Integrating community perspectives to enhance the utility of wastewater-based epidemiology for addressing substance use in the United States

Abstract

Purpose:

Wastewater-based epidemiology (WBE) of substances can serve as a valuable tool to supplement traditional surveillance techniques, providing information rapidly on community use. Despite ongoing WBE-opioid programs occurring throughout the world, few have integrated such data into public health decision-making to drive meaningful interventions. This gap could be due to several factors and concerns that vary across diverse communities. This perspective examines multiple levels of stakeholders involved in the implementation of WBE for substance use, their roles, and the challenges facing each.

Recent findings:

Challenges have been identified by our team while conducting a multiyear project focused on integrating WBE in several communities across the Uniters States. We also highlight communities that have successfully implemented such programs and the benefits they have seen from this approach. Based on our experience and the current state of the literature, we identify current priority needs to increase the utility and impact of using WBE for monitoring substance use across communities.

Summary:

There is great promise for the utility of WBE as a tool for strengthening public health systems to address substance use. Understanding the roles and perspectives of stakeholders broadly will help to move this concept into an effective and trusted approach.

Introduction

The ability to quantify chemicals in sewage, including substances like fentanyl, provides valuable data on the types of drugs likely being consumed in specific geographical areas (1). Chemicals that enter the human body through ingestion, injection, inhalation, or dermal absorption are eventually excreted and can make their way into municipal wastewater systems. Understanding the area served by a wastewater reclamation facility helps define the sewer network and the population size contributing to the system. These data are then used to estimate the drug consumption rate of a community, typically expressed as milligrams consumed per day per 1,000 people. This process is part of wastewater-based epidemiology (WBE), a field that has been in practice for several decades (1,2), with the goal of supporting public health strategies focusing on substance use. Fully harnessing the potential of WBE for public health good involves using chemical consumption rate signatures in defined spatial and temporal contexts—not only to identify the presence of circulating drugs, but also to link these measurements to predicted health outcomes. In this way, WBE could serve as a predictive tool to inform and guide public health interventions. The full WBE framework is illustrated in Figure 1.

Figure 1.

Schematic of the process of wastewater-based epidemiology and how it can be used to inform about the community consumption of fentanyl and other substances. 1) catchment areas within a state or county and 2) the population served are defined; 3) absorbed substances are excreted into wastewater streams which commonly lead to 4) wastewater reclamation facilities in municipal settings where samples are collected; 5) obtained samples and processed and 6) analyzed for drug targets, typically using mass spectroscopy-based methods; 7) data and processed to produce consumption rates for a give community; 8) Data trends are disseminated to various stakeholders; 9) public health responses may be set in motion to address community substance use and prevention.

Our group, along with others (3–7), have been involved in drug-focused WBE efforts to refine this framework in the U.S. which has been largely supported through the National Drug Early Warning System (NDEWS, ndews.org). We have been fortunate to engage with numerous stakeholders, which will serve as the defined communities for this perspective. These interactions have revealed several challenges in establishing WBE as a practical public health tool in the context of illicit drug use. We share what we have learned with one important caveat: this opinion piece is written exclusively from a public health perspective, which may differ from other applications of WBE, such as those focused on drug trafficking or law enforcement. Additionally, although many of the challenges we discuss are global in nature, the Uniters States (U.S.), due to its size and regulatory frameworks, faces unique issues. As such, this manuscript will focus specifically on the utility of WBE in tackling substance use in the U.S.

