Fentanyl Test Strip Distribution Acceptability and Use among Substance-Related Emergency Department Visits

U.S. overdose deaths involving fentanyl have escalated in recent years, including in Cook County, Illinois, where over 91% of the 2000 overdose deaths in 2022 involved fentanyl compared to 56% of 1195 overdose deaths in 2017.1 As such, distributing fentanyl test strips (FTSs) to persons who use drugs (PWUD) has rapidly become a key harm reduction strategy. FTSs are point-of-care immunoassay dipstick tests that can detect the presence of fentanyl; dry substances (e.g., powder, tablets) can be crushed and dissolved in water for testing. Previous studies focused on PWUD engaged in syringe service programs have found that FTSs are acceptable and associated with subsequent changes in overdose prevention behaviors.2-5 There is limited research regarding if these findings can be extended to a more general population of patients in the emergency department (ED) setting. We sought to characterize FTS acceptability and harm reduction behaviors among ED patients receiving FTSs. We conducted an institutional review board–approved prospective cohort study of discharged visits offered a harm reduction kit consisting of two intranasal naloxone devices and three immunoassay FTSs (cutoff 20 ng/mL) from an urban academic ED in downtown Chicago, Illinois, from August 2022 to August 2023. In our ED, clinicians routinely dispense harm reduction kits to patients deemed at risk of opioid overdose following discharge; although there are no strict eligibility criteria, we typically offer kits to patients presenting with opioid overdose, intoxication, or withdrawal. We identified 172 ED visits during the study period based on an electronic medical record (EMR) order for take-home naloxone dispensing.6 Patients with multiple visits had only the first visit included. For each eligible visit, we collected prespecified demographic and clinical variables from the EMR using a standardized data collection form. In addition, in anticipation of a low follow-up contact rate based on previous work,7 ED pharmacists queried patients during the index ED visit about their previous experiences with FTSs and anticipated plans using a structured clinical note. Pharmacists then used a pictogram handout (Data S1) to educate patients on FTS use. While pharmacist clinical notes were documented whenever possible, they could not always be completed due to competing clinical obligations in a busy ED environment and occasional cross-staffing by pharmacists from other departments. In total, 113 ED pharmacist notes were recorded (65.7%). One month after the ED visit, we called patients up to three times to evaluate FTS use and outcomes via a structured interview guide. We attempted follow-up with all patients who had a telephone number listed in the EMR (n = 110, 64%), regardless of whether they had a pharmacy note. Open-ended responses were transcribed contemporaneously; we elected not to record interviews to encourage open dialogue. We summarized quantitative data using Stata MP 17.0 and present open-ended responses descriptively. Of 172 ED patients offered harm reduction kits, most were male (84.3%), Black (59.3%), and publicly insured (Medicaid 65.1%) and presented for acute overdose (89.5%) from a public location. The majority endorsed using a single substance (68.0%), most commonly heroin (76.1%; Table 1). Of the 113 patients with a pharmacist note, 85.8% (n = 97) accepted FTSs and 14.2% (n = 16) did not. Among those not accepting FTS, four stated they were not interested and two did not plan on using the substance again; the remainder did not specify. Among 94 patients discussing prior FTS use with the ED pharmacist, most had not previously used FTSs (n = 81, 86.1%). Thirteen (13.8%) reported previously using FTSs: four disposed of the substance following a positive result and one confirmed fentanyl as their preferred substance. Among 66 patients who offered anticipated plans following a positive FTS result, 41 (62.1%) stated they would either not use or dispose of the substance, seven (10.6%) stated they would use less, and one planned to confirm fentanyl as their preference; 17 (25.7%) were not sure what to do or asked the pharmacist for advice. When asked for advice, pharmacists suggested that patients use less of the substance than they normally would, use with a friend nearby, and have naloxone on hand. Among the 110 patients with a listed telephone number (64.0%), we reached 24 (21.8%) at a median follow-up of 29.5 days; 44.5% had a wrong or out-of-service number and 29.1% were not reached after three attempts. Twelve patients (50.0%) had not yet used their FTSs, while four had; the remaining participants did not recall receiving FTSs or accidentally left the FTSs behind. Of the four patients who had used their FTSs, two disposed of the substance (both heroin) after a positive result, one did not recall the substance tested or the result, and one tested their own urine 2 days later (negative test result after ketamine use); this participant stated that they "wished there was a way to test whether fentanyl was in my system while I was there." One patient reported that it "scared me a bit to see a positive result" and that it was "such a blessing to be able to get them." Another patient described that the FTS "makes me feel more aware about what I'm doing." Of the 12 