Fentanyl test strip distribution programs

There is some evidence that fentanyl test strip distribution programs can reduce risky drug use behavior amongst people who use drugs (Reed 2024, Goldman 2019). Additional evidence is needed to confirm its effects.

Rapid fentanyl test strips (FTS) can be used to detect fentanyl to inform people who use drugs about their risk of exposure to fentanyl prior to drug consumption (Goldman 2019). Testing illicit drugs before consumption can help people who use drugs understand risk and can inform others in the community about the presence of fentanyl; this can lead to behavioral changes and reduce potential harms of drug use (Peiper 2019). Some individuals have reported changing their behavior when using drugs after utilizing FTS (Reed 2022b). Some pattern changes include discarding drugs that test positive, using drugs with someone present instead of alone, and making sure to have naloxone on hand (Goldman 2019). Overall, surveyed young adults (Krieger 2018), people who use drugs (Reed 2022a), and those with opioid use disorder (Mistler 2021) agree that FTSs are an acceptable form of harm reduction. Besides FTS, drug checking services that test drugs at facilities like a syringe services program or overdose prevention centers can provide people who use drugs with real-time results on the presence of fentanyl in illicit drugs (Park 2023a). Drug checking services can be a good alternative as FTS need to be properly used to be effective, however, some individuals lack the knowledge and understanding on how to effectively use them (Barrolle 2023).

FTS distribution programs may be able to engage with people who use drugs and their family and friends and connect them to important care services and community resources (Olson 2022). Furthermore, there may be an association between use of FTSs and carrying naloxone, but more research is needed (Tilhou 2024).

The compounds and drugs that are added to illicit drug supplies are constantly changing and pose a challenge for people who use drugs and harm reduction efforts. In addition to fentanyl, xylazine is a sedative not approved for human use but has been found in illicit drug supplies and is linked to increased overdose deaths in the U.S (CDC-Xylazine). Testing for xylazine in illicit drugs can potentially change drug use behavior; more research is needed to validate this (Peiper 2019).

It is unclear what impact fentanyl test strip (FTS) distribution programs have on disparities in drug use behavior and overdose related deaths.

Inequalities by race, geographic location, and economic status persist in drug overdose deaths (CDC-Disparities widen, Zhang 2018c). Most people who overdose are non-Hispanic whites, about 10% are non-Hispanic Blacks, and 8% are Hispanic (Salmond 2019). Experts attribute this demographic breakdown to the unconscious bias and prejudices of health care providers, who are more cautious prescribing opioids to non-white patients based on the prejudiced assumption that non-white patients are more likely to abuse or sell opioid prescription drugs (Salmond 2019). Individuals who exhibit mental health conditions are also more likely to use opioids (Salmond 2019).

Proper implementation of fentanyl test strip distribution programs is key to reaching people who use drugs. Educating people who use drugs on the correct use of FTSs and interpreting results is important (Barrolle 2023). Tailored outreach is necessary to reach marginalized individuals, especially people who inject drugs that are older and Black (Oh 2020).

Opioid overdose deaths have been increasing since 1999 (Freeman 2018). The rise in opioid overdose deaths began in the 1990s with a substantial increase in the prescription of both natural and semi-synthetic opioids because they were effective at managing chronic pain and falsely marketed to health care providers as non-addictive (CDC-Understanding the epidemic, Bennett 2021, Haffajee 2020). Prescription opioid sales increased fourfold between 1999 and 2008 (Judd 2023). Many patients who became addicted to prescribed opioids turned to non-prescribed forms of opioids, such as heroin, which lead to a second wave of opioid overdoses in 2010. In 2013, a third wave began when synthetic opioids, such as fentanyl, that are much more potent than other forms of opioids were combined with other drugs or counterfeit prescription pills, often unknown to the purchaser (CDC-Understanding the epidemic). Synthetic opioids like fentanyl have contributed to nearly 74,000 overdose deaths in 2022, a 4% increase from the previous year (CDC-Fentanyl). In 2013, the U.S. Department of Health and Human Services declared the misuse of prescription opioids an epidemic. Four years later, in 2017 the opioid epidemic was declared a national public health emergency (Salmond 2019). Between 2020 and 2021, the opioid overdose death rate increased by over 15% and the synthetic opioid overdose death rate increased by over 22% (CDC-Understanding the epidemic). However, between 2022 and 2023 there has been a decrease in opioid related deaths for some groups, but increases are seen for non-Hispanic Black individuals and Native Hawaiian or Other Pacific Islander non-Hispanic people (CDC-Drug overdose deaths in the US).

