High willingness to use rapid fentanyl test strips among young adults who use drugs

North America is in the midst of an unprecedented overdose epidemic. In 2016, provisional data indicates that overdose mortality increased over 20% from 2015 to reach a record high of 64,070 deaths [1, 2]. The opioid overdose epidemic, once dominated by prescription opioid misuse, is now driven by the use of heroin and other illicit drugs [3–6]. Heroin-related deaths have quadrupled since 2010, while prescription opioid deaths have increased only slightly [7, 8]. Although diversion of pharmaceutical fentanyl, such as transdermal patches, is an ongoing problem, in recent years, illicitly manufactured fentanyl and related compounds have been regularly mixed into heroin, cocaine, and counterfeit prescription pills [9–13]. Since the widespread introduction of illicitly manufactured fentanyl into the drug supply in North America in 2013 [11], fentanyl-related deaths have sharply increased [8, 14]. In the United States (US), six states that publish data on fentanyl-related fatalities reported that the number of overdose deaths attributable to fentanyl increased by over 350% between 2013 and 2014, from 392 to over 1400 [15]. In British Columbia, Canada, fentanyl-related overdose deaths increased over 600% from 2014 to 2016, with fentanyl being detected in 67% of all overdose-related deaths in 2016 compared to 25% in 2014 [16].

Young adults have experienced the greatest increases in fentanyl overdose mortality as heroin and counterfeit pill use has surged over the last decade [17, 18]. In Rhode Island, a state with the fifth highest overdose rate in the US, over half of all fentanyl overdose deaths in 2014 and 2015 were among individuals under the age of 35 [19]. Drug-using young adults may have less experience with overdose prevention strategies and may engage in drug-using behaviors that put them at higher risk for overdose, such as polysubstance use or combined alcohol and drug use [14]. Moreover, harm reduction services such as needle distribution programs are currently underutilized by the majority of young adults who use drugs, due in part to the stigma associated with using such services [20, 21].

People who use drugs may not know if fentanyl is being cut into their drugs and might rely on ineffectual information regarding smell, taste, color, and word of mouth to determine the presence of fentanyl [22]. To address the alarming public health challenges associated with illicitly manufactured fentanyl, recent innovations in rapid drug testing technology may promote risk reduction behaviors among young adults who are at high risk of fentanyl overdose. Rapid fentanyl test strips, such as those recently piloted at a supervised injection facility (SIF) in Vancouver, Canada, are used to detect the presence of fentanyl in drug samples or urine [23, 24]. A pilot study at the Vancouver SIF found a high positivity rate of fentanyl-contaminated drugs and that clients who used the strips prior to consumption reduced their dose and decreased the risk of overdose [24]. In this study, we sought to determine whether young people (aged 18 to 35) who use drugs in Rhode Island were willing to use take-home rapid fentanyl test strips as a harm reduction intervention to prevent accidental overdose due to fentanyl contamination. We hypothesized that young adults would report high interest in and willingness to use rapid fentanyl testing and that those who had ever overdosed would be more willing to use rapid fentanyl test strips than young adults with no prior overdose experience.

After the brief training, overall willingness to use rapid fentanyl test strips was high among participants who had ever overdosed and those who had not; overall, 95% agreed or strongly agreed that they planned to use the provided rapid fentanyl take-home test strips. Almost all study participants (n = 92, 99%) reported that it would be easy to use the fentanyl testing strips. Among the participants who were trained to use rapid fentanyl test strips on their urine (n = 40), over half (56%) reported that they would prefer to use a test that could detect fentanyl in drugs dissolved in water before using them. Nearly three quarters of the overall sample (n = 66, 71%) endorsed “yes” when asked “Do you think your friends would be interested in using the fentanyl testing strips?”.

