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ToxiPharm LLC
ToxSignal
Clinical Toxicology Intelligence
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Issue
#06
June 2026
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Hi *|FNAME|*,
Three things this issue. First: carfentanil, a fentanyl analog roughly 100 times more potent than fentanyl itself, has reemerged in the drug supply, and there is a confirmatory testing gap worth knowing about: a fentanyl-only LC-MS/MS panel will not catch it. In regulatory: a federal bill introduced this month would roll back the 2024 MOUD take-home and telehealth flexibilities that many OTPs, including programs here in Virginia, have built admission workflows around. And in science: new adherence data on monthly injectable buprenorphine gives a concrete number for a conversation many of you have with patients regularly.
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◆ Drug Trend Spotlight
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Carfentanil Is Back. Your Fentanyl Confirmatory Panel May Not Be Looking For It.
Carfentanil, a fentanyl analog roughly 100 times more potent than fentanyl itself, has reemerged in the U.S. drug supply after near-absence in 2021 to 2022. Labcorp's June 2026 Evolving Drug Trends report found carfentanil in more than 10% of fentanyl-positive urine specimens. DEA laboratories identified carfentanil in 1,400 drug seizures in 2025, up from 145 in 2023, a tenfold increase in two years. CDC surveillance shows deaths with carfentanil detected increased approximately sevenfold nationally, from 29 in the first half of 2023 to 238 in the first half of 2024, across 37 states.
Here is the testing gap that matters most for clinical interpretation: a confirmatory LC-MS/MS panel that targets only fentanyl and norfentanyl will not identify carfentanil, even when it is present in the specimen. Carfentanil has to be included as its own target analyte on the confirmatory method. A result reported as fentanyl positive, norfentanyl positive does not rule carfentanil in or out unless the laboratory's panel specifically includes it.
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Why it matters
For clinical staff: if a patient required unusually high or repeated naloxone doses, or needed prolonged monitoring after reversal, consider carfentanil co-exposure even when the confirmatory result reads fentanyl positive, norfentanyl positive. For laboratory consultants: confirm with clients whether carfentanil is an included target analyte on the fentanyl confirmatory panel, particularly in communities with an active carfentanil advisory. This month's Tox Pearl (#6) covers the full confirmatory testing distinction: download it free at toxipharm.org/education.html.
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Labcorp. Evolving Drug Trends: June 2026 Report. Labcorp; 2026. · Tanz LJ, Stewart A, Gladden RM, Ko JY, Owens L, O'Donnell J. Detection of Illegally Manufactured Fentanyls and Carfentanil in Drug Overdose Deaths, United States, 2021-2024. MMWR Morb Mortal Wkly Rep. 2024;73:1099-1105. PMID 39636782 · MMWR →
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◆ Regulatory & Policy Update
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Status: Pending; Reported June 10, 2026
A Federal Bill Would Roll Back the 2024 MOUD Take-Home and Telehealth Rule. Here Is What Is at Stake.
STAT reported June 10, 2026, on a growing federal push, including the Houchin-sponsored HR 5629, to nullify SAMHSA's 2024 MOUD final rule. That rule, effective April 2, 2024, expanded methadone take-home eligibility in the first two months of treatment, permitted telehealth admission exams without an initial in-person visit, and allowed split dosing. HR 5629 would strip each of these provisions. ASAM, AAFP, and patient advocacy groups have warned that the rollback would result in more opioid overdoses.
For OTPs and CTCs that have built admission and take-home workflows around the 2024 flexibilities, particularly telehealth induction and early take-home eligibility, a reversion would mean redesigning those workflows on short notice if the bill advances. The bill has not been enacted; this is a watch item, but one with a clear action attached now.
If you operate or advise an OTP, this is the moment to map which of your current operational practices depend on the 2024 rule's take-home, telehealth, and split-dosing provisions, so a contingency plan is ready rather than improvised after the fact.
STAT News, June 10, 2026. · SAMHSA. Medications for the Treatment of Opioid Use Disorder. Final Rule. 89 Fed. Reg. 7426 (Feb 2, 2024); effective Apr 2, 2024. · Federal Register →
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◆ Science Worth Reading
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OUTCOMES ANALYSIS / ADHERENCE DATA
Adherence to Monthly Injectable Buprenorphine Cuts Bacteremia by 62%. Here Is the Practice Implication.
New analyses reported May 20, 2026 examined outcomes associated with adherence to monthly injectable, extended-release buprenorphine compared with oral buprenorphine. Patients who remained adherent to the injectable formulation showed a 62% reduction in bacteremia relative to those on oral buprenorphine, along with fewer relapses.
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My Take
Bacteremia in patients with opioid use disorder is overwhelmingly an injection-related complication, so a 62% reduction tied specifically to adherence is a number worth having on hand. When a patient or program administrator asks why extended-release buprenorphine costs more or requires a monthly visit, this is a concrete answer: adherence to the injectable formulation appears to meaningfully reduce one of the most serious injection-related complications these patients face, on top of the relapse benefit. For CTC patients with a history of IV use, this is a data point I would bring into the conversation directly, not just file away.
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New Studies Show Adherence to Monthly Injectable Buprenorphine Is Associated with Relapse Reduction and Lower Healthcare Utilization. GlobeNewswire. May 20, 2026. · Full release →
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From Bill
"Carfentanil's reemergence is a useful reminder: the overdose numbers moving in the right direction nationally and here in Virginia do not mean the drug supply itself is getting safer. It means the threats are shifting, sometimes faster than testing menus and protocols keep up. Between this issue's carfentanil piece and this month's medetomidine coverage, the throughline is the same: confirm what your confirmatory panel actually covers. 'Fentanyl positive' is telling you less of the story than it used to."
Dr. William Bundy Jr., PharmD
Clinical Toxicologist & Consultant · ToxiPharm LLC
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ToxiPharm LLC
Clinical toxicology consulting, expert review, UDT interpretation, and Tox In Focus clinical references.
toxipharm.org
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Clinical Disclaimer
Content in this newsletter is intended for clinical reference and educational purposes for use by qualified clinicians, medical review officers, and drug program administrators. It does not represent an all-inclusive review of available evidence. Clinical data, regulatory guidance, and laboratory standards evolve; readers should verify current requirements with applicable authorities. Content in this newsletter does not constitute medical, legal, or regulatory advice and should not replace independent clinical judgment. ToxiPharm LLC makes no warranties regarding completeness or applicability in all clinical situations. © 2026 ToxiPharm LLC · toxipharm.org
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