Back in mid-2017 I embarked on a journalistic endeavor that, to my knowledge, has not been replicated. Through a contact in the New York harm reduction community, I purchased a box of 100 test strips developed by a Canadian firm to detect the presence of fentanyl in urine. I had learned that some community outreach workers in California, Massachusetts and New York were successfully using the highly sensitive strips to analyze street drugs for the presence of the powerful synthetic opioid—responsible for nearly doubling the number of overdose fatalities in Philadelphia between 2015 and 2017.

In July 2017—as Philadelphia Mayor Jim Kenney and Conrail waged battle over the impending closure of the West Kensington injection drug user site known as “El Campamento,” a move that would bring many unintended negative consequences—I set out on what I thought would be a simple mission.

I hoped to determine how much of Philadelphia’s retail heroin was adulterated with fentanyl, and what, if any, geographical variations existed in the composition of the city’s street dope. This would, among other things, inform my lifelong fascination with the dynamics of government paternalism and illicit markets. I added strips capable of detecting the presence of cocaine and morphine derivatives (heroin) to my toolkit, and began.

With very few exceptions, all of Philadelphia’s retail heroin is now adulterated with illicitly made fentanyl.

For over a year, in North Philadelphia neighborhoods from Fairhill to Port Richmond, and deep into South Philly (home to the ZIP code with the second highest fatal overdose rates in the city outside Kensington), I regularly asked drugs users on the streets if I could test their samples, and recorded the results.

Before long, I had established a small army of willing research assistants who would save me their bags of heroin, cocaine and crack that were coated with enough residue to detect the presence of fentanyl. I instructed them as best I could on how to avoid cross contamination, and provided Ziploc bags into which they could drop their samples.

And if I was lucky enough to be around during one of the several “sample calls” that went out each day, as new drug corners offered free bags to entice new clientele, I even acquired a few samples myself. At the peak of Philly homeless drug-user crisis last winter, it wasn’t uncommon for three or four drug “sets” (crews of dealers) a day to pepper the streets with new “work” (the term here for what comes inside the small waxine stamp baggies in which retail heroin is sold).

Before long, that first box of 100 fentanyl test strips turned into 200. And today, the results of my experiment fill two filing cabinets of index cards with notes on samples of not only heroin, but of cocaine, crack, methamphetamine, Xanax and K2—the generic term for any of roughly 400 known synthetic cannabinoids that could wind up in the lungs or veins of an unsuspecting consumer.

The percentage that contained fentanyl-only increased.

The news isn’t good. With very few exceptions and city-wide, all of Philadelphia’s retail heroin is now adulterated with illicitly made fentanyl. But as I suspected—as drug users got pushed further away from established corners and more freelance drug dealing operations opened to fill the void—the percentage of bags that contained a mixture of heroin and fentanyl declined during my project. The percentage that contained fentanyl-only increased.

The heroin-fentanyl mix fell from around 80 percent of samples to between 50-60 percent, with the remainder composed of just fentanyl (or one of about a dozen analogs that the test strips detect) and cut—usually with mannitol or lactose, according to lab and drug-seizure results I’ve been able to access.

While my methodology won’t win any science awards, my conversations with ground-level and expert sources over the past year lend support to the broad trends I found.

A Positive Move by the Philly Department of Health

Exactly one year after I began testing street drugs, the Philadelphia Department of Health announced that it would begin investing in fentanyl test strips, in an effort to give drug users the tools to protect themselves. City officials told me a few weeks before the announcement that they had purchased thousands of the strips and were determining how best to put them to use.

I suggested full-scale distribution to people who use cocaine and crack, as well as heroin users. In my testing, roughly two out of 10 $5 bags of powder “shooting” coke tested positive for fentanyl or one of its analogs.

Any campaign to distribute fentanyl strips to drug users must engage people who use drugs other than heroin.

The DOH also linked three fatalities to fentanyl-contaminated crack in May 2018. A Philadelphia Weekly piece I co-authored with reporter Max Marin in June told the story of a group of crack users who experienced adverse reactions after smoking what was reported to be fentanyl-laced crack. Two people died. However, according to the Department of Health, both suffered “significant morbidity”— including acute kidney injury and anoxic brain injury. Six months later, no one seems to know if any actual drugs or paraphernalia were tested.

In the meantime, neither my own testing nor that of my colleagues in the East Coast drug-testing community has yet identified a crack sample testing positive for fentanyl. I’ve personally tested nearly 100 such samples.

Tests showing positive for crack cocaine, negative for fentanyl.

Given the powder cocaine findings (at least), as well as fentanyl showing up in larger quantities in the cocaine supplies of other cities, such as New York, it’s nonetheless clear that in order to be successful, any campaign to distribute fentanyl strips to drug users must engage people who use drugs other than heroin.

Crack and “Xanax” samples await testing.

I applaud the city for getting on board with fentanyl-strip testing. At the time of the DOH announcement, only one other municipality (San Francisco) was using city funding on this important harm reduction tool. Burlington, Vermont recently became the third.

Philadelphia’s courage is all the more commendable given that under state law, mere possession of drug-testing items could be considered a crime. Pennsylvania’s Controlled Substances, Drugs, Device, and Cosmetic Act states: “Testing equipment used, intended for use or designed for use in identifying or in analyzing the strength, effectiveness or purity of controlled substances.”

I should add that local cops have not obstructed my work; two of them once sat and waited for a couple of guys to shoot up after I’d tested for them, before telling us to pick up our trash and leave.

“Pennsylvania has the fourth highest overdose rate in the nation by percentage,” said Devin Reaves, executive director of the Pennsylvania Harm Reduction Coalition. “Fentanyl overdose makes up a majority of those overdose deaths. The fact that this vital evidenced-based tool is illegal has slowed implementation. We must engage in education and advocacy to effectively implement this and other hard reduction interventions.”

Reaves is advocating to change the language of the state’s law around testing items.

We Need More Than Just Test Strips

Fentanyl test strips are a rudimentary tool; they can’t distinguish between fentanyl analogs or determine the potency of a drug sample. But researchers from John Hopkins University in Baltimore recently confirmed that the tests, which retail for only a dollar a piece, are even more accurate at detecting fentanyl than some of the most sophisticated lab equipment used by forensic researchers.

With proper training, users can test their drugs without wasting a single grain, and have the result in seconds. Without a shadow of doubt, putting the strips in the right hands can save lives.

But with the city’s heroin stamp bags overwhelmingly testing positive for fentanyl, test strips alone will not be enough to bring down our historic overdose rate without other critical reforms to the city’s approach to IV drug use and addiction.

A safer consumption site in Philly—preferably a number of them—could provide the safe space needed to empower drug users to use fentanyl test strips effectively.

For starters, most users already know they’re getting fentanyl, and more and more have developed a taste for the strong rush it provides—as shown by feedback from my sources and research assistants, as well as the increasing prevalence of fentanyl-only results. Two people have told me that they use fentanyl strips to confirm the presence of the drug, rather than avoid it.

One might ask, what’s the point of testing heroin that will almost universally produce a positive result for fentanyl, when people are going to use the drugs regardless?

There is also some suspicion that the strips may be