Fentanyl accounts for the majority of fatal overdoses. But ER doesn’t test him.

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

Tyler had been in and out of sober houses in Los Angeles after battling drug addiction for years, and his family suspected he may have taken illicit drugs. The doctor said they did a standard drug test and the fentanyl didn’t show up in the toxicology screen.

Juli Shamash believes the doctor was unaware that fentanyl was not included in standard tests carried out in emergency rooms across the country. A standard drug test panel in most emergency rooms only checks 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 discovered five months later, after the coroner wrote a toxicology report, that fentanyl had been found in his system.

“I was so in disbelief because you trust doctors; you go to doctors for advice,” Shamash told NBC News. “It’s amazing to me that not all institutions test it [fentanyl]. Why wouldn’t you? But then I think the answer to that is: they think they are.

The death of her son in 2018 prompted Shamash to advocate for legislation that would require the addition of a sixth test for fentanyl. Thanks to 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 must expire in just five years.

Overdose deaths associated with fentanyl have exceeded those from heroin or other opioids. In 2022, the Drug Enforcement Administration seized 50.6 million fentanyl-containing pills posing as regulated prescription pills like Xanax or oxycodone and over 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 enacting federal legislation.

“Every time I hear about another child dying, it’s like, why didn’t we do it?” she says. “I don’t know if it’s… like I didn’t save my own son, so I feel like I have to save everyone.”

She teamed up with Dr. Roneet Lev, an addictions emergency physician at Scripps Mercy Hospital in San Diego, who developed a toolkit to help other hospitals perform fentanyl testing, which she said the hospitals are already equipped to do so and is relatively inexpensive – costing around 75 cents to add a reagent to test for fentanyl.

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

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

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 found out about the California law after going “down a search hole” when Josh’s initial toxicology report came back showing only cocaine – even though his family had found fentanyl in his apartment.

She was further baffled when she discovered an Epic Research study done in conjunction with the University of Maryland’s Center for Substance Abuse Research that indicated that only 5% of drug screeners tested for fentanyl. When testing takes place, positivity rates for fentanyl approach 50%, more than three times the positivity rate for opioids.

“How are we going to track fatal and non-fatal overdoses? How are we going to build systems around data that we don’t have? How are we going to tell people who don’t know they’re taking fentanyl? Yates said in an interview. “Drug addiction impacts all races, all genders, all ages, all socio-economic groups. There is no one who is free from it.”

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

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

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

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