(83) Fentanyl Test Strip Distribution Among Patients with Substance-Related ED Visits

Background & Introduction: Fentanyl test strip (FTS) distribution has become a key harm reduction strategy in the current opioid overdose crisis and has been endorsed by both the CDC and SAMHSA. Previous research demonstrates that a majority of people using substances who are given FTS will use them and are interested in continuing to use them in the future (1,2). FTS distribution studies conducted via community outreach and syringe services programs have demonstrated that positive FTS results are associated with positive changes in overdose prevention behaviors in people who use substances, such as using a smaller amount of a substance or going slower when using the substance (1–3). However, research on FTS distribution in the emergency department (ED) setting has been limited to ED clinicians and has not yet explored patient acceptability and use (4). The objective of this study was to characterize acceptability and harm reduction behaviors among patients receiving FTS from the ED setting.

Methods: We conducted an IRB-approved prospective cohort study of English-speaking patients discharged from an urban academic ED in downtown Chicago, IL from August 2022 to August 2023 who received an ED harm reduction kit consisting of two take-home naloxone intranasal devices and three fentanyl test strips (cut-off 20ng/ml). Using structured data collection forms and a pilot-tested interview guide, we collected data from a combination of the electronic medical record, patient interview at the index ED visit, and a follow-up telephone call four weeks after the ED visit. The main measures were: 1) acceptability of fentanyl test strips, defined as patient willingness to receive fentanyl test strips during the ED visit, and 2) patients’ previous, planned, and actual FTS use and harm reduction behaviors following a positive result. We also collected patient demographic characteristics and clinical details relating to the index ED visit. Descriptive statistics were conducted in Stata MP 17.0 to summarize quantitative data. Open-ended responses were summarized at the time of data collection and are presented descriptively.

Results: A total of 172 patients received harm reduction kits during the study period; median age was 51 years (IQR 34-60), 84.3% were male, 59.3% were Black, and 65.1% had Medicaid as primary insurance; 94.2% of the visits were opioid-related and 70.9% of visits were administered pre-hospital naloxone; 70.3% of patients were brought to the ED from a public location such as a sidewalk, park, or bus/train. Most patients (68.0%) endorsed using a single substance, most commonly heroin (83.7%), opioid pills (5.1%), or cocaine (3.4%); 25.0% reported using multiple substances. Of 113 patients who had a documented interview during their index ED visit, 85.8% accepted the FTS and 86.1% reported never being offered FTS before. Among a subset of 66 patients stating their anticipated behavior changes following a positive FTS result, 62.1% stated they would dispose of the substance, 25.8% were not sure what they would do, and 10.6% would use less of the substance.
Only 110 patients (64.0%) had a phone number listed in the medical record for follow-up, of which 29 patients had an out-of-service number listed and 20 patients had the wrong number or number of a friend/family member listed. We were able to contact 24 patients for follow-up interviews, of which 12 had not yet used their FTS; 8 patients reported they had not used substances since their ED visit or did not plan on using substances again. Four patients had used the FTS: two tested heroin and disposed of it after a positive test result, one tested ketamine and had a negative result, and one did not recall the substance tested or result.
Qualitatively, several patients described being scared by the initial overdose that brought them to the ED and cited this event as motivation to reduce or stop their substance use. Many were grateful for the opportunity to receive a harm reduction kit and planned to keep it on their person, and suggested we continue distributing kits in the ED.

Conclusion & Discussion: We found high patient acceptability and low previous exposure to FTS, suggesting there may be utility to distributing FTS in the ED setting. When queried on anticipated behaviors following a positive FTS result, most patients stated they would dispose of or not use the tested substance. These findings contrast with previous studies on behaviors following FTS positivity among people who use opioids (e.g., syringe exchange programs), where individuals reported engaging in safer use behaviors following a positive FTS result (e.g., using a smaller amount, going slower) (1-3,5). Our study results may have differed due to its focus on the ED and the clinical context of recent overdose, which may favor more conservative anticipated behaviors. Future work could explore the potential effectiveness of tailored patient guidance following FTS positivity in acute care versus supervised consumption settings and for persons who primarily use opioids vs non-opioids. Limitations of this study include limited generalizability given our focus on a single urban ED and a low follow-up rate. However, even this follow-up rate may be instructive for future work, as most patients (64.5%) could not be reached due to lack of reliable phone access; future work should consider alternative patient follow-up strategies.

References: 1. Park, J. N., Frankel, S., Morris, M., Dieni, O., Fahey-Morrison, L., Luta, M., Hunt, D., Long, J., & Sherman, S. G. (2021). Evaluation of fentanyl test strip distribution in two Mid-Atlantic syringe services programs. The International Journal on Drug Policy, 94, 103196. https://doi.org/10.1016/j.drugpo.2021.103196
2. Krieger, M. S., Goedel, W. C., Buxton, J. A., Lysyshyn, M., Bernstein, E., Sherman, S. G., Rich, J. D., Hadland, S. E., Green, T. C., & Marshall, B. D. L. (2018). Use of rapid fentanyl test strips among young adults who use drugs. The International Journal on Drug Policy, 61, 52–58. https://doi.org/10.1016/j.drugpo.2018.09.009
3. Peiper, N. C., Clarke, S. D., Vincent, L. B., Ciccarone, D., Kral, A. H., & Zibbell, J. E. (2019). Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States. The International Journal on Drug Policy, 63, 122–128. https://doi.org/10.1016/j.drugpo.2018.08.007
4. Reed, M. K., Salcedo, V. J., Hsiao, T., Esteves Camacho, T., Salvatore, A., Siegler, A., & Rising, K. L. (2023). Pilot testing fentanyl test strip distribution in an emergency department setting: Experiences, lessons learned, and suggestions from staff. Academic Emergency Medicine, 30(6), 626–635. https://doi.org/10.1111/acem.14624
5. Goodman-Meza, D., Arredondo, J., Slim, S., Angulo, L., Gonzalez-Nieto, P., Loera, A., Shoptaw, S., Cambou, M. C., & Pitpitan, E. V. (2022). Behavior change after fentanyl testing at a safe consumption space for women in Northern Mexico: A pilot study. International Journal of Drug Policy, 106, 103745. https://doi.org/10.1016/j.drugpo.2022.103745