Fentanyl accounts for the majority of fatal overdoses. But ERs don’t test it.

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

Tyler Shamash.Family photo

Tyler was in and out of sober homes in Los Angeles after years of battling addiction, and his family suspected he might be taking illegal drugs. The doctor said they had done a standard drug test and fentanyl had not shown up on the toxicology screen.

Juli Shamash believes the doctor was unaware that fentanyl is not included in the standard testing routine in emergency rooms across the country. A typical drug testing team in most emergency rooms only tests for marijuana, cocaine, amphetamines, PCP, and natural and semi-synthetic opioids (like heroin and oxycodone) — but not synthetic opioids like fentanyl.

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Tyler Shamash overdosed again the next day and died. His family found out five months later, after the medical examiner did a toxicology report, that fentanyl was found in his system.

“I was so skeptical because you trust doctors. go to doctors for advice,” Shamash told NBC News. “It’s unbelievable to me that every institution doesn’t try it [fentanyl]. Why didn’t you? But then I think the answer to that is: They think they are.”

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

Charles and Julie Samas.
Charles and Julie Samas.NBC News

Overdose deaths related to fentanyl have surpassed those due to heroin or other opioids. In 2022, the Drug Enforcement Administration seized 50.6 million fentanyl-laced pills masquerading as regulated prescription pills like Xanax or oxycodone and more than 10,000 pounds of fentanyl powder. But there is no federal mandate that emergency rooms specifically test for fentanyl.

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

“Every time I hear about another kid dying, it’s like, why didn’t we go to them?” he said. “I don’t know if it’s… like I didn’t save my son so I feel like I have to save everyone else.”

He collaborated with Dr. Roneet Lev, an addiction emergency physician at Scripps Mercy Hospital in San Diego, who developed a toolkit to help other hospitals conduct fentanyl testing, which he said hospitals are already equipped with and is relatively inexpensive — it costs about 75 cents for add a reagent to test for fentanyl.

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

Dr. Roneet Lev.
Dr. Roneet Lev.NBC News

He sees patients every day who don’t know they’ve taken something laced with fentanyl. Now armed with the knowledge of the seriousness of the drugs they’ve used, Lev said patients “may want to change or do something different. They might throw away those pill bags… or it might lead 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 guidance is being considered.

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

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

Josh Sims.
Josh Sims.Courtesy of Melanie Yates

She was even more confused when she found an Epic Research study done in conjunction with the University of Maryland Center for Substance Abuse Research that showed only 5 percent of toxicology screens tested for fentanyl. When tests are conducted, positive rates for fentanyl approach 50% — more than three times the positive rate for opiates.

“How will we track 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’re taking fentanyl?” Yates said in an interview. “Drug addiction affects every race, every gender, every age, every socioeconomic group. There is no one who is exempt from this.”

More than 107,000 Americans died of drug overdoses in 2021 — the majority of them suspected to be from fentanyl, according to the CDC. The DEA warns on its website: “Drug dealers are increasingly mixing fentanyl with other illegal drugs — in powder and pill form — to drive addiction and create repeat customers.”

With fentanyl’s rapid expansion into the illegal 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,” he said.

“It’s the right thing to do,” said Lev, the addiction doctor. “We have a Covid outbreak, we tested for Covid. We have a fentanyl epidemic. Why aren’t we testing for fentanyl?”

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