Consumer Discernment of Fentanyl in Illicit Opioids Conﬁrmed by Fentanyl Test Strips: Lessons from a Syringe Services Program in North Carolina

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International Journal of Drug Policy

journal homepage: www.elsevier.com/locate/drugpo

Research Paper

Consumer discernment of fentanyl in illicit opioids conﬁrmed by fentanyl test strips: Lessons from a syringe services program in North Carolina

Jon E. Zibbell a,∗, Nicholas C. Peiper b, Sarah E. Duhart Clarke a, Zach R. Salazar c,

Louise B. Vincent c, Alex H. Kral a, Judith Feinberg d a Center for Behavioral Health Epidemiology, Implementation, and Evaluation Research, RTI International, Research Triangle Park, NC, United States b Paciﬁc Institute for Research and Evaluation, Louisville, KY, United States c North Carolina Survivors Union, Greensboro, NC, United States d Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, United States

a r t i c l e i n f o a b s t r a c t

Keywords: Background: The United States (U.S.) continues to witness an unprecedented increase in opioid overdose deaths Opioid overdose driven by precipitous growth in the supply and use of illicitly-manufactured fentanyls (IMF). Fentanyl’s growing

Fentanyl test strips market share of the illicit opioid supply in the U.S. has led to seismic shifts in the composition of the country’s

Drug discernment heroin supply. The growth in fentanyl supply has transformed illicit opioid markets once offering heroin with PWID fairly consistent purity and potency to a supply overpopulated with fentanyl(s) of inconsistent and unpredictable Needle syringe programs potency. In response, people who inject drugs (PWID) have developed a number of sensory strategies to detect fentanyl in illicit opioids. The current study examined the accuracy of sensory discernment strategies by measuring study participants’ descriptions of the last opioid injected and checked with a fentanyl test strip (FTS) by that test’s positive/negative result. The primary objective was to determine associations between FTS results and descriptions of the illicit opioid’s physical appearance and physiological effects. Methods: Between September-October 2017, a total of 129 PWID were recruited from a syringe services program in Greensboro, North Carolina and completed an online survey about their most recent use of FTS. Participants were instructed to describe the appearance and effects associated with the most recent opioid they injected and tested with FTS. We conducted bivariate and multivariate analyses to determine differences in positive vs negative FTS results and the physical characteristics and physiological experiences reported. An exploratory analysis was also conducted to describe the types and bodily locations of unusual sensations experienced by PWID reporting positive FTS results. Results: For physical characteristics, 32% reported that the drug was white before adding water and 38% reported the solution was clear after adding water. For physiological effects compared to heroin, 42% reported a stronger rush, 30% a shorter high, 30% a shorter time to the onset of withdrawal symptoms, and 42% experienced unusual sensations. In the multivariable model adjusting for demographics and polydrug correlates, white color of drug before adding water, stronger rush, shorter time to withdrawal, and unusual sensations were significantly associated with a positive FTS result. The most common unusual sensations were pins and needles (51%), warming of the head and face (35%), and lightheadedness (30%), and the most common locations where sensations occurred were face and neck (61%), arms/legs (54%), and chest (37%). Conclusion: We found positive FTS results were significantly associated with the physical characteristics and physiological effects described by PWID. Descriptions concerning physical appearance were consistent with law enforcement profiles of illicitly-manufactured fentanyl and physiological effects were concomitant with scientific and clinical medical literature on iatrogenic fentanyl use. Taken together, these findings suggest sensory strategies for detecting fentanyl in illicit opioids may be an effective risk reduction tool to help consumers navigate unpredictable markets more safely.

