In the past, population-based surveys provided helpful information on who abused drugs (by age, gender, race).

Key datasets supplemented survey data with treatment admission data, poison control calls, and ER overdoses.

We can track in real-time which drugs a whole community uses by analyzing what ends up in wastewater.

Victor Hugo, in Les Misérables, refers to the city's sewer system as the "conscience of the city," where the waste products of society are gathered, bringing all secrets to light. Today, analyzing sewage or wastewater-based epidemiology (WBE) is a new way to determine which drugs are being used, when, and where. It can’t tell you, for example, that Johnny Jones of 15 Maple Street used ketamine a few days ago. It can tell you if there’s just been an upward surge in ketamine or other drugs in Johnny’s city.

When people take drugs, their bodies break them down, and they leave traces in urine and feces that flow into the sewer system for measurement.

Why is this important? Emergency room doctors and other healthcare providers need timely information on which drugs are currently being used. Public health and government agencies need current information to protect the public. The media needs accurate information to reduce harm, inform, and warn the public. And families, including users themselves, need to know about new drug combinations or risky drugs that could be lethal if ingested.

By analyzing drug metabolites in municipal sewage, WBE can provide drug information that also aids in preparedness. For example, wastewater signals precede overdose surges, permitting proactive interventions, such as targeted Narcan distribution to reverse opioid overdoses and EMS preparedness. Some cities, such as Denver, have implemented pilot programs to track high-risk substances and guide intervention tactics.

Traditionally, substance use epidemiology—who is using what drugs by age, gender, and race/ethnicity—relied on large annual population surveys, including the Monitoring the Future study, the National Survey on Drug Use and Health, and the Youth Risk Behavior Surveillance System. But these methods are subject to underreporting, recall bias, and long periods (9-18 months) needed to collect, tabulate, analyze, and report this data. While surveys often underestimate the prevalence and intensity of drug use, we still use these longitudinal annual surveys to provide comparisons (changes over time) and insights into attitudes and risk perceptions. However, individual numbers are affected by biases. Sometimes people lie about their drug use, and also recall bias undermines accuracy, particularly over long timeframes. These biases are most pronounced in high-risk populations.

Surveys assume individuals know which substances they used, but this assumption is increasingly invalid. Drug markets now are characterized by widespread adulteration and drug substitutions, as well as a proliferation of novel psychoactive........

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