Contrary to our primary hypothesis, nearly all participants reported high willingness to use the fentanyl test strips, regardless of previous overdose history. The majority of the study participants reported wanting to know if their drug supply was contaminated with fentanyl. All study participants reported feeling confident in their ability to test their drugs or urine for fentanyl after a brief skill-based training. Nearly all participants reported wanting to know if there was fentanyl in their drugs before taking them, indicating a clear preference for testing their drugs or residue directly rather than testing their urine after drug use. These findings suggest that rapid drug testing is an acceptable, low threshold intervention that could be used to address concerns associated with emerging adulterants (e.g., fentanyl) in the illicit opioid drug supply.

Despite the fact that reporting a history of overdose was not associated with higher willingness to use the fentanyl testing strips, prior non-fatal overdose is among the strongest predictors of future overdose death [31, 32]. In this study, young adults who had ever experienced an overdose were more likely to have been homeless, have an arrest history, and report more frequent and injection drug use, among other risk factors. If fentanyl rapid test strips are found to be an effective harm reduction intervention, making the technology readily available to individuals who demonstrate these characteristics may be a high public health priority. Although off-label use of fentanyl testing strips has not been approved by the US Food and Drug Administration (FDA), they are already being used at syringe exchange programs in areas with a high burden of fentanyl-related overdoses, such as Vancouver, New York City, and Boston [33, 34]. Rapid fentanyl drug testing may also be incorporated into drug checking services provided at nightclubs and music venues seen in Europe [35].

While there has been some concern raised about the ability of the rapid fentanyl test strips to detect novel fentanyl analogs [34], the tests have been shown to detect the most common fentanyl analogs currently circulating in the illicit drug supply, such as carfentanil and acetyl fentanyl [29]. Further studies should examine which fentanyl analogs are able to be detected in urine or drugs and to what degree of sensitivity. Nonetheless, in light of concerns regarding false negatives, rapid fentanyl test strips should be distributed alongside information about what to do regardless of whether the drug tests positive for fentanyl, such as using with someone nearby who is capable of calling emergency medical services. In general, our results suggest that rapid drug tests might be an acceptable intervention for young adults who use drugs for identifying adulterants in the drug illicit supply.

Future research is needed to determine if using fentanyl rapid testing strips will lead to desired behavioral changes outlined in the IMB model, such as obtaining naloxone and using drugs with others who can call an ambulance if an overdose occurs [36, 37]. A future manuscript will discuss follow-up data and whether knowledge of a drug being contaminated with fentanyl will encourage overdose risk reduction practices. Future research is needed to determine if a higher level of concern about overdose will predict actual rapid test strip utilization or more consistent use patterns. Research is also needed to better understand the feasibility of using the rapid test strips among individuals who do not see themselves as at risk for fentanyl overdose, such as people who buy pills on the street or people who use cocaine. Additional studies are also needed to determine the sensitivity and specificity of using immunoassay tests on drugs directly and in real-world, non-clinical settings.

We are aware of a number of limitations to this study. This is a small pilot study which recruited a convenience sample from a region highly impacted by the fentanyl overdose epidemic; therefore, this study may not be generalizable to other settings. Additionally, in some regions, fentanyl contamination is widespread throughout the drug supply, and it has yet to be determined how that may affect uptake of rapid fentanyl test strips. Third, we only assessed lifetime overdose history generally and did not ask participants about their experiences with opioid overdose specifically. It is possible that participants who have previously experienced an opioid overdose, or had an overdose they thought was caused by fentanyl, may be more willing to use the fentanyl testing strips. Finally, this study relied on self-report, which may be subject to socially desirable reporting. However, evidence has shown a high association between willingness to use a harm reduction program and subsequent uptake of the intervention among people who use drugs [38].

In summary, this study assessed the feasibility and acceptability of take-home rapid fentanyl tests. We found a high willingness to use take-home rapid fentanyl test strips among young people who use drugs and are at risk for accidental fentanyl overdose. Initial results suggest that rapid fentanyl test strips may be an acceptable harm reduction intervention for communities facing growing rates of fentanyl overdoses. Study follow-up is ongoing to determine whether, how, and under what circumstances participants used these rapid test strips and if positive test results contribute to positive changes in overdose risk behavior.