We are all learning how to be good stewards of prescription opioids which has resulted in a significant downward trend in dispensing rates over the past decade. However, the number of fatal overdoses due to fentanyl continues to rise.
As the fentanyl crisis worsens, visits to the ED for opioid-related adverse events have more than doubled in the past decade. Patients who present post-opioid overdose and survive are 100 times more likely to die from a drug overdose and are at an 18-fold increased risk of suicide the year following their discharge when compared to the general population.
Harm-Reduction Strategies for the Fentanyl Crisis
The ED may be the only place patients with opioid use disorder obtain health care. Patients who use illicit drugs are a vulnerable population in which EDs are already well-equipped to provide acute stabilization in the event of an overdose. EDs are also uniquely positioned to implement harm-reduction strategies to mitigate the risk of future fatal overdose.
Here are some of the best harm-reduction strategies available to us at this time:
- Increasing access to naloxone, medication-assisted therapy with buprenorphine, and fentanyl test strips are three risk-reducing strategies to combat overdose deaths.
- At the crux of the issue is distribution and access to these resources. In order to overcome these obstacles, education must be widely available and the stigma surrounding drug use needs to be removed.
- Addiction is considered a moral failing instead of a disease that is not only treatable but curable. The language surrounding opioid use disorder has to evolve if barriers to treating substance use disorder are to be removed. (You can continue your education around destigmatizing language here.)
The Case for Fentanyl Test Strips
Fentanyl test strips were not created to deter people from using drugs but as a means of harm reduction and reducing death from unintentional overdose. It buys time for contemplation and provides information, allowing for people who use drugs to weigh their options and calculate their risk rather than blindly and unknowingly making uninformed choices.
While a positive test would ideally dissuade a person from using that drug or batch altogether, it also provides valuable information if they still decide to use it. Other life-saving alternative choices could include using less of the drug, using a different batch, having someone present or nearby when using, ensuring naloxone is at the ready, or gathering information regarding their source of the drug and informing others.
In a perfect world, the goal would be to prevent illicit drug use in the first place. However, we can’t be so naive to think the D.A.R.E. program’s old slogan of “just say no to drugs” is enough to deter someone.
In fact, the staggering increase in overdoses proves that this epidemic needs to be hit from all angles if the ultimate goal is to save lives. Just as touting abstinence failed to prevent unwanted pregnancies and STIs, saying that “drugs are bad” isn’t going to deter the determined. So, we must provide proverbial condoms. Barrier methods and education proved to be successful preventative measures and did not ultimately increase or give a “pass” for teenagers to engage in sexual activity but did protect those who were already going to make that choice regardless.
Other Use Cases for Fentanyl Test Strips
It may seem as though fentanyl test strips were created for those suffering from opioid use disorder or using illicit drugs on the streets, but there are so many other scenarios where normalized use of this resource can prevent an unpredictable and uncharacteristic tragedy.
Think of the young adult looking to experiment for the first time; the person lacking healthcare access suffering from anxiety who is offered a benzo from an acquaintance; the student looking to get ahead in class taking a stimulant from a classmate; the concert goer who thinks using MDMA “just once” would enhance their experience; or the person in recovery who is overcome with temptation. These people who are trying to quell their anxiety, fit in, get high, or get ahead in life are all one poor decision away from unknowingly ending their life instead.
Eli’s Story is just that. An unsuspecting sophomore with his entire life ahead of him had his life cut short by one uninformed decision. A coroner's report surprised those closest to him when it revealed kratom (a legal herbal supplement) and fentanyl in his body.
Eli, the son of two physicians, with no history of drug abuse, was indiscriminately targeted by the fentanyl crisis. He’s one of 106,000 deaths in 2021, of which 70,601 of those deaths included synthetic opioids (primarily fentanyl.) To hear more about this topic, tune into Eli’s Story: The Fentanyl Crisis and What Clinicians Can Do About It, on ERcast this August, featuring Eli’s mom and advocate Dr. Beth Weinstock.
Next Steps to Slow the Fentanyl Crisis
While the fallout from this crisis has been tragic, medicine is beginning to take steps to prevent it from continuing further:
- We are starting to see EDs initiate processes to provide naloxone and fentanyl test strips to patients with OUD and/or overdose upon discharge. Naloxone vending machines for public use have been popping up in front of EDs.
