患者 UDT 标本进行可卡因和芬太尼分析（中位数[四分位距]年龄，44 [19-69] 岁；55.0%为女性）中，可卡因阳性结果中非处方芬太尼阳性率显著增加，从 2013 年的 0.9%（n=84）（95%CI，0.7%-1.1%）增加到 2018 年的 17.6%（n=427）（95%CI，16.1%-19.1%），增加了 1850%（τ=0.78；z=9.45；P<0.001）。在同样的 100 万标本采样中，甲基苯丙胺阳性结果中非处方芬太尼阳性率也显著增加，从 2013 年的 0.9%（n=29）（95%CI，0.6%-1.2%）增加到 2018 年的 7.9%（n=344）（95%CI，7.1%-8.7%），增加了 798%（τ=0.72；z=8.75；P<0.001）。
越来越多的可卡因或甲基苯丙胺 UDT 阳性结果也呈非处方芬太尼阳性。这为最近报告的可卡因和甲基苯丙胺相关药物过量增加提供了更多的见解。当接触到芬太尼时，可能对阿片类药物不敏感的兴奋剂使用者的药物过量风险会增加。临床医生需要意识到，因疑似药物过量或药物使用障碍而接受治疗的患者可能已经暴露于多种物质，包括兴奋剂和阿片类药物的混合。
