By Courtney Kraik
Read this article to learn:
- How do fentanyl test strips work
- Why fentanyl test strips are banned
- What is the chocolate chip cookie effect
- What are the barriers to fentanyl test strip use
“Birria.” “Chiva Loca.” “Facebook.” “Takeover.”
These are just a few of the street names for illicit drugs that have been mixed or “cut” with fentanyl. According to multiple health departments across the globe, when these substances are mixed with fentanyl, it dramatically increases the risk of a lethal overdose. As states, territories and countries grapple with the ever-changing landscape of the opioid crisis, new tools to reduce harm and positively impact the safety of people who use drugs have begun to emerge, including an increase in the use of fentanyl test strips.
According to the National Institute on Drug Abuse and the CDC, opioid-related overdoses resulting in death across the United States went from 49,860 in 2019 to almost 82,00 in 2022, before falling slightly in 2023. Many harm reduction tools and strategies are present in different forms across the country, and now fentanyl test strips have joined the discussion.
Fentanyl test strips were originally banned as drug paraphernalia by 42 states and the District of Columbia in the beginning of 2023. By August 2024, only 5 states (Iowa, Idaho, Indiana, North Dakota and Texas) continued to maintain the strips’ categorization as illegal despite the continued rise in opioid-related overdose deaths in all five states. In those states, reported push back comes almost exclusively from law enforcement and policy makers who focus on the moderate potential for false negative results, even though the effects of the presence and use of fentanyl test strips in the community has a much broader and more diverse reach [1].
A 2022 study reported the use of fentanyl test strips by individuals intending to use drugs decreased their risk of overdose by 34% and was associated with those individuals using less, injecting or ingesting in smaller, slower doses and not using alone [2].
When fentanyl or fentanyl analogs (substances that chemically resemble fentanyl and produce the same clinical presentations) are added into a drug supply, they are essentially undetectable. This is often intention on the part of dealers and suppliers who want to increase the potency of a particular batch, therefore decreasing the amount of product they need to sell. Fentanyl and its analogs, most commonly carfentanil, are approximately 50-100 times more potent than morphine.
How fentanyl test strips work
When used appropriately, fentanyl test strips can detect the presence of fentanyl and some fentanyl analogs in a drug supply either before or after consumption. In Canada, fentanyl test strips are considered a consumer product and they were not assessed by Health Canada prior to being put on the market for use. As such, there are multiple manufacturers and distributors of the test strips both in Canada and the U.S., but all the strips work in essentially the same way.
The strips require a minimum of 10 mgs of the substance in question to be mixed with approximately one teaspoon of water. The most accurate results come from testing the entire batch of the drug intended for consumption, as fentanyl and its analogs are most often not evenly distributed – the chocolate chip cookie effect.
The tested drug can still be consumed by the individual once the test results confirm the presence or absence of fentanyl. The drug in question can also be crushed in a small baggie, separated, and then water can be added to the residue inside the bag for testing; or, a single pill or tablet can be crushed inside a small glass, mixed with the teaspoon of water and tested. The third and last option has been deemed as the least accurate in measuring the presence of fentanyl due to the assumption that fentanyl will not be mixed evenly [3].
The strips are one-time use and can also be used up to 3 days post-consumption to test a urine sample [4]. Fentanyl Test Strips are relatively cheap and easily distributed (British Columbia Centre on Substance Use., 2024) so why aren’t they being used everywhere?
Barriers to fentanyl test strip use
Some reported difficulties and challenges with fentanyl test strip (FTS) use include [2,5]:
- The stigma attached to people who use drugs
- The criminalization or fear of prosecution under certain state laws
- Social determinant factors such as transportation, safe housing and access
- Technical difficulties
- FTS will not detect the presence of other opioids or benzodiazepines
- They can also produce a false-negative result if the sample is too small or too watered down, with the minimal limit being 1,000 nanograms/mL
First responder implications of fentanyl test strips
For first responders, the presence of fentanyl test strips in their communities acts as another tool in their toolbox while they provide prehospital care for patients experiencing a potential overdose due to a toxic drug supply. The first line of care for these patients should always be the management of ABCs while anticipating potential complications involving respiratory depression, aspiration, acute hypotension and cardiac arrest.
In the presence of a suspected polypharm drug poisoning, with stimulants in particular, first responders should always be vigilant for aggressive or violent behaviour following the administration of an opioid antagonist like naloxone.
As fentanyl test strips continue to gain momentum and popularity across North America, it’s important for prehospital healthcare providers to educate themselves and their patients experiencing a confirmed or suspected opioid related overdose on the importance of additional harm reduction resources and services provided in their area. As most providers know, often we are the first and only point of medical contact for this subset of patients and bridging that healthcare gap is an important step towards changing behaviours and decisions (Culli, L., 2024).
REFERENCES
- Filtermag.org. Lekhtman, A. (August 2024). Iowa Advocates Seeking to Legalize Fentanyl Strips
- Tilhou et al., Harm Reduction Journal (2022)
- New York City Health. (August 2021). How to test your drugs using fentanyl test strips. Retrieved from https://www.nyc.gov/assets/doh/downloads/pdf/basas/fentanyl-test-strips-brochure.pdf
- British Columbia, Interior Health. (June 2023). Drug checking with fentanyl test strips. Retrieved from https://www.interiorhealth.ca/sites/default/files/PDFS/drug-checking-with-fentanyl-test-strips.pdf
- British Columbia Centre on Substance Use. (April 2024). NWT launches fentanyl test strips in response to drug poisonings. Retrieved from https://www.bccsu.ca/blog/news/nwt-launches-fentanyl-test-strips-in-response-to-drug-poisonings/
- John Hopkins Bloomberg School of Public Health. Culli, L. (August 2024) New Research Sheds Light on Treatment and Harm Reduction Gaps Among Drug Users
ABOUT THE AUTHOR
Courtney Kraik is a primary care paramedic in the Toronto area in Ontario, Canada. Her education began with an undergraduate degree in political science and English, followed by formal training in journalism and creative communications. She found paramedicine later in life after spending 10-plus years working as a freelance journalist, content creator and grant writer. Her love for all things tiny human is reflected in her dedication to supporting and delivering continuing medical education in pediatric emergency care through KinderMedic to her peers and colleagues. Her passion for social determinants of health and obstacles to success pivoted from telling people’s stories for entertainment to advocating for patients to facilitate change.
