Background West Virginia in the USA has the highest fatal drug overdose rate in the country; rates (91/100,000 population) are three times than national rates. New drugs and patterns of drug use are changing rapidly but there are long-time delays in reporting of drug testing on fatalities.

Objective To address the need for more rapid information on the actual drugs being used and to track trends and emergence of new drugs, we set up a rapid and near real-time reporting system on drugs being injected in the community through testing/analysis of the residual content among used syringes submitted to six syringe exchange programs across the state.

Methods Each week between 50–75 used syringes were randomly selected from each syringe exchange program and submitted for forensic chemical analysis of the residual content within each syringe and screened for 169 drugs. Detailed confirmative forensic analysis was performed as the goal of the study was to allow for the detection of new emerging substances prior to a fatal overdose, detect shifts in the illicit drug supply, and changes in the drug use patterns, as against more restricted onsite drug checking.

Results Fentanyl and its analogs were detected in 61.7% of the tested syringes, emphasizing the ongoing challenge of synthetic opioids in West Virginia. Methamphetamine was found in 83.3% of the syringes and increased over time. Cocaine and its metabolite were present in 66.7% of the syringes. We also saw the emergence of xylazine with wide variation in across the state ranging from 0.7% to 43.8% (mean 19%) and it is increasing.

Conclusions The study has provided valuable data on the multiple drugs being injected current including the high use of methamphetamine. It also enabled early alerts to the presence of xylazine, an adulterant associated with serious health risks. By identifying the emergence of xylazine which can cause unusual necrotic skin wounds, local programs have been able to respond proactively by enhancing wound care services for participants experiencing soft tissue injuries related to xylazine use.