- ACEP has recently created PACED (Pain and Addiction Care in the Emergency Department) which is an accreditation program for EDs specializing in “safe and effective pain and addiction treatment while minimizing the use of opioids or prioritizing alternatives to opioids.” Three levels of accreditation are available. In the Opioid Stewardship section, you will find requirements to include opioid harm reduction following an opioid overdose, naloxone prescription and education, and implementation of a buprenorphine treatment program.
- A recent study in 2022 demonstrated both the feasibility and acceptability of ED fentanyl test strip distribution for patients with opioid-related ED visits. So if fentanyl strips haven’t made it to your ED yet, it will likely be a tool in your arsenal against the opioid crisis sooner than later. For now, you can obtain free test strips from many health departments, and a quick online search will produce a number of organizations providing tests as well.
How To: Fentanyl Test Strip Edition
Knowing how to properly use fentanyl test strips and educating your patients is vital to preventing fatal overdose in those with OUD.
If you’re like many on our EM team and were not familiar with how to use these strips, you’re not alone. (Here is a study outlining ED staff experiences distributing strips during a pilot testing.) To get everyone up to speed, here’s a how-to for using the fentanyl test strips with best practices.
Directions according to the CDC (you can follow along with this video by Jefferson Health):
1. Put a small amount of the drug in a clean, dry container (bottle cap, cooker, shot glass)- 10 mg is recommended (approximately the area of Lincoln’s hair on a penny)
- For most drugs, you need ½ teaspoon of water but for stimulants (methamphetamine, MDMA, or cocaine) use 1 full teaspoon
3. Hold the blue end of the test and submerge the wavy end of the strip in the water for 15 seconds, keeping the liquid level below the blue line
4. Remove the strip from the water and place it on a flat surface for 2 to 5 minutes
5. Read the results within 10 minutes of starting the test- Positive results: A single pink line = fentanyl or a fentanyl analog has been detected in your drugs. If you receive a positive result, it is much safer to discard the batch. Using it could kill you. Illicitly manufactured fentanyl is extremely potent and can be deadly.
- Negative results: Two pink lines = fentanyl or a fentanyl analog has not been detected in your drugs. However, note that no test is 100% accurate and your drugs may still contain fentanyl or fentanyl analogs even if you receive a negative result. You should be cautious as test strips may not detect more potent fentanyl-like drugs, like carfentanil. Fentanyl may not be everywhere in your drugs, the portion of the drug you tested may not contain fentanyl, and your test might miss it.
- Invalid results: A single pink line on the right-hand side or no lines indicate an invalid test. If you get an invalid result, test your drugs again using a new strip.
Think “N-O” has 2 letters → 2 lines N-O fentanyl
For more information, state and city health departments like New York City Department of Health and Cook County Department of Health have helpful handouts. California Department of Public Health has shareable content for social media.
Further Considerations for Fentanyl Test Strips
- “Chocolate chip cookie effect”: fentanyl is packed into illicit pills and can clump together in small pockets like chocolate chips in a cookie, which means one section of the drug can contain fentanyl while the remaining portion doesn’t. This can lead to a false negative and false sense of security.
- Test strips are not able to determine the amount or potency of fentanyl in a drug, just whether fentanyl is present in the portion tested.
- Fentanyl test strips do not detect all variations of fentanyl.
- False positive results can occur if the drug sample was contaminated with MDMA, methamphetamine, or diphenhydramine.
- No test is 100% accurate, including fentanyl test strips.
- Fentanyl test strips are one of many harm-reduction tools and should not be relied upon solely for overdose prevention.
With the right education, medical best practices, and destigmitization, we can combat the fentanyl crisis together. Please share with your friends and colleagues to raise further awareness.
Recovery from substance use disorder is possible. The Substance Abuse and Mental Health Services Administration National Helpline can be reached at 1-800-662-HELP (4357) or by visiting findtreatment.gov. This is for individuals and families facing mental or substance abuse disorders looking for evidence-based treatment and service options near them.
More information:
https://end-overdose-epidemic.org/data-dashboard/
https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-018-0276-0
https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
https://www.cdc.gov/drugoverdose/deaths/synthetic/index.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744207/
https://pubmed.ncbi.nlm.nih.gov/34172303/
https://pubmed.ncbi.nlm.nih.gov/31402152/
https://www.addictionpolicy.org/post/language-matters-1
