In December, Texas Gov. Greg Abbott did an about-face on an issue that has been a flash point in the debate over decriminalization of drug paraphernalia: the use of test strips that can detect fentanyl, the synthetic opioid. Abbott had previously opposed legislation legalizing the test strips, but he cited a stunning 89% increase in fentanyl deaths in Texas the prior year.
“It’s an extraordinarily deadly problem,” Abbott said in a press conference where he explained his change of heart.
More than 100,000 people died of drug overdoses in the United States from September 2021 to September 2022, according to the CDC. Almost 70% of those were from fentanyl and other synthetic opioids. Now, the death toll is causing lawmakers across the country to change their tune.
A Policy Shift
Fentanyl test strips were developed in 2011 to test for the drug in urine by law enforcement, for parents wanting to know what their kids were taking, and for users wanting to know what was in the drugs they previously took. A Johns Hopkins University study in 2018 found that the strips could accurately detect fentanyl in drug residue. Soon after, California and Oregon were among the first states to provide their public health departments with free strips to distribute at needle exchanges.
The strips are simple to use and effective. When dipped in water that contains dissolved drug residue, the strips indicate immediately whether trace elements are contained in a substance, such as heroin, cocaine, or ecstasy. As little as 2 milligrams of fentanyl can be deadly depending on a person’s weight, tolerance, and past usage.
States across the country have been legalizing fentanyl strips in the hopes of saving lives. Georgia passed a bill in July. Alabama, Tennessee, Pennsylvania, Wisconsin, South Carolina, and New Mexico all did the same. A similar bill has been introduced in Florida’s legislature. These states join some 30 others that have decriminalized the strips and made them available to drug users.
When the strips first came on the scene, they were used to remove fentanyl entirely from the drug supply. But today that’s not as true as it once was because fentanyl is now so prevalent, says Aaron Ferguson of Austin, TX, who advocates for safer drug use through the Urban Survivors Union. The organization hands out strips to people who are thought to be more likely to use some type of precaution to prevent against fentanyl overdose. For example, he recently distributed the strips and naloxone, a medication commonly used to reverse opioid overdoses, to a mother who knew her son was using opioids and wanted him to be safe.
A Poisoned Supply
“We’re in a drug poisoning crisis,” says Jacqueline Goldman, a research assistant at the Brown University School of Public Health. The crisis has deepened not necessarily because more people are using drugs, Goldman says, but rather “more people are dying from them because they’re so potent.”
Compared to other Western countries, the United States has always had a “puritanical” view of harm reduction strategies to cope with drug use and abuse, says John McIlveen, PhD, the top opioid treatment official for the Oregon Health Authority. “Now is an excellent opportunity to change the narrative,” he says, “because the drug supply is no longer just contaminated with fentanyl, it is fentanyl.”
Because fentanyl is readily available and so potent, people from all walks of life are prone to overdose. “If there’s any silver lining, it’s that views are shifting and we’re finally seeing more acceptance of the test strips and other harm reduction methods that save lives,” he says.
Losing the Battle
Even as the strips become more widely decriminalized, they remain an imperfect solution. While the strips are accurate at detecting fentanyl and its analogues, they don’t tell you how much the substance contains.
According to Ferguson, the high expense of drugs and the legal risk of obtaining them means that users may be unlikely to toss out a supply of drugs even if a test strip shows signs of fentanyl. And there’s also the risk of a false positive result. A May 2020 study published in the International Journal of Drug Policy found that the strips returned a false positive 10% of the time. This means that the test reads positive when it contains no fentanyl.
More concerning is the risk of false negative results, especially in pressed pills. The CDC calls it the “chocolate chip cookie effect.” Fentanyl clumps in pill form so when you cut into the pill to test the drug, it’s possible that a portion is free of fentanyl when the pill contains it. The International Journal of Drug Policy study found that false negatives occur in 3.7% of cases.
What’s more, fentanyl’s potency means that some users are addicted to the high it provides and may be seeking it out rather than avoiding it, says McIlveen. The more the drug supply contains fentanyl, the more users become addicted to it because it’s 50 times more powerful than heroin
The drug supply is also constantly changing and it’s hard for the strips to keep up. New contaminants like xylazine, a powerful sedative used in cattle and horses, have recently overtaken the opioid marketplace. Xylazine can’t be detected using the strips.
Nora D. Volkow, MD, director of the National Institute on Drug Abuse, says fentanyl test strips need to be available for free throughout the country along with a steady stream of other harm reduction tools, namely naloxone.
“Currently, an opioid user may see someone overdosing and they don’t have enough naloxone on hand to stop it from happening,” she says.
Other medications like buprenorphine and methadone help wean patients off fentanyl and other opioids, but they’re not available in many parts of the country. Patients may get a prescription from their doctor, but the pharmacy in their area can’t fill it because they don’t have the medication.
There are some effective treatments for saving people, such fentanyl test strips, naloxone, syringe service programs, buprenorphine, and methadone, but states are not providing them consistently. In West Virginia, for example, 62% of convictions were for drugs and the state also had the highest number of drug overdose deaths in the nation. The hope is that in the future, more resources will point toward harm reduction rather than incarceration.
“Discrimination and stigma have resulted in laws that are interfering with the survival of people who take drugs,” Volkow says.
CDC: “Provisional Drug Overdose Death Counts,” “Fentanyl Test Strips: A Harm Reduction Strategy.”
GoodRx Health: “What Are Fentanyl Test Strips? Here’s How They Help Prevent Drug Overdoses.”
Johns Hopkins University: “Detecting Fentanyl. Saving Lives.”
Aaron Ferguson, Urban Survivors Union, Austin, TX.
Jacqueline Goldman, research assistant, Brown University School of Public Health.
John McIlveen, PhD, Oregon Health Authority.
International Journal of Drug Policy: “An assessment of the limits of detection, sensitivity and specificity of three devices for public health-based drug checking of fentanyl in street-acquired samples.”
Nora D. Volkow, MD, director, National Institute on Drug Abuse.
Drubabuse.com: “Sentencing by State 2.”
The Health Care Manager: “The Opioid Epidemic in West Virginia.”