Communities as data users

The use of WBE to monitor substance use at a population scale is not a new concept. This tool has been in use since the early 2000s (8) for tracking both licit and illicit substances across cities, particularly in Europe (7,9,10), Australia (7,11), and Canada (12). These early studies established foundational methods and best practices for sample collection, analysis, and data interpretation. Around a decade later, the U.S. piloted a wastewater opioid monitoring programs in Tempe, Arizona, through an academic-municipal partnership. This led to the creation of the one of the world’s first open-access dashboard displaying longitudinal trends in opioid use (including fentanyl and other drugs) at a neighborhood-level (i.e., sub-sewer shed) scale (13). Despite these pioneering efforts, the field did not gain widespread attention and acceptance until the COVID-19 pandemic, when there was an urgent need for rapid data on viral presence and transmission to inform public health decisions. This led to the broader adoption of WBE for pathogen surveillance (14–16). While the overarching methodology remains similar between chemical and biological targets, there are key differences in implementation—such as sample collection methods, processing and extraction techniques, data analysis and interpretation, and data dissemination—that must be carefully considered when conducting WBE for substance use, especially for widely-used opioids, like fentanyl.

Data generated through WBE is most valuable when it is used to enhance understanding of community drug and health profiles, driving relevant public health responses and interventions. This level of investigation involves multidisciplinary teams or communities, which we broadly define here as “data consumers.” These include individuals or groups at wastewater reclamation facilities that provide sewage samples; federal and state health agencies (e.g., departments of health); governing bodies (i.e., city officials); funding agencies; researchers; community-engaged workers (e.g., community health workers); and local residents. Each of these groups plays a unique role in the partnership, and each face distinct and overlapping challenges, as highlighted in Table 1. These challenges are discussed in more detail below.

Table 1.

Description of stakeholders, their roles and challenges related to WBE.

Stakeholders	Role	Challenges
Wastewater reclamation facilities	Provide wastewater samples and associated metadata	Resources associated with sample collection and shipment; varied state regulations that minimize data sharing
Federal and state health agencies	Utilize data to examine drug use trends; Initiate community-based responses; Provide resources to support local WBE	How to understand and optimize data use; data ownership; privacy concerns
State/local governing bodies (i.e., city and state officials)	Support community-based responses	How to understand and optimize data use; data ownership; privacy concerns
Funding agencies	Provide resources to refine the WBE process and support downstream actions	Balancing research needs (publication, open access reporting) with privacy and risk management concerns of researchers and health agencies
Researchers	Refine and/or implement method development, data harmonization, predictive modeling, effective dissemination and intervention best practices	Balancing research needs (publication, open access reporting) with privacy and risk management concerns of researchers and health agencies; Focus on surveillance vs. hypothesis driven research; Availability of accompanying health data
Community-engaged workers (i.e., community health workers, clinical personnel etc.)	Communicate data to communities effectively	How to optimize data use; Managing community perceptions
Community/local residents	Beneficiary of data; Requires buy-in of WBE process	Data interpretation; Privacy concerns

Community challenges to fully integrating WBE as public health practice.

Putting the Cart Before the Horse:

As mentioned earlier, quantifying drugs like fentanyl in wastewater is not a new practice and has been conducted for several decades. However, our ability to interpret these data in the broader context of public health action remains underdeveloped. The utility of these data has been hindered, at least in part, by concerns over how the data will be used. We have encountered such concerns across the communities described, with common worries about how the general public might react to the rollout of WBE initiatives. Public pushbacks are a legitimate concern and could potentially lead to the dismantling of such programs. While these concerns may or may not be justified, a notable example occurred in New Mexico, where a statewide WBE program was launched to monitor drugs of concern in schools. Significant concerns about how the data would be used were raised by the public, researchers and others about the cost of the program, safety of students and stigmatization of communities (17). These actions generated news headlines that did not necessarily support the effectiveness of WBE for public health purposes, despite the data generated that could inform community health. In our experience, through discussions with partner cities, we have observed success stories where the public dissemination of WBE data on drugs was well-received. For example, in the case of the academic (Arizona State University) and municipal (City of Tempe, Arizona) WBE-Opioid Monitoring Program (now called BioIntel) (18), a tremendous amount of community outreach and engagement occurred before the project began (19). This included hosting town halls, workshops, and webinars to inform the community about the program’s overarching goals and provide opportunities for constituents to voice their concerns. Unique to this program was the involvement of Fire and Medical Rescue teams, as well as crisis intervention and response teams, which were integrated into the working group. This not only helped establish community acceptance by demonstrating that the program was intended for public health purposes (excluding law enforcement), but these actions also allowed for the use of WBE-opioid data to promote relevant and appropriate intervention strategies. The public-facing dashboard, formally launched in February 2019, was accompanied by detailed explanations of the substance measurement process in wastewater, including graphics and visual aids, as well as other pertinent information to help the public better understand the data, reduce the potential for misinterpretation and ultimately support the program (13). Anecdotally, community engagement is not always a component of WBE study design. Perhaps because there is no requirement to enroll participants that such studies are not approached with a community-engaged framework, which prioritizes community participation at the outset. However, this step seems critically important for gaining the trust of key stakeholders.

