Fentanyl Test Strip Pilot: San Francisco 2017-2018
In August 2017, in response to an increase in fentanyl in the drug supply in San Francisco, the DOPE Project partnered with the Syringe Access Collaborative (SAC) to pilot a fentanyl test strip monitoring survey.
The SAC includes the San Francisco AIDS Foundation’s Syringe Access Services, Glide Harm Reduction Services, St. James Infirmary, SF Drug Users Union and the Homeless Youth Alliance—all of which are DOPE Project naloxone distribution sites in addition to syringe access service providers.
The strips are provided to SF syringe access programs through the California Supply Clearinghouse, supported by the California Department of Public Health.
Findings:
- Test strips are a useful engagement tool to foster discussion with people who use drugs (PWUD around practicing universal precautions and anticipating the presence of fentanyl in their drug supply.
- Test strips are easy for PWUD to use with minimal instruction, and the response from PWUD about their availability has been extremely positive.
- Test strips are detecting positives in various drug supplies in SF and indicate that we have an increasingly frequent presence of fentanyl.
- Test strips allow PWUD to be more informed about the drugs they are buying and using, leading to behavior change and the adoption of increased harm reduction measures, including sharing information among peers.
- Test strips allow providers to better engage with non-injectors and non-opioid users around overdose prevention and resulted in an increase in naloxone trainings with non-opioid users.
- PWUD demonstrate a high likelihood of implementing one or more harm reduction strategies when learning that their drugs are positive for fentanyl.
- Test strip use has increased general awareness and understanding of fentanyl among PWUD and providers at SAC sites.
Considerations:
- Important that providers have adequate knowledge of the test strip technology, how to read results and what results mean in order to accurately communicate with PWUD.
- Test strips and the surveys are not an effective tool for systematically documenting the presence of fentanyl in the drug supply.
- Test strips are extremely sensitive, and pick up on minimal amounts of fentanyl, often so little that PWUD do not feel the effects of it, casting doubt on the utility of the technology.
- Test strips often show a faint line for negatives, which can cause mistakes in reading them, resulting in false positives.
- Test strips do not tell any information about the percentages of fentanyl in drugs nor do they detect any other drugs.
SAC providers worked in close partnership with syringe access participants to test samples of drugs and complete a brief survey regarding the findings, including the participant’s behavior upon learning if their sample tested positive or negative. The surveys were voluntary, anonymous, and asked participants what drug they tested, where they purchased it (neighborhood, cross streets, etc.), what the result of the test was, whether the test was performed before or after they used the drug, the method they used to take the drug, and what – if any – actions did they take upon learning the results.
Providers engaged with participants around fentanyl primarily during overdose prevention trainings and naloxone distribution, and in some cases, were able to test the drug (residue in cookers or empty bags were tested) on-site and fill out the survey with the participant. Participants were also given test strips for testing their drugs on their own time, and the survey was completed with providers when they returned to site. Participants also had the option take copies of the survey and return completed surveys to any syringe access site. This was the least effective method of obtaining completed surveys.
The DOPE Project received a total of 242 surveys between August 2017 to January 2018 from all 5 SAC partners, with the majority of results coming from program participants accessing services in the Tenderloin and South of Market/6th Street corridor as well as the Haight-Ashbury district of SF. It’s important to note, however, that all but one of the SAC partners primarily serve the Tenderloin and South of Market neighborhoods, meaning other neighborhoods with significant drug use like the Mission, Castro, and Bayview neighborhoods are underrepresented in the data. After the first round of data came in and this under representation was noted, Homeless Youth Alliance increased their testing efforts in the Haight.
A little more than half of the drugs tested for this survey were purchased in the Tenderloin (54 percent), and though a variety of drugs were tested, crystal meth/speed and black tar heroin made up the largest percentages (32.2 percent and 37.2 percent, respectively). A variety of heroin types that were not reported to be black tar (i.e. powdered heroin of different colors) made up 14.1 percent of drugs tested, while other drugs tested included crack cocaine, powdered cocaine, Xanax, ecstasy, unmarked pills, and meth/heroin mixes.
