Mubazar Ishfaq, BS
Illicit synthetic fentanyl abuse is increasing across America and is the cause of the current 4th wave of the Opioid Epidemic.
People who use drugs are often unaware that their drugs have been contaminated with fentanyl.
Drug checking services have been shown to influence drug use behavior.
Fentanyl test strips are relatively inexpensive and simple and inexpensive to detect undesired fentanyl.
Fentanyl test strip use has been shown to potentially encourage harm reduction behaviors among people who use drugs.
Synthetic fentanyl abuse is increasing across America and has been attributed as the cause of the 4th wave of the ongoing Opioid Epidemic . Fentanyl is a synthetic opioid that is highly potent and has almost 50 times greater potency than heroin . Fentanyl is viewed to have several advantages to those making it illicitly over other types of opioids due to its high potency requiring less weight to distribute it and its ability to be reliably manufactured synthetically from chemicals instead of grown from a plant . For those using fentanyl, they may prefer it due to its high potency leading to a stronger perceived effect and faster onset of action leading to faster pain relief and feelings of euphoria when compared to other opioids . These perceived advantages allow fentanyl to be inexpensively manufactured and readily accessible .
Drugs contaminated with illicit fentanyl are increasingly striking communities nationwide with overwhelming numbers of unintentional drug overdose deaths. In 2020 alone, there were over 93,000 overdose deaths in the United States and of those deaths, opioids were responsible for a total of 69,710 with the majority specifically due to fentanyl . Since 2013, there has been a significant rise in illicit fentanyl being mixed with other opioids such as heroin. More recently, there has been an alarming increase in non-opioid illicit drugs such as cocaine, methamphetamine, counterfeit hydrocodone, and counterfeit Xanax, also contaminated with fentanyl. This exposure is especially dangerous in opioid-naïve individuals, as unintentional fentanyl consumption leaves them more susceptible to opioid overdose. In. response, fentanyl test strips (FTS) have been introduced as a harm reduction tool for people who use drugs (PWUD) to utilize to determine the safety of their drug. FTS provides an inexpensive, quick, and simple method to identify contamination with fentanyl or fentanyl analogs . FTS allow PWUD to make an informed decision regarding their drug consumption.
The purpose of this analysis is to review the current literature on unintentional fentanyl use, evaluate the evidence of FTS, and evaluate how PWUD may change their drug use behavior following a positive FTS.
Uncertainty of Drug Contents among PWUD
There is growing awareness of fentanyl contamination among PWUD. In 2016, a Connecticut-based report identified fentanyl, which was advertised to PWUD as cocaine, caused 12 opioid-related overdose incidents . Moreover, all incidents occurred six hours following consumption and resulted in four ICU admissions and three deaths (4). A survey of 242 participants across 17 harm reduction sites in British Colombia, Canada revealed that of the 29% of participants who screened positive for fentanyl, 73% of them had been unaware they had used fentanyl . Additionally, in a Massachusetts study evaluating drug use behaviors among 231 participants experiencing opioid withdrawal, approximately two-thirds of those that reported never intentionally or unintentionally using fentanyl screened positive for fentanyl . These studies illustrate just how common it is for PWUD to unknowingly use drugs contaminated by fentanyl.
Drug Checking Services Influence on Drug Use Behaviors
Although FTS has only recently emerged as a potential harm reduction strategy to combat the opioid crisis, screening illicit drugs prior to use is not a new concept. Drug checking services (DCS) have been prominent across Europe, particularly in the setting of live music. A 2016 study in Portugal evaluated the behavioral intentions of PWUD following results from a DCS at a music festival . The study found that 94.3% of participants that had an unexpected result, such as the result was not the drug they thought it was, reported refusal to use their illicit drug . Also, when the test results indicated that it was the expected substance but there were additional contaminants in the sample, 32% of participants reported refusal of drug administration . While this is a unique patient population, the data suggest that PWUD have the potential to change their drug use behaviors when they receive an analysis of the true contents of their drugs.
