Broad harm reduction efforts needed to save lives from overdose

Nearly 88,000 Americans died from a drug-related overdose from September 2019 through September 2020, according to the U.S. Centers for Disease Control and Prevention (CDC). Illicitly manufactured fentanyl and fentanyl analogs were involved in more than 52,000 of those deaths. That represents a more than 500 percent increase since 2015.

“Without naloxone, there likely would have been tens of thousands more who would be dead,” said Patrice A. Harris, MD, MA, AMA Immediate Past President. “While we must continue to increase naloxone in the community, we also need to think about harm reduction in broader terms, including helping people who use drugs know what is in their supply as well as providing legal protections for drug checking supplies.”

A positive step occurred recently when the CDC and the Substance Abuse and Mental Health Services Administration announced that “federal funding may now be used to purchase rapid fentanyl test strips.” Evidence has shown that the knowledge of what is in drug supply can have a positive impact on drug use and safety.

“This is a good step, but because of laws that were adopted decades ago, drug checking supplies that could save people’s lives can often be considered illegal drug paraphernalia. This can lead to individuals getting arrested, having their parole revoked, losing their housing and otherwise being harmed,” said Corey Davis, JD, MSPH, Director of the Harm Reduction Legal Project at the Network for Public Health Law. “Especially in the midst of a drug overdose epidemic, law and policy needs to reflect public health goals and center the health, dignity, and safety of people who use drugs.”

Colorado, the District of Columbia, and Rhode Island are among the states that have taken positive steps to change their drug paraphernalia laws to clearly permit the use or distribution of drug checking equipment. Colorado, for example, specifically excludes “Testing equipment used, intended for use, or designed for use in identifying or in analyzing the strength, effectiveness, or purity of controlled substances,” from its definition for drug paraphernalia. Arizona recently removed fentanyl test strips from its state drug paraphernalia law. Other states, however, often include testing/checking supplies (and a wide variety of other supplies) as subject to criminal or civil penalties, potentially limiting the ability of programs to distribute drug checking materials and people who use drugs to utilize them.

“Labeling fentanyl test strips as drug paraphernalia is an antiquated policy that needs to change,” said Ruchi Fitzgerald, MD, a family physician and addiction medicine specialist who treats patients in some of Chicago’s most underserved areas. “We also need to teach our medical students and residents why it’s essential to understand the lived experience of their patients. We certainly don’t want anyone to use illicit drugs, but if they do, we need to be able to explain about safer use.”

“Knowledge is power and certainly can save lives,” said Mishka Terplan, MD, MPH, an obstetrician-gynecologist and addiction medicine physician who serves as Senior Physician Research Scientist with the Friends Research Institute. “The legal classification of substances into licit and illicit is historical and social and doesn’t map onto harm or health. in fact, it is primarily the illegal classification that creates risk and causes harm, rather than the chemical substance itself.”

Dr. Terplan highlighted that state and federal authorities have access to vast testing resources through toxicology centers as well as lab testing facilities used by law enforcement and others. “The key, however, is to get the information into the hands of the people who use drugs so they can make better choices. Fentanyl strips are a small step towards democratizing this information.”

Boston addiction medicine physician Sarah Wakeman, MD, sees the results of harsh drug paraphernalia laws in her patients’ lives.

“Drug checking, which includes but is not limited to fentanyl test strips, creates a way for people who use unregulated drugs to have more information to use in safer ways and reduce the risk of overdose,” said Dr. Wakeman.  “When my patients lose their home, get kicked off Medicaid, or get arrested for having used needles or other supplies, it makes it much more likely that they will lose their life. We need to change that.”

“We encourage all state medical societies to work with the AMA to seek changes to state law and policy to clearly permit the distribution and use of fentanyl test strips and other drug checking supplies,” said Dr. Harris.