“You smoke weed?” Eufamia Lopez asked the half-dozen young men lounging on benches in a public housing courtyard in the South Bronx.
The soft September air reeked of the obvious answer.
Lopez, who works for a New York University health support program, plunged into her spiel. Street drugs — meth, coke, molly, Xanax, heroin and even marijuana — are being cut with fentanyl these days, she said, which can kill you. But you can test your supply before using it to see whether there’s any fentanyl in it. She was giving out free kits.
She had their attention, and not just because she is 5-foot-10, frank but ebullient, with cascading black curls scarcely held in check by a brightly colored scarf. The neighborhood, Mott Haven, has one of New York City’s highest overdose rates. After she recited the simple instructions, each man readily accepted a kit with three fentanyl test strips. One asked for a second kit.
“I appreciate you,” she said, rewarding him with a smile.
The spread of fentanyl, a cheap synthetic opioid 50 times as lethal as heroin, into most kinds of illicit drugs has pushed fatal overdoses to record highs in the United States. Fentanyl test strips have become a popular but contentious tool in response. Supporters say they help drug users make lifesaving decisions. Opponents contend that they facilitate drug use.
Test strips are a part of a broader approach called harm reduction, which holds that ending the overdose crisis can be achieved only by first ameliorating the deadliest risks of drug use, then taking steps to curb behavior, such as addiction treatment. President Joe Biden is the first president to embrace harm reduction, and he has made fentanyl test strips a key component in his proposed $307 million harm reduction drug control strategy. Within the past year, about 10 states — including Louisiana, Tennessee, Alabama and Georgia, where hard-line abstinence views are more typically favored — have legalized test strips and made them more available.
But test strips are illegal in about 20 states — including Florida, Texas, Kansas and Kentucky — classified as “drug paraphernalia.”
Critics say test strips encourage drug use by giving users the green light if the supply is free of fentanyl. To some opponents, the test strips are even more objectionable than other forms of harm reduction, like distributions of clean syringes, because those at least prevent the spread of HIV, hepatitis and other dangerous infections to users and nonusers.
In May, Kansas legislators blocked a proposal to legalize the strips. “Fentanyl strips don’t save lives. Let’s be clear. There are individuals that want fentanyl in the drug that they’ve purchased or acquired,” Molly Baumgardner, a Republican state senator, said at the time, according to the Kansas Reflector, which reports on state government.
The Biden administration’s drug czar refutes such criticism. “There is no scientific evidence to support this notion that harm reduction services like fentanyl test strips somehow encourage drug use, but there is significant evidence to support the fact that these tools can save lives,” said Dr. Rahul Gupta, director of the federal Office of National Drug Control Policy.
In fact, there is not yet a substantial body of evidence that directly shows test strips have saved lives. Results have been mixed from a handful of relatively small studies looking at whether the strips deter sustained drug use.
A 2020 study of 68 female sex workers in Baltimore found that after receiving the strips, 84% tested their drugs and 69% subsequently took precautionary measures, such as asking someone to check on them or using smaller amounts. But a 2018 study looked at a supervised drug injection site in Vancouver, British Columbia, where users were asked whether they wanted to check their drugs (usually heroin) for fentanyl. Scarcely 1% chose to do so. Nearly 80% of those samples indeed tested positive for fentanyl.
In a 2021 study, researchers at the Johns Hopkins Bloomberg School of Public Health, among others, surveyed 225 drug users in Baltimore and Delaware who had been given strips at two syringe distribution programs. About three-quarters reported having used them. In Delaware, 69% said that when results were positive for fentanyl, they subsequently took risk-reduction measures; in Baltimore, just 23% did so.
Certainly acceptance of the strips has soared among casual drug users. This summer, Chicago officials urged people attending the Lollapalooza music festival to pick up free kits from the city. The nonprofit TACO (Team Awareness Combating Overdose) has given away thousands of strips to students on at least a dozen college campuses. Many emergency rooms provide strips to overdose patients upon discharge.
Lopez said she had even persuaded some drug sellers to try the strips. “I’ve had drug dealers tell me, ‘I don’t have any fentanyl in my stuff!’” she said. “And I say, ‘Well, how do you know?’”
