2018 - JHU FORECAST Low-tech, low-cost test strips show promise for reducing fentanyl overdoses Summary Report.pdf

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Fentanyl Overdose
Reduction Checking
Analysis Study
FORECAST
FEB RUA RY 6, 2 0 1 8
Bloomberg American Health Initiative
The Fentanyl Crisis
BACKGROUND
Life expectancy in the United States has declined for two years in a row, largely driven by
the opioid epidemic. Overdoses claimed more than 64,000 lives in 2016 and all indications
are that the impact of the crisis in 2017 will be even greater. Fentanyl, a synthetic opioid that
is 50 to 100 times more potent than morphine, is the primary cause of the rapid increase in
overdose deaths. Fentanyl and its associated analogues (including carfentanyl, furanyl fentanyl,
and acetyl fentanyl) have been found mixed with heroin, cocaine and pressed into counterfeit
prescription drugs. In 2015, the Drug Enforcement Agency issued a nationwide alert calling
fentanyl a “threat to health and public safety.” Recently, the Centers for Disease Control
and Prevention reported that fentanyl and associated analogues were associated with over
half of the opioid overdoses in ten states during the second half of 2016.
The potential of death from even small amounts of fentanyl has changed the landscape of opioid
use in the United States. Evidence to date suggests that people who use drugs often do not know
whether fentanyl is present in what they are about to consume. A recent study among 242 heroin
users across 17 sites in British Columbia, Canada, found that 29% tested positive for fentanyl, 73%
of whom did not report knowingly using fentanyl.
To explore the viability of a public health response to the fentanyl crisis, the Bloomberg American
Health Initiative awarded funding to support the Fentanyl Overdose Reduction Checking Analysis
Study (FORECAST). This study aimed to examine the accuracy of three technologies in identifying
the presence of fentanyl in samples of illicit drugs. It also aimed to gauge whether people who
use drugs and other stakeholders would be interested in using such technology as part of harm
reduction programs.
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U.S. Drug Enforcement Agency. DEA issues nationwide alert on fentanyl as threat to health and public safety. 18 March 2015. Accessed January 18, 2018 online at .https://www.dea.gov/divisions/hq/2015/hq031815.shtml
Centers for Disease Control and Prevention. Fentanyl involved in over half of opioid deaths in 10 states. 27 October 2017. Accessed January 18, 2018 online at https://www.cdc.gov/media/releases/2017/s1027-fentanyl-
deaths.html.
Amlani A, McKee G, Khamis N, Raghukumar G, Tsang E, Buxton JA. Why the FUSS (Fentanyl Urine Screen Study)? A cross-sectional survey to characterize an emerging threat to people who use drugs in British Columbia,
Canada. Harm Reduct J. 2015 Nov 14;12:54.
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The Concept of “Drug Checking”
“Drug checking” is a service that chemically analyzes drug samples and provides results to people
who use drugs so that they can take steps to protect themselves. The results are also available
to organizations or agencies to inform understanding of the drug supply. In some cases,
the chemical analysis is on-site with immediate results; in other cases, people who use drugs
leave a small sample of drugs for testing and retrieve the results online or by phone using a code;
other variations provide training to people who use drugs and hand out simple testing materials
to use on their own. The use of drug checking in the United States has been limited primarily
to event-based field testing for MDMA and other synthetics commonly associated with raves
or similar events.
The inconsistency of the drug supply and the lethality of fentanyl have increased interest in drug
checking. Recently, several syringe services programs in the United States, as well as Insite,
the supervised injection facility in Vancouver, B.C., have distributed one form of drug checking,
fentanyl testing strips, to people who use drugs. This technology was originally developed to test
the presence of fentanyl in urine samples; data on the accuracy of testing of drug samples for
personal quantities of drugs are lacking, hindering broader scale-up as part of a public health
response to the opioid crisis.
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The FORECAST Study
FORECAST had three phases, conducted between April
2017 and November 2017: (1) evaluating drug checking
technologies; (2) interviewing people who use drugs;
and (3) interviewing key informants from organizations
that work with people who use drugs.
Phase 1
In the study’s first phase, we tested the ability of three technologies to assess for the presence
of fentanyl in street drug samples, compared to a gold standard for this type of analysis, a Gas
Chromatograph/Mass Spectrometer. These technologies were:
• The BTNX fentanyl testing strips. These strips are based on an immunoassay to detect
the presence or absence of fentanyl. An immunoassay utilizes the bonding of an antibody
with an antigen to signal the presence of a substance. The strips are simple to use, with
the results easy to read.
• The TruNarc machine. This machine uses Raman Spectroscopy and can provide results on
the presence of fentanyl in a sample. Raman Spectroscopy detects molecular vibrations to
determine the chemical makeup of a substance. This machine was tested with and without
a Surface Enhanced Raman Spectroscopy (SERS) kit to improve detection. The TruNarc can
detect many controlled substances and cutting agents, based on the library to which it
matches scanned results.
• The Bruker Alpha machine. This machine uses Fourier-transform infrared spectroscopy (FTIR)
and can provide results about the quantity of fentanyl and other components in a sample. FTIR
Spectroscopy uses infrared light to determine the properties of a substance. We tested the
Bruker Alpha using libraries specific to controlled substance and cutting agents, to compare
scans. The performance may improve with the addition of other libraries or as additional
substances are added to existing libraries. When used for drug checking, the Bruker Alpha
can detect the main components, differentiates drug mixtures, and gives the percent
composition of the substance, based on the libraries to which it matches scanned results.
For each technology, we determined the lowest concentration (or percent amount for the Bruker
Alpha) that could be detected (known as the detection limit), as well as the ability to detect
fentanyl when it was present (sensitivity) and when it was not present (specificity) in street drug
samples provided for this research study by the Baltimore and Providence Police Departments.
The BTNX fentanyl testing strips and TruNarc were tested in Baltimore at the Baltimore City Police
Department Forensic Laboratory against 52 known positive and 52 known negative samples.
These technologies as well as the Bruker Alpha II were tested in Rhode Island at the Rhode Island
State Public Health Laboratory, Drug Chemistry Unit, against 54 known positive and 52 known
negative samples.
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