Introduction

The United States (U.S.) continues to witness an unprecedented in-

∗ Corresponding author. crease in opioid overdose deaths driven by precipitous growth in the E-mail address: [email protected] (J.E. Zibbell). supply and use of illicit fentanyls ( Armenian, Vo, Barr-Walker & Lynch, https://doi.org/10.1016/j.drugpo.2021.103128

Please cite this article as: J.E. Zibbell, N.C. Peiper, S.E. Duhart Clarke et al., Consumer discernment of fentanyl in illicit opioids conﬁrmed by fentanyl test strips: Lessons from a syringe services program in North Carolina, International Journal of Drug Policy, https://doi.org/10.1016/j. drugpo.2021.103128 ARTICLE IN PRESS JID: DRUPOL [m5GeSdc; January 22, 2021;2:49 ]

J.E. Zibbell, N.C. Peiper, S.E. Duhart Clarke et al. International Journal of Drug Policy xxx (xxxx) xxx

2018 ). The Centers for Disease Control and Prevention (CDC) reports sory strategies for detecting fentanyl in illicit opioids may be effective nearly 47,000 opioid overdose deaths in 2019 with 80% involving illicit at both the pre and post-consumption phases of an injection episode. fentanyls ( CDC, 2020 ). The National Forensic Laboratory Information While encouraging, the sensory strategies documented by these studies System, a database administered by the Drug Enforcement Administra- could not been verified for accuracy at point-of-use due to the absence tion (DEA) to collect toxicological results for illicit drugs confiscated by of portable drug verification technology that can be used in real time law enforcement, indicates the number of fentanyl seizures more than with PWID ( Giné et al., 2017 ). doubled from 2015 to 2016, from 14,440 to 34,119 ( CDC, 2018 ). The Quite recently, fentanyl test strips (FTS) have emerged as a harm growth in illicit fentanyl supply continued through 2017 and into 2018, reduction tool by their ability to detect fentanyl in illicit drug prod- jumping from 56,530 to 83,765, a 480% increase from 2015 to 2018 ucts at point of use ( BTNX, 2018 ; Skov-Skov Bergh et al. 2021). ( DEA, 2018 , 2019 ). European countries are similarly experiencing over- Needle syringe programs (NSPs) in many parts of the U.S. are cur- dose crises that involve illicit opioids but fentanyl and fentanyl analogs rently distributing FTS and early studies on their utilization by PWID as the leading cause has proven unique to North American illicit drug show a capacity to facilitate safer drug use among consumers of il- markets at the time of writing ( EMCDDA, 2019 ; Grund & Shaw, 2019 ). licit opioids ( Peiper et al., 2019 ; Weicker et al., 2020 ). That FTS Fentanyl’s market growth over the last several years has led to can enable safer drug use is consistent with decades of interna- seismic shifts in the composition of America’s illicit opioid supply tional research establishing point-of-use drug checking as an effective ( DEA, 2020 ). Illicit supply chains previously dominated by Colombian- risk reduction strategy (e.g., Butterfield, Barratt, Ezard & Day, 2016 ; sourced heroin have become saturated with fentanyl, fentanyl analogs, Decorte, 2001 ; Hungerbuehler, Buecheli & Schaub, 2011 ; Saleemi, Pen- and a growing number of novel synthetic drugs (e.g., isotonitazene). nybaker, Wooldridge & Johnson, 2017 ). FTS use by PWID provides a Illicit opioid markets once dominated by heroin at fairly consistent unique opportunity to evaluate the effectiveness of sensory discernment levels of purity and potency are now populated by a miscellany strategies by verifying self-reported descriptions of a drug’s physical ap- of fentanyls with inconsistent and unpredictable potency and purity pearance and physiological effects by FTS result. Accordingly, we hy- ( Ciccarone, 2017 ; Ciccarone, Ondocsin & Mars, 2017 ). The cumulative pothesize that PWID have gained a high degree of a posteriori knowledge effect of these changes has been a radical transformation of America’s il- from years of consuming and injecting drugs and employ this ‘practi- licit opioid supply epitomized by steep declines in heroin supply and the cal knowhow’ to inform sensory strategies for detecting fentanyl in il- growing dominance of synthetic opioids as a more lucrative, easier-to- licit opioids. The current study examines the accuracy of these sensory make alternative to heroin ( Zibbell, 2019) . The rapid decline of a stable strategies by measuring PWID’s descriptions of the appearance and ef- heroin supply during an unprecedented fentanyl crisis involving myriad fects of the last opioid they injected and checked with FTS by that test’s analogs and a growing number of novel psychoactive substances has positive/negative result. The primary objective was to