Fentanyl is claiming lives across North Texas, so why aren’t more people tested for it?

By Claire Ballor and Sharon Grigsby

Drug users switch to fentanyl and pass court-ordered drug tests. Courts lecture first-time drug offenders on the dangers of fentanyl but don’t screen them for it. Emergency rooms send overdose patients home without testing them for the substance driving the nation’s drug crisis.

These are several of the alarming gaps in fentanyl drug testing The Dallas Morning News found during months of reporting this year on the synthetic opioid’s deadly impact across North Texas. While fentanyl is linked to more deaths of Americans under the age of 50 than any other cause, The News’ reporting for its “Deadly Fake” series revealed the inconsistency and infrequency with which fentanyl is tested for in many medical and judicial systems.

Interviews with more than 20 toxicologists, medical professionals, researchers, judicial experts, local officials, drug prevention advocates and families revealed a little-understood fault line in the war on fentanyl.

The lack of widespread testing for fentanyl is especially concerning given that the drug is often disguised as other substances and its users aren’t always aware they’re taking it, according to many of the experts interviewed. Fifty times more potent than heroin and far cheaper to manufacture, fentanyl has become the most powerful, dangerous and pervasive drug on North Texas streets.

The reasons for the gaps in testing are complex. They range from municipal budgetary constraints to a confusing federal regulatory environment that, until last month, didn’t permit rapid fentanyl testing in clinics or hospitals.

Three major national drug policy organizations in the fight against fentanyl — the National Institute on Drug Abuse, the Substances Abuse and Mental Health Services Administration and the White House’s Office of National Drug Control Policy — did not answer The News’ questions about the state of fentanyl testing.

Sixteen days after The News contacted the Food and Drug Administration to request an interview on its testing regulations and the lack of a rapid fentanyl test for clinical use, the department announced Oct. 27 that it cleared the first over-the-counter rapid fentanyl test for use in all settings.

“This test is an example of the FDA’s continued commitment to authorize tools that can reduce deaths associated with overdoses,” Jeff Shuren, director of the FDA’s Center for Devices and Radiological Health, said in a written statement.

The agency expedited clearance of the test and made a decision 16 days after it was submitted for review by the manufacturer, Shuren said.

The FDA would not grant an interview to The News to discuss fentanyl testing. Its press officer said it would respond to written questions for basic explanations of current regulations. Those questions were submitted Oct. 19; the FDA provided answers a week after it announced the test.

The newly cleared urine test, the type experts in the medical community have been asking the FDA to approve for at least three years, eliminates one of the obstacles to fentanyl testing in clinical settings. But it’s not a cure-all.

While drug testing is regulated by the FDA in medical settings, no such governing body oversees testing in judicial settings, where drug testing is a crucial part of probation and court programs designed to help offenders with substance-use disorder. Instead, testing is dictated by budgets and financial constraints, creating a patchwork of approaches. For example, of the four largest counties in North Texas, only Collin County’s judicial system tests all drug offenders for fentanyl.

Without widespread fentanyl drug testing in clinical and judicial systems, lives are at stake, said Stefanie Turner, who founded Texas against Fentanyl after losing her teenage son Tucker to the drug.

“If we can’t identify what the problem is — the depth of it — how can we defeat it?” said Turner, who advocated for the passage of Tucker’s Law this year to require drug education in Texas schools.

“It’s crazy how little has been done.”

Drug tests should reflect ‘what we see on the streets’

Before the FDA cleared the over-the-counter rapid fentanyl test in October, hospitals and clinics could only test for fentanyl if they had their own accredited lab, if they sent urine samples to a third-party lab, or if they bought a recently FDA-approved point-of-care chemical analyzer machine.

For years, many in the medical community have called for an affordable rapid fentanyl test. Doctors need to know in minutes, not days, if a patient is taking fentanyl, especially because many people who overdose think they are taking a drug like Percocet or Xanax, not realizing a high percentage of drugs sold on the street are fentanyl in disguise. Patients may need to start carrying the overdose reversal medication naloxone and need to warn friends who are using the same pills.

