THE COMMONWEALTH OF MASSACHUSETTS and its 351 cities and towns have an extraordinary opportunity to address the scourge of high-risk drug use with the Opioid Recovery and Remediation Fund, set up to distribute the settlements from opioid manufacturers and distributors. State officials and members of the advisory council tasked with overseeing the fund distribution should consider earmarking a portion of those abatement funds for wastewater surveillance around the state in an effort to identify and stem the use and abuse of high-risk drugs at the front end of issue.

The Department of Public Health released data last week showing more than 1,700 opioid-related overdose deaths in just the first nine months of 2023, much of it due to the presence of fentanyl. That is a slight drop of less than 2 percent over the same period last year, which was the highest number of opioid overdose deaths the state has ever recorded. The data shows that overdose deaths have steadily increased since 2015 about 3 percent a year on average through last year. Since 2000, the state has recorded 25,000 opioid-related overdose deaths, with nearly 75 percent of those deaths occurring in just the last nine years.

The state has so far received $101.7 million from the opioid settlement agreement, according to the most recent annual report of the fund filed in October. The attorney general’s office has estimated the state will receive more than $1 billion over the next 18 years.

By statute, 40 percent of the settlement funds are being distributed to communities to enact mitigation strategies to address the treatment and recovery of those who are in need of the services as well as institute harm reduction programs. Some of the laudable guidelines include supporting housing for those seeking treatment, distribution of overdose treatments such as naloxone, diversion programs for those entering the criminal justice system, syringe distribution and safe injection sites, and increased access to medication for opioid use disorder, including mobile methadone clinics.

All these programs are essential but they all have one thing in common – they are geared toward addressing the problem after it has begun to take a toll and, in many cases, require drug abusers to identify themselves to seek help, something many active addicts are reluctant to do.

In contrast, 60 percent of the abatement settlement is earmarked for the Opioid Recovery and Remediation Fund and the advisory council is “charged with developing recommendations for the expenditure of [those funds] to mitigate the impacts of the opioid epidemic in the Commonwealth,” according to its mission statement. Investing just a fraction of those funds in wastewater surveillance, which has proved enormously beneficial with COVID-19, could be a welcome boost in identifying where drug use and abuse are occurring and aid public health responses in a more efficient and faster manner.

Earlier this year, a research team cited wastewater monitoring efforts as a model that could be applied to tracking opioid use. About 100 communities in the country are currently utilizing wastewater surveillance in some manner to identify high-risk drug use. Many have partnered with Cambridge-based Biobot Analytics, which is the company performing most COVID-related wastewater surveillance in Massachusetts and first began monitoring drug concentration in wastewater in 2017.

The analysis has helped public health officials identify the presence of a wide variety of drugs in the wastewater, including methamphetamine, fentanyl, cocaine, and Xylazine, an animal tranquilizer dealers use to enhance the strength of street drugs. Xylazine has been identified by federal officials as an emerging threat similar to fentanyl and can have harmful, even fatal, effects on humans.

Data on drug use and overdose deaths lag months behind while regular sampling and analyses of wastewater can show the increased presence of drugs in a community in real time. Using wastewater surveillance can not only identify what drugs are being used in a community, it can also help identify seasonal trends and daily usage, such as heightened weekend abuse or holiday spikes, and assist in developing public health strategies such as distributing naloxone in targeted areas and alerting medical providers to aid in diagnosis and treatment.

In addition, using wastewater to monitor the presence of drugs in a community shows how much drugs are being used rather than who is using them and reduces the risk of those who are using to become involved in the criminal justice system. The information can be utilized by law enforcement to set and plan priorities in concert with public health officials rather than for law enforcement against individuals.

Wastewater surveillance for opioids can also assist in identifying potential issues around disease such as the hepatitis A virus (HAV). IV drug use is a common risk factor in HAV infection and transmission. While not a predictor, by monitoring increases in the presence of opioids in a community’s wastewater, public health officials and health care providers can marshal resources, ramp up education efforts, and coordinate mitigation strategies before, not after, a potential outbreak of HAV similar to what the state experienced between 2018 and 2020.

The approximate average cost per wastewater treatment facility is $50,000 annually for sampling, dashboard access, and analyses. If multiple communities joined in a collaborative, the cost could be reduced by 15 percent per site. Even that cost, though, is prohibitive for most communities but if the state provided as little as $3 million per year from the abatement fund, 20 percent of the state’s cities and towns could participate in the wastewater surveillance.

We have seen the effectiveness of wastewater surveillance in COVID-19 and that infrastructure is in place in dozens of communities. Expanding this to a wider pool of cities and towns can help the Commonwealth stay ahead of this crisis.

Jack Sullivan is the regional epidemiologist for the Blackstone Valley Partnership for Public Health as well as for a collaborative in Franklin County consisting of Greenfield, Montague, Deerfield, and Sunderland. He can be reached at jsullivan@northbridgemass.org or john.sullivan@greenfield-ma.gov.

Jack Sullivan is now retired. A veteran of the Boston newspaper scene for nearly three decades. Prior to joining CommonWealth, he was editorial page editor of The Patriot Ledger in Quincy, a part of the...