ISIH S2 E4 / The Opioid Overdose Crisis: Testing Drugs for Adulterants

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Carl Hart: All the public health officials need to do, first of all, they have to understand that illicit drug use has been with us since humans have engaged in... well, since humans have walked the earth, and it's not going anywhere...

Celine Gounder: Dr. Carl Hart is the Chair of Psychology at Columbia University.

Over the course of my reporting for this series, I spoke with Carl about a number of issues related to drug use and the opioid overdose epidemic in this country, including the question of whether addiction is a brain disease.

At one point, Carl brought up an idea that’s still pretty new in the addiction response... something that’s very new in the U.S.

CH: If we start there and we say we want to keep people safe, all you have to do is set up free drug purity testing sites where people can take a sample of whatever they have to some location and get anonymous tests done. And if it has fentanyl, people are aware and they know to scale back, don't use as much. They do this sort of thing in Spain, they do this thing around the globe. But in the United States morality has shaped the way we deal with these issues.

CG: Welcome back to “In Sickness and in Health,” a podcast about health and social justice. I’m Dr. Celine Gounder. I care for patients in places where I think there’s a great need, in this country and overseas. This means different things in different communities, and in this season of "In Sickness and in Health," we’re asking how we can save lives… the lives of opioid users… and how we can help communities affected by addiction and the drug trade.

There’s a test strip… kind of like a drug store pregnancy test… that doctors can use to test a patient’s urine for fentanyl… the powerful drug that’s now infiltrating the opioid market... and causing a big spike in overdose deaths. Fentanyl is hard to detect once it’s in the system… regular urine tox screens won’t pick it up… but these special strips will.

These same strips can be used to do something simple but revolutionary: test a drug for adulterants like fentanyl before they harm or kill.

CH: You know there's still, even to this day, there still are more accidents, deaths caused by accidents than there are opioids.

CG: Carl Hart has a serious problem when it comes to the way we talk about opioid use… how the media covers it. He thinks exaggeration and sensationalism create misperceptions… and ultimately… lead to more deaths.

CH: When you actually look at the numbers... I know people, newspaper articles say, 'oh overdose related to drugs have surpassed automobile accidents.' When they do that, they include everything, not only the opioids… every drug that you can think of. And it's, but then they talk about opioids in the article. So they are playing these tricks with words, and it's not keeping the public safe.

CG: Carl Hart thinks that inaccurate framing of the opioid problem is one of the biggest barriers to keeping drug users alive... and curbing the rate of opioid overdoses. Too often, in people’s minds, he says, drug overdose has become synonymous with opioid overdose. But many drug overdoses are the result of drugs used in combination… say opioids and benzodiazepines like Valium or Xanax… or from the use of fentanyl. Fentanyl, in particular, is responsible for a recent spike in opioid overdose deaths in the United States.

It’s important to understand that some celebrities who’ve died from opioid overdoses… like Prince… or Michael Jackson… aren’t representative of the average death from drug overdoses in this country. They were prescribed pharmaceutical grade fentanyl by their doctors. They knew what they were taking. As for Philip Seymour Hoffman… he overdosed on heroin… in 2014… before fentanyl had fully penetrated the heroin supply.

What we’re talking about here are people who are using street drugs today… who can’t be sure what combination of drugs they’re taking… and if they might be tainted with fentanyl.

CH: So my point is is that each year in the country there are 30,000 deaths caused by automobile accidents -- 30,000 or more. Rather than talking about an epidemic related to automobile deaths, what we do instead is that we make sure people wear seatbelts. We make sure that people are attending to their speed. We're making sure that they're not drinking and driving, all the things that we know are related to these deaths. We don't do the same thing with the opioids, and the public media and the public have been irresponsible. And they have contributed to these deaths.

CG: Carl sees a rational response to opioid addiction and overdose as a harm reduction response. Motor vehicle accidents kill… it’s a leading cause of death in the U. S. ...but we allow people to drive… and work to remove factors that increase the risk of accident and death.

Carl thinks we should take a similar approach to drug use. This might sound radical… but it has a certain logic to it. People are going to take drugs. So why not make it safer for those who do… why not offer testing so people know what they’re taking?

CH: The most important thing to do is anonymous, free drug-purity testing. That's the most important thing to do.

CG: Adulterant testing is something that can be done in the United States by scientists in the lab… but anonymous purity-testing for users? That’s not something that’s being done in any widespread way in this country.

But Carl’s insistence is based on real evidence... on what has been shown to save lives… on data from Europe…  where deaths are prevented every day by way of government-supported drug testing.

