To mark National Fentanyl Awareness Day on May 9, Gov. Glenn Youngkin tasked the Virginia Department of Health with harnessing existing wastewater monitoring infrastructure in order to flush out fentanyl across the state. The directive is one component of a 10-step executive order to crack down on the manufacture and distribution of the powerful synthetic opioid in Virginia.
Fifty to 100 times more potent than morphine, fentanyl killed nearly 2,000 Virginians in 2022, slightly down from 2,600 in 2021. While Virginia’s drug overdose mortality rate is lower than surrounding states, more Virginians have died from fatal drug overdoses than motor vehicle and gun-related deaths combined each year since 2020, the Department of Health’s Office of the Chief Medical Examiner reported. The agency’s preliminary analysis of overdose deaths found fentanyl caused or contributed to more than three-quarters of fatal overdoses last year.
“What we’re looking for are spikes, and spikes that will also tell us about the potency of the fentanyl that’s in the water system,” Secretary of Health and Human Resources John Littel said in an interview. “Our hope is that we can be more quick in how we respond to fentanyl in communities.”
The directive to track the presence of illicit drugs marks an evolution in wastewater monitoring, a once obscure epidemiological process that expanded exponentially during the pandemic. This would be the first time Virginia has moved from infectious disease monitoring to drug surveillance.
In 2021, the Department of Health received an Epidemiology and Laboratory Capacity grant from the Centers for Disease Control and Prevention to monitor rates of COVID-19 throughout the state. Since then, Virginia’s wastewater surveillance program has grown to monitor other infectious diseases including influenza, RSV, mpox and, in some locations, local fungi.
Water from residential and commercial toilets, showers, kitchen and laundry flows into wastewater treatment plants, where samples are collected before any significant treatment takes place. The Virginia Department of General Services’ Division of Consolidated Laboratory Service tests the samples and transfers results to the Department of Health, which analyzes the results to better track rates of infectious disease — and, under the new program, eventually fentanyl — in communities.
Virginia’s infectious disease wastewater monitoring program collects samples from 36 of the state’s 1,250 wastewater treatment plants each week. While that number seems small, samples from more than one-third of the state’s population are captured under the current program.
Fourteen of the 36 wastewater treatment plants that currently provide samples for COVID-19 monitoring are in Southwest Virginia: Blacksburg, Clintwood, Coeburn-Norton-Wise, Hillsville, Lebanon, Low Moor, Lower Jackson, Lynchburg, Pepper’s Ferry, Pound, Roanoke, Rocky Mount, Tazewell and Wolf Creek.
The fentanyl wastewater monitoring program is voluntary, Julie Henderson, director of the Department of Health’s Office of Environmental Health, said. She said participating wastewater treatment plants and potential changes to sampling methods were “TBD,” to be determined.
The governor gave the Department of Health 120 days to develop a strategy to monitor fentanyl in wastewater, and the department is in the early stages of evaluating the capacity of the existing wastewater monitoring program and crafting a response strategy.
Littel laid out a bird’s-eye view of the proposed three-pronged response to any observed “spikes” in the frequency, potency and occurrence of fentanyl: law enforcement intervention, prevention campaigns and additional treatment resources for impacted communities.
“With the COVID pandemic, there was a significant acceleration in that decrease in life expectancy. And opioid use disorder is one of the primary reasons that our life expectancy is going down. So, from a public health perspective, this is a crisis that we must deal with and having a multi-pronged approach is the only way forward,” said Dr. Cynthia Morrow, health director for the Roanoke and Alleghany Health Districts.
Targeting users for criminal prosecution is “not really all that helpful,” Littel said, emphasizing efforts to expand access to treatment such as naloxone, the nasal spray commonly known as Narcan that’s been a game changer in reversing opioid overdoses.
“We are not focused on going after the users, we are focused on going after the dealers and the distributors,” Littel said. “We want to make sure that we maintain privacy.”
“We really need to emphasize that these are population data, they’re community-wide data. These are not data that can be looked at at an individual level,” Morrow said.
Public awareness campaigns are a major focus for the overall efforts of the Department of Health, which has requested $5 million this year to launch a fentanyl awareness campaign.
“I think one of the things that we need to continue to do is primary prevention, so working with making sure that we stop people from developing substance use disorder in the first place,” Morrow said.
The department also asked for $7 million to expand free provision of naloxone, up from $3 million the previous year. The Department of Health will soon release a request for proposals for the production of naloxone to ensure a low-cost, readily available stockpile.
Littel urged anyone who witnesses an overdose to contact emergency responders right away. He cited Virginia’s Good Samaritan law, which protects anyone who reports an overdose to authorities from misdemeanor drug possession and intoxication charges.
“If you call the police, if you call 911 and they come, you are not at risk. You are not going to be arrested for using drugs because you called to save someone,” Littel said.
Littel said he was “surprised” by the public attention on the wastewater monitoring component of the executive order, calling it an “obvious” tool to combat illicit fentanyl. Morrow called wastewater monitoring “one of many tools in my surveillance toolbox.”
There are some limits to using wastewater to track spikes in fentanyl, including the novelty of the program. Henderson said the department was looking to other states and counties across the country as models to help assess outstanding questions on the best methods for sampling and new resources that might be needed.
Other states and counties are beginning to experiment with the idea of wastewater monitoring of illicit drugs. California’s Marin County, north of San Francisco, launched a pilot program in February to test wastewater samples for substances including methamphetamines, cocaine and nicotine. Delaware’s New Castle County introduced its own plan to test wastewater for these drugs last month.
There are also simply limits to what community-level data can convey about the frequency, potency and occurrence of fentanyl within a population.
“It’s unbiased, objective, but it is community-level, population-level, which makes any type of causal association challenging,” Morrow said.
On-site septic tanks are also not included in wastewater sampling. Approximately 30% of Virginians dispose of their wastewater using a septic system, particularly in rural areas, which means that wastewater will not flow into the treatment plant.
Other limitations include the prescription of legal fentanyl for pain management and heavy rains that may dilute sewersheds. Additional limitations will be studied and identified as the Department of Health crafts its plan to execute the new fentanyl wastewater monitoring program.
Ultimately, public health officials express optimism about the program’s potential to shed light on prevalence of fentanyl in populations across the state.
“We need to get as much data from as many different sources in as timely a manner as we can so that we can make the best policy decisions,” Morrow said. “I can’t emphasize how important it is to me as a public health professional to get as much data as I can that is timely and valid.”
“The process is there. The partners are there. The science is there. It was just like, hey, this is a tool that could actually contribute. Let’s see how it works,” Littel said.