Written by MJ Stowe.

As part of the Support Don’t Punish Global Day of Action, Youth RISE’s MJ Stowe joined the Step Up Project on a day of outreach to the beneficiaries of their needle and syringe programme (Fig. 1). The Step Up Project provides evidence-based mobile HIV/TB/STI prevention to people who inject drugs, using a harm reduction model. The aim of the day’s outreach was to introduce on-site drug safety testing using the Rapid ResponseTM Fentanyl Test Strip (BTNX, Inc.) to service beneficiaries of Step Up Project’s needle and syringe programme.

Figure 1. Group members from the Step Up Project and Youth RISE.

The contamination of drugs that are currently illegal to use, such as heroin, with fentanyl and its analogues makes it difficult for even the most experienced drug user to anticipate and mitigate the likelihood of overdose. While no cases of fentanyl adulteration have been reported in South Africa to date, the severity of the opioid overdose epidemic in North America and other countries, makes this issue of global importance. 

Service beneficiaries of the Step Up Project’s needle and syringe programme were introduced to what fentanyl is and what the associated risks are. The beneficiaries were informed that fentanyl, a synthetic opioid, can be up to 50 times more potent by weight than heroin, with a rapid onset of action and relatively short duration of effect. Furthermore, the beneficiaries were introduced to the occurrence of fentanyl-contaminated drugs, specifically in the United States of America, where fentanyl and its analogues have been detected in prescription opioids such as OxyContin, as well as stimulants including cocaine

Recently, there have been calls for promoting on-site drug testing as a means of detecting fentanyl to prevent unintentional fentanyl use and related overdose risk3. Fentanyl self-test strips (i.e. lateral flow immunochromatographic assays), when dipped into a solution containing a dissolved substance (i.e. drugs), can indicate the presence of fentanyl and certain analogues (Fig. 2a). A limitation of the test strips is that they do not give any indication of how much fentanyl – or fentanyl analogues – is present. Additionally, if a test result is negative, participants are informed that the test strip only tested for fentanyl and some analogues and their negative test result could not ensure that their drugs were not adulterated with other substances which could be more potent than fentanyl (e.g. carfentanyl). This description of the test strip, as well as its limitations were provided to the service beneficiaries.

2a)                                                                                                                                                                      2b)

                                      

Figure 2. a) Result showing two red lines on the test strip, which is a negative result for fentanyl. b) Image showing the Rapid ResponseTM Fentanyl Test Strip (BTNX, Inc.), adapted from Peiper et al. (2019).

To supplement the information above, service beneficiaries were provided with substance-specific harm reduction information, as well as details of possible interventions (Fig. 3a, b). This information was provided in the form of cards (Fig. 3a, b) produced by TB HIV Care. Included on the cards were descriptions of signs of an overdose (Fig. 3a), along with details on what to do when an overdose occurs (Fig.3b).

3a)                                                                                                                                                              3b)

                                     

Figure 3. Substance specific harm reduction information given to the service beneficiaries which a) describes what an overdose is and b) what to do when someone overdoses.

Responses to the explanation of fentanyl-contaminated drugs and fentanyl test strips varied between the service beneficiaries. Given that no cases of fentanyl adulteration have been reported in South Africa, numerous individuals were not aware of what fentanyl is and the prevalence of fentanyl adulteration globally. Despite this, many individuals expressed that they would make use of an analysis service if available. Furthermore, these same individuals indicated that either themselves or other known users had had unexpected adverse reactions when using previously, which they suspect may be the result of adulteration, albeit not necessarily with fentanyl. 

Given an increasing presence of fentanyl-adulterated drugs in countries other than the United States, the Rapid ResponseTM Fentanyl Test Strip (BTNX, Inc.) represents a low-cost and effective technique that can inform evidence-based overdose prevention and provide the foundation for developing safer drug use practices for PWID. These initial discussions with the service beneficiaries open the door for future research to examine if fentanyl test strips may be an acceptable and feasible harm reduction intervention for communities serviced by the Step Up Project. However, future research is needed to investigate these initial responses further, as well as to determine if using fentanyl test strips will lead to desired behavioural changes.