Fentanyl test strip distribution programs
Drug checking equipment, like fentanyl test strips, can be used by people who use drugs (PWUDs) to detect the presence of fentanyl or other potentially harmfuladulterants in illicit drugs1. Fentanyl is a potent synthetically made opioid used to treat pain that is linked to overdoses and overdose deaths when it is added to other illicit drugs like methamphetamine or cocaine and unknowingly consumed2. Fentanyl test strips are easy to use and can inform PWUDs about their risk of exposure to fentanyl prior to drug use. Fentanyl test strips should be combined with other strategies to help communities reduce the harms of substance misuse. Harm reduction is an approach that uses prevention, treatment, and recovery to connect PWUDs with tools and information to create positive and healthy changes3. Fentanyl test strips may not detect the presence of fentanyl analogs like carfentanil or alfentanil and do not indicate how much fentanyl is present in a drug.
Some states consider drug checking equipment like fentanyl test strips drug paraphernalia and may prohibit or limit access for PWUDs4.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Reduce risky drug use behavior
What does the research say about effectiveness?
There is some evidence that fentanyl test strip distribution programs can reduce risky drug use behavior amongst people who use drugs (PWUDs)5, 6. Additional evidence is needed to confirm its effects.
Rapid fentanyl test strips (FTS) can be used to detect fentanyl to inform PWUDs about their risk of exposure to fentanyl prior to drug consumption6. Testing illicit drugs before consumption can help PWUDs understand risk and can inform others in the community about the presence of fentanyl; this can lead to behavioral changes and reduce potential harms of drug use7. Some individuals have reported changing their behavior when using drugs after utilizing FTS8. Some pattern changes include discarding drugs that test positive, using drugs with someone present instead of alone, and making sure to have naloxone on hand6. Overall, surveyed young adults9, PWUDs10, and those with opioid use disorder11 agree that FTSs are an acceptable form of harm reduction. Besides FTS, drug checking services that test drugs at facilities like a syringe services program or overdose prevention centers can provide PWUDs with real-time results on the presence of fentanyl in illicit drugs12. Drug checking services can be a good alternative as FTS need to be properly used to be effective, however, some individuals lack the knowledge and understanding on how to effectively use them13.
FTS distribution programs may be able to engage with PWUDs and their family and friends and connect them to important care services and community resources14. Furthermore, there may be an association between use of FTSs and carrying naloxone, but more research is needed15.
The compounds and drugs that are added to illicit drug supplies are constantly changing and pose a challenge for PWUDs and harm reduction efforts. In addition to fentanyl, xylazine is a sedative not approved for human use but has been found in illicit drug supplies and is linked to increased overdose deaths in the U.S16. Testing for xylazine in illicit drugs can potentially change drug use behavior; more research is needed to validate this7.
How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.
It is unclear what impact fentanyl test strip (FTS) distribution programs have on disparities in drug use behavior and overdose related deaths.
Inequalities by race, geographic location, and economic status persist in drug overdose deaths19, 20. Most people who overdose are non-Hispanic whites, about 10% are non-Hispanic Blacks, and 8% are Hispanic21. Experts attribute this demographic breakdown to the unconscious bias and prejudices of health care providers, who are more cautious prescribing opioids to non-white patients based on the prejudiced assumption that non-white patients are more likely to abuse or sell opioid prescription drugs21. Individuals who exhibit mental health conditions are also more likely to use opioids21.
Proper implementation of fentanyl test strip distribution programs is key to reaching PWUDs. Educating PWUDs on the correct use of FTSs and interpreting results is important13. Tailored outreach is necessary to reach marginalized individuals, especially people who inject drugs that are older and Black22.
What is the relevant historical background?