Daan van der Gouwe: OK the Drugs Information Monitoring System or shortly, DIMS, as we call it, is a system set up already in the 90s of last century... which is testing and analyzing drug samples that we have, that are being submitted by drug users themselves. So it's not seizures or anything else. It's just the drugs that drug users deliver at our services in order to have it tested.

CG: Daan van der Gouwe works for the Trimbos Instituut in the Netherlands, an institution that deals with issues of drug addiction and mental health.

The Drug Information Monitoring System, or DIMS, is a government supported program that tests party drugs and heroin for adulterants that could cause overdose and death in unsuspecting users.

DvdG: It's offices where they can hand in drugs that say, well, I've bought cocaine or bought speed or bought ecstasy. Definitely I want to use it. But first I would like to know what it actually contains. And so we do various sets of analysis, simple tests, but also chemical analysis if needed.

CG: A drug user drops a sample of their supply off at one of these offices, and, Daan says, then they wait.

DvdG: So a week later, then they can call a specific number, and then they say well, last week I was at the service, I delivered ketamine, and now I would like to know the outcome. And so the outcome would be, well this sample contains this and this percentage of ketamine, or worse the sample that you have bought or delivered doesn't contain ketamine but it contains something which is even more risky, maybe even lethal. So we advise you strongly not to take it, but we also would like to know where it was bought so we can set up a complete warning for the specific sample.

CG: These users get their drugs tested for free… but in so doing… help create a surveillance system… providing the Trimbos Instituut with information about what’s out there on the drug market. This helps not just the individual user… but… if an adulterant is potentially lethal… the Instituut can issue a national media warning. Take, for example, the case of a bad batch of MDMA...

DvdG: For instance, so it will go on national news programs, anywhere possible to warn about the risks of the specific tablets. We also sent leaflets, we prepare leaflets and brochures, and we distribute them to festivals and all kinds of places where possible users of ecstasy might go.

CG: Daan calls this a win-win... the user and potential future users get safety information to prevent overdose from lethal substances... and the Trimbos Instituut gets information about what’s in circulation… how much drugs are being sold for… and where.

DvdG: And so this is what we do. And also we share our data within the European Union, with European Monitoring Centre for Drugs and Drug Addiction. So in case we have a very risky, risky substances on the market, we will inform them and they will inform all the focal points in the EU. So in order to prevent people dying from this substance.

CG: But keeping individuals safe through this program extends beyond the sharing of information in the name of prevention. Trimbos doesn’t share all its data with law enforcement... but they do work with law enforcement to locate the source of new or deadly drugs on the market.

DvdG: So the Instituut helps prevent the creation and sale of dangerous drugs… but at the same time… has made a deal with public prosecutors to ensure that anyone who walks into a testing office with drugs in their pocket will not be arrested.

CG: Protecting individual users... while simultaneously collaborating with law enforcement to protect the public at large... may sound bizarre by U.S. standards… but it’s worked well for the Netherlands.

For one thing, widespread heroin use is just not the problem there that it is here in the U.S. Daan can’t say for sure why that is... save for perhaps a different mindset about drug use in Europe.

DvdG: But really you have this you know in Europe, especially in the Netherlands, we have this idea of freedom of, you... should be able to have the full right of your body and what you would take and so on and so on. And what you do, unless you harm other people. So we have this this kind of idea, and drug use is basically part of that. Whatever you do at home, it's your business, whether you drink wine all night or something else it's up to you. But you should be able to function the next day. So this is the bottom line for forbidding everything is not the solution.

CG: This different mindset has led to different ways of dealing with drug abuse… decriminalization, adulterant testing, and the like… approaches that many Americans might think are crazy… that are widely criticized by abstinence-focused groups in the U. S.

DvdG: We are among the countries with the lowest drug-related deaths in Europe ... over the years we have had the number of around 120 to roughly 130 drug-related deaths per year.

CG: If the ultimate goal of politicians, law enforcement, doctors and others is to prevent deaths from drug use… then why are the American and Dutch responses to drug use so different? Especially when you consider the U.S. has almost ten times as many drug-related deaths relative to the size of its population as the Netherlands.

It isn’t that the U.S. is without creative thinkers and problem solvers… but just because a policy might save lives… doesn’t mean it’ll be implemented. Politics… funding… red tape… regulations and restrictions… can all get in the way.

And that’s why some are taking matters into their own hands…

Tino Fuentes: I can safely go into a shooting gallery or open air market or anywhere where people are using… and test and not worry about jeopardizing the agency.