Regular use of strips by dealers could make a difference, said Corey S. Davis, who directs the Harm Reduction Legal Project at the Network for Public Health Law. “People are already there to buy heroin, so if a dealer can say, ‘Hey, I’ve tested it, and I’m actually selling you what you think you’re buying,’ that’s a good thing,” he said. “Dealers are making sure they’re not poisoning their customers with a much more dangerous drug.”
The divergent messaging on fentanyl test strips gets translated into inconsistent practices even within the same state. Kentucky considers them drug paraphernalia but gives decision-making authority to local health departments. So in cities like Lexington and Louisville, mobile units or clinics readily hand out the strips, said Jim Thacker, project director of Target4, an HIV-prevention and harm reduction program at the University of Kentucky. But in many rural counties, he said, police officers have detained program participants and confiscated the kits.
Thacker said that particularly in the Bible Belt, resistance to harm reduction springs from a stigma that still attaches to drug use.
“Addiction is not seen by a lot of people as an illness,” he said. “It is seen as a moral failure. I’ve heard multiple times that ‘the best way to solve the drug problem in Kentucky is to gather up all the drug users and lock them in a big space and supply all the drugs they could possibly want and let them all overdose and die.’”
Even where test strips are easily obtained, they have limitations. They measure the presence of fentanyl but not its concentration. While many clinics, pharmacies and drug treatment programs provide them free, in locations where access is difficult or banned, they must be purchased online for about $1 or $2 each, a cost that can add up quickly for a regular user.
The effectiveness of the testing, in which a small drug sample is dissolved in scarcely a capful of water into which a strip is then dipped, relies completely on the user’s compliance. That’s why outreach workers like Lopez try to engage users directly, clambering under bridges to find them and perusing parks near high schools.
The tests require even more diligence from people who buy counterfeit versions of pills like Xanax, OxyContin or Percocet through social media or street dealers. Cartels that press the pills salt them haphazardly with fentanyl filler. So while one pill might test negative, others could be contaminated. Each pill should be tested.
But such rigor is antithetical to young people looking to party, or to people who struggle with addiction, said Kevin Sabet, who, with former congressman Patrick Kennedy, is a founder of the Foundation for Drug Policy Solutions.
“Addiction is chaotic and disturbing,” said Sabet, who thinks the strips’ utility is modest. “It hijacks the brain. So the idea that while you are in active addiction you are going to make a lot of rational choices with regard to your drugs sort of goes against the very notion of what addiction is.”
Lopez disagreed with that broad-brush view, saying she knows functioning heroin users who use the strips responsibly because they fear an inadvertent fentanyl overdose.
But she acknowledged that people who are deeply in addiction tend to reject the strips. “They want fentanyl,” she said, “because their goal is being high. Their lives have become so empty that they figure that even if they die in the pursuit of that goal, it’s worth it to them.”
Fentanyl overdoses: What to know
Devastating losses. Drug overdose deaths, largely caused by the synthetic opioid drug fentanyl, reached record highs in the United States in 2021.
Understand fentanyl’s effects. Fentanyl is a potent and fast-acting drug, two qualities that also make it highly addictive. A small quantity goes a long way, so it’s easy to suffer an overdose. With fentanyl, there is only a short window of time to intervene and save a person’s life during an overdose.
Stick to licensed pharmacies. Prescription drugs sold online or by unlicensed dealers marketed as OxyContin, Vicodin and Xanax are often laced with fentanyl. Only take pills that were prescribed by your doctor and came from a licensed pharmacy.
Talk to your loved ones. The best way to prevent fentanyl use is to educate your loved ones, including teens, about it. Explain what fentanyl is and that it can be found in pills bought online or from friends. Aim to establish an ongoing dialogue in short spurts rather than one long, formal conversation.
Learn how to spot an overdose. When someone overdoses from fentanyl, breathing slows, and their skin often turns a bluish hue. If you think someone is overdosing, call 911 right away. If you’re concerned that a loved one could be exposed to fentanyl, you may want to buy naloxone, a medicine that can rapidly reverse an opioid overdose and is often available at local pharmacies without prescription.