determine asso- created volatility in the illicit opioid market and heightened overdose ciations between FTS results and the types of physical appearances and risk for consumers ( Griswold et al., 2018 ). physiological experiences reported. In response, people who inject drugs (PWID) have developed a number of sensory strategies as a grassroots approach to detect fentanyl Methods in illicit opioids ( Rouhani, Park, Morales, Green & Sherman, 2019 ). A growing body of literature suggests PWID can recognize and dis- Study background and procedures tinguish the type of drugs they regularly consume by correlating how drugs visually appear to the physiological sensations they produce Anonymous, in-person, online surveys were administered to 129 when injected ( Mars, Ondocsin & Ciccarone, 2018 ). The type of sen- PWID to examine associations between FTS results taken from partic- sory strategies PWID are employing to detect fentanyl in illicit opioids ipants’ most recent injection of drugs and self-reported descriptions of can be categorized by when they occur during the injection episode. that product’s physical appearance and its physiological effects. Four Pre-consumption techniques are procedures employed before the drug is respondents reported uncertain FTS results and were excluded from the injected, such as inspecting the color of a recently purchased illicit opi- analysis ( N = 125). Participants were recruited from September to Octo- oid. Post-consumption strategies involve techniques to evaluate the phys- ber 2017 from an NSP in North Carolina operated by the North Carolina iological sensations produced after the drug is injected, such as scruti- Survivors Union (NCSU). NCSU is a community-based organization that nizing the specific character of the ‘rush’ and ‘high’ ( Somerville et al., provides syringe services, naloxone, and FTS to program participants as 2017 ) or measuring its capacity to stave-off withdrawal ( McKnight & part of its overdose prevention strategy. Eligibility criteria included be- Des Jarlais, 2018 ). While both heroin and illicit fentanyl are illegally- ing aged 18 years or older, having injected illicit opioids in the past 24 h, manufactured opioids, they nevertheless differ in physical appearance and used FTS in the past 24 h. Recruitment occurred onsite via direct and pharmacologic effect and these differences provide clues that can intercepts with help from informational flyers, social media advertise- be used to identify and distinguish fentanyl from ( Mars, Ondocsin & ments, and referrals by current NSP participants to PWID not enrolled Ciccarone, 2017) . in the NSP at time of study. Study participants completed the survey on Ethnographic and qualitative research has shown that PWID can use computers stationed at the NSP using a secured online data collection physical appearance and physiological sensations as signs for detect- platform (SurveyGizmo, Boulder, Colorado). Upon completion verified ing fentanyl and as portents for increased overdose risk ( Mars, Bour- by study staff, respondents were provided a $20 Visa gift card as re- gois, Karandinos, Montero & Ciccarone, 2016 ). An overdose outbreak muneration for their time and effort. Participants were asked to iden- investigation in 2016 conducted by the CDC documented a number of tify the physical characteristics of the last illicit opioid they injected atypical effects (e.g., acute respiratory distress) that PWID were learn- and tested with FTS and describe its physiological effects in relation to ing to recognize as signs of fentanyl adulteration and indications of the the ‘rush’ and ‘high’ typically experienced when injecting ‘pure’ heroin need to modify subsequent behavior ( Somerville et al., 2017 ). A 2018 (i.e., without fentanyl). The study protocol was approved by the insti- study in Baltimore by Ciccarone and colleagues (2018) observed PWID tutional review board at RTI International. Additional details about the inspecting the color and texture of illicit opioids prior to injecting before study background and procedures are presented elsewhere ( Peiper et al., confirming fentanyl’s presence by the physiological sensations they re- 2019 ). ceived after injecting (e.g., strong ‘rush’). And a recent study from Ohio compared the drugs PWID reported consuming with their urine drug Survey measures screen results and found strong agreement between self-reported fentanyl use and fentanyl-positive samples ( Daniulaityte, Carlson, Juhascik, Participants reported demographic information of age, gender, race, Strayer & Sizemore, 2019 ). This growing body of evidence suggests sen- and ethnicity: participants were asked to self-report their date of birth