Opioid overdose deaths have been increasing since 199923. The rise in opioid overdose deaths began in the 1990s with a substantial increase in the prescription of both natural and semi-synthetic opioids because they were effective at managing chronic pain and falsely marketed to health care providers as non-addictive24, 25, 26. Prescription opioid sales increased fourfold between 1999 and 200827. Many patients who became addicted to prescribed opioids turned to non-prescribed forms of opioids, such as heroin, which lead to a second wave of opioid overdoses in 2010. In 2013, a third wave began when synthetic opioids, such as fentanyl, that are much more potent than other forms of opioids were combined with other drugs or counterfeit prescription pills, often unknown to the purchaser24. Synthetic opioids like fentanyl have contributed to nearly 74,000 overdose deaths in 2022, a 4% increase from the previous year28. In 2013, the U.S. Department of Health and Human Services declared the misuse of prescription opioids an epidemic. Four years later, in 2017 the opioid epidemic was declared a national public health emergency21. Between 2020 and 2021, the opioid overdose death rate increased by over 15% and the synthetic opioid overdose death rate increased by over 22%24. However, between 2022 and 2023 there has been a decrease in opioid related deaths for some groups, but increases are seen for non-Hispanic Black individuals and Native Hawaiian or Other Pacific Islander non-Hispanic people29.
The dramatic increase in opioid sales was the result of pharmaceutical companies that overproduced and oversupplied opioid drugs for huge profits, pharmacies that filled the prescriptions, and health care providers who overprescribed the medications27. In rural areas many physicians overprescribed opioids to patients who travel long distances for treatment, do not have the ability to attend frequent appointments, and do not have alternative pain management interventions in their area27.
Increasing overdose deaths highlights the need to connect communities to appropriate resources and to expand prevention methods. Drug checking equipment, like fentanyl and xylazine test strips can be used to reduce the harms associated with substance misuse. However, drug checking equipment is considered drug paraphernaliain some states and is illegal. Many states have passed legislation to clearly indicate that such test strips are legal and have decriminalized them4, 17.
Equity Considerations
- Are fentanyl and xylazine test strips legal in your state? Where can community members access them? How can your community improve access to such drug checking equipment?
- Do community members know about the availability of test strips? Are those interested in test strips provided proper education on how to effectively use test kits and interpret results?
Implementation Examples
Drug checking equipment such as fentanyl and xylazine test strips are considered drug paraphernalia under some state laws. As of 2023, 15 states have introduced legislation to decriminalize drug checking equipment, while two states have expanded regulations to increase access to harm reduction tools like fentanyl and xylazine test strips; FTSs are legal in 44 states based on 2023 data under laws specific to drug checking equipment, exceptions to syringe service programs, or Good Samaritan laws17. In 2021, the CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA) announced that federal funding could be used to purchase FTSs by state and community-based organizations18.
Implementation Resources
‡ Resources with a focus on equity.
CDC-What you can do to test for fentanyl - Centers for Disease Control and Prevention (CDC). Stop overdose. What you can do to test for fentanyl.
Footnotes
* Journal subscription may be required for access.
1 CDC-Stop overdose - Centers for Disease Control and Prevention (CDC). Stop overdose. What you can do to test for fentanyl.
2 SAMHSA-Fentanyl and xylazine test strips - Substance Abuse and Mental Health Services Administration (SAMHSA). Fentanyl and xylazine test strips.
3 SAMHSA-Harm reduction - Substance Abuse and Mental Health Services Administration (SAMHSA). Harm reduction.
4 Davis 2022 - Davis CS, Lieberman AJ, O’Kelley-Bangsberg M. Legality of drug checking equipment in the United States: A systematic legal analysis. Drug and Alcohol Dependence. 2022;234:109425.
5 Reed 2024 - Reed MK, Siegler A, Esteves Camacho T, et al. Making harm reduction more accessible: Fentanyl test strip awareness and attitudes among emergency department patients who use drugs. Substance Use and Misuse. 2024;59(3):398-404.
6 Goldman 2019 - Goldman JE, Waye KM, Periera KA, et al. Perspectives on rapid fentanyl test strips as a harm reduction practice among young adults who use drugs: A qualitative study. Harm Reduction Journal. 2019;16(1):1-11.
7 Peiper 2019 - Peiper NC, Clarke SD, Vincent LB, et al. Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States. International Journal of Drug Policy. 2019;63:122-128.
8 Reed 2022b - Reed, M. K., Guth, A., Salcedo, V. J., Hom, J. K., & Rising, K. L. (2022). “You can’t go wrong being safe”: Motivations, patterns, and context surrounding use of fentanyl test strips for heroin and other drugs. International Journal of Drug Policy, 103, 103643.
