Harm reduction measures employed by people using opioids with suspected fentanyl exposure in Boston, Baltimore, and Providence

Abstract

Background Exposure to potent synthetic opioids such as illicitly manufactured fentanyl (IMF) has fueled the escalating overdose crisis in the USA, particularly in the east coast. Drug checking services, which allow people who use drugs (PWUD) to learn about the contents of their drugs, remain limited and even criminalized in many states. Further, there is a persistent belief that PWUD are not willing or able to change their behaviors despite being aware of their potential exposure to fentanyl through drug use. Methods We conducted a multi-site cross-sectional study among PWUD to assess what behaviors, if any, were employed in the case of suspected fentanyl exposure, and the correlates of engaging in harm reduction behaviors (HRB). PWUD ( N = 334) were recruited in Boston ( n = 80), Providence ( n = 79), and in Baltimore ( n = 175). At the time of the survey, no legal drug checking services were available in these cities. Results The majority of PWUD (84%) expressed concern about fentanyl. Among those who suspected fentanyl exposure prior to using their drugs ( n = 196), 39% reported employing HRB including using less of the drug (12%) or abstaining altogether (10%), using more slowly (5%), and doing a tester shot (5%). In adjusted logistic regression models, the odds (aOR) of practicing HRB after suspecting fentanyl exposure were increased among PWUD who were non-White (aOR 2.1; p = 0.004) and older (aOR 1.52 per decade of age; p < 0.001). Daily injection (aOR 0.50; p < 0.001), using drugs in public (aOR 0.58; p = 0.001), using drugs alone (aOR 0.68; p < 0.001), and experiencing multiple recent overdoses (aOR 0.55; p < 0.001) were associated with decreased odds of practicing HRB. Conclusions These data illustrate that PWUD employ a number of practices to reduce overdose risk in a context of unknown drug purity and content. Results may also guide efforts to identify early adopters of drug checking services and engage them in peer-outreach to target the most socially and structurally vulnerable PWUD, who are not reporting behavior change, with harm reduction messaging.

What is needed for implementing drug checking services in the context of the overdose crisis? A qualitative study to explore perspectives of potential service users

“…Such outcome measures for community drug checking can minimize the value of drug composition evidence to further inform drug use and harm reduction. Our study concurs with findings from recent Canadian and American research teams that discarding one's drugs is a much less relevant and respectful service objective for community drug checking services seeking to reach people impacted by poverty, homelessness and other structural vulnerabilities where it may not be feasible for many to discard and purchase from another source [8,18,45,46]. Further research is needed to better understand the benefits and impacts of drug checking within these contexts that take this into account.…”

“…Similar to research in Vancouver, BC [45], for the relative advantage of drug checking to be high enough to outweigh these risks, participants wanted accurate, precise and detailed information on composition of substances and harm reduction. As noted in other research [18,46], participants expressed that the value of drug checking would be in providing new information so they could have the most knowledge to further inform their drug use and personal harm reduction practices. Similar to the FORCAST research in the USA [19], we heard this requires designing an intervention that includes skilled technicians to operate sophisticated technology that provides results with a high degree of accuracy and detail, that are pragmatic and useful (such as potency), for those accessing the services.…”

Drug Checking and Its Potential Impact on Substance Use

“…In addition to most nightlife attendees believing that drug checking could contribute to harm reduction, several studies showed that it could in fact influence the user’s consumption patterns: After having encountered unexpected substances, most users intended to use less of the sample or not at all [3, 6, 11-14]. These findings do not only apply to the heterogenous group of nightlife attendees but also to heavy and addicted drug users, which is why drug checking might be used to face the fentanyl overdose epidemic in the USA [15, 16].…”

Opportunities to Offer Harm Reduction to People who Inject Drugs During Infectious Disease Encounters: Narrative Review

“…According to the CDC, from 2016 to 2017, the rate of opioid-related fatal ODs increased by 47% [ 73 ], and for many, the person was unaware of the presence of fentanyl in the drug supply [ 74 ]. The FORECAST study, conducted in 2017, found that the vast majority of people who use drugs would modify their behavior, abstaining from use, slowing down consumption, or using with others who have naloxone, if they were made aware that their drugs contained fentanyl [ 75 , 76 ]. Testing at the Insite Safe Injection Facility in Vancouver, where drug checking with fentanyl test strips was pioneered, showed that during 1 month in 2016, 79% of all substances tested were positive for fentanyl, whether pills or powder [ 77 ].…”