Amid a nationwide overdose epidemic, more states are legalizing at-home fentanyl rapid tests to spot the potentially fatal substance hidden in recreational drugs.
Last week, and became the latest states to legalize fentanyl test strips (FTS) -- single-use, disposable rapid tests that can detect fentanyl or fentanyl analogs in pills, powder, or injectables. Arizona, Delaware, Wisconsin, and North Carolina have also legalized the strips in the past few years.
The movement by a growing number of states to decriminalize fentanyl test strips -- which have historically been banned under drug paraphernalia laws -- follows the emergence of research that supports access to the tests as a harm reduction tool.
While many experts believe that distributing fentanyl test strips is low risk and may improve informed decision-making for people who use drugs, varying laws across states and lingering stigma around harm reduction pose barriers to access.
"Harm reduction as a concept is really not societally accepted," said Emily Einstein, PhD, chief of the Science Policy Branch at the National Institute on Drug Abuse (NIDA). "As these tools emerge, if we can normalize the idea of harm reduction, that would be a huge public health benefit."
Fentanyl is an increasing factor in overdose deaths, contributing to 64% of the staggering 100,000 U.S. deaths from drug overdoses from May 2020 through April 2021. In December, the CDC reported that overdose deaths involving fentanyl skyrocketed in nearly all regions of the country.
In the midst of crisis, experts say that harm reduction approaches, such as syringe exchange programs, naloxone distribution, and fentanyl test strips, are critical to helping people who use drugs adopt safer practices.
Experts say fentanyl test strips are valuable not just for those who use opioids but also for those who use stimulants, such as methamphetamine and cocaine, which are increasingly becoming contaminated with the drug.
The strips were created in 2011 by biotech company BNTX, for use by doctors to detect prescription fentanyl in urine. But when fentanyl became more frequently detected in drug overdoses, the harm reduction community began using the tests off-label. Many syringe services sites began to give people who use drugs the agency to understand what's in the substances they consume, and therefore make safer, educated decisions about how to use.
Arguments that people who use drugs would not adopt fentanyl test strips and that the tests could actually end up as a marketing tool for batches with fentanyl are "a really good example of the misconceptions around people who have addiction," Einstein said.
While people who have addiction may struggle with abstaining from using, they do not entirely lose their ability to make decisions, she added.
"Fentanyl test strips are a way for people to understand what's in the drugs that they're about to take and make some decisions to potentially use them in a way that's less likely to result in overdose," Einstein said.
Evidence for FTS
There's existing evidence that fentanyl test strips are not only accurate in detecting 12 different fentanyl analogs, but also that they may encourage people to practice safer drug use behaviors, researchers have found.
People who inject drugs were more likely to report safer behaviors if their substances tested positive for fentanyl, according to a 2019 study published in the . The researchers surveyed 125 people in North Carolina about their last use of a fentanyl test strip, and how it impacted their decisions around substance use.
Around 43% reported that a positive fentanyl test result encouraged them to use safer behaviors, such as using less of a drug, administering a test shot, injecting slower, or snorting the substances instead of injecting them. Additionally, more than three-quarters of people who used a fentanyl test strip said it made them feel safer.
"Testing does something to the psyche," said Jon Zibbell, PhD, a public health researcher at RTI International and senior author of the study. "It slows them down during the preparation process, and makes people who use drugs think more about what they are using and how they are using."
Another found an association between positive fentanyl test results and safer behavioral changes among 93 youth in Rhode Island. Nearly all reported being confident in their ability to use fentanyl test strips, and 95% wanted to use them again in the future.
"People, particularly who received positive results, reported significant positive changes in overdose risk behavior," said Brandon Marshall, PhD, an epidemiologist at Brown University and senior author on the paper. Positive changes included using less or making sure someone was around in case of an overdose.
Marshall and colleagues are conducting a to assess whether fentanyl test strip training, along with other interventions, will affect rates of overdose. Initial results are expected in 2023.
Barriers to Access
While there's evidence that fentanyl test strips could lead to safer drug behaviors, there are still barriers to access, particularly confusion around where the tests are lawful.
It's clearly legal to possess fentanyl test strips in 22 states, according to a recent legal review published in . In 14 states where drug checking equipment is not clearly legal, it is lawful when the equipment is obtained from a syringe services program, the review found.
Actions by the states to decriminalize fentanyl test strips can result in confusion about where they are lawful, and where they are not.
"What we don't want people to take from this is, 'if my state hasn't done that, then it is definitely not OK,'" said Corey Davis, JD, MSPH, a public health lawyer and lead author of the legal review.
Fentanyl test strips have long been considered illegal because they are categorized as drug paraphernalia, which can consist of anything used to consume illicit drugs. But while laws that define drug paraphernalia are written broadly, those laws are not always enforced broadly, Davis told 鶹ý.
However, Davis added that the variance in laws across states may very well prevent some places from moving forward with use of fentanyl test strips. "Legal uncertainty is not a place where people like to live," he said.
In addition to a confusing regulatory landscape, cost can be a barrier. At $1 a test, its difficult for syringe services programs to afford enough tests to have a widespread public health impact, said Daniel Ciccarone, MD, an addiction medicine specialist at the University of California San Francisco.
"There's no way anyone has enough money to access these things," Ciccarone said. "If you are going to use FTS correctly, you have to use them for every single shot."
In April, the Biden administration on use of federal grant funds for buying fentanyl test strips, which could allow more widespread access to the tests, Einstein said.
More Research Needed
While there is preliminary evidence that fentanyl test strips might influence behaviors, NIDA is funding further research to understand how FTS are used and how effective they might be as a harm reduction tool, Einstein said in an interview. "I think we still don't know that yet."
What is clear, though, is that "harm reduction is a super critical element for addressing our overdose crisis," Einstein said. "People think a lot about prevention and treatment, but harm reduction is really for people who are currently using drugs, and their lives are valuable."