The dramatic increase in opioid sales was the result of pharmaceutical companies that overproduced and oversupplied opioid drugs for huge profits, pharmacies that filled the prescriptions, and health care providers who overprescribed the medications (Judd 2023). In rural areas many physicians overprescribed opioids to patients who travel long distances for treatment, do not have the ability to attend frequent appointments, and do not have alternative pain management interventions in their area (Judd 2023).

Increasing overdose deaths highlights the need to connect communities to appropriate resources and to expand prevention methods. Drug checking equipment, like fentanyl and xylazine test strips can be used to reduce the harms associated with substance misuse. However, drug checking equipment is considered drug paraphernaliain some states and is illegal. Many states have passed legislation to clearly indicate that such test strips are legal and have decriminalized them (ASTHO-Substance misuse and overdose prevention, Davis 2022).

• Are fentanyl and xylazine test strips legal in your state? Where can community members access them? How can your community improve access to such drug checking equipment?
• Do community members know about the availability of test strips? Are those interested in test strips provided proper education on how to effectively use test kits and interpret results?

Drug checking equipment such as fentanyl and xylazine test strips are considered drug paraphernalia under some state laws. As of 2023, 15 states have introduced legislation to decriminalize drug checking equipment, while two states have expanded regulations to increase access to harm reduction tools like fentanyl and xylazine test strips; FTSs are legal in 44 states based on 2023 data under laws specific to drug checking equipment, exceptions to syringe service programs, or Good Samaritan laws (ASTHO-Substance misuse and overdose prevention). In 2021, the CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA) announced that federal funding could be used to purchase FTSs by state and community-based organizations (CDC-What you can do to test for fentanyl).

CDC-What you can do to test for fentanyl - Centers for Disease Control and Prevention (CDC). Stop overdose. What you can do to test for fentanyl.

* Journal subscription may be required for access.

ASTHO-Substance misuse and overdose prevention - Association of State and Territorial Health Officials (ASTHO). Substance misuse and overdose prevention.

Barrolle 2023* - Barrolle AA, Gable KN, Dell N. A pilot study assessing client understanding and use of fentanyl test strips for harm reduction. Journal of the American Pharmacists Association. 2023;63(1):295-300.

Bennett 2021* - Bennett AS, Elliott L. Naloxone’s role in the national opioid crisis — past struggles, current efforts, and future opportunities. Translational Research. 2021;234:43-57.

CDC-Disparities widen - Centers for Disease Control and Prevention (CDC). Vital signs. Drug overdose deaths rise, disparities widen.

CDC-Drug overdose deaths in the US - Centers for Disease Control and Prevention (CDC). Drug overdose deaths in the United States, 2003-2023.

CDC-Fentanyl - Centers for Disease Control and Prevention (CDC). Overdose prevention. Fentanyl.

CDC-Stop overdose - Centers for Disease Control and Prevention (CDC). Stop overdose. What you can do to test for fentanyl.

CDC-Understanding the epidemic - Centers for Disease Control and Prevention (CDC). Understanding the opioid overdose epidemic.

CDC-What you can do to test for fentanyl - Centers for Disease Control and Prevention (CDC). Stop overdose. What you can do to test for fentanyl.

CDC-Xylazine - Centers for Disease Control and Prevention (CDC). Overdose prevention. What you should know about xylazine.

