Do Fentanyl Test Strips Contribute to Harm Reduction

In this post, I share a few thoughts about the use of fentanyl test strips (FTS) to reduce opioid overdose complications and death.

More than 2.1 million Americans have an opioid use disorder (OUD), including 626,000 with heroin related OUD. According data on the opioid overdose crisis from the January 4, 2019 issue MMWR, 47,600 Americans died of opioid overdoses in 2017, a 12% increase over 2016. This means that on average, 130 Americans died each day from opioid overdoses in 2017. Synthetic opioid, primarily illicitly manufactured fentanyl and fentanyl analogs were involved in almost 60% of opioid overdose deaths, an increase of about 45% from the previous year.

Fentanyl and its analogs are sold as adulterated heroin, heroin substitutes and fentanyl-laced counterfeit opioid pills. The involvement of synthetic opioids in a majority of opioid overdose deaths underscores the need for a robust harm reduction strategy, particularly for non-treatment seeking individuals (opioid users). There is reasonable agreement about many components of an overall harm reduction strategy, including: (i) using drugs only in the presence of others who can call for help; (ii) naloxone rescue training and dispensing; and (iii) activating emergency medical services upon overdose. However, there continues to be an urgent need to develop more effective harm reduction interventions in response to the harm producing effects of heroin adulterated with fentanyl.

Recently, some organizations have advocated the use of fentanyl test strips (FTS) to identify illicitly manufactured fentanyl in street purchased drugs (“drug checking services”) as part of a harm reduction strategy. A small number of published studies suggest that use of FTS has the potential to effect changes in drug use behavior and reduce opioid overdose fatalities. In one study of young adults in Rhode Island in whom 37% had previously overdosed, 92% wanted to know if there was fentanyl in their drug supply prior to use. In another study of 32 stakeholders in Baltimore, Boston and Providence, there was significant support for the concept of FTS use with the goal of providing risk reduction resources and a point for greater engagement for users. Unfortunately, FTS provide only qualitative results, i.e., whether fentanyl is present, absent or the test is invalid, and not quantitative results, i.e., how much fentanyl is present. Since approximately 90% of heroin is adulterated or substituted with fentanyl or its analogs, FTS can only allow for limited decision making regarding the opioid supply: do not use it; use it in a small, test amount; or use as before, at greater risk of opioid overdose and death.  

The use of FTS is not without controversy, particularly for self-administration by drug users. Dr. Elinore McCance-Katz MD, PhD, Assistant Secretary for Mental Health and Substance Use who leads SAMHSA recently published a blog entitled “For Beating The Opioid Crisis, America Has Better Weapons Than Fentanyl Test Strips” which states that “The entire approach is based on the premise that a drug user poised to use a drug is making rational choices, is weighing pros and cons, and is thinking completely logically about his or her drug use. Based on my clinical experience, I know this could not be further from the truth. People who are addicted to opioids are not making a rational choice to continue their drug use. Addicted individuals whose bodies demand that they find their next opioid to stave off withdrawal symptoms are not in positions to weigh all options and to choose to not use the only opioid at their disposal.”

Concerns have been expressed that perhaps FTS are being distributed for self-testing in the absence adequate ethical, scientific and operational deliberation and a full understanding of potential unintended consequences that might increase harm. Others have argued that in the face synthetic opioid proliferation and their widespread use as opioid adulterants and substitutes which now account for a majority of opioid overdose deaths, the harm reduction movement cannot wait any longer. This is a self-described self-made “movement for social justice built on a belief in, and respect for, the rights of people who use drugs”. Some proponents of FTS would argue that syringe exchange and naloxone peer distribution initiatives came out of the harm reduction movement and went mainstream grudgingly and only after considerable loss of life.

Dr. Najib Babul, PharmD, MBA.

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