ArticleSubstance abuse treatment, prevention, and policy2026
The positivity rate of opioid drug urine testing in an emergency department between 2016 and 2024, before and after the introduction of fentanyl testing.
Article in Substance abuse treatment, prevention, and policy, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundDespite all Health Maintenance Organizations in Israel having documented an increased use of prescription opioids, a decrease in admissions with positive opioid toxicology was observed in emergency departments (EDs). We hypothesized that following the fentanyl test introduction in 2023 in the largest acute care facility in Israel, opioid detection and naloxone usage would increase, and death rates would decrease.
methodsBetween 2016 and June 2024, 20,337 ED-admitted individuals were screened for drugs via urine toxicology tests. Opioid trends, their characteristics, the administration of naloxone, and death rates were analyzed. The pre- and since fentanyl testing initiation periods were compared.
resultsThe proportion of individuals screened via urine toxicology increased from 0.7% in 2016 to 1.3% in 2024. Individuals screening positive for opioids were predominantly male, older-aged, non-Israeli born, with opioid and benzodiazepine prescriptions, screened positive for other substances, naloxone-treated, hospitalized, and had a higher death rate. Excluding fentanyl results, the proportion of opioid-positive tests decreased from 15.4% in 2016 to 11.6% in 2024, but when including fentanyl (available since 2023), the proportion in 2024 was 14% and did not show a significant trend. A higher opioid proportion was observed at the period with fentanyl tests (2023–2024) (12.7% vs. 10.4%, p < 0.001) with no differences in death within first day rate (0.8% vs. 0.5%, p = 0.1) and naloxone usage (3.4% vs. 3.8%, p = 0.2). During the fentanyl testing period (2023–2024), among those receiving naloxone, a higher opioid proportion observed when fentanyl testing was included (56.7%) than excluded (45%).
conclusionsAs was hypothesized, a gradual decrease in opioid-positive tests was attenuated after the fentanyl test was introduced. Given the absence of evidence for a large-scale illicit fentanyl market in Israel, fentanyl exposure is likely to originate primarily from legally prescribed medications, which may reflect a tendency to prescribe fentanyl more often than less potent opioids (hence not detected before the fentanyl test was added). Additionally, the higher opioid positivity among naloxone-treated patients observed after the fentanyl test was introduced supports the need to add fentanyl to the urine toxicology test battery in all EDs across the country. Still, stable low death and naloxone-use rates suggest no impact on overdose diagnosis and treatment. CLINICAL TRIAL NUMBER: Not applicable.
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