Frequency of Fentanyl-Adulterated Street Drugs Consumed by Mothers with Substance Use: The Value of Umbilical Cord Testing

 

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Abstract

Objective

Reports indicate that street drugs are frequently adulterated with fentanyl. However, standard urine drug toxicology may not detect fentanyl, and neonates with prenatal fentanyl exposure often experience severe withdrawal. This study aimed to determine the frequency of fentanyl-adulterated street drugs consumed by mothers with substance use disorders (SUD) using umbilical cord tissue toxicology (UCT).

Study Design

This retrospective observational study (2020–2022) analyzed mothers with SUD and their neonates, utilizing UCT to confirm fentanyl exposure. Additionally, we compared maternal characteristics between those who acknowledged fentanyl use during pregnancy and those who did not, along with neonatal outcomes.

Results

Among 353 infants born to 342 mothers with opioid use, 21.8% (77/353) had in-utero fentanyl exposure confirmed by UCT. Notably, 54% (40/74) of mothers in the fentanyl-positive group did not acknowledge fentanyl use. However, these mothers more frequently reported using other substances, including marijuana (p < 0.01) and cocaine (p < 0.03), suggesting fentanyl adulteration in street drugs. Umbilical cord fentanyl concentrations were similar between groups, though variance was higher among those who did not report fentanyl use, indicating potential inconsistent exposure. No significant differences were observed in neonatal characteristics.

Conclusion

Our study highlights the high frequency of prenatal fentanyl exposure due to adulterated street drugs used by mothers. Although the infant's characteristics and the severity of NOWS were similar in both groups, long-term outcomes may depend on UCT fentanyl concentrations. Therefore, umbilical cord drug screening is a crucial tool for detecting fetal exposure to fentanyl and appropriate neonatal assessment and intervention.

Key Points

• Fentanyl, a potent synthetic opioid, is increasingly found in street drugs, often unbeknownst to users.

• Mothers struggling with substance use may be exposed to illicit fentanyl without their knowledge.

• Umbilical cord testing is crucial for identifying substance exposures in newborns.

• Newborn assessment and treatment can differ and impact their short- and long-term outcomes.

Ethical Approval

This study was approved by the Institutional Review Board of the University of Tennessee Health Science Center (UTHSC), Memphis, Tennessee. Approval to waive consent was also obtained.

Authors' Contributions

Conception and design of the work were done by M.P. Acquisition, analysis and interpretation of data, drafting and reviewing it critically for important intellectual content, final approval of the version to be published, and agreement to be accountable for all aspects of the work were done by D.R., L.D., and M.P.

Publication History

Received: 28 March 2025

Accepted: 28 May 2025

Article published online:
24 June 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