9 Krieger 2018 - Krieger MS, Goedel WC, Buxton JA, et al. Use of rapid fentanyl test strips among young adults who use drugs. International Journal of Drug Policy. 2018;61:52-58.
10 Reed 2022a - Reed MK, Salcedo VJ, Guth A, Rising KL. “If I had them, I would use them every time”: Perspectives on fentanyl test strip use from people who use drugs. Journal of Substance Abuse Treatment. 2022;140:108790.
11 Mistler 2021 - Mistler C, Rosen A, Eger W, Copenhaver M, Shrestha R. Fentanyl test strip use and overdose history among individuals on medication for opioid use disorder. Austin Journal of Public Health and Epidemiology. 2021;8(6):1-12.
12 Park 2023a - Park JN, Tardif J, Thompson E, et al. A survey of North American drug checking services operating in 2022. International Journal of Drug Policy. 2023;121:104206.
13 Barrolle 2023 - Barrolle AA, Gable KN, Dell N. A pilot study assessing client understanding and use of fentanyl test strips for harm reduction. Journal of the American Pharmacists Association. 2023;63(1):295-300.
14 Olson 2022 - Olson R, Case P, Palacios WR, et al. Law enforcement and community provision of fentanyl test strips to people who use drugs for engagement and referral to services. Journal of Public Health Management and Practice. 2022;28(6):S343-S346.
15 Tilhou 2024 - Tilhou AS, Zaborek J, Baltes A, et al. Association of fentanyl test strip use, perceived overdose risk, and naloxone possession among people who use drugs. Substance Use and Misuse. 2024;59(2):254-257.
16 CDC-Xylazine - Centers for Disease Control and Prevention (CDC). Overdose prevention. What you should know about xylazine.
17 ASTHO-Substance misuse and overdose prevention - Association of State and Territorial Health Officials (ASTHO). Substance misuse and overdose prevention.
18 CDC-What you can do to test for fentanyl - Centers for Disease Control and Prevention (CDC). Stop overdose. What you can do to test for fentanyl.
19 CDC-Disparities widen - Centers for Disease Control and Prevention (CDC). Vital signs. Drug overdose deaths rise, disparities widen.
20 Zhang 2018c - Zhang X, Marchand C, Sullivan B, Klass EM, Wagner KD. Naloxone access for Emergency Medical Technicians: An evaluation of a training program in rural communities. Addictive Behaviors. 2018;86:79-85.
21 Salmond 2019 - Salmond S, Allread V. A population health approach to America’s opioid epidemic. Orthopaedic Nursing. 2019;38(2):95-108.
22 Oh 2020 - Oh H, Kim K, Miller D, et al. Fentanyl self-testing in a community-based sample of people who inject drugs, San Francisco. International Journal of Drug Policy. 2020;82:102787.
23 Freeman 2018 - Freeman PR, Hankosky ER, Lofwall MR, Talbert JC. The changing landscape of naloxone availability in the United States, 2011 – 2017. Drug and Alcohol Dependence. 2018;191:361-364.
24 CDC-Understanding the epidemic - Centers for Disease Control and Prevention (CDC). Understanding the opioid overdose epidemic.
25 Bennett 2021 - Bennett AS, Elliott L. Naloxone’s role in the national opioid crisis — past struggles, current efforts, and future opportunities. Translational Research. 2021;234:43-57.
26 Haffajee 2020 - Haffajee RL, Cherney S, Smart R. Legal requirements and recommendations to prescribe naloxone. Drug and Alcohol Dependence. 2020;209:107896.
27 Judd 2023 - Judd D, King CR, Galke C. The opioid epidemic: A review of the contributing factors, negative consequences, and best practices. Cureus. 2023;15(7):e41621.
28 CDC-Fentanyl - Centers for Disease Control and Prevention (CDC). Overdose prevention. Fentanyl.
29 CDC-Drug overdose deaths in the US - Centers for Disease Control and Prevention (CDC). Drug overdose deaths in the United States, 2003-2023.
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