Inconsistent guidelines/directives.

The varying requirements and regulations across states regarding how information can be shared and used have, in our experience, hindered scientific discovery and the sharing of data that could ultimately benefit communities. For instance, in each wastewater sample, hundreds of drugs may be quantified, yet the end users of these data often request a partial dataset containing select drug targets. This practice can result in limited site participation, incomplete datasets, and can ultimately impede progress. Additionally, there are tensions between agencies over data ownership and sharing expectations, which are often not fully aligned, further stalling momentum. For example, confusion and disagreement between funding agencies, academic institutions, and state and local governing bodies regarding who owns the data and what can be done with it have, has in our experience, led to the dissolution of important partnerships and ultimately the loss of valuable data and progress.

Data Interpretation.

Currently, there is no standardized approach for interpreting drug consumption rates derived from wastewater in the context of public health. We have had numerous discussions about how to identify fentanyl hotspots in catchment areas over time but have yet to reach a consensus on what consumption rate should be considered concerning and when a follow-up action is warranted. These discussions are complicated by relatively small datasets from a biostatistical perspective. As a simplified example, we are currently comparing weekly fentanyl consumption rates (FCR) in defined catchments to the mean FCR over time for each city where the catchment is located (local), and the mean FCR over time for multiple states combined (national). Without additional data, it is unclear which, if either, of these approaches best supports community goals. Other complexities include input of fentanyl into wastewater streams from sources other than illicit use, such as medical waste, pharmaceutical formulation facilities (20) and direct dumping, as well as the transient nature of the drug users in defined catchment areas. Currently our understanding of the contribution of these inputs to overall consumption rates of fentanyl in communities is not well understood. Targeting select fentanyl analogs that better differentiate illicitly used fentanyl from that found in medical waste streams has been proposed, but such approaches have not been adopted broadly.

Dissemination:

Sharing drug-related data derived from wastewater has proven to be one of the more challenging aspects to navigate. Broad dissemination, if not done thoughtfully, can have significant negative consequences. For instance, releasing information about drug-related issues in already stigmatized communities may not help advance public health in these areas. Improper dissemination can have serious social, economic, and other repercussions, which could hinder efforts to improve these communities. Furthermore, limited data sharing among researchers makes it more difficult to learn from each other. Use of WBE for opioids and other substances requires an interdisciplinary approach, involving chemists, wastewater engineers, epidemiologists, biostatisticians, community engagement experts, and other stakeholders. If we cannot share data—whether informally (i.e., through discussions) or formally (i.e., through publications)—we miss valuable opportunities to advance the collective science of WBE. Although data can be anonymized upon request, the field would greatly benefit from improved dissemination practices, enabling us to fully capture the insights that WBE offers.