FTS Use Influence on Drug Use Behaviors
FTS are an inexpensive tool (typically costing less than $1 per strip) that can be used to detect fentanyl and fentanyl analogs present in various drugs. A small of amount of drug is mixed with water and the FTS is dipped into the solution. The strip processes for a few minutes before the result can be read directly from the strip . In a 2017 study of 125 PWUD in North Carolina, 63% reported having used an FTS and obtaining a positive result for fentanyl contamination in the past . The study further found that PWUD that obtained a positive result were five times more likely to change their drug use behaviors when compared to those who obtained a negative result . Changes in drug use behaviors were categorized as to whether the participant either used the drug less than usual, administered a tester shot, pushed the syringe plunger slower than usual, or chose intranasal as opposed to intravenous administration of the drug. These results have important implications in promoting access of FTS in the future as it helps to reduce overall drug use. In fact, 43% of PWUD changed their behavior following FTS use prior to using drugs .
Furthermore, a study of 68 female sex workers following FTS use education revealed that 69% employed harm reduction strategies following a positive FTS result, with 96% of participants also reporting continued use of FTS at the time of follow-up . Harm reduction strategies reported among the participants included using a smaller amount of the drug, ensuring someone else was present while using the drug, and using a tester spot. Additionally, a significant reduction in daily illicit opioid use (77% to 56%), injection frequency (40% to 25%), and solitary drug use (96% to 68%) was found among the participants at the one-month follow-up . Overall, access to FTS can potentially be an important harm reduction tool by increasing the safety of drug use among PWUD while also altering drug use behavior.
Illicit fentanyl contamination of both heroin and non-heroin drugs has exacerbated the opioid crisis and starkly increased the number of opioid-related deaths. Increasing access to FTS across the nation can serve as a potential harm reduction strategy among PWUD as it may influence more informed decision-making regarding their drug use and encourage safer drug use behavior. Future studies should be conducted to analyze the correlation between access to FTS and opioid-related mortalities.
Reed MK, Salcedo VJ, Guth A, Rising KL. “If I had them, I would use them every time”: Perspectives on fentanyl test strip use from people who use drugs. Journal of Substance Abuse Treatment. 2022:108790. doi:10.1016/j.jsat.2022.108790
Peiper NC, Clarke SD, Vincent LB, Ciccarone D, Kral AH, Zibbell JE. Fentanyl test strips as an opioid overdose prevention strategy: Findings from a Syringe Services Program in the Southeastern United States. International Journal of Drug Policy. 2019;63:122-128. doi:10.1016/j.drugpo.2018.08.007
Fairbairn N, Coffin PO, Walley AY. Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic. International Journal of Drug Policy. 2017;46:172-179. doi: 10.1016/j.drugpo.2017.06.005
Tomassoni AJ, Hawk KF, Jubanyik K, et al. Multiple Fentanyl Overdoses - New Haven, Connecticut, June 23, 2016. MMWR Morb Mortal Wkly Rep. 2017;66(4):107-111. doi:10.15585/mm6604a4
Amlani A, McKee G, Khamis N, Raghukumar G, Tsang E, Buxton JA. Why the fuss (Fentanyl Urine screen study)? A cross-sectional survey to characterize an emerging threat to people who use drugs in British Columbia, Canada. Harm Reduction Journal. 2015;12(1). doi:10.1186/s12954-015-0088-4
Kenney SR, Anderson BJ, Conti MT, Bailey GL, Stein MD. Expected and actual fentanyl exposure among persons seeking opioid withdrawal management. Journal of Substance Abuse Treatment. 2018;86:65-69. doi:10.1016/j.jsat.2018.01.005
Valente H, Martins D, Carvalho H, et al. Evaluation of a drug checking service at a large scale electronic music festival in Portugal. International Journal of Drug Policy. 2019;73:88-95. doi:10.1016/j.drugpo.2019.07.007
Park JN, Tomko C, Silberzahn BE, Haney K, Marshall BDL, Sherman SG. A fentanyl test strip intervention to reduce overdose risk among female sex workers who use drugs in Baltimore: Results from a pilot study. Addictive Behaviors. 2020;110:106529. doi:10.1016/j.addbeh.2020.106529