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Opioid misuse takes an enormous toll on the health and economy of the U.S., costing 130 lives per day, and an estimated 157 billion dollars per year. Mitigating the epidemic requires better information on the mix of drugs being used in a community and when and where drug use concentrates. Many widely used data sources, such as national population surveys, have a two-year lag before the data are available, and underestimate the prevalence of drug use because they rely on self-reported information about a stigmatized behavior. For rural populations, the data gap is compounded by privacy policies that suppress key information (for example, opioid-related death rates) in small populations. Municipal wastewater testing is an innovative approach to assessing community-level drug use that can provide near real-time, cost-effective, and unbiased measures of drug use. Importantly, wastewater-based data cannot reveal who is using a particular drug, mitigating privacy concerns. The methodology is routinely used across Europe and Australia as part of a holistic multi-indicator monitoring and alert system. When combined with geospatial mapping and advanced analytics, wastewater-based data can help locate geographic hotspots of use and provide an early warning for new substances entering into a community. We conducted a pilot study to compare temporal trends in estimates of per-capita drug use between wastewater-based data and other local data sources in two municipalities (one urban, one rural) in Montana. In the first phase of our study (Bishop et al. 2020, manuscript is in submission to Sci Total Environ), we optimized testing to estimate per-capita drug use in wastewater in an urban and rural municipality. Here, we report the value of these data for public health officials to predict rather than react to changes in drug use patterns. We also illustrate how rural populations can use the methodology to assess the impacts of local law enforcement efforts and evaluate the effectiveness of programs, such as the prescription take-back program, to improve public health and safety.

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