Davis 2022* - Davis CS, Lieberman AJ, O’Kelley-Bangsberg M. Legality of drug checking equipment in the United States: A systematic legal analysis. Drug and Alcohol Dependence. 2022;234:109425.

Freeman 2018* - Freeman PR, Hankosky ER, Lofwall MR, Talbert JC. The changing landscape of naloxone availability in the United States, 2011 – 2017. Drug and Alcohol Dependence. 2018;191:361-364.

Goldman 2019 - Goldman JE, Waye KM, Periera KA, et al. Perspectives on rapid fentanyl test strips as a harm reduction practice among young adults who use drugs: A qualitative study. Harm Reduction Journal. 2019;16(1):1-11.

Haffajee 2020* - Haffajee RL, Cherney S, Smart R. Legal requirements and recommendations to prescribe naloxone. Drug and Alcohol Dependence. 2020;209:107896.

Judd 2023* - Judd D, King CR, Galke C. The opioid epidemic: A review of the contributing factors, negative consequences, and best practices. Cureus. 2023;15(7):e41621.

Krieger 2018* - Krieger MS, Goedel WC, Buxton JA, et al. Use of rapid fentanyl test strips among young adults who use drugs. International Journal of Drug Policy. 2018;61:52-58.

Mistler 2021 - Mistler C, Rosen A, Eger W, Copenhaver M, Shrestha R. Fentanyl test strip use and overdose history among individuals on medication for opioid use disorder. Austin Journal of Public Health and Epidemiology. 2021;8(6):1-12.

Oh 2020* - Oh H, Kim K, Miller D, et al. Fentanyl self-testing in a community-based sample of people who inject drugs, San Francisco. International Journal of Drug Policy. 2020;82:102787.

Olson 2022 - Olson R, Case P, Palacios WR, et al. Law enforcement and community provision of fentanyl test strips to people who use drugs for engagement and referral to services. Journal of Public Health Management and Practice. 2022;28(6):S343-S346.

Park 2023a* - Park JN, Tardif J, Thompson E, et al. A survey of North American drug checking services operating in 2022. International Journal of Drug Policy. 2023;121:104206.

Peiper 2019 - Peiper NC, Clarke SD, Vincent LB, et al. 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.

Reed 2022a* - 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;140:108790.

Reed 2022b - Reed, M. K., Guth, A., Salcedo, V. J., Hom, J. K., & Rising, K. L. (2022). “You can’t go wrong being safe”: Motivations, patterns, and context surrounding use of fentanyl test strips for heroin and other drugs. International Journal of Drug Policy, 103, 103643.

Reed 2024* - Reed MK, Siegler A, Esteves Camacho T, et al. Making harm reduction more accessible: Fentanyl test strip awareness and attitudes among emergency department patients who use drugs. Substance Use and Misuse. 2024;59(3):398-404.

Salmond 2019 - Salmond S, Allread V. A population health approach to America’s opioid epidemic. Orthopaedic Nursing. 2019;38(2):95-108.

SAMHSA-Fentanyl and xylazine test strips - Substance Abuse and Mental Health Services Administration (SAMHSA). Fentanyl and xylazine test strips.

SAMHSA-Harm reduction - Substance Abuse and Mental Health Services Administration (SAMHSA). Harm reduction.

Tilhou 2024* - Tilhou AS, Zaborek J, Baltes A, et al. Association of fentanyl test strip use, perceived overdose risk, and naloxone possession among people who use drugs. Substance Use and Misuse. 2024;59(2):254-257.

WI DHS-Free FTS - Wisconsin Department of Health Services (WI DHS). Dose of Reality: Get the Facts on Opioids. Get free fentanyl test strips.

Zhang 2018c* - Zhang X, Marchand C, Sullivan B, Klass EM, Wagner KD. Naloxone access for Emergency Medical Technicians: An evaluation of a training program in rural communities. Addictive Behaviors. 2018;86:79-85.