(84) Fentanyl Test Strip Distribution in the Emergency Department: Early Experience and Outcomes

Background & Introduction: Deaths from fentanyl, and its analogues, increased by 49% from 2020 to 2021, and represent the majority of all opioid overdose deaths today. Fentanyl is a commonly reported adulterant in methamphetamines and heroin, and is an ingredient found in counterfeit opioids and benzodiazepines, contributing to the rise in overdose deaths. Fentanyl test strips (FTS) are a tool that can confirm the presence of fentanyl when a person intends to use drugs. Identifying the presence of fentanyl in these instances empowers people who use drugs (PWUD) with knowledge and may reduce the risk of overdose. Fentanyl test strips are among currently recommended harm reduction approaches. Studies have shown that the emergency department (ED) is an ideal source of FTS distribution, as the ED serves as a common touchpoint with the healthcare system for many PWUD, though they remain illegal in some states. There is little evidence on the implementation, feasibility, and outcomes of FTS distribution in the ED. In November 2023, our institution piloted an FTS distribution program in the ED. The purpose of this study is to share our early experience in FTS distribution, compliance, and outcomes at an urban, level 1 trauma center.

Methods: Fentanyl Test Strip distribution at our institution started in November 2023 at a large, urban, academic, level-1 trauma center in a major metropolitan area in the Midwest. Test strips were offered to patients that presented to our institution in the setting of an acute drug overdose. Physician training on the utility of FTS was done prior to implementation, and a script of talking points was distributed among staff. Physicians, advanced practice practitioners, and licensed drug and alcohol counselors were authorized for FTS distribution. Clinicians were instructed to document FTS distribution through the electronic medical record. Test strip kits included four FTS, instructions for use, and a contact card with addiction medicine treatment resources, including referral information to buprenorphine and methadone providers. Kits were translated into Spanish, Hmong, and Somali languages. A retrospective review of all patients presenting to the ED in the setting of an overdose was conducted. Patient demographics, nature of overdose, and 30-day follow-up in the ED were recorded. The primary purpose of the study was to evaluate FTS distribution compliance. The secondary purpose was to evaluate 14-day ED repeat presentation for overdose. Chi-square analysis was done to test for statistical significance at a p value of 0.05.

Results: Over the three-month evaluation period, 186 total opioid overdose encounters were identified. Patients were predominantly male (67%), and the average age was 36 years old. Narcan was utilized in the field or in the ED in 86% of cases. A conversation about FTS was documented in 58 patients (31%), and 52 patients (28%) accepted FTS. There was no statistically significant difference in age, sex, or race in patients that were offered FTS versus those that were not. Overall, there were 21 (11%) repeat presentation encounters with suspected overdose pathology involved, with an average time from original presentation to subsequent overdose of 22 days (2-84). Of the 21 overall overdose repeat presentations, four occurred in patients who had previously been offered FTS at our institution, representing a 6.4% repeat overdose rate for those who were offered FTS in comparison with 13.2% repeat overdose rate in those who were not offered FTS. When looking at the secondary outcome of 14-day overdose repeat presentation, there was one occurrence (1.9%) in the FTS group vs. eight (6.4%) in the group that were not offered FTS; this difference was not statistically significant (p = 0.18).

Conclusion & Discussion: In the first three months of our institution’s FTS distribution program, a structured conversation coupled with FTS distribution was offered to 31% of patients presenting to the emergency department with an overdose. Of the patients that were offered FTS, there was a subsequent overdose presentation at our facility within 14 days of index, in only one case (1.9%). Conversely, subsequent overdose within 14 days occurred in eight cases (6.4%) of patients who were not offered FTS. There are several limitations to this study. Firstly, our institution is still in the preliminary phases of distribution and this new harm reduction strategy introduces a new element of care that brings logistical challenges which have been previously noted at similar facilities. We also have no data on the utilization of the FTS on the patient side, nor do we have data on patient specific overdose risk factors. This study is a first-glance audit of this novel program and the first study to attempt objective outcome measures for FTS distribution in the acute-care setting; this is an ongoing evaluation.

References: Centers for Disease Control and Prevention. (2023, August 8). Opioid data analysis and resources. Centers for Disease Control and Prevention. https://www.cdc.gov/opioids/data/analysis-resources.html

Sherman, S.G., Park, J.N., Glick, J., McKenzie, M.,Morales, K., Christensen, T., Green, T.C. (2018). FORECAST Study Summary Report. Johns Hopkins Bloomberg School of Public Health.

Reed MK, Salcedo VJ, Hsiao T, et al. Pilot testing fentanyl test strip distribution in an emergency department setting: Experiences, lessons learned, and suggestions from staff. Academic Emergency Medicine. Published online December 12, 2022. doi:https://doi.org/10.1111/acem.14624

Reed M, Siegler A, Tracy Esteves Camacho, London KS, Schaeffer K, Rising KL. Making Harm Reduction More Accessible: Fentanyl Test Strip Awareness and Attitudes among Emergency Department Patients Who Use Drugs. Substance Use & Misuse. Published online November 1, 2023:1-7. doi:https://doi.org/10.1080/10826084.2023.2275561
‌
‌