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J.E. Zibbell, N.C. Peiper, S.E. Duhart Clarke et al. International Journal of Drug Policy xxx (xxxx) xxx and then to select their gender identity, race, and ethnicity. Demo- street sellers by FTS result among an analytical sample of 125 PWID are graphic information for the final sample can be found in a previous reported ( Table 1 ). The sample consisted of 32% PWID who reported publication ( Peiper et al., 2019 ). Participants were instructed to re- the raw drug appearing white before adding water and 38% who report on the physical characteristics and physiological experiences as- ported the solution was clear after adding water. For physiological ef- sociated with the opioid used during their most recent injection episode fects compared to heroin, 42% reported a stronger rush, 30% a shorter and tested with FTS. A catalog of a priori measures pertaining to the duration of euphoria, 30% a shorter time until withdrawal, and 42% physical appearance and physiological sensations of each illicit opioid experienced unusual sensations. Nearly half (47%) reported using the were identified by extensive community-based ethnographic fieldwork same seller either never or some of the time (i.e., they used numerous with PWID and confirmed by key harm reduction stakeholders and drug sellers) and 62% reported that sellers in their network disclosed product- user unions. Answers were not mutually exclusive and participants were level changes either never or some of the time. With the exception of asked to choose all answers that apply. Questions pertaining to physical a clear drug solution after adding water ( p < 0.08), there were statisti- appearance include color of drug before adding water (white, tan, gray, cally significant differences between FTS results for all of the physical other), color of drug after adding water (clear, cloudy/milky, brown, characteristics ( p ≤ 0.02), physiological experiences ( p ’s < 0.001), and other), and taste of drug before use (did not taste, had no taste, bitter, seller interactions ( p ’s < 0.04). sweet, medicinal, other). Questions related to the physiological effects In the bivariate logistic regression models ( Fig. 1 ), the highest produced when injecting the drug include intensity of the rush compared odds of a positive FTS result were found for shorter time to with- to heroin (less intense, same, more intense), length of the high compared drawal (OR = 6.80, 95% CI = 2.34–19.80), stronger rush (OR = 5.97, 95% to heroin (shorter, same, longer), length of time to withdrawal compared CI = 2.52–14.18), shorter euphoria (OR = 5.16, 95% CI = 1.91–13.96), and to heroin (shorter, same, longer), and any unusual sensations not typ- unusual sensations (OR = 4.70, 95% CI = 2.04–10.86). Slightly lower ically produced by heroin (choose all that apply: lightheaded, burning but still significant odds were yielded for white color of drug be- sensations, pins and needles, warmth in head/face, difficulty breathing, fore adding water (OR = 3.10, 95% CI = 1.30–7.37), use of multiple sell- and suffocating). Those reporting unusual sensations were asked to in- ers (OR = 2.20, 95% CI = 1.05–4.63), and sellers not disclosing product dicate the location(s) on the body where sensations appeared (choose changes (OR = 2.27, 95% CI = 1.08–4.76). In the final multivariable model all that apply: face/neck, arms/legs, chest, elsewhere). Questions per- ( Fig. 2 ), white color of drug before adding water (aOR = 3.04, 95% taining to the use of drug sellers include the frequency with which the CI = 1.14–8.15), stronger rush (aOR = 3.02, 95% CI = 1.12–8.19), shorter same seller is used (never, some, most, all the time) and the frequency time to withdrawal (aOR = 6.31, 95% CI = 1.99–19.95), and unusual sen- with which sellers disclose a product contains fentanyl (never, some, sations (aOR = 3.09, 95% CI = 1.17–8.14) were significantly associated most, all the time). Study participants were asked to report the FTS re- with a positive FTS result. sult (positive/negative) from last use. The results from the sensitivity analysis were consistent with the multivariable model. White color of drug before adding wa- Statistical analysis ter (aOR = 2.90, 95% CI = 1.09–7.76), stronger rush (aOR = 2.72, 95% CI = 1.01–7.33), shorter time