“The medical community needs the appropriate tools and data to fight the fentanyl crisis,” a group of San Diego doctors wrote to federal regulators citing all these reasons in 2020.

The newly approved test, which requires a few drops of urine to screen for fentanyl, answers that demand, but some medical experts caution against relying on it.

“Fentanyl is cleared very quickly from the system,” said Dr. Ibrahim Hashim, medical director for clinical chemistry at Dallas’ Parkland Memorial Hospital. “In three to four days, it’s gone.”

After fentanyl is ingested, 90% of it is metabolized into norfentanyl, which the rapid fentanyl test — unlike more detailed lab tests — cannot detect.

“It’s a step in the right direction,” Hashim said of the rapid test, but “there will be a lot of false negatives.”

Despite the limitations of rapid fentanyl tests, they are an important tool for drug treatment centers.

When Nyah Berrios, a woman who told The News her story of overcoming fentanyl addiction while pregnant, first checked into an Abilene treatment clinic in early 2021, she was drug tested and was told there were no drugs in her system.

“Are you sure you have a drug problem?” she recalls a clinic staffer asking her.

She was sure. Before walking through the clinic doors, she took one of the Percocet pills she’d gotten hooked on, Nyah told the staffer.

The woman asked Nyah if she had ever taken fentanyl.

“I don’t know what that is,” Nyah said.

Her urine was tested for fentanyl and it came back positive. She was addicted to a drug she never even knew she had taken.

A growing number of people who show up at Nexus Recovery Center, a women’s in-patient treatment clinic in Dallas, are addicted to fentanyl without knowing it, CEO Heather Ormand said.

When clients arrive at Nexus for detox, staff members need fast analysis of the drugs in the women’s systems to make the right clinical decisions and correctly monitor their withdrawal. Fentanyl, for example, requires a different detox approach than other opiates because of its short-acting properties.

Nexus uses rapid urine analysis tests for all of their drug testing. Results that require a closer look are sent to a lab for confirmation.

“I can’t imagine how a medical detox can be done correctly without testing for fentanyl,” Ormand said.

To understand how fentanyl testing is conducted in hospital settings, The News contacted Parkland and two other local Level I trauma centers. Methodist Dallas Medical Center did not respond to multiple queries, and a Baylor Scott & White Health spokesperson said the hospital system conducts fentanyl testing on a case-by-case basis.

At the 882-bed Parkland, Dallas County’s only public hospital, fentanyl testing has been in place since June 2022. The hospital spent several months reoutfitting its on-site lab to test for fentanyl after it began to see a spike in usage in the community.

Since then, Parkland has tested 3,765 urine samples for fentanyl, and 30% have come back positive, said Hashim. “We are more or less screening anyone who is presenting with symptoms.”

The hospital should test for fentanyl in every drug test it conducts considering the drug is an epidemic in the city, Hashim said, but they first need to implement confirmation fentanyl testing, which is an even more detailed testing procedure that can rule out false positive results. The hospital is putting those procedures in place, he added.

Hashim said he’d also like to see accrediting agencies such as the FDA formally recommend that hospitals and clinics test for the drugs circulating in their communities.

The federal government and many private companies use a five-panel drug test, which dates back to the 1980s. The test, called the “federal five,” includes amphetamines, cocaine, marijuana, phencyclidine and opiates. This five-panel test, which does not detect synthetic opioids such as fentanyl, is the standard panel used by many organizations and labs today.

“We need to have a process where that magic five is updated every now and then, reflecting what we see on the street,” Hashim said.

‘Why in the world would they not be testing for that?’

While federal regulations control fentanyl testing in medical settings, budgets and financial constraints drive screening decisions in courtrooms and probation departments. No governing body regulates what kinds of tests are used or what circumstances trigger the tests in the judicial system. Instead, screening is a patchwork of approaches.