CG: This is Tino Fuentes. Tino was born and raised in New York City. He’s been in the field of harm reduction for fifteen years. He’s also a former heroin dealer and user.

Tino recently stepped down from his job as Director of Syringe Access and Naloxone programs at St. Ann’s Corner of Harm Reduction in the Bronx.

Working at St. Ann’s, Tino and his team were well-aware of drug testing… Tino went so far as to order some test strips, buy bags of heroin from different dealers, and test them himself. Knowing how much of the heroin supply in New York City contains fentanyl, St. Ann’s didn’t need to be convinced that drug testing was a good idea… but when budgets are tight… a dollar or more per strip adds up quickly.

Tino’s now a freelance harm reduction consultant. He goes into existing agencies and provides advice about needle exchanges, naloxone, adulterant testing… and then, he takes to the streets... seeking out drug users... and offers to test their drugs for fentanyl.

TF: So the test strips… originally… they’re urine test strips and that’s where a physician… somebody… if a doctor prescribes somebody fentanyl, and I guess they want to check and make sure someone’s taking their fentanyl, you do the urine test. I use them for testing the drugs, right? And, like I said before, I actually test the drugs that they’re going to put in their body… I wait til they draw everything out, and then add water to the cooker, which could be the spoon or the bottle cap. Because the strips work off of the water it soaks up or the urine it soaks up, and then it activates the, you know, the positive or negative. They’re really sensitive, so, instead of actually testing the drugs, like I was saying before, I can just test the residue. The same thing, you know, draw out, take out all of your drugs, add some water, and test it. They don’t… so this is a problem… but like I mentioned before… they don’t tell you the purity, and they don’t tell you what analogue it might be. Like, I know they test for carfentanil, fentanyl and several of the analogues… but it won’t tell you. So… so when you actually use a strip, it will give you either one or two lines or no lines. So one line will be positive, two lines will be negative, just one line at the bottom will be an invalid test, or no lines will be an invalid test. But that’s the limit that you have.

CG: Though these test strips aren’t perfect diviners of a drug’s contents, merely getting a drug user to try a test strip, Tino says, breaks down barriers… and helps start a conversation.

TF: And I still have people to this day that say the same thing. You know, I’ve been dealing with the same person for two years. You know, they wouldn’t do that to me. So it’s one of those things where I have to see it to believe it, and I still tell people the same thing. I’ll give you ten dollars if it’s negative. If it’s positive, we’ll sit down and have a conversation. I still haven’t paid the ten dollars. And we sit down, and we have a conversation, you know. Test it. It’s positive, you know. How to use it safely if you’re going to use it. Are you willing to throw it away, and most people are not, you know. Using with somebody. Having naloxone. Don’t use the same cooker, syringes and everything, of course. Have somebody use first, wait a couple minutes… if they’re good, then you use. So these are the conversations that you’re going to have that kind of have slowed down over the years… kind of a little bit like complacency… it’s happening now, so it’s fine. You can come in and get your things, but you’re not having that actual conversation. And we’re at a point right now when you need that conversation. People are dying.

CG: Tino’s mission is not to get someone to stop using drugs. His work is... first and foremost... about preventing harm to a user... about breaking patterns of behavior that are especially unsafe… patterns that can lead to overdose and death. If someone’s drugs test positive for fentanyl, Tino doesn’t expect them to throw ’em away… but he hopes this information will help them use more safely.

TF: I don’t expect people to throw them out, and one of the reasons is because, for the most part, especially if you’re in the street, you know, whatever you had to do, whatever hustle you had to do to get that money, that’s all you have, and especially if you’re dope sick, you’re not going to throw it out. And I’ve had, still, the same three people, right? Two of them, they had the money, they could afford to throw it out, buy it from somebody else. And one, just the key one, overdosed the day before, several doses of naloxone, rescue breathing, got picked up by EMTs, on the way to the hospital, they had to give him another dose of naloxone. After everything happened, I had his cooker, so after everything happened, I tested his cooker. And that’s one of the ones where the results came back really quick, really dark, positive for fentanyl. He was released… being New York… if you’re breathing, you’re good, whatever, he was released. The next day he called me up. He’d bought three bags from three separate people. He asked me if I could come down and test them. I came down. All three of them were positive. He threw the bags away and asked me to get him into a detox. That’s rare, very rare because during this whole time, it’s still the same three people that haven’t had it happen again. But I’m not expecting anybody to throw it away.  