to withdrawal (aOR = 5.76, 95% CI = 1.84– Descriptive statistics were calculated overall for the physical char- 18.05), and unusual sensations (aOR = 3.18, 95% CI = 1.19–8.48) were acteristics, physiological experiences, and encounters with street sellers slightly attenuated but remained associated with a positive FTS result by FTS result. We used the 𝜒2 statistic (or Fisher exact test in instances ( Supplement 1 ). No effects were found for the entered covariates. Lastly, of small cell sizes) and unadjusted logistic regression models to evaluate Fig. 3 summarizes findings from the exploratory analysis of PWID re- bivariate differences between FTS results. Bivariate results are presented porting unusual sensations and a positive FTS result ( n = 43). Of these, to highlight the sizeable number of a priori variables known to be asso- the most common sensations were pins and needles (51%), warming ciated with heroin and fentanyl to further demonstrate the importance of the head and face (35%), and lightheadedness (30%), and the most of identifying variables that are both statistically significant and practi- common locations where sensations occurred were face and neck (61%), cally accurate. Variables significant at the p ≤ 0.05 level in the bivariate arms/legs (54%), and chest (37%). analyses were retained in a multivariable logistic regression model that employed a backward stepwise procedure to determine a final set of covariates independently associated with FTS result at the p ≤ 0.05 level. Discussion Variables not achieving significance at the p ≤ 0.05 level were excluded from the final model. A penalized likelihood method was used to account This is one of the first studies to use FTS results to validate PWID’s for biased parameter estimates from small sample sizes in the final mul- ability to detect the presence of fentanyl in illicit opioids and subse- tivariable model (Firth 1993), yielding adjusted odds ratios (aOR) and quent drug solutions. In a sample of 125 PWID, we found statistically 95% confidence intervals (95% CI) for the retained variables. We per- significant differences in the types of physical appearances and physio- formed sensitivity analyses by entering a set of theoretically relevant logical effects reported and whether the drug described tested positive co-variates that might confound the relationship between drug discern- or negative for fentanyl using FTS. Consistent with our hypothesis, we ment variables and a positive FTS result: age (20–29, 30–39, 40 + ), gen- discovered that PWID have the ability to recognize fentanyl in illicit opi- der (male, female), race (non-Hispanic [NH] White, NH Black, other), oid products by physical appearance and physiological effect. We found and a polydrug count variable for concurrent use of prescription opioids, that white color of the drug before adding water, a stronger rush com- benzodiazepines, gabapentin, alcohol, cocaine, and methamphetamine pared with heroin, a shorter time to onset of withdrawal compared to in the past 30 days (range 0–6). Lastly, we conducted an exploratory heroin, and experiencing unusual sensations compared with heroin were analysis of the types (lightheaded, burning sensations, pins and needles, significantly associated with a positive FTS result in the multivariable warmth in head/face, difficulty breathing, suffocating) and locations analysis. The physical descriptions indicated by study participants (i.e., (face/neck, arms/legs, chest, elsewhere) of unusual sensations experi- white color of drug) with a positive test result aligns with DEA field re- enced by PWID with a positive FTS result. Stata version 15.1 was used ports detailing fentanyl’s illicit appearance as a fine white powder more for all analyses. emblematic of pharmaceutical grade opioids than heroin (DEA, 2020). Correspondingly, the physiological effects reported by respondents with Results a positive FTS result (i.e., stronger rush compared to heroin) are consistent with fentanyl’s pharmacologic profile as a highly lipophilic syn- A total of 125 PWID completed the survey. The distribution of physi- thetic opioid that is 50 times more potent than heroin and capable cal drug characteristics, physiological experiences, and interactions with of crossing the blood-brain-barrier more quickly and with a shorter