patients who had not yet used their FTSs, eight stated this was because they had not used any substances since their ED visit or did not plan on using substances again. One patient stated they did not want to "mess with that stuff anymore" following their ED visit, one cited their ED visit as a "wake-up call" and had not used substances since, one said they were "working on staying clean," and two stated that the overdose was a "one-off instance" or unique circumstance: "I just happened to be going through a tough time and someone offered me heroin." Two patients had not yet used their FTSs but planned to use them in the future, one of whom was interested in gathering supplies and handing them out in the community: "I like to pass on knowledge that I get. A lot of people don't understand the seriousness of it all because actually they're not getting opiates, they are getting fentanyl and tranq [xylazine]." In this prospective study of ED visits offered FTSs, we found high acceptability and low previous exposure to FTSs, in concurrence with our initial pilot study and the limited existing research in the ED setting.7, 8 When queried on anticipated plans following a positive result, most patients reported that they would either not use or dispose of the substance. Following the ED visit, a small number of patients reported using FTSs and disposing of the tested substance. Notably, several patients who had not yet used the FTSs cited their intent not to use the offending substance again. These findings make an important contribution to the nascent literature on FTS acceptability and use. Whereas most prior FTS studies have been conducted among PWUD engaged in syringe service programs or with regular opioid use,2-5, 9 we examined FTS acceptability and behaviors among a more general population of ED visits, most commonly for overdose-related reasons. We uniquely found that ED patients expressed strong inclinations toward drug disposal following a positive test. This differs from harm reduction behaviors cited by PWUD using FTSs from other settings,3, 4, 9 possibly due to differences in PWUD characteristics (e.g., regular opioid use vs. nonopioid substance use), treatment setting, or recency of overdose. Additionally, we found that many ED patients who did not use their FTSs cited strong commitments to future abstinence, suggesting that patient acceptability of FTSs at the distribution point may not translate to downstream use. Given the low efficacy of abstinence-only approaches, we recommend exploring tailored patient guidance for individuals preferring abstinence-based messaging. For example, FTS guidance in this population might emphasize a "just-in-case" approach similar to guidance on epinephrine autoinjector carriage. This strategy might more effectively communicate the importance of FTS (and naloxone) possession and carriage while also acknowledging the real possibility of future substance use despite an earnest intent of abstinence. Future studies might also explore how individual perceptions may differ among persons with regular opioid use versus those with infrequent opioid use or nonopioid substance use or whether these perceptions might evolve over time in the setting of frequent test positivity (i.e., the possibility of developing "alarm fatigue" in the setting of near universal fentanyl contamination, which in turn makes drug disposal a decreasingly realistic tactic). This study's generalizability is limited by its focus on a single urban academic ED. Additionally, our follow-up contact rate and resulting sample size was low, albeit consistent with other similar studies.10 Although we attempted to mitigate this by prospectively collecting data at the index ED visit, patient responses were sometimes incomplete and may have been subject to acquiescence bias. In summary, we find that FTSs are acceptable among a heterogeneous population of ED visits. Patients described anticipated and actual patient-reported FTS use following the ED visit, with strong inclinations toward drug disposal following a positive test result. Patients also cited commitments to future abstinence, which has important implications for whether FTSs are ultimately used and how patient guidance could be tailored to maximize effectiveness. Howard S. Kim, Patrick M. Lank, and Danielle M. McCarthy conceived the study and obtained research funding. Howard S. Kim supervised the conduct of the study. Howard S. Kim, Allison Kannam, Allison Cowett, Kelsea Caruso, Kaylie Lau, and Katherine Allen collected data. Howard S. Kim and Allison Kannam conducted data analysis and drafted the manuscript; all authors contributed substantially to its revision. Howard S. Kim takes responsibility for the paper as a whole. This study was funded by The Davee Foundation. A number of fentanyl test strips were initially provided by the Chicago Department of Public Health (CDPH) and the publicly available pictogram handout was provided by the Cook County Department of Public Health (CCDPH). Neither the Davee Foundation, CDPH, nor CCDPH played any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. HSK receives a stipend from the American Medical Association as an Associate Editor for JAMA Network Open. PML is now primarily employed at AbbVie and reports stock ownership. The other authors declare no conflicts of interest. Data S1. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.