Public health advocates and officials are at odds over programs that allow drug users to bring in their illicit drugs to test them for a deadly synthetic opioid.
Health advocates say such programs help reduce fatal overdoses by fentanyl, a powerful synthetic that has taken lives and ravaged communities across the country.
But government officials express concern that the programs send the wrong message — that there is a safe, acceptable level of illicit drug use.
The most popular test, a fentanyl test strip, officially is intended for drug-testing urine, but it has been found to be effective in detecting traces of the opioid in drugs themselves.
“There’s people who’ve used the tests and come back and said, ‘Look, it’s saved my life,’” said Mark Townsend, who works in syringe exchange programs in Manhattan.
Costing about $1 each, the strips resemble those used to test pools for chlorine. They display lines to indicate the presence of fentanyl — one for positive, two for negative.
Health officials say the strips are inaccurate and misleading.
“I would not want the message to be, just because the fentanyl strip test is negative, that the drug is safe to use,” said Baltimore City Health Commissioner Dr. Leana Wen. “For us, naloxone [the overdose reversal medication] needs to be in everyone’s medicine cabinet and everyone’s first aid kit.”
Advocates play an integral role in informing policies made by public health officials, and then put policy into practice by providing harm reduction services like syringe exchange, condom distribution, HIV testing and more.
The test strips have been used for years in safe injection and overdose prevention sites in Canada, and their usefulness made the rounds of discussion among advocates in the U.S.
In February, researchers from Johns Hopkins Bloomberg School of Public Health published results supporting the test strips as a cost effective and scalable intervention for reducing fentanyl overdoses.
Called the Forecast study, it surveyed drug users in Baltimore, Boston and Providence, Rhode Island, and found that 70 percent said they would take more precaution if they knew the fentanyl, and how much of it, was present in their stash.
“This project was started, it was faster than the speed of light,” said lead researcher Susan Sherman, a professor in the Department of Health, Behavior, and Society at Johns Hopkins.
Overdose deaths attributable to highly potent fentanyl surpassed those from prescription pain pills in 2016, representing 45 percent of the more than 42,000 opioid-related deaths that year.
“A lot of the interviews we did, people who use drugs are interested in what else is in their drugs and also the quantity of fentanyl,” Ms. Sherman said.
In California, the state health department had been providing funds for purchasing strips as early as May 2017. Since then, about 57,000 test strips have been ordered by syringe exchange programs throughout the state.
Yet in states and cities most affected by the opioid epidemic, and with rising rates of overdoses linked to fentanyl, governments aren’t considering the test strips as a viable preventive measure.
Health departments in West Virginia, Ohio, New York City and Washington, D.C., said they aren’t providing funds for or distributing the strips to test for fentanyl.
New York and D.C. officials did say they are considering the results of the Forecast study and talking with harm reduction workers about the benefits of the strips.
Organizations, however, are stepping up to provide a service they say gives drug users more information and autonomy over their addiction.
“The point is that it allows people to make choices, to have a little more information,” said Ms. Sherman. “It’s not a small thing that people who are drug users feel a sense of autonomy and it gives them a choice.”
Advocates teach drug users how to test their supply with the strips and often pair this information with naloxone training, showing people how to administer the overdose reversal medication.
“To me, it’s not controversial,” said Eliza Wheeler of the Harm Reduction Coalition, a consortium of needle exchange providers, advocates and drug users. “It is a harm reduction tool for people who use drugs to be better informed about the supply and how to be safe.”
There are drawbacks. It’s often confusing to read the results — there have been instances in which the lines are faded, or people misinterpret them.
The strips also can’t tell how much fentanyl is present, or if the positive reading is for an analog.
Carfentanil, for example, is an analog that is 100 times more potent than fentanyl, or 1,000 times more powerful than morphine.
Drug users who have developed a high tolerance unlikely will be swayed by a positive test result, instead taking the chance that they won’t die, officials said.
More detailed results can be found with laboratory machines, evaluated in Ms. Sherman’s Forecast study. They were able to detect multiple drugs and quantity in one sample.
But such interventions can be rather expensive.
One machine, the Bruker Alpha spectrometer, can cost up to $20,000 — and that price tag doesn’t take into account where the machine would be placed in the community and who would to operate it, interpret its results and explain the data.Public health officials lean heavily on the advice and experience of advocates, the on-the-ground workers engaging daily with the drug using community. But policy decisions often only take shape after tangible research supports years of advocacy.
The two camps do agree that drug users should be warned and educated about the increasing presence of fentanyl in the drug supply and what can be done to protect oneself — throw the drugs away, don’t shoot up alone, only take a little bit, make sure someone is with you who has naloxone.
Where they diverge is when and how to present that information. For Dr. Wen, physicians should be talking to patients when they come into the emergency department after an overdose.
“Let’s say a patient is coming in with a suspected overdose, they may think that they took heroin but it would be useful information to that patient and to the provider if actually what they took was fentanyl,” she said. “They’re not testing the drug in order for someone to use it.”