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In 2020, an estimated 92,000 Americans died of drug overdoses and fentanyl became the leading cause of death for Americans ages 18-45, beating COVID-19 and suicide. In Massachusetts, fentanyl was found in 92 percent of drug overdoses from January 2020 to September 2021 where a toxicology screen was available.
Advocates say this is a powerful sign that Massachusetts needs to step up its harm reduction strategies for preventing overdose deaths. And, as the state considers ways to respond to the crisis, a simple, inexpensive harm reduction method is flying under the radar.
Drug checking—testing illegal substances for contaminants and toxins—is an easy way of providing harm reduction services to drug users. Advocates say expanding and bringing more awareness to drug checking programs could help prevent some of those overdoses and change the way people use drugs.
“For harm reduction, we’re at this really important turning point, I think, in looking at the numbers for the country and for our local areas where we’ve had a huge increase in drug related overdoses,” Traci Green, the director of Brandeis University’s Opioid Policy Research Collaborative, said. “There’s a lot more we can do. And drug checking I think is absolutely part of that.”
A series of studies have shown that if users test their drugs for fentanyl and get a positive result, they are much more likely to take precautions—using smaller amounts of the drug, using more slowly, using with someone else present or throwing out the drug entirely.
Green said drug checking can help users treat drugs as they would any other product: by looking at the quantity, quality and consistency before deciding how much or what to use.
“Even thinking about alcohol, I can’t even imagine walking into a liquor store and not knowing what proof any of the alcohol on the shelf is,” Green said.
Fentanyl test strips, the most common form of drug checking, have been promoted by the CDC as a harm reduction strategy, and are already present in Massachusetts. They cost about one dollar each, and are simple to use. Just dip one in water mixed with drug residue and wait a few minutes for a result.
Drug checking isn’t a one-size-fits-all solution—advocates are careful to maintain that a range of harm reduction approaches is necessary. A 2019 harm reduction commission report recommended that Massachusetts pilot a supervised consumption site and expand drug checking, needle exchanges and naloxone distribution.
But fentanyl test strips have the advantage of being easily distributable almost anywhere in the community.
“This is a key strategy to plan on investing in,” Green said. “I’d love to see a lot more fentanyl test strips going out into the community. And for drug checking, access to drug checking be to be more normalized. And for more people to know about it.”
Unlike syringes, which people might not want lying around, Green said fentanyl test strips could be incorporated into places we wouldn’t normally connect with harm reduction, like barbershops, restrooms, schools or vending machines.
It’s also easy for users to give strips to friends or peers, and for outreach workers and police officers to distribute them. This is exactly what The Police Assisted Addiction & Recovery Initiative does. The organization, founded in Gloucester, MA in 2015, now operates in over 700 police departments in 40 states and helps police departments distribute fentanyl test strips and naloxone.
John Rosenthal, the co-chairman and co-founder of PAARI, said fentanyl test strips “ought to be like Narcan, where it’s in the hands of every single person suffering or their family member to help save a life of a loved one.”
PAARI’s program works on a “no blame, no arrest” policy, so users who might normally be arrested for illegal drug use are instead given fentanyl test strips, naloxone and referrals to treatment options.
Distributing test strips is also a way for outreach workers to connect with drug users and offer referrals to services including housing assistance, employment assistance, mental health services and recovery coaching. In 2021, PAARI distributed more than 2,300 test strip kits in Massachusetts and Maine, and made approximately 2,500 referrals.
PAARI also distributes fentanyl test kits to people who have recently been released from jail, who are 40 times more likely to die of an opioid overdose in the two weeks after being released from prison than someone in the general population.
“There’s no downside to non-arrest, access to treatment programs, and there certainly is no downside to Narcan or Naloxone and fentanyl test strips,” Rosenthal said. “It saves lives, it builds trust, and it gives people a second chance or a third chance.”
But fentanyl test strips do have a weakness: they’re inexact. They don’t measure the quantity or potency of fentanyl in a drug sample and they can’t detect other contaminants, such as xylazine—a sedative meant for large animals that has been showing up more and more frequently in the East Coast’s drug supply.
That’s where spectrometers come in. These machines conduct much more detailed analysis of drugs, finding what contaminants are present and in what quantities. But they can cost around $50,000, take 30 minutes to deliver results and 10 days to deliver a complete analysis.
Green said the combination of spectrometers and easily distributable fentanyl test strips can help prevent overdoses while allowing community organizations to get an idea of what contaminants are circulating in the drug supply. They can then send warnings out to drug users and doctors.
Rosenthal and Green are both adamant that with more and more people dying of fentanyl-related overdoses each year, expanding access to drug checking will save lives.