Fentanyl, a drug at least 50 times more powerful than morphine with derivatives that are tens of thousands of times stronger, keeps killing Americans. But few government efforts have helped stem the tide. In fact, some strategies for targeting the broader opioid epidemic—such as the introduction of "abuse resistant" Oxycontin pills and the shutdown of pill mills without providing treatment—have shown the potential to make things even worse.
Thursday is International Overdose Awareness Day, and as good a time as any to take stock of the country's opioid problems, along with our failure to manage them effectively. Despite plenty of press coverage and a president who has at least said (if not acted like) the opioid crisis is a national emergency, the death toll won't stop climbing.
But there is a drug policy that has been shown to help whenever it's practiced appropriately. Known as harm reduction, its key tenet is to view people who take drugs as human beings and focus on saving their lives rather than preventing their sins. Among its most recent innovations is the introduction of test strips that can detect the presence of fentanyl in drugs—the kind of common-sense policy that America needs to embrace, fast.
A pilot study presented at this spring's Harm Reduction Conference in Montreal found that people who found out their drugs tested positive for fentanyl were ten times more likely to reduce their dose and 25 percent less likely to overdose. The research was led by Dr. Mark Lysyshn, medical health officer at Vancouver Mental Health in that city's supervised injection facility (SIF), called Insite, and included around 1,000 tested drug samples.
Originally designed for urine testing, the fentanyl strips seem to work just as well when water is added to a few specks of drug (about the size of a grain of salt). And the tests appear to register fentanyl analogues like carfentanil (10,000 times stronger than morphine) and furanyl fentanyl (20 times stronger), according to Lysyshyn. DanceSafe—the organization that pioneered drug checking at music festivals—recently tested the strips on ten different analogues, all of which produced positive results, Lysyshyn told me.
The fact that the strips pick up various fentanyls reduces concern that they might offer a false sense of security when the dangerous opioid is actually present. Nonetheless, Lysyshyn cautioned, test users are told explicitly that false negatives can occur, either due to error, the presence of previously unknown analogues, or because fentanyl might not be evenly distributed in a packet of drugs. He uses the analogy of testing a chocolate-chip cookie for chocolate: If you test a piece that is only dough, it might be negative for chocolate.
Dr. Kirk Maxey, president and CEO of Cayman Chemical, which provides pure samples of drugs like fentanyl to law-enforcement agencies and others who need it to calibrate equipment, told me testing with this type of bias can be useful even if it isn't exact. "A crude test with a lot of false fentanyl positives is likely to have a strong positive public health benefit," he said.
At Insite, around 83 percent of drugs sold as heroin tested positive for some fentanyl—so did 82 percent of samples from drugs sold as crystal meth and 40 percent of drugs sold as cocaine. It might seem to make little business sense to sell stimulant customers a drug that has the opposite effect and is especially likely to kill people who don't already use opioids. But reports of fentanyl contamination of cocaine have also come from New York and other cities, where more precise lab tests were used. "We have no idea why they're doing that," said Lysyshyn, who speculated that it might occur by accident if several drugs are processed in the same lab.
Although only a small proportion of visitors to Insite chose to test their drugs, Lysyshyn suspects this is likely due to the fact that no fatal overdoses have ever occurred at a safe-injection facility, which now exist in at least 66 cities in ten countries. "Insite is proven to save lives and prevent people from dying of overdose," he told me. "We think that the setting influences whether people think that it's important to check drugs. In an SIF, they know they're not going to die."
Daniel Raymond, deputy director of policy at the Harm Reduction Coalition, has been offering fentanyl test strips to programs for people who use opioids, such as St. Ann's Corner of Harm Reduction in the Bronx. "Some respond [to positive tests] by reducing their dosage," he said. "But some respond by trying to avoid using alone or getting extra supplies of naloxone." All of these measures can reduce harm.
Unfortunately, policy innovations like drug checking tend to face strong resistance—despite the fact that the arguments against are repeatedly refuted by actual data. The same basic claims recur: Opponents contend that people with addiction are so irrational or out of control that they won't bother to do anything to protect their health. They worryp that "enabling" or reducing negative consequences associated with addiction could prolong it. And they profess that anything making addiction more survivable or less awful will encourage kids to take drugs.
These arguments have been made about syringe exchange to prevent the spread of HIV. They've been made about distribution of the overdose antidote, naloxone. They've been made about heroin prescribing—and are currently being made about supervised injection facilities (SIFs) and drug checking.
Not once have they ever been shown to be accurate.
Needle exchange is the canonical example. When it was first introduced in the US, there was widespread opposition—in New York, this included the Catholic Church under the leadership of Cardinal O'Connor, the treatment center Phoenix House, the Black Leadership Commission on AIDS and even the Guardian Angels, a group focused on subway crime.
These disparate groups were united in the belief that it was immoral to provide the means by which to inject drugs rather than addiction treatment—even though real treatment was not going to be available to enough people, and relapse is the most common initial response. New York's health commissioner, Woodrow Myers, actually argued that eliminating IV drug USE was a "higher goal" than preventing the spread of AIDS.
Activists led by Jon Parker—who had himself injected drugs—and members of ACT UP, the AIDS Coalition to Unleash Power, persisted. By 1990, it was already clear that places allowing over-the-counter sales of syringes without a prescription had far lower HIV rates—and that cities cracking down on needle access had deadlier epidemics.
Today, there is no doubt about the effectiveness of needle exchange. In New York—the state with the biggest epidemic of HIV linked to intravenous drug use—the rate of infection among injectors had climbed to 54 percent by 1990. By 2012, after expansion of needle exchange and over the counter sales, that rate was down to 3 percent, prompting the state health department to label syringe exchange the "gold standard" for HIV prevention. Needle exchange participants were found to be more likely to seek treatment—not less so. Oh, and the programs are not associated with increases in drug use.
The same pattern holds for expanding access to naloxone, the overdose antidote. One study found that counties with greater public access to and use of the drug cut their overdose death rates by more than 50 percent compared to those with less access. Naloxone's proliferation has allowed more people to survive long enough to enter treatment, and likewise is not associated with increased drug use. And supervised injection facilities are similarly linked to improved health.
The good news is that Lysyshyn seems to be encountering a bit less resistance to drug checking than was common with earlier harm reduction efforts, like needle exchange. "There's a lot less pushback on this," he told me. "People are quite interested, and could see how this would help. As much as people don't want people taking drugs, they don't want them taking contaminated drugs, so they are a bit more supportive."
If America really wants to reduce the death toll from overdose, the only way to do so is by fully embracing harm reduction. That means allowing SIFs, expanding naloxone access, reducing barriers to maintenance treatment with drugs like methadone and buprenorphine (and, ideally, heroin) and, from here on, distributing test strips for drug checking. If we start now, by this time next year, there might be real progress to celebrate.
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