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Table 1 Physical drug characteristics and physiological experiences by fentanyl test strip (FTS) result, North Carolina ( N = 125).

FTS Result ( n = 125) ∗

Negative ( n = 46) Positive ( n = 79) Total

Characteristics n (%) n (%) n (%) p-value

Color of drug before adding water 0.016 White 8 (17.4) 32 (40.5) 40 (32.0) Tan 20 (43.5) 30 (38.0) 50 (40.0) Grey 15 (32.6) 11 (13.9) 26 (20.8) Other 3 (6.5) 6 (7.6) 9 (7.2) Color of drug after adding water 0.076 Clear 13 (28.3) 35 (44.3) 48 (38.4) Cloudy/milky 11 (23.9) 18 (22.8) 29 (23.2) Brown 18 (39.1) 15 (19.0) 33 (26.4) Other 4 (8.7) 11 (13.9) 15 (12.0) Intensity of onset ( “rush ”) < 0.001 Same/less intensity as usual 38 (82.6) 34 (43.0) 72 (57.6) More intense than usual 8 (17.4) 45 (57.0) 53 (42.4) Duration of euphoria ( “high ”) < 0.001 Same/longer than usual 41 (89.1) 47 (59.5) 88 (70.4) Shorter than usual 5 (10.9) 32 (40.5) 37 (29.6) Time to withdrawal < 0.001 Same/longer than usual 42 (91.3) 46 (58.2) 88 (70.4) Shorter than usual 4 (8.7) 33 (41.8) 37 (29.6) Unusual sensation during use < 0.001 No 37 (80.4) 36 (45.6) 73 (58.4)

Yes ∗∗ 9 (19.6) 43 (54.4) 52 (41.6) Regularly use same seller 0.034 Most/all of the time 30 (65.2) 36 (45.6) 66 (52.8) Never/some of the time 16 (34.8) 43 (54.4) 59 (47.2) Dealer discloses product changes 0.029 Most/all of the time 23 (50.0) 24 (30.4) 47 (37.6) Never/some of the time 23 (50.0) 55 (69.6) 78 (62.4)

∗Values expressed as count (column percentage).

∗∗Reported one or more of the following types of unusual sensations: lightheaded, burning sensations, pins and needles, warmth in head/face, diﬃculty breathing, suﬀocating.

Fig.. 1. Bivariate associations between physical drug characteristics, physiological experiences, § and interactions with drug sellers by fentanyl test strip result §

Compared with heroin. ∗Referent = tan, gray, other. ∗∗Referent = cloudy/milky, brown, other. Abbreviation: FTS, fentanyl test strip; aOR, adjusted odds ratio.

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Fig.. 2. Multivariable associations between physical drug characteristics and physiological experiences § with a positive fentanyl test strip result § Compared with heroin. ∗Referent = brown, tan, gray, other. Abbreviation: FTS, fentanyl test strip; aOR, adjusted odds ratio.

Fig. 3. Types and locations of unusual sensations among people with a positive fentanyl test strip result ( n = 43). duration of effect ( Kim et al., 2014 ; Marinetti & Ehlers, 2014 ; Market volatility caused by a rapidly declining heroin supply Ray, Baidya, Gregory & Sunder, 2012 ). and a growing diversity of fentanyls with inconsistent potency Also noteworthy is a number of unusual sensations described by a ( Rosenblum, Unick & Ciccarone, 2020 ; Zibbell, Aldridge, Cauchon, majority (54%, n = 43) of respondents with a positive FTS result. The DeFiore-Hyrmer & Conway, 2019 ) has made it increasingly difficult for most common sensations were “pins and needles ” (51%) and warming consumers to become accustomed and adapt to the illicit opioid sup- of the head/face (35%) with the most common locations on the face and ply, a requirement inter alia for making informed decisions about drug neck (61%) and lower extremities (54%). These findings are consistent use. This study demonstrates that FTS distribution can be coupled with with epidemiological studies on fentanyl overdose that report fentanyl- training initiatives and educational materials illustrating sensory strate- induced paresthesia and histaminosis ( Carroll, Marshall, Rich & Green, gies that together can provide a pre-consumption layer of overdose pre- 2017 ). Clinical case studies have documented facial tingling and other vention. Both FTS and sensory strategies can play an important role as neurological complications associated with bolus fentanyl administra- primary overdose prevention because they each provide actionable in- tion ( Gupta, Ramchandani, Balakrishnan & Kumar, 2014 ; Han, Arnold, formation to inform individual decision making prior to injecting. Com- Bond, Janson & Abu-Elmagd, 2002 ) and medical science warns that pared with naloxone, a medication administered post-consumption in pharmaceutical fentanyl and its prescription analogs (e.g., sufentanil) the event of an opioid overdose, drug checking with FTS has the capacity can cause skeletal muscle/chest wall rigidity ( Burns, DeRienz, Baker, to increase locus of control for consumers by supplying pre-consumption Casavant & Spiller, 2016 ), brain hypothermia ( Solis, Cameron-Burr & information before dosing amounts and choice of injection technique are Kiyatkin, 2017 ), and unusual amnestic syndrome ( Duru et al., 2018 ). finalized. Given the consistency between current study findings and the medical In places and situations where both naloxone and FTS are sparse or and epidemiological literature on fentanyl, the unusual sensations re- unavailable, the use of sensory discernment strategies in tandem with ported by PWID in the current study may provide a consistent set of behavioral strategies like tester shots may be the next best option to post-consumption indicators to recognize fentanyl and modify subse- reduce overdose risk in resource-deprived areas . And with fentanyl quent use. being detected in illicit stimulants like cocaine and methamphetamine

