2023 Public Health Laboratory Annual Report
Testing Reveals Which Drugs Are Involved in Overdoses

Biomonitoring can provide critical information to identify groups at risk for chemical exposure

When a person experiencing an overdose arrives in a hospital, clinicians must make quick judgments on proper treatment protocols. They base decisions on the patient’s behaviors and symptoms and potentially on the information provided by the patient. Health professionals have often suspected they were working from inadequate and incomplete information when treating overdoses.

In 2017, the opioid epidemic claimed a then-record 421 Minnesotan lives. The problem extended beyond opioids alone; many overdoses resulted from a combination of substances. To gain more information, the Minnesota Department of Health initiated the Minnesota Drug Overdose and Substance Use Surveillance Activity (MNDOSA) project.

A handful of hospitals in Northeast Minnesota and the Twin Cities signed up to participate in the program. When a doctor in one of these hospitals has a patient whose case warrants further study, they direct a sample of blood or urine to be sent to the Minnesota Environmental Laboratory. The lab uses an advanced instrument, a liquid chromatography high resolution mass spectrometer (LC-HRMS), to detect the presence of more than 1,000 different compounds in a single sample, including:

• Opioids
• Cocaine
• Amphetamines
• Heroin
• Cathinone (the stimulant in khat)
• Synthetic cannabinoids
• Caffeine
• Marijuana
• Cotinine (a metabolite of nicotine) 

The lab sends individual patients’ results to the site leads at hospital systems, who choose how to disseminate the information. For the purposes of the MNDOSA program, the samples are de-identified, meaning that all individual patient information is removed. MNDOSA’s results are used as population-level data, showing what substances are involved in overdoses, in which combinations, and in which areas of the state. 

Finding Deadly Combinations

Over the past five years, the project has uncovered many important insights. Results of the project show an increase in the rate at which multiple drugs have been implicated in overdoses. Opioids and amphetamines are an especially common combination, found in around half of all samples analyzed. 

The MNDOSA project also revealed the inadequacy of the information doctors work with in overdose cases. For almost every category of illicit substances, doctors underestimated the percentage of patients with the drug in their system.

The Need to Expand Across Minnesota

The MNDOSA data applies only to two hospital systems within Minnesota. Legislation being considered at this writing would expand MNDOSA throughout all eight hospital regions of Minnesota and increase the funding to cover more samples being submitted to the lab.

In the most general sense, MNDOSA has firmly established that opioids are not solely to blame for the recent increase in overdoses. By revealing the combination of substances at play, the program gives information to health professionals that is critical to addressing the latest patterns of abuse and to saving lives. 

MDH developed MNDOSA (Minnesota Drug Overdose and Substance Use Surveillance Activity) to understand substance misuse and drug overdose patterns in real time.

MNDOSA ...

• Helps identify clusters of substance misuse.
• Illuminates the types of substances used in Minnesota.
• Analyzes cases seen in the emergency department as a result of substance misuse. 
• Can inform clinicians, community partners, and the public about substance use trends and can guide prevention efforts.

MDH uses a high-resolution testing method that can identify over 1,000 substances.

MDH tests samples from MNDOSA cases with severe or unusual symptoms of substance use to identify the substances involved.

MNDOSA currently operates in Northeast Minnesota and the Metro area.

68% of MNDOSA cases are missed through traditional hospital-based overdose surveillance.

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