• References

• 1 Chang G, Ondersma SJ, Blake-Lamb T, Gilstad-Hayden K, Orav EJ, Yonkers KA. Identification of substance use disorders among pregnant women: a comparison of screeners. Drug Alcohol Depend 2019; 205: 107651
  PubMedSearch in Google Scholar
• 2 Centers for Disease Control and Prevention. . Substance Use During Pregnancy. Accessed March 27, 2025 at: https://www.cdc.gov/maternal-infant-health/pregnancy-substance-abuse/index.html
  PubMed
• 3 Addiction Group. . Fentanyl Statistics 2025 . Accessed March 27, 2025 at: https://www.addictiongroup.org/resources/fentanyl-statistics/
  PubMed
• 4 Centers for Disease Control and Prevention. . Drug Overdose Deaths in the United States, 2002–2022. Accessed March 27, 2025 at: https://www.cdc.gov/nchs/products/databriefs/db491.htm
  PubMed
• 5 Tennessee Department of Health. . Maternal Mortality and Substance Use in Tennessee. Accessed March 27, 2025 at: https://www.tn.gov/content/dam/tn/health/program-areas/maternal-mortality/Substance-Use-TN-2021.pdf
  PubMed
• 6 American College of Obstetricians and Gynecologists, American Society of Addiction Medicine. Committee opinion no. 711: opioid use and opioid use disorder in pregnancy. Obstet Gynecol 2017; 130 (02) e81-e94
  CrossrefPubMedSearch in Google Scholar
• 7 Patel E, Bandara S, Saloner B. et al. Heterogeneity in prenatal substance use screening despite universal screening recommendations: findings from the pregnancy risk assessment monitoring system, 2016-2018. Am J Obstet Gynecol MFM 2021; 3 (05) 100419
  CrossrefPubMedSearch in Google Scholar
• 8 Salomone A, Palamar JJ. Toxicosurveillance of novel opioids: just screening tests may not be enough. Am J Drug Alcohol Abuse 2021; 47 (03) 271-272
  PubMedSearch in Google Scholar
• 9 O'Donnell JK, Gladden RM, Seth P. Trends in deaths involving heroin and synthetic opioids excluding methadone, and law enforcement drug product reports by census region—United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017; 66 (34) 897-903
  PubMedSearch in Google Scholar
• 10 Ciccarone D. The triple wave epidemic: supply and demand drivers of the US opioid overdose crisis. Int J Drug Policy 2019; 71: 183-188
  PubMedSearch in Google Scholar
• 11 Drug Enforcement Administration. 2020 National Drug Threat Assessment. Washington, DC: US Department of Justice; ; Accessed 2021. at: https://www.dea.gov/documents/2021/03/02/2020-national-drug-threat-assessment
  Search in Google Scholar
• 12 Mars SG, Ondocsin J, Ciccarone D. Toots, tastes and tester shots: user accounts of drug sampling methods for gauging heroin potency. Harm Reduct J 2018; 15 (01) 26
  PubMedSearch in Google Scholar
• 13 Han B, Cotto J, Etz K, Einstein EB, Compton WM, Volkow ND. Methamphetamine overdose deaths in the US by race and ethnicity. JAMA Psychiatry 2021; 78 (05) 564-567
  PubMedSearch in Google Scholar
• 14 Rana D, Gaston KP, DeBaer L, Pourcyrous M. Illicit fentanyl in the prenatal period: a significant emerging risk for neonatal opioid withdrawal syndrome. Am J Perinatol 2025; 42 (07) 891-898
  PubMedSearch in Google Scholar
• 15 Aygun C, Tekgunduz KS, Senel GB, Yilmaz Y. Neonatal abstinence syndrome treated with fentanyl: a case report. Haseki Med Bullet 2021; 59 (03) 254-257
  PubMedSearch in Google Scholar
• 16 Jones J. Toxicology as a diagnostic tool to identify the misuse of drugs in the perinatal period. Front Pediatr 2023; 10: 1071564
  PubMedSearch in Google Scholar
• 17 Pourcyrous M, Elabiad MT, Rana D, Gaston KP, DeBaer L, Dhanireddy R. Racial differences in opioid withdrawal syndrome among neonates with intrauterine opioid exposure. Pediatr Res 2021; 90 (02) 459-463
  CrossrefPubMedSearch in Google Scholar
• 18 Rana D, McLeod AR, Gaston PK, Hill DM, Pourcyrous M. Assessing neonatal opioid withdrawal syndrome severity as a function of maternal buprenorphine dose and umbilical cord tissue concentrations. Ann Pharmacother 2023; 57 (08) 892-898
  CrossrefPubMedSearch in Google Scholar
• 19 Finnegan LP, Connaughton Jr JF, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment and management. Addict Dis 1975; 2 (1-2): 141-158
  PubMedSearch in Google Scholar
• 20 Timpson W, Killoran C, Maranda L, Picarillo A, Bloch-Salisbury E. A quality improvement initiative to increase scoring consistency and accuracy of the Finnegan tool: challenges in obtaining reliable assessments of drug withdrawal in neonatal abstinence syndrome. Adv Neonatal Care 2018; 18 (01) 70-78