Research:

Research is crucial to the advancement of WBE. While academic institutions, federal and state agencies, and the private sector are utilizing WBE for surveillance of illicit drugs like fentanyl, significant work remains. Research needs to span the WBE pipeline, particularly in key areas such as: community engagement/community-based participation in study design and outputs; optimal study design, including site selection and timing for wastewater sample collection; harmonization of wastewater and human health data to support the development of predictive models; and the accurate and effective dissemination of data to various stakeholders through tailored communication. The majority of research funded to date is extremely limited and is dominated by pathogen surveillance. Of the limited number of WBE research projects funded, chemical measurements and surveillance have been prioritized, with less emphasis on how the data will be used and acted upon. Efforts to better understand the implications of the data and how it can be most effectively applied are complicated by issues surrounding data ownership; how the data will be used and disseminated is not always aligned across academic institutions, granting agencies, and data users. For example, academics often publish their work in peer-reviewed journals to measure productivity and share data broadly, while state agencies are governed by different priorities, which may involve limiting data dissemination that could identify their city or state. Navigating these differences upfront through formal agreements has proven to be an effective approach to maintaining research integrity without compromising community perceptions. Second.

Priority Needs

In order to continue to drive the science and impact of WBE forward and enhance our ability to rapidly and accurately understand community drug use while promoting effective public health responses, it is imperative that we develop and implement shared best practices. To achieve this, we must prioritize several key actions:

1. Leverage Community-Based Practices: Engaging with communities and incorporating their perspectives is essential for ensuring that WBE initiatives are relevant, accepted, and effective. Community involvement is critical for building trust, addressing concerns, and ensuring that data is interpreted and used in ways that reflect the needs and priorities of local populations.

2. Implement Effective Communication Strategies: Transparent, clear, and consistent communication is vital to overcoming public concerns and misconceptions surrounding the use of WBE data. Public outreach campaigns, informational resources, and community forums should be developed to demystify the process, clarify the potential benefits, and address concerns about privacy and data use.

3. Integrate Data Sets: For WBE to be truly impactful, it is essential to integrate data from multiple sources, including wastewater data, health records, and socio-economic indicators. Large data sets are a necessity for developing predictive and forecasting models that support the effectiveness of WBE. Such integration will enable a more comprehensive understanding of community drug use patterns and facilitate the development of targeted interventions that can improve public health outcomes.

4. Invest in Continued Research: Continued research is needed to refine WBE methodologies, enhance data analysis techniques, and develop predictive models that can help guide public health decision-making. Research efforts should also explore ways to address gaps in data availability, improve the accuracy of drug consumption estimates, and ensure that WBE can effectively support a wide range of public health initiatives.

5. Navigate Data Use and Dissemination Guidelines: The varying regulations and guidelines governing data use and dissemination across states present a significant challenge to advancing WBE. We must work collaboratively to establish clearer, more consistent standards for data ownership, sharing, and usage, while ensuring that privacy concerns are respected. A unified approach will foster greater collaboration among stakeholders and facilitate the widespread application of WBE to address pressing public health issues.

By addressing these priorities, we can unlock the full potential of WBE to better understand and respond to community drug use, ultimately driving positive public health outcomes. It is crucial that all stakeholders—including government agencies, researchers, community organizations, and the public—collaborate to move WBE forward as a transformative tool in public health. Let us come together to develop shared best practices that will enable us to act swiftly, precisely, and effectively in addressing the evolving challenges of drug use in our communities.

Conclusions

• Broad-scale wastewater-based epidemiology programs focusing on substance use have the potential to drive meaningful public health strategies and interventions.

• There are significant challenges to implementing this approach spanning multiple community levels, which has prevented widespread adoption of this approach, in the content of the United States.

• Examples of success have highlighted the importance of community participation and outreach, clearing defined partnerships/data agreements, and a large focus on effective risk communication.

• Further research is needed to establish best practices for implementing wastewater-based epidemiology of illicit drugs before widespread adoption commences.

Key points.

• WBE has promise as a public health tool in addressing substance use in communities.

• There are numerous stakeholders with varied roles and challenges related to implementing WBE in practice.

• Consideration of stakeholders perspectives on data use and dissemination is critical to incorporating WBE into public health strategies.