HORSHAM, Pa. — Inside the sprawling complex of NMS Labs in Horsham, scientists are mapping the contours of a crisis.
The toxicology lab, one of the largest in the country, tests blood and tissue samples for a host of substances, helping clinicians, law enforcement, and medical examiners’ offices investigate everything from suspicious deaths to suspected arsenic exposures.
But over the last decade, as the overdose crisis has worsened, the lab — which also has branches in Texas and South Carolina — has been steadily cataloging overdose deaths in the hundreds of thousands of samples it receives each year.
Now, the lab’s nonprofit arm, the Center for Forensic Science Research and Education, is partnering with the Philadelphia Department of Health to help officials learn more about the city’s drug supply — which is increasingly contaminated with synthetic opioids such as fentanyl, and newer additives such as the animal tranquilizer xylazine. Nearly all of the city’s overdose deaths now involve fentanyl, which was once considered a rare, powerful additive to the region’s otherwise pure heroin.
And more Philadelphians — 578 in 2020 alone — are dying from overdoses with both opioids and stimulants such as cocaine in their system. That could mean that some drug users are combining substances for an enhanced high, or that they’re unknowingly ingesting stimulants contaminated with an opioid. CFSRE researchers have tested cocaine samples from Philadelphia that contained fentanyl as recently as May.
“Each case is like a mini research project — particularly nowadays, where there are multiple drugs, and you don’t necessarily know what’s in any given case,” said Barry Logan, the chief scientist at NMS and executive director of CSFRE. “We can help bring some resolution to a death investigation, and help bring some closure to families.”
Logan, who also is senior vice president of forensic sciences at NMS, has worked at NMS for nearly 15 years, and recalls when fentanyl — the powerful synthetic opioid that’s replaced most of Philadelphia’s heroin, and is driving a nationwide wave of overdose deaths — rarely turned up in the lab’s death investigations.
“It was almost all coming from medicinal fentanyl,” usually patches that are prescribed for extreme pain, Logan said. “People were chewing them, smoking them, squeezing the gel out of them to ingest, but the cases were few and far between. Heroin was the predominant opioid that was killing people.”
Then illicit fentanyl, manufactured on the black market, began making its way into the drug supply. Now, about 30,000 of the 200,000 death cases NMS investigates each year involve fentanyl, Logan said.
They also began to see a rise in polydrug overdoses — cases linked to two or more drugs. Sometimes, drug users were taking different substances at the same time to enhance a high. Other times, they were unwittingly sold dangerous combinations of drugs they weren’t used to or didn’t expect to ingest.
In 2018, NMS helped test drug samples linked to an overdose spike that sickened more than 100 people in Kensington. Researchers tested drugs branded “Santa Muerte” — Holy Death — that dealers had advertised as pure heroin. Instead, they were found to contain fentanyl, heroin, and a synthetic cannabinoid.
NMS and CSFRE’s work helps law enforcement and medical examiners track overdose deaths, but it also helps public health officials learn about the extent of contaminants in the drug supply. The lab’s equipment can detect not just the presence of a given contaminant, but also its potency — something most municipal crime labs aren’t sophisticated enough to handle.
“In terms of drug possession, laws are typically written with respect to aggregate weight,” Logan said. “If you have a gram of white powder, and it tests positive for cocaine, you’ll be charged with possession of a gram of cocaine. The law doesn’t require that you figure out how much of that powder was actually cocaine and how much of it was, say, sugar. But in terms of public health, it’s helpful to notice how variable the drug supply is.”
Since November 2020, researchers at CSFRE have been testing samples collected by the Philadelphia Health Department, and working with outreach workers in Kensington to interview drug users about their experiences with contaminants. The partnership is funded by a grant from the Centers for Disease Control.
Between March and May, the nonprofit tested 90 drug samples from Philadelphia. Almost every “dope” sample — a catch-all term that the department uses to describe anything sold as heroin or fentanyl — contained both fentanyl and xylazine, Logan said.
That tracks with recent research on the city’s drug supply, as well as anecdotal evidence from drug users. Xylazine, an animal tranquilizer that’s not approved for human use, can suppress breathing, just like fentanyl, making the two a potentially deadly combination. And drug users have reported painful, prolonged withdrawal symptoms and serious skin infections after using xylazine.
CFSME found that the average dope sample from Philadelphia comprised about 20% to 40% xylazine, and about 2% to 10% of fentanyl, Logan said. Fentanyl was also present in a handful of cocaine samples, another concern for stimulant users who aren’t used to opioids.
Jen Shinefeld, a field epidemiologist for the Philadelphia Health Department, said the partnership has allowed city officials to warn drug users, outreach workers, and hospitals about the presence of new or unexpected drugs in the city’s supply.
The lab work alone isn’t enough to keep drug users safe, but it does help officials and drug users better understand what’s on the market.
“There’s always the issue surrounding the fact that it’s lab-based testing, and not point-of-care,” Shinefeld said. Health workers can learn from lab testing that a certain bag of dope contained 20% fentanyl, but by the time the testing is done, that batch has usually been distributed and used, she said.
Still, she said, intel from the lab has helped hospitals and outreach workers better understand how different drugs may be affecting patients and provide more effective treatment. Before the drug testing program, field workers such as Shinefeld could only conjecture that xylazine was causing the intense withdrawals and serious skin infections that drug users were reporting.
“Now, with confidence, we can say, ‘This is the xylazine,’” she said. “And while all the terrible things are still happening, it’s empowering [for people who use drugs to know that]. When they go into treatment or a medical facility, they have the information to tell doctors what they’ve been using.”
It’s important, Logan said, for public health officials and drug users to know as much as they can about the local drug supply — especially as overdoses involving multiple drugs increase. And as deaths in Philadelphia have reached an all-time high, time is of the essence.
“The goal, eventually, is to be able to do routine quantitative testing of these drugs, so that you can detect when the supply starts to get more potent, or more dangerous,” Logan said. “And the faster you can get this information out, the more actionable it is in terms of educating drug users about its harms.”