  PubMedSearch in Google Scholar
• 21 Young LW, Ounpraseuth ST, Merhar SL. et al; ACT now collaborative. Eat, sleep, console approach or usual care for neonatal opioid withdrawal. N Engl J Med 2023; 388 (25) 2326-2337
  CrossrefPubMedSearch in Google Scholar
• 22 Baptiste-Roberts K, Hossain M. Socioeconomic disparities and self-reported substance abuse-related problems. Addict Health 2018; 10 (02) 112-122
  PubMedSearch in Google Scholar
• 23 Metz VE, Brown QL, Martins SS, Palamar JJ. Characteristics of drug use among pregnant women in the United States: opioid and non-opioid illegal drug use. Drug Alcohol Depend 2018; 183: 261-266
  PubMedSearch in Google Scholar
• 24 González-Colmenero E, Concheiro-Guisán A, Lorenzo-Martínez M. et al. Drug testing in biological samples vs. maternal surveys for the detection of substance use during whole pregnancy. J Addict Dis 2021; 39 (02) 175-182
  CrossrefPubMedSearch in Google Scholar
• 25 Smid MC, Allshouse AA, McMillin GA. et al. Umbilical cord collection and drug testing to estimate prenatal substance exposure in Utah. Obstet Gynecol 2022; 140 (02) 153-162
  PubMedSearch in Google Scholar
• 26 Austin AE, Naumann RB, Simmons E. Association of state child abuse policies and mandated reporting policies with prenatal and postpartum care among women who engaged in substance use during pregnancy. JAMA Pediatr 2022; 176 (11) 1123-1130
  PubMedSearch in Google Scholar
• 27 Garg S, Patel M, Davis T. Self-reported illicit drug use and its implications for prenatal care. J Matern Fetal Neonatal Med 2016; 29 (13) 2155-2160
  PubMedSearch in Google Scholar
• 28 Price HR, Collier AC, Wright TE. Screening pregnant women and their neonates for illicit drug use: consideration of the integrated technical, medical, ethical, legal, and social issues. Front Pharmacol 2018; 9: 961
  CrossrefPubMedSearch in Google Scholar
• 29 Wright TE, Terplan M, Ondersma SJ. et al. The role of screening, brief intervention, and referral to treatment in the perinatal period. Am J Obstet Gynecol 2016; 215 (05) 539-547
  CrossrefPubMedSearch in Google Scholar
• 30 Jones CM, Bekheet F, Park JN, Alexander GC. The evolving overdose epidemic: synthetic opioids and rising stimulant-related harms. Epidemiol Rev 2020; 42 (01) 154-166
  CrossrefPubMedSearch in Google Scholar
• 31 Park JN, Rashidi E, Foti K, Zoorob M, Sherman S, Alexander GC. Fentanyl and fentanyl analogs in the illicit stimulant supply: results from U.S. drug seizure data, 2011-2016. Drug Alcohol Depend 2021; 218: 108416
  PubMedSearch in Google Scholar
• 32 Lorvick J, Hemberg J, George M, Piontak J, Comfort M. “Just another thing for me to stress off of:” Responses to unintentional fentanyl use in a community-based study of people who use opioids. Res Sq 2023; 20 (01) 128
  PubMedSearch in Google Scholar
• 33 Wagner KD, Fiuty P, Page K. et al. Prevalence of fentanyl in methamphetamine and cocaine samples collected by community-based drug checking services. Drug Alcohol Depend 2023; 252: 110985
  PubMedSearch in Google Scholar
• 34 Magura S, Lee-Easton MJ, Abu-Obaid R. et al. Prevalence and drug use correlates of inadvertent fentanyl exposure among individuals misusing drugs in seven U.S. states. J Addict Dis 2024; 42 (04) 515-523
  PubMedSearch in Google Scholar
• 35 Shover CL, Falasinnu TO, Dwyer CL. et al. Steep increases in fentanyl-related mortality west of the Mississippi River: recent evidence from county and state surveillance. Drug Alcohol Depend 2020; 216: 108314
  PubMedSearch in Google Scholar
• 36 Montgomery DP, Plate CA, Jones M. et al. Using umbilical cord tissue to detect fetal exposure to illicit drugs: a multicentered study in Utah and New Jersey. J Perinatol 2008; 28 (11) 750-753
  PubMedSearch in Google Scholar
• 37 Patrick SW, Barfield WD, Poindexter BB. Committee on fetus and newborn, committee on substance use and prevention. Neonatal opioid withdrawal syndrome. Pediatrics 2020; 146 (05) e2020029074
  CrossrefPubMedSearch in Google Scholar
• 38 Smart R, Kim JY, Kennedy S. et al. Association of polysubstance use disorder with treatment quality among Medicaid beneficiaries with opioid use disorder. J Subst Abuse Treat 2023; 144: 108921
  PubMedSearch in Google Scholar