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( Zibbell et al., 2019 ), more community-based, field studies are needed tection skills by verifying the appearance and effect of drugs by FTS to better understand how FTS and drug discernment may be used across result. As this happens, PWID will become subject matter experts with multiple drug classes (e.g., opioids and stimulants) and source-forms the ability to teach sensory strategies to peers in their social networks, (e.g., crystal, rock, powder, and counterfeit pills). Given the profound as well as serving as critical research partners to help with future public implications that drug discernment may hold for overdose prevention, health investigations on front-line drug checking ( Friedman et al., 2007 ; there is a pressing need to investigate the effectiveness of sensory strate- Guirguis, Gittins & Schifano, 2020 ). gies in the context of FTS and naloxone utilization. There is a particular Thirty years of public health research with people who use drugs has need to examine whether sensory strategies can be deployed in conjunc- shown that consumer knowledge about psychoactive substances most tion with FTS as a two-prong approach to primary prevention, or by in- often parallels or exceeds the expertise of researchers and is consis- cluding FTS and sensory strategies with naloxone as a post-consumption tent with evidence from behavioral research on substance use ( Bryan strategy to provide full-spectrum overdose prevention. & Singer, 2010 ). The knowledge PWID gain about drugs from time Several limitations need to be considered. First, the small sample and repetition, and the techniques and strategies they devise to protect size limited a more detailed examination of discernment methods in re- themselves and peers from drug-related harm, frequently precede the lation to a positive FTS result. Our statistical approach helped balance development of evidence-based practices and public health guidelines theory and model parsimony but larger sample sizes will be necessary (e.g., lay naloxone, syringe exchange, FTS, safe consumption spaces) to derive more precise estimates. That said, most of the results were [Lambdin, Zibbell, Wheeler & Kral, 2017] , proving that PWID as a popu- statistically significant, even with such a limited sample size. Second, lation are capable of identifying risks, developing risk prevention strate- this study was conducted in North Carolina (NC) in 2017–2018 when gies, and communicating strategy to peers and drug researchers alike fentanyl was already introduced into supply chains long dominated by ( Zibbell, 2011 ). To combat an unpredictable and lethal illicit opioid Colombian-sourced, brown powder heroin. The sensory strategies por- market, FTS utilization in combination with sensory strategies of drug trayed above were performed on illicit opioids available to study par- discernment represents an emerging approach to risk reduction by pro- ticipants in NC during the time frame of the study and may not trans- moting informed and measured decision-making to increase locus of late to regions/markets with a different configuration of illicit opioids, control for consumers of illicit drugs. or even to the NC markets of the current study at a later date due to persistent changes in local supply. Future studies involving black tar Authors’ contribution heroin and pressed fentanyl pills with FTS confirmation are needed and will help provide external validity of our findings. Third, due to Jon. E. Zibbell, Nicholas C. Peiper, and Louise B. Vincent originated a comparatively small sample that was purposively recruited, current the idea and design for this article. Nicholas C. Peiper, Sarah Duhart study findings may not be generalized to the larger population of PWID Clarke, and Alex H. Kral analyzed the data. Nicholas C. Peiper and Sarah in North Carolina or elsewhere. While this study represents the demo- Duhart Clarke created the figures and tables. Jon E. Zibbell, Nicholas graphical profiles of program participants at NCSU’s NSP ( Peiper et al., C. Peiper, Sarah Duhart Clarke, Zach R. Salazar, and