In April 2021, the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration announced that federal funds could be used to purchase rapid fentanyl test strips (FTS). In response, many states are doing so and, as a harm reduction measure, distributing them to people who use drugs. FTS are increasingly being distributed at community-based harm reduction organizations, [i],[ii] jails upon discharge,[iii] and medical settings (e.g., hospitals,[iv] emergency rooms,[v] clinics). If your clinic has the opportunity to distribute FTS, below are some key facts to know.
[i] Peiper NC, Clarke SD, Vincent LB, Ciccarone D, Kral AH, Zibbell JE. Fentanyl test strips as an opioid overdose prevention strategy: findings from a syringe services program in the Southeastern United States. Int J Drug Policy. 2019 Jan;63:122–128. doi: 10.1016/j.drugpo.2018.08.007. PMID: 30292493
[ii] 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. J Subst Abuse Treat. 2022 Sep;140:108790. doi: 10.1016/j.jsat.2022.108790. PMID: 35577663
[iii] University of New England. International Student Group Assembles 800 Harm Reduction Kits for Released Inmates. https://www.une.edu/news/2022/interprofessional-student-group-assembles-800-harm-reduction-kits-released-inmates. Published March 31, 2022. Accessed September 26, 2022.
[iv] Perera R, Stephan L, Appa A, et al. Meeting people where they are: implementing hospital-based substance use harm reduction. Harm Reduct J. 2022 Feb 9;19(1):14. doi: 10.1186/s12954-022-00594-9. PMID: 35139877
[v] Lima RA, Karch LB, Lank PM, Allen KC, Kim HS. Feasibility of emergency department-based fentanyl test strip distribution. J Addict Med. 2022 Aug 16. doi: 10.1097/ADM.0000000000001008. Epub ahead of print. PMID: 35972152
What are they?
FTS were initially created to test urine samples for the presence of fentanyl. In light of increasing fentanyl-associated overdose deaths, researchers and community-based harm reduction organizations determined FTS could be used off label to test drugs to determine if a sample contained fentanyl. FTS use the same technology as at-home pregnancy tests.
How are they used?
A small amount of a substance is mixed with water (the sample), and the test strip is dipped in. If the strip shows two lines, it means no fentanyl was detected; one line means fentanyl was detected. This information allows the individual to adapt substance use behaviors to reduce risk of overdose.
Are the results accurate?
FTS have a high level of accuracy, though, like rapid tests, limitations exist.
One research study that tested 210 drug samples found that FTS had 3.7 percent false negative rate (i.e., the test strip did not show evidence of fentanyl when it was actually present).[i] Additionally, FTS are able to detect some, but not all, fentanyl derivatives.[ii]
The same study found a 10 percent false positive rate (i.e., the test strip says fentanyl is present when it is actually absent).6 False positive results are more common when testing methamphetamine, MDMA (aka Ecstasy/Molly), and diphenhydramine (a common agent mixed in heroin). For this reason, it is often recommended to use more water when diluting methamphetamine or MDMA for FTS testing (sample instructions can be found in a PDF about how to use fentanyl test strips).
Reusing a cooker or baggie previously used for another drug consumption event may compromise results. Therefore, it is vital—to prevent HIV/HCV and to get accurate results with one’s FTS—to use new equipment for each testing event.
[i] Green TC, Park JN, Gilbert M et al. 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. Int J Drug Policy. 2020 Mar;77:102661. doi: 10.1016/j.drugpo.2020.102661. PMID: 31951925
[ii] Bergh MS, Øiestad ÅML, Baumann MH, Bogen IL. Selectivity and sensitivity of urine fentanyl test strips to detect fentanyl analogues in illicit drugs. Int J Drug Policy. 2021 Apr;90:103065. doi: 10.1016/j.drugpo.2020.103065. PMID: 33333419
Do people change overdose risk behaviors in light of the FTS results?
Community-based research has found that many individuals who use FTS report changing their drug use behaviors based on FTS results. Behavior changes include discarding their drug supply, using a smaller dose of the drug, doing a tester shot, using with someone else, asking someone to check on them, and changing the route of administration (e.g., snorting instead of injecting).1,[i],[ii]
[i] Park JN, Tomko C, Silberzahn BE, Haney K, Marshall BDL, Sherman SG. A fentanyl test strip intervention to reduce overdose risk among female sex workers who use drugs in Baltimore: results from a pilot study. Addict Behav. 2020 Nov;110:106529. doi: 10.1016/j.addbeh.2020.106529. PMID: 32683172
[ii] Goldman JE, Waye KM, Periera KA, Krieger MS, Yedinak JL, Marshall BDL. Perspectives on rapid fentanyl test strips as a harm reduction practice among young adults who use drugs: a qualitative study. Harm Reduct J. 2019 Jan 8;16(1):3. doi: 10.1186/s12954-018-0276-0. PMID: 30621699
Can FTS be considered drug paraphernalia?
Some states consider FTS drug paraphernalia. However, many have passed legislation specifically allowing the distribution of FTS. If you are uncertain about the legality of FTS possession in your state, contact your state Public Health Department or the Single State Agency (agency in your state that oversees all substance use treatment funding) to ask for additional information.
If our clinic distributes FTS, what are the key messages for our staff and patients?
- FTSs are a useful harm reduction tool and can be used to test opioids, cocaine, methamphetamine, benzodiazepines, and any pill or powder.
- FTS don’t tell someone how much fentanyl is in the drug, just if it is present or absent in the portion of the sample being tested.
- It is important to stress that cross-contamination happens easily and can lead to false positives. People should make sure that the cooker or baggie they are testing has not been previously used, or the chance of a false positive increases.
- The timing of testing matters: it is strongly encouraged that people test before using the substance.
- The results are not 100 percent accurate, so standard harm reduction measures should still be recommended (e.g., try not to use alone, always carry naloxone).
- Appropriate dilution is key to increasing the accuracy of results. How to Test Your Drugs Using Fentanyl Test Strips PDF handouts can be helpful to visually show recommended dilution based on type of substance.
Our clinic is interested in distributing FTS. How can we obtain them?
A good first step is to contact your local or state health department (see links above) to ask if it is donating FTS to community-based organizations. You can also order FTS directly from suppliers (e.g., BTNX, Amazon).
Additional Resources
This recorded webinar, Advanced Technology Drug Checking Services, provides more information about drug checking and FTS.
This FTS website provides a variety of resources, including training resources, links to research articles, and information on purchasing.