Testing for the substances circulating in a community is imperative for local court systems and their programs, said Paul Cary, a consultant for All Rise, formerly the National Association of Drug Court Professionals.

“If fentanyl is the No. 1 substance of abuse and you aren’t testing for it, your program is pointless,” said Cary, who for more than three decades was the scientific director of the Toxicology and Drug Testing Laboratory at the University of Missouri.

Regardless of FDA regulations, probation departments and court programs can use the much more affordable rapid fentanyl tests. But many don’t, often because of the red tape involved in changing policies and procedures.

Some systems struggle to adapt as newer drugs take hold in the community, Cary said, but without testing, it’s hard to curb an epidemic. “The sooner you respond to undesirable behavior, the more likely you are to change that behavior,” he said.

One Fort Worth mother’s ordeal due to the absence of across-the-board fentanyl testing in Tarrant County illustrates Cary’s point.

Ricki Ferrell watched helplessly for two years as her daughter moved about their home like a zombie, her face coated with the sooty remains of the fentanyl she smoked off strips of tin foil.

Ferrell, who spoke to The News on the condition that her daughter not be publicly identified, said she spiraled into opioid addiction after being prescribed hydrocodone after a car accident at 17. The past decade had been a blur of detox centers, treatment programs, halfway houses and courtrooms, Ferrell said.

Her daughter regularly took drug tests as part of her probation on a 2021 drug charge. She passed them all, Ferrell said, even though she was a daily fentanyl user.

On Sept. 18, shortly before the end of her probation, Ferrell’s daughter overdosed. Ferrell brought her home from the hospital and helplessly watched her walk right back out the door to find more drugs. Then she got a hold of her probation officer.

It was then Ferrell learned the probation department had not once tested her daughter for fentanyl. “Why in the world would they not be testing for that?” Ferrell said. “Fentanyl is everywhere.”

After Ferrell pleaded with the probation officer to do the test, her daughter was finally screened for fentanyl. She failed the test, and her probation was extended another year as a result. When she failed a second test, Ferrell said, the probation officer gave her daughter two choices: enter an in-patient rehab or go to jail. The 30-year-old is now in rehab.

The Tarrant County Community Supervision and Corrections Department declined to comment on this case but told The News it tests some offenders for fentanyl on a case-by-case basis.

Department director Cobi Tittle said the county’s drug-testing vendor relies on lab-based tests. She declined to provide additional information, including what percentage of drug offenders in the county are tested for fentanyl.

Collin County’s probation department took on the added expense of across-the-board fentanyl lab testing in February because of concern about overdose trends, Yoon Kim, director of its Community Supervision and Corrections Department, said in an email.

The cost increase was significant, Kim said, because “the cost of a fentanyl panel can be close to $24 to $27, but we only charge drug court and substance-abuse caseload offenders $10 for a urine-analysis test.” In September, he said, the probation department ordered 455 fentanyl tests through its vendor; nine came back positive.

Drug testing costs fluctuate depending on a probation department’s testing vendor or contract. Funding from the state and fees paid by the offenders who must submit to testing covers a portion of the expenses. Each department picks up the tab for the rest, including for offenders who can’t pay.

In Denton County, the drug treatment court requires everyone in its program be routinely tested for fentanyl, said Toby Ross, director of the Community Supervision and Corrections Department.

In all other Denton courts — including the first-offender drug court — and for offenders on probation, fentanyl is not part of the lab-tested drug panel, Ross said, but it can be added if a judge or probation officer asks for it.

“Fentanyl is killing people like no other drug has, so we take this seriously,” Ross said. “We just try to be strategic in our testing.”

Ross cited cost and demand — only 3% of all fentanyl tests done since last year have come back positive. The fentanyl test adds $7.25 to the $20.75 for the basic screen, he said.

If every drug screen included fentanyl, the probation department would pay an extra $225,000 annually, Ross said.