Judith Feinberg 2019 ), in addition to resembling study participants from past research conducted literature searches and wrote the article. This manuscript has on FTS use among PWID ( Weicker et al., 2020 ), more research with been approved by all authors and is not being reviewed or considered diverse samples of PWID from both urban and non-urban areas of the for publication at another journal. U.S. is urgently needed to assess how race, geographic location, and other social determinants of health contribute to FTS-related outcomes Role of funding sources ( Rhodes et al., 2019 ). Fourth, there is a possibility of a Hawthorne effect ( McCambridge, Witton & Elbourne, 2014 ) due to our study design This research was supported by funding from RTI’s Opioid Strategic not being able to ask respondents if they believed a product contained Investment Fund and by grants DA046444 and DA047334 from the U.S. fentanyl before using FTS. Since many respondents followed the NSP’s National Institutes of Health, National Institute on Drug Abuse to Dr guidance and tested their drug prior to consumption, it is possible that Zibbell (PI). their memory of appearances and sensations was influenced by the FTS result. Lastly, we included two ‘drug seller’ variables in the model based Declaration of Competing Interest on findings from our previous study (Peiper et al., 2018). Both variables were significantly associated with positive FTS results in the bivariate The authors declare no conflict of interest. analyses but did not achieve statistical significance in the final multivariable model. Still, it is important to note that research shows PWID Acknowledgements who have established trust with a consistent seller are more likely to know when illicit opioids contain fentanyl ( Bardwell, Boyd, Arredondo, This research could not have been conducted without the help and McNeil & Kerr, 2019 ; Carrol, Rich & Green, 2020 ; Daniulaityte et al., support of program participants and staff at the Piedmont Exchange, a 2019 ; Kolla & Strike, 2020 ). syringe services program in North Carolina operated by the North Car- Overall, these results reveal that PWID are capable of using sensory olina Survivors Union. Many thanks for your generousity and commit- strategies to detect fentanyl in illicit opioids. The current study demon- ment to this project. strates how FTS can aid PWID in making informed decisions about their drug use even when anticipating fentanyl. The findings also suggest that Supplementary materials FTS presents opportunities for PWID to sharpen their fentanyl detection skills by the strip’s capacity to confirm fentanyl’s presence or absence in Supplementary material associated with this article can be found, in illicit drugs. Because physiological sensations (e.g., strong rush, unusual the online version, at doi:10.1016/j.drugpo.2021.103128 . sensations) present post-injection, their utility as sensory indicators become available only after the drug is injected, thereby diminishing pre- References ventative capacity. Over time, however, PWID’s growing proficiency in identifying and recognizing fentanyls by physical and physiological in- Armenian, P., Vo, K., Barr-Walker, J., & Lynch, K. (2018). Fentanyl, fentanyl analogs and dicators has the potential to bolster consumer knowledge via repeti- novel synthetic opioids: A comprehensive review. Neuropharmacology, 134 , 121–132. tion and influence subsequent injections. If FTS utilization continues to 10.1016/j.neuropharm.2017.10.016 . Bardwell, G., Boyd, J., Arredondo, J., McNeil, R., & Kerr, T. (2019). Trusting the source: gain momentum as a primary prevention tool, the larger population of The potential role of drug dealers in reducing drug-related harms via drug checking. PWID will be able to use this technology to sharpen their sensory de- Drug and Alcohol Dependence, 198 , 1–6. 10.1016/j.drugalcdep.2019.01.035 .

6 ARTICLE IN PRESS JID: DRUPOL [m5GeSdc; January 22, 2021;2:49 ]

J.E. Zibbell, N.C. Peiper, S.E. Duhart Clarke et al. International Journal of Drug Policy xxx (xxxx) xxx

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