CG: Instead of throwing the whole bag out... an unrealistic expectation... especially among users who don’t have a lot of cash to spare… and don’t want to go into withdrawal… users can know that their supply contains a highly deadly substance… and try a smaller dose of it when they inject.

And even if their batch tests negative, Tino says, he encourages users to try a test shot anyway. Inject… wait five minutes. If the batch contains fentanyl, a user’s going to feel it. Once Tino gets his foot in the door... introducing the idea of testing a supply before using… he takes the opportunity to suggest other ways to use more safely.

Don’t just test your drugs, Tino says, but make sure you have someone to use with… and make sure you have naloxone on-hand. Make sure you know how to practice rescue breathing… take turns injecting.

Tino says if users inject in pairs… a buddy system of sorts... then one can watch the other and wait to see if an overdose begins. With fentanyl, Tino says, overdoses typically present within a few minutes. So if someone is watching that drug user, they’ll be able to administer naloxone and call an EMT… before they’ve injected a deadly dose of the drug into themselves.

TF: So what we’re looking for is a change in drug use, a change in pattern. So instead of injecting a whole bag, you know, you do a small shot, you do a test shot, right? Have someone with you. I suggest all the time for nobody to use alone. And some people still, for whatever reasons, they do. And it’s really dangerous. But I tell people, you know, have somebody… and lots of times, people have buddies that they get high with together. Have somebody use with you. Have the person use first. Wait a couple minutes. With fentanyl, within a few minutes you’re gonna know if the person starts to overdose, at least you’re there, you can administer some Narcan, call EMTs, start the whole reviving process. And if they don’t, then you can go ahead and use yours. And even though, people are different, right? So what might not put you into an overdose might put me, so, you were fine, so I did mine and… the thing is that you’re still capable if I overdose, though, to save me. We’re trying to change drug use patterns. People use. People are gonna continue to use. What it will do is it will at least keep someone alive.

CG: When Tino talks about changing patterns, he means patterns of use. If he can teach users a safer way to inject… even when they don’t have test strips on hand… they can proceed as though their supply might have fentanyl in it... and begin with a small test dose. If he can teach users to always inject their drugs with a partner, then he’ll be spreading best practices throughout a community, encouraging information sharing.

For Tino, these test strips open a door to thinking differently about a drug and the way it’s used. Tino isn’t telling them to stop use just because the drug has become more dangerous… advice that would likely fall on deaf ears… instead… he’s suggesting a series of steps that acknowledge some users will keep using… but potentially prevent overdose.

TF: Everybody’s life has value, right? Nobody should die because they use drugs. That’s what I use the strips for. That’s my tool, you know. That’s my way of helping, of contributing, or whatever word you want to use. And I’ll continue to do it until I can’t no more, and I don’t see that happening. I mean, you know, it can happen right. Anything can happen, but I’m going to continue and continue to push other people to do it. Yeah, my commitment to this is really strong.

CG: If you’d like to learn more about fentanyl test strips, you can find information on planned studies in the U.S. and the sale of these fentanyl test strips at dancesafe.org. Please be aware that these test strips are not perfect or foolproof. In December, the Canadian government warned its citizens that the test strips could create a false sense of security. In a preliminary study, Health Canada’s Drug Analysis Service found that the strips don’t always pick up fentanyl… or fentanyl analogues… so users should continue to take other precautions to prevent overdose and death.

If you use drugs… or know someone who does… one of the most important things you can do to prevent an overdose is to carry naloxone, also known as Narcan or Evzio. You can get naloxone from your local pharmacist without a prescription. … Or go to getnaloxonenow.org, that’s getnaloxonenow.org. Or contact your local health department, drug treatment or syringe exchange program.

Be aware that if someone has taken fentanyl, they made need multiple doses of naloxone... as well as rescue breaths or mouth-to-mouth.

If you or a loved one needs help, you can reach out anonymously and confidentially to SAMHSA’s National Helpline at 1-800-662-HELP, that’s 800-662-4357. SAMHSA stands for Substance Abuse and Mental Health Services Administration. You can also find information online at www.findtreatment.samhsa.gov, that’s www.findtreatment.samhsa.gov.

Today’s episode of “In Sickness and in Health” was produced by Hannah McCarthy and me. Our theme music is by Allan Vest. You can learn more about this podcast and how to engage with us on social media at insicknessandinhealthpodcast.com, that’s insicknessandinhealthpodcast.com.

I’m Dr. Celine Gounder. This is “In Sickness and in Health.”