A high-tech strategy for keeping drug users safe: Analyzing their fentanyl

CHAPEL HILL, N.C. — The white powder in a small tube arrived one morning by FedEx in a basement office on the campus of the University of North Carolina at Chapel Hill.

“Quick OD, half bag, weirdly lethargic after,” the anonymous drug user from Wilmington, North Carolina, wrote on a slip of paper the size of an index card, which came with the tube. The user had a hunch that there was fentanyl in the powder but feared the presence of xylazine, a dangerous animal tranquilizer that can leave oozing wounds on limbs.

Erin Tracy, a chemist at the university who specializes in testing drugs, began searching for the answer. She dispensed the sample into a small vial, then loaded it into a $600,000 refrigerator-size device known as a gas chromatograph mass spectrometer, which is commonly used in academic chemistry laboratories. A nearby computer displayed the results in a line graph with a dramatic peak: the signal for fentanyl.

There was only a trace of xylazine, the machine confirmed. In a state increasingly besieged by the drug in the street supply, the results from the test in September amounted to partial relief.

The work at the North Carolina lab is part of a strategy known as harm reduction, which aims not to lead users to abstinence but to give them the tools to use drugs safely, keeping them from infections, injuries and death. President Joe Biden is the first president to endorse the strategy, lending it a federal imprimatur that health experts say could transform how the United States contends with drug use.

The testing of drug samples at the lab and in a growing number of cities across the country is delivering new insight to researchers and drug users about what is in the local drug supply. Drug users can learn what is in a substance before they use it, alert other users to possible dangers in the supply or find out why a drug led to an overdose or some other reaction. The Chapel Hill team has also examined samples of drugs that caused fatal overdoses and then relayed the results to harm reduction groups.

The testing work in North Carolina and elsewhere, known as drug checking, has become especially critical to recognizing fentanyl, a synthetic opioid and a chief culprit in many overdose deaths in recent years. Other drugs, such as cocaine and heroin, are often mixed with fentanyl.

But the U.S. drug supply is increasingly being contaminated by other substances as well, like xylazine. The volatile and expanding medley has intensified calls from public health experts and some federal officials to invest in more sophisticated forms of drug checking.

Dr. Nora Volkow, director of the National Institute on Drug Abuse, a division of the National Institutes of Health, noted that people who were fatally overdosing from drugs were not just dying from fentanyl but also from other contaminants.

“We need to understand that, and we need technology that can give you the information,” she said.

Drug policy experts say that while the exact number is difficult to determine, there are dozens of health departments, academic laboratories or harm reduction groups using machines for drug checking around the country, including in New York and Chicago. But the work needs more funding, experts say, in part because of how difficult it is to scale. While test strips that can check for the presence of fentanyl in a sample typically cost $1, drug checking machines have a price tag in the tens or even hundreds of thousands of dollars.

The Biden administration’s 2022 national drug strategy aims to increase drug checking services at harm reduction programs by 25% within three years, a feat that policy experts say will require more money to be directed to groups that typically operate on shoestring budgets.

Drug checking has long been a feature of harm reduction efforts in Canada, Australia and Europe, including in social settings like nightclubs and music festivals. But the practice has picked up in the United States only in recent years, a reflection of the nation’s slow adoption of harm reduction measures.

In more than a dozen states, even the basic tools of drug checking, such as fentanyl test strips, are outlawed as drug paraphernalia; conservatives criticize the practice as permissive of drug use.

As the opioid supply has surged in recent decades, drug checking has typically been conducted by crime laboratories or the Drug Enforcement Administration, which examine the contents of drug seizures. Law enforcement agencies have long been hesitant to share the results quickly or publicly for the purposes of helping drug users know more about the local supply.

Drug checking tools are needed in part, experts say, because of the limited value of fentanyl test strips — one of the core components of the Biden administration’s drug control strategy. Unlike some drug checking machines, the strips do not tell a user the variety or amount of fentanyl in a sample — only whether it contains the drug. And because fentanyl is so widespread, users often ingest substances knowing they contain the drug.

Some harm reduction groups now have cheaper, toaster-size machines that conduct less comprehensive checks than the Chapel Hill device but are highly portable. Those machines allow health workers in cities like New York, Chicago, San Francisco and Boston to test drug samples out of vans or small rooms, with results reported back to users in minutes.

“We have regulars that come back week after week, folks that get a supply and don’t want to use it until they come to the drug testing service,” said Ro Giuliano, who directs syringe exchange programs at the San Francisco AIDS Foundation, which checks drugs using the smaller machines.

The Chapel Hill team has developed what some drug policy experts see as the most ambitious model. Its mail-in program, which began last year, allows the work to stretch beyond a single organization or community, including to states where drug checking might be considered illegal.

The program does not know the identities of the users who submit drugs for testing; the samples are typically routed through harm reduction organizations, which have relationships with the drug users and can communicate results to them. The results are also posted online.

The researchers have so far tested drugs from 18 states and 51 clinics and programs.

To collect samples, the Chapel Hill team provides drug users with kits that include a small vial with a chemical solution that effectively neutralizes the substance. Nabarun Dasgupta, the scientist who oversees the program, said that step helps fend off possible skepticism about the legality of the work.

Drug checking has already benefited users in states with drug paraphernalia laws that make it more difficult to test drugs, said Aaron Ferguson, a leader of the Urban Survivors Union, a group that represents harm reduction organizations and drug users. In recent months, he has gathered dozens of heroin samples from cities in Texas, where drug checking tools are outlawed, to send to Dasgupta’s team, suspecting they contain fentanyl.

Tools for drug checking “create an early warning system that simply is never going to happen from DEA drug seizures in a criminalized drug supply,” Ferguson said. “Even the people dealing the drugs don’t know what’s in them in most instances.”

Traci C. Green, a public health researcher at Brandeis University who leads a drug checking program in Massachusetts that collects samples from harm reduction groups and law enforcement agencies, said that when government agencies and drug users communicated about what was in the drug supply, local authorities were less likely to caricature drug use.

The drug supply is “not this massive, lethal, heaving beast,” Green said. “It is something that we’re coexisting with.”