Is our drinking water contaminated with illicit drugs?

MDlinx Aug 24, 2024

Although concerns over fentanyl have heightened in recent years, the drug is not new. The first reports of misuse occurred in the 1980s and '90s. By the mid-2000s, there was a notable increase in fatal overdoses secondary to illicit fentanyl use.

In 2006, the DEA identified a fentanyl lab in Mexico that was responsible for an outbreak of fentanyl deaths. By 2013, the fentanyl epidemic had arrived in full force.

Trawiński J, Szpot P, Zawadzki M, et al. Photochemical transformation of fentanyl under the simulated solar radiation – Enhancement of the process by heterogeneous photocatalysis and in silico analysis of toxicity. Sci Total Environ. 2021 Oct 15;791:148171.

Water sources have become increasingly contaminated with active pharmaceutical ingredients. Due to fentanyl’s high potency at very low doses, worries about fentanyl contaminating community water supplies are not unfounded.

Illicit drugs in drinking water

Fentanyl has been found in environmental samples worldwide. Polish researchers studying fentanyl as an environmental contaminant reported that, in Ontario, Canada, it has been detected in drinking water from the Grand River.

Levels were approximately 200 ng/L at upstream sampling points, 800 ng/L in wastewater treatment plant effluent, 300–650 ng/L at downstream sampling points, and 100–150 ng/L in drinking water treatment plants.

In the Netherlands, fentanyl was found at a concentration of 8 ng/L in effluent sewage water. Fentanyl has also been found in river water in Croatia, as well as in hospital effluents at a concentration of 10 ng/L.

Notably, US researchers did not find ultratrace concentrations of fentanyl in the drinking water samples gathered from 53 US locations in 2022.

Skaggs CS, Logue BA. The prevalence of opioids in US drinking water sources detected using direct-injection high-performance liquid chromatography–tandem mass spectrometry. Environ Toxicol Chem. 2022 Nov;41(11):2658-2666.

They did, however, find hydrocodone and codeine in approximately 40% of samples—using high-performance liquid-chromatography tandem mass spectrometry—at concentrations between 0.3 and 20.0 ng/L. The concentration of codeine was 7.3 times higher than that of hydrocodone.

Potency

Fentanyl is similar to morphine but is 50- to 100-times more potent. A 100-microgram dose of this synthetic opioid yields an equal anesthetic effect as that of 10 mg of morphine.

Ramos-Matos CF, Bistas KG, Lopez-Ojeda W. Fentanyl. In: StatPearls [Internet]. Treasure Island, Florida: StatPearls Publishing. Updated May 29, 2023.

The adverse effects of fentanyl are akin to heroin and include confusion, euphoria, respiratory depression, drowsiness, visual disturbances, hallucinations, and “narcotic delirium.”

Ramos-Matos CF, Bistas KG, Lopez-Ojeda W. Fentanyl. In: StatPearls [Internet]. Treasure Island, Florida: StatPearls Publishing. Updated May 29, 2023.

Hypotension, coma, and death can occur.

Although the LD(50) value for humans has yet to be elucidated, a 2-mg dose is generally lethal in most people, with the lowest published toxic dose being 2 μg/kg via intravenous administration.

The Polish researchers, commenting in Science of The Total Environment, wrote: “Considering the extraordinary toxicity of this drug, knowledge of its presence in the natural environment as well as recognition of its environmental fate is essential for the safety of both humans and non-target organisms.”

Fentanyl stability and next steps

Opioids exhibit high stability in river water. Investigators found that only 22.5% of fentanyl degraded after 6 days in river water, and only 15% of tramadol and 26% of buprenorphine.

Niroula V, Pagsuyoin SA. Stability and degradation of opioids in river water. ACS Omega. 2024 Jun 7;9(24):26355-26362.

Even though drinking water–treatment plants help reduce the presence of active pharmaceutical ingredients, contamination is still of high concern in sources of drinking water.

One obvious intervention that is required is better methods to clean our drinking water, as traditional waste treatment falls short.

The authors writing in Science of The Total Environment pointed to the need for effective fentanyl elimination. “There is little understanding of the effectiveness of commonly applied water treatment methods in the context of fentanyl decontamination. Considering the relatively low efficiency of traditional [waste water] treatment procedures in the case of other pharmaceuticals, alternative methods may also be sought,” they wrote.

In the meantime, it’s important to continue to monitor the drinking-water supply for ultratrace levels of fentanyl and other potentially dangerous pharmaceuticals. Current monitoring fails to capture risk posed, predicted exposure levels, or potency of fentanyl and various other drugs.

Khan U, Nicell J. Human health relevance of pharmaceutically active compounds in drinking water. AAPS J. 2015 May;17(3):558-585.

What this means to you

The presence of fentanyl and other potentially dangerous drugs in the water supply is an emerging concern for public health officials. Physicians should be aware of this possible risk factor. To date, levels of fentanyl found in drinking water have been low. However, it’s important to remember that even low doses of fentanyl can be toxic.

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