In the first two months of this pilot, test results were overwhelmingly positive (78.8 percent). We believed this was not an accurate representation of the presence of fentanyl in the drug supply in San Francisco, as providers tended to only record positive results, and participants tended to only return surveys or report back if the results were positive. After we addressed these issues, providers began recording more negative results on-site,though they still were not receiving report backs from program participants unless results were positive. This shift allowed for a slight change in percentages, with 68.2 percent of surveys reporting positive results.
Program participants reported an almost even split between testing their products before they used, or after (51.8 percent and 48.2 percent, respectively), and while respondents reported utilizing a number of harm reduction strategies to keep themselves safe after learning the results of the test, over half (58.8 percent) reported that they shared the results of the test with their community, and this seemed to be regardless of whether the result was positive or negative. This indicates that people who use drugs continue to do a large amount of on-the-ground work of disseminating information among their peers and sources, as well as relying on harm reduction strategies to use and prevent overdose – using less, doing test shots, having a friend monitor them while they used, and/or changing their mode of use, i.e. smoking instead of injecting.
Additionally, 78 percent of the speed/crystal meth samples tested came back positive, as did 67 percent of the crack cocaine samples. Again, taking into consideration that positive results were being reported back to program staff at higher rates than negative and that the BTNX test strips are extremely sensitive, it’s worth noting that the city has not seen a significant rise in fatal opiate overdoses among people who use speed/crystal meth or crack to date. This indicates that those drugs have not been cut with fentanyl, but possibly contaminated, or contain such an insignificant amount of fentanyl that it doesn’t pose widespread danger.
That being said, there have multiple confirmed fatalities in San Francisco within less than a year of each other wherein people were using what they thought were stimulants at the time of the overdose: In March 2017, nine people experienced overdoses while using crack cocaine containing fentanyl in a hotel on 6th Street, and eight of them were revived with naloxone and one person died; and in February 2018, three young people overdosed and died outside while using methamphetamine containing fentanyl and acetyl fentanyl. In both incidents, toxicology reports revealed that the stimulants contained fentanyl and/or a fentanyl analogue. Harm reduction programs and community members immediately responded, disseminating the alert wide, and outreach efforts were increased to get naloxone to stimulant users.
This uncertainty around how much fentanyl is in the drug supply strongly informs the need for a more comprehensive drug monitoring program, where samples of drugs are tested in a clinical setting to determine how much fentanyl (and other drugs) are in the heroin (tar and powder), crack cocaine, and speed/crystal meth. The test strips provide only a snapshot, and understanding exactly what drugs and how much of them are in the supply allows people to make accurate, informed decisions around their drug use, and combining that knowledge with other evidence-based harm reduction strategies, ensures people can prevent overdose/death and other harms associated with drug use.
As fentanyl becomes the “new normal” for people who use drugs in San Francisco, we’re beginning to get a more accurate picture of how it’s showing up and impacting the community. The surveys and fentanyl test strips should act less as a reliable way to accurately and thoroughly monitor the street drug supply and more as tools to assist providers in engaging deeper with participants regarding the uncertainty and inconsistency of the city’s drug supply. The surveys and test strips also gave providers opportunities to offer overdose prevention training and naloxone to community members who were not always seen as at-risk for opioid overdoses, such as speed/crystal meth users, crack users, and other non-injection drug users.
Providing the test strips, overdose prevention training, and naloxone continues to honor the autonomy of people who use drugs, allowing them to make educated decisions with the most accurate information available to them, and to prevent and respond to overdoses.
Report authored February 18, 2018 by DOPE Project Manager Kristen Marshall, marshall@harmreduction.org. For more information contact Kristen or the Harm Reduction Coalition’s Overdose Response Strategist Eliza Wheeler, wheeler@harmreduction.org