In Brief:
Drug overdose deaths are high enough in number to be a major factor driving down life expectancy in the U.S. Almost 80 percent of preventable overdose deaths are caused by opioids, and nearly 90 percent of these involve synthetic opioids such as fentanyl. As law enforcement struggles to contain the flow of illicit opioids and treatment capacity remains below need, states are placing new emphasis on harm-reduction programs to reduce the likelihood of fatalities.
In recent years, numerous states have changed their drug paraphernalia laws to allow users to possess fentanyl test strips. They are now allowed in every state except Idaho, Indiana, Iowa, North Dakota and Texas, according to the Legislative Analysis and Public Policy Association. The strips allow people who use drugs — whether street drugs or counterfeit versions of pharmaceuticals — to test them for fentanyl content. This enables informed decisions to modify use, whether reducing or abstaining altogether. They are also useful to those responding to overdoses.
Baltimore began distributing the test strips in 2018, one of the first health departments to do so. A study of test strip distribution through a syringe services program found that almost half of the people receiving them changed their behavior. This fell short of not using drugs at all, but the changes that resulted, such as using fewer drugs or doing a “test” shot, have direct impact on the likelihood of a dangerous overdose.
Detecting what’s in the pills and powders that end up in the hands of drug users is increasingly important, and test strips are just part of the testing infrastructure necessary to prevent harm. The drug supply is volatile, changing all the time, says Kristen Pendergrass, vice president of state policy for Shatterproof, a nonprofit that works on addiction issues. “People don’t necessarily know what’s in there. It’s kind of scary,” she says.
Some policymakers continue to push back. Joey Hensley, a Tennessee state senator who is also a physician, voted against decriminalization of the strips in 2022. "I just don't think it's a good policy to make it easier for people addicted to drugs to use drugs," the Republican said at the time.
Those who oppose harm-reduction programs designed to make drug use safer by preventing overdoses and the spread of disease through needle sharing see them as “giving up,” says Ju Park, an assistant professor of medicine and epidemiology at Brown University. They are better understood as a stopgap measure, she suggests, which can stop needless deaths while long-term solutions are being developed and implemented.
“Not doing anything is very costly,” Park says. “The opioid crisis is a trillion-dollar-a-year issue.”
A Life-Saving Tool
Several laws that will expand the use of test strips in Illinois went into effect at the beginning of this year. One allows overdose responders to dispense them, another will allow them to be sold over the counter in pharmacies and retail stores. A third mandates that state-required health courses for students in grades 9-12 provide detailed information about the dangers of fentanyl and overdose prevention, including how to buy and use test strips.
It's a mistake to see drug misuse as a problem that affects only societal outcasts, says Joan Thome, director of health education at the Sangamon County, Ill., health department. The people who come in for services look like anyone else you’d see on the street, she says — businesspeople, soccer moms, restaurant workers. She’s especially concerned about the risks to children, with overdoses occurring on campus at the 11 school districts in the county.
The county coroner has found that 80 percent of fatal overdoses have a link to fentanyl. Dealers and suppliers use filler to bulk up drugs including heroin, cocaine and methamphetamines, so they have more to sell. They add fentanyl to give their product more punch, Thome says.
Fentanyl can also be added to counterfeit versions of pharmaceuticals that look exactly like the real thing. It can be pressed into drugs such as ecstasy that come in pill form.
Users can test their drugs with the strips to see if they contain fentanyl and adjust their usage, or avoid them entirely. “They tell you it’s there, but they don’t tell you how much,” says Thome. “So it’s still a danger.”
Test strips are available at the health department’s front desk, along with information cards on how to use them. The department distributes them — in some cases along with Narcan (a nasal spray containing naloxone, used as an overdose treatment) — to social service agencies, liquor stores, pawn shops, libraries and laundromats. They’re available at some gas stations and head shops.
Law enforcement officers, ambulance drivers and firefighters are encouraged to leave boxes behind when they go to places where drug use is known to occur. The program is funded through the Illinois Department of Human Services and covers seven counties in all.
Thome rejects the suggestion that this encourages drug use. “It’s a life-saving tool,” she says. People develop substance-use problems as a result of mental health issues or trauma, not because fentanyl strips or Narcan give them the idea that using a drug like fentanyl is “safe.”
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Opportunities for Recovery
There’s a particular need to make test strips available to recreational drug users, says Pendergrass, the Shatterproof vice president. Regular drug users are aware that opioids are likely to contain fentanyl or one of its analogs. People who occasionally take street drugs to enhance a concert experience, or students who use an illicit copy of a prescription stimulant as a “study drug,” may not be.
Test strips are also available to detect the presence of xylazine, a sedative known as Tranq originally intended for use with non-human mammals. Drug traffickers have begun to add it to drugs to prolong the effects of fentanyl, in an effort to attract customers who want a longer high or to stretch their use of fentanyl. Xylazine made its way into the illicit drug chain in the U.S. more than a decade ago, but in recent years it has been responsible for an increasing number of overdose deaths.
Researchers are working to understand more about how the test strips affect behavior. Park, the Brown professor, leads the Harm Reduction Innovation Lab at Rhode Island Hospital and has been a co-investigator in several studies of fentanyl strip programs, including efforts by Baltimore’s health department.
“If you talk to people who have been running the services for many years, they will tell you that they save lives,” Park says. “Setting up programs is the first step in really understanding their effectiveness.”
Even when regular drug users seek treatment, it takes an average of eight times for them to succeed, Thome says. The window of time during which they feel empowered enough to reach out for recovery services can be as short as two hours and accessing them can be difficult.
Test strips don’t change any of this, but they could prevent outcomes from which there is no return. “We're talking about human beings, so I think we should give them many opportunities to try to get into recovery,” Thome says.