Dallas County’s specialty drug courts and probation department, which only occasionally order fentanyl screens due to cost, expect the drug to be included in their standard test by early next year.

Unlike other large North Texas jurisdictions, Dallas County uses rapid drug tests. Positive results are confirmed with a lab test.

“Not nearly enough” fentanyl testing is being done in the drug courts, said Julie Turnbull, chief of the Restorative Justice Division in the Dallas County district attorney’s office. From Jan. 1 through Oct. 10 of this year, of 6,177 samples collected, six were tested for fentanyl, she said. Of those six, two tested positive. “One-third were positive for fentanyl,” Turnbull said. “That number really scares me.”

Arnold Patrick, director of the Dallas County Community Supervision and Corrections Department, said his operation spends more than $360,000 annually on drug tests, which includes add-on screens for fentanyl when necessary. He said including those fentanyl tests in all drug testing would double the cost.

In recent weeks, the county’s drug-testing vendor has begun offering a new rapid test that includes fentanyl as part of the panel, and Dallas County will switch to it — perhaps even sooner than early 2024. “It will be a cost increase, but it won’t be that much,” Patrick said.

The new test can’t come too quickly. “We know our clients are using fentanyl because they know we aren’t testing for it,” Turnbull said. “This is a very dangerous drug for them to be playing that kind of roulette game with.”

‘How do we catch up?’

As Parkland and the Dallas County judicial system work to implement across-the-board fentanyl testing, the health department plans to use funds from a nationwide opioid settlement to staff and equip a new lab building next year.

Department director Dr. Phillip Huang hopes to conduct FDA-approved fentanyl tests for various local operations that otherwise have to send urine samples out of state.

Huang’s office also has partnered with Parkland on a “urine pooling” project for 2024. Similar to researchers testing wastewater to detect viruses such as the one that causes COVID-19, urine submitted for drug testing would be pooled and tested to identify the drugs circulating in the community.

“The more information we have, the better,” Huang said. “We are always looking for additional data sources.”

Other efforts around the country to expand fentanyl testing have yielded new laws. In California, legislation known as Tyler’s Law went into effect Jan. 1 requiring hospitals to test for fentanyl anytime a urine drug screen is ordered. A similar law in Maryland went into effect Oct. 1. No such legislation has had serious consideration in Texas.

The gaps in fentanyl testing have lingered for years, which points to a larger problem: Illicit drug manufacturers are far ahead of the testing landscape.

That is part of the argument made by researchers at the University of Tennessee Institute for Public Service who published a white paper in March calling for rapid testing for all illicit substances.

“We’re way behind the illicit substance manufacturers and dealers,” Dr. Julia Van Zyl, a hospitalist at the University of Tennessee Medical Center, said in an interview with The News.

“By the time we get the fentanyl strips to the point we can use them, it will be too late,” she continued. “Because xylazine has taken over.”

Xylazine, an animal tranquilizer not intended for human use, is the latest drug starting to wreak havoc on communities. It’s increasingly linked to overdose deaths and causes ulcers and necrosis that can lead to amputations. Because xylazine is not an opioid, Narcan and other versions of naloxone cannot reverse its effects.

Earlier this year, the director of the White House’s Office of National Drug Control Policy, Dr. Rahul Gupta, designated fentanyl combined with xylazine as an emerging national threat.

In July, Gupta’s office released a fentanyl-xylazine response plan, which included recommendations to standardize forensic testing practices and to develop and distribute new tests.

Despite the efforts, drugmakers can introduce synthetic substances faster than testing capabilities can adapt.

A two-year lag always seems to exist between what illicit drug manufacturers put on the street and what hospitals have a test for, Parkland’s Hashim said.

“How do we catch up with them? I don’t know — unless we actually hire them.”

This story, originally published in The Dallas Morning News, is reprinted as part of a collaborative partnership between The Dallas Morning News and Texas Metro News. The partnership seeks to boost coverage of Dallas’ communities of color, particularly in southern Dallas.