By Victoria Caruso
As the opioid epidemic rages on, the presence of synthetic fentanyl in drugs such as heroin has become one of the major drivers in increased overdose fatalities in the U.S. In Rhode Island, deaths involving this highly potent, synthetic opioid rose from twelve in 2012 to over 200 in 2017.
To combat the dangers posed by contaminated opioids, the National Institute of Health awarded Brown University’s School of Public Health a grant worth $3.5 million spread over five years to study the effectiveness in harm reduction of a recent technology— disposable test strips that can detect fentanyl contamination in a drug.
“Fentanyl is a very potent opioid, about 50 to 100 times more powerful than heroin or morphine,” said Brandon Marshall, an associate professor of epidemiology at Brown and the principal investigator of the NIH-funded Rhode Island Prescription and Illicit Drug Study (RAPIDS).
“The equivalent of several grains of salt can cause an overdose.” According to the Center for Disease Control and Prevention, fentanyl, often referred to as illicitly manufactured fentanyl (IMF), is usually mixed with heroin and/or cocaine or pressed into counterfeit pills—with or without the user’s knowledge. With only a small amount of IMF needed to cause an overdose, it is easy for fentanyl contamination to go undetected by the naked eye.
About five years ago, fentanyl test strips began being manufactured by a Canadian company called BTNX and are now being distributed in the U.S. by harm reduction organizations. Originally designed to test for fentanyl in urine, the skinny, disposable strips are now used to test drugs directly for the presence of fentanyl contamination. The idea behind the strips is that people who use drugs can better assess their risk of overdose. Marshall explains, “We know what’s in our food, right? We can make decisions around whether to eat something or not.” Similarly, people can make more informed decisions about what drugs they put into their bodies and what they may do to reduce their risk of overdose, like using less of the drug or getting rid of it completely.
The RAPIDS study will test whether or not educating people who use drugs about the harms of fentanyl and showing them how to use test strips reduces the risk of overdose. Through Craigslist, flyers on RIPTA buses, and connections with local organizations, researchers at Brown hope to recruit people who use drugs between ages 18 and 65 for randomized intervention trials. In order to study the effect of distributing fentanyl test strips, specific fentanyl intervention and physical test strips will be randomly provided to some participants while others will be informed on how to obtain them from other organizations. All participants will be trained to engage in general overdose risk reduction behaviors through videos and will receive naloxone, a medication designed to rapidly reverse opioid overdose.
Marshall and his research team predict that giving test-strips to people will lower overdose rates. In 2017, the team ran a pilot study, finding that many young adults who used fentanyl test strips took precautions against overdose. Among the 93 participants in the study, half found fentanyl in the drugs they tested. Of those, 45 percent reported using smaller amounts of the drug, 42 percent proceeded more slowly when using, and 39 percent used with someone else present who could seek help in an emergency.
“We found that people really liked the strips” said Marshall. “They use them and when drugs were tested positive for contamination they reduced their overdose risk behaviors.” The RAPIDS study aims to significantly expand the results of the pilot study, a small-scale but promising effort.
Originally illegal in Rhode Island, the test strips had to be approved by the FDA as an investigational device in order to be used for the pilot study. The findings of the study consequently helped to pass a bill in the House on June 23rd, 2018 that made fentanyl test strips legal to use and distribute in Rhode Island. Now, fentanyl test strips are easily accessible and free to the public at local nonprofits such as Project Weber/Renew (640 Broad St, Providence, RI 02907) and RICARES (134 Mathewson St, Providence, RI 02903).
“You can walk in, grab what you need, and walk out,” said Jacqueline Goldman, the project coordinator for the RAPIDS study. “Their goal is to make it as low of a threshold as possible.”
In other states, fentanyl test strips are considered drug paraphernalia and are still illegal. The RAPIDS study could potentially demonstrate the importance of providing resources that aid harm reduction, such as fentanyl test strips, in combating the opioid epidemic. It will also be a valuable reference when it is time to evaluate how and where these test strips should be distributed.
According to the Harm Reduction Coalition, harm reduction is a movement for social justice built on a belief in, and respect for, the rights of people who use drugs. “If we offer people resources and meet them where they are, they’re more likely to then engage, use harm reduction, and possibly seek treatment,” said Goldman.
Though the use of fentanyl test strips appears to be promising in reducing opioid overdose, Marshall and his team recognize that fentanyl test strips are not the silver bullet that will end the opioid overdose epidemic.
“I believe that fentanyl test strips are going to be an important tool, but they won’t solve the problem,” said Marshall. “They’re a technology that we hope people can use on their own to reduce the risk of overdose, but they don’t address the larger structural issues that are putting people at risk in the first place, like homelessness and incarceration. We always have to be mindful of those upstream determinants of health and should be continuing to work to address them.”