When New York City's overdose prevention center detects an unusually potent bag of illegal fentanyl, it quickly sends out a "bad batch alert" on the "canary network" to warn other drug users of the urgent danger.
Staffers walk drug user encampments in East Harlem, Washington Heights and the South Bronx to spread the news. Word goes out on social media. The city's health department is notified, along with other organizations.
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With nearly 300 people in the United States dying of drug overdoses every day, authorities are hoping to make a dent in the crisis by sharing information in real time - or as close as they can get - to predict where the next cluster of deaths may be and prevent at least some of them.
"We've had [drug users] come in and say, 'Oh, man, I heard about this,'" said Sam Rivera, executive director of OnPoint NYC, which runs the only two sites in the United States where people can use illicit drugs under supervision to prevent overdoses. "They're not saying, 'I'm not going to use it.' But they're saying, 'I'm going to use it here and be safe.'"
OnPoint NYC's approach is one of many attempts to warn large numbers of users about the imminent threat of fatal overdoses from the opioid fentanyl and other drugs laced with it. In a nation where overdose deaths have quintupled in the past two decades, reaching nearly 107,000 in 2021, a wide range of ideas is under consideration.
Cities around the country are examining their wastewater for opioids and other drugs. Academic researchers are sifting drug-related chatter on Reddit. Others are combing dispatches of first responders for patterns. In addition to funding many of the experiments, the federal government has launched its own program to track and share information on nonfatal overdoses, which have proved to be a reliable predictor of individual fatal overdoses.
Many of these projects are nascent and most suffer from time lags, lack of coordination or information gaps. But researchers believe the day may come when some combination of these efforts helps curb the epidemic of overdose fatalities. Nothing else, they argue, has worked - including the long, costly effort to keep drugs out of the country.
"Strengthening the infrastructure for surveillance of drug use definitely will have an impact in reducing overdose deaths," said Annick Borquez, an assistant professor in the division of infectious diseases and global public health at the University of California at San Diego, who studies such programs.
Walking the streets to warn users may be the most labor intensive of the efforts, but Rivera believes it saves lives. OnPoint NYC's two centers also have prevented 701 overdose deaths since they opened 14 months ago by intervening with oxygen and naloxone inside the centers, where they monitor drug users, he said.
OnPoint NYC staff are aided by dealers' habit of stamping or marking their product in some way, to distinguish it from competitors' drugs. That allows staff to identify drug batches that may endanger users.
The nonprofit's drug-testing equipment has become so well known, he said, that more affluent users of cocaine and other stimulants are bringing their drugs to the organization for testing on its mass spectrometer, because fentanyl has infiltrated so much of the drug supply. The device is one of three operated by New York City.
"Early in the morning, we're seeing a lot of nice cars," he said.
Boots on the ground and drug sampling, he argued, are the best way to prevent overdoses, a theory supported by some research, said Jon Zibbell, senior public health analyst in the behavioral and urban health program at RTI International, a North Carolina think tank.
"If we acquire real-time information on the local drug supply from community-based drug checking services ... these data can indeed predict ODs down to the county and municipal level, and with more speed and accuracy" than other methods, he wrote in an email.
The sharing of drug testing results has long occurred in some places. Since 2019, a test-and-text service called Bunkbot has operated at music festivals, notifying its users about dangerous, adulterated drugs. But testing sometimes operates in a legal gray area and can be expensive. The machine OnPoint NYC uses costs $40,000, which is too expensive for smaller, more rural health departments.
And few communities want overdose prevention centers, for fear they will become magnets for drug use and crime.
Other experiments are also underway. In December, federal drug czar Rahul Gupta launched the Non-Fatal Opioid Overdose Tracker, which uses EMS call data to compare county and state overdose information with a national average. The data does not pinpoint precisely where overdoses are happening and it has a two-week time lag. But anyone can view it to identify areas where tainted drugs may be circulating.
The federal government also operates a more granular map that is not available to the public called The Overdose Detection Mapping Application Program, a dashboard for 4,100 agencies across the United States, including law enforcement and emergency medical responders. That map updates with data on nonfatal overdoses as soon as they are recorded. It alerts authorities to county-level spikes in overdoses over a rolling 24-hour period, said Jeff Beeson, deputy director of the High Intensity Drug Trafficking Areas program, also run by Gupta's Office of National Drug Control Policy.
When the map flashes a warning of a spike in overdoses, paramedics in that community might increase shifts to reduce response times, he said. Police can be on the lookout for possible overdoses. Health departments may alert communities to deadly batches of drugs, or a higher-than-normal number of overdoses. More drug users and their families may be willing to carry the opioid antidote naloxone or avoid certain drugs.
"The public knowing what's going on in real time is greatly, greatly beneficial to lifesaving efforts," Beeson said. "The more information we have, the better we are."
