Fentanyl is responsible for most fatal overdoses. But ERs don’t test for it.

LOS ANGELES — When Tyler Shamash survived a drug overdose at age 19, his mother, Juli, asked his doctor several times if he had been tested for fentanyl.

Tyler Shamash.Family photo

Tyler had been in and out of austere residential homes in Los Angeles after battling addiction for years, and his family suspected he might be using illegal drugs. The doctor said they ran a standard drug test and fentanyl didn’t show up on the toxicology screen.

Juli Shamash believes the doctor was unaware that fentanyl is not included in the standard test run in emergency rooms across the country. A standard drug testing panel in most emergency rooms only checks for marijuana, cocaine, amphetamines, PCP, and natural and semi-synthetic opioids (such as heroin and oxycodone) – but not synthetic opioids such as fentanyl.

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Tyler Shamash overdosed again the next day and died. His family discovered fentanyl was found in his system five months later, after the coroner prepared a toxicology report.

“I was so incredulous because you trust doctors; you go to doctors for advice,” Shamash told NBC News. “I find it unbelievable that not every institution tests for it [fentanyl]. why wouldn’t you? But then I think the answer to that is: they think so.”

Her son’s death in 2018 prompted Shamash to push for legislation that would require a sixth test for fentanyl. Through a bipartisan effort, Tyler’s law passed unanimously and went into effect in California in early 2023 — the first and so far only state to do so, though the law expires in just five years.

Charles and Juli Shamash.
Charles and Juli Shamash.NBC news

The number of deaths from fentanyl overdose is higher than the number of deaths from heroin or other opioids. In 2022, the Drug Enforcement Administration seized 50.6 million fentanyl-laced pills masquerading as controlled prescription pills such as Xanax or oxycodone and more than 10,000 pounds of fentanyl powder. But there is no federal mandate that specifically tests emergency departments for fentanyl.

Shamash is now working with other families who have suffered a similar loss in hopes of getting federal legislation enacted.

“Every time I hear another child dies, it’s like we haven’t reached them?” she said. “I don’t know if it’s… like I didn’t save my own son, so I feel like I have to save everyone else.”

She collaborated with Dr. Roneet Lev, an emergency room addiction physician at Scripps Mercy Hospital in San Diego, who developed a toolkit to help other hospitals perform fentanyl testing, which she says hospitals are already equipped for and is relatively inexpensive — costing about 75 cents to adding a reagent to test for fentanyl.

“Fentanyl testing has dramatically changed the way I approach patients and how my conversation with them goes when the test is positive,” said Lev.

Dr.  Ronet Lev.
Dr. Ronet Lev.NBC news

She sees patients every day who don’t know they’ve taken anything containing fentanyl. Now armed with knowing the severity of the drugs they’ve been on, Lev said patients “might want to change or do something different. They can throw those packets of pills away… or it leads to a prescription for Naloxone, the opioid- reversal agent.

Both the American Hospital Association and the American Academy of Emergency Medicine declined to comment on testing practices and whether national guidelines are being considered.

Legislation replicating Tyler’s law is making its way through the Maryland State House, led by the family of Josh Siems, who died of an overdose last year.

Josh’s partner, Melanie Yates, said she discovered the California law after “going down a rabbit hole of research” when Josh’s first toxicology report came back showing only cocaine — even though his family had found fentanyl in his apartment.

Josh Sims.
Josh Sims.Thanks to Melanie Yates

She was even more stunned to discover an Epic Research study conducted in conjunction with the University of Maryland’s Center for Substance Abuse Research found that only 5% of toxicology screens tested for fentanyl. When tested, fentanyl positivity rates approach 50% – more than three times the opiate positivity rate.

“How are we going to detect fatal and non-fatal overdoses? How are we going to build systems around data we don’t have? How are we going to warn people who don’t know they are using fentanyl?” said Yates in an interview. “Drug addiction affects every race, every gender, every age, every socioeconomic group. No one is exempt from this.”

According to the CDC, more than 107,000 Americans will die of drug overdoses in 2021 — a majority of them suspected to be from fentanyl. The DEA warns on its website, “Drug traffickers are increasingly mixing fentanyl with other illicit drugs — in powder and pill form — to fuel addiction and create repeat business.”

With fentanyl’s rapid expansion into the illicit drug market, Yates says it’s irresponsible for hospitals not to test for it.

“We’re going to kill people if we don’t test for fentanyl,” she said.

“It’s the right thing to do,” said Lev, the addiction physician. “We’re having a Covid epidemic; we’ve been doing Covid testing. We’re having a fentanyl epidemic. Why aren’t we doing fentanyl testing?”

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