But information gaps persist in most small and rural health departments, which do not have advanced tools, said Lori Freeman, chief executive of the National Association of County and City Health Officials.
Just as incomplete, messy data hampered the early response to the coronavirus pandemic, they have hurt the response to the overdose epidemic, she said.
"Being the most developed country in the world, we have one of the least developed public health data systems," Freeman said. In many European countries, Borquez said, surveillance of drug use is more advanced, even though the drug problem isn't nearly as severe.
Some experts are hopeful the new federal dashboard of nonfatal overdoses will encourage emergency responders to improve their reporting.
It has been slow to get off the ground, however. Members of the National League of Cities had not heard about the dashboard in advance of its release, and they have yet to be trained on how to use the data, officials said. "Awareness of this is quite low," said Sue Polis, the group's health and wellness director.
Some communities had already figured out how to use locally generated data. Health officials in King County, Washington, where Seattle is located, created a public dashboard in August 2019 that tracks fatal and nonfatal overdoses in real time, using medical examiner and EMS data, said Brad Finegood, a strategic adviser for public health for the city and county.
Users can see how areas of the county performed over the previous two months, which Finegood said is a better measure than the federal dashboard's comparison to a national average. "It doesn't help me to be compared to any other jurisdiction," he said. "What's happening here is what's happening here."
The King County tracker also shows changes in the drug supply, such as an inundation of light blue pills resembling Mallinckrodt's oxycodone tablets but containing fentanyl. More recently, health officials sent alerts about a cluster of overdoses from white fentanyl powder, Finegood said.
"We don't want to scare people," he said. "We want to inform people concretely about what's happening."
Some local efforts are more unusual: In 2017, Baltimore launched an anonymous text-alert system to warn people of "bad batches" of drugs, thanks to video game programmer Michael LeGrand, co-founder of the local nonprofit "Code in the Schools," which teaches city students computer science skills. The service, in coordination with the city's health department, analyzes data from EMS reports of nonfatal overdose spikes on a one-day lag. People can text "JOIN" to 443-201-7598 to receive the updates.
Ohio State University student Pranav Padmanabhan and others created SOAR Columbus, which has received reports of glass found in methamphetamine, and counterfeit Adderall pills laced with fentanyl - warnings that could save the lives of college students experimenting with drugs. The team has since expanded the service to everyone in Ohio.
The most widespread effort by cities and counties analyzes local wastewater for drugs to help communities assess the scope of their drug problems and the types of drugs consumed.
Private companies, such as Biobot Analytics of Cambridge, Mass., are part of the wastewater testing effort. Other programs that pull data from a variety of places are publicly funded, including the National Drug Early Warning System, a two-year-old collaboration run by three universities.
"What we're doing is looking for signals," said Linda B. Cottler, a professor of epidemiology at the University of Florida and NDEWS director. "But then what do we do when we get them? We have spent our time looking for ways to get the freshest data. Because what happened two years ago doesn't matter."
In Cary, N.C., an affluent suburb of Raleigh that is home to many people who work in the area's Research Triangle, wastewater collected from city sewers showed a fairly low level of opioids compared with other communities. But it was enough to persuade officials to launch a public information campaign and step up distribution of naloxone to first responders.
"Here's where we're at, and let's just stay there," Town Manager Sean Stegall said.
Marin County, Calif., will draw the first samples from its wastewater treatment plant the week of Feb. 6, intending to establish baseline levels of cocaine, fentanyl, methamphetamine and nicotine, said Haylea Hannah, a senior member of the county's epidemiology team. Later changes in results could trigger responses, she said.
While the same information can be gleaned from drug seizures, 911 calls and overdose death statistics, it arrives too late to warn unsuspecting drug users. The turnaround time for wastewater is a few days at most, and the information will be paired with the other data, she said.
Wastewater testing offers other advantages, Hannah said. Samples come from the wastewater of thousands of people, she said, making it useless for targeting individuals violating drug laws.
Even more valuable than being able to respond quickly to new drug use patterns would be the ability to predict them ahead of time. That's the goal of Elan Barenholtz, an associate professor of psychology and complex systems at Florida Atlantic University, and doctoral student Paul Morris.
Morris created a system that uses machine learning to analyze thousands of daily comments in Reddit forums about emerging drugs and how people experience them.
A study they published in the International Journal on Drug Policy showed they found seven drugs discussed online before they turned up in drug overdoses or intoxications.
"We found out that what we're seeing on Reddit was really predictive of toxicology," Morris said. Their reports are read by law enforcement analysts and first responders, among others, Barenholtz said.
Recently, they have been watching discussion of the synthetic opioid U-47700, a powerful analgesic made in China. It has turned up in the United States occasionally since the middle of the last decade and has been implicated in several fatalities. The occasional mention concerns Barenholtz and Morris, because it might signal renewed interest in the drug.
"The Reddit is really supposed to be a canary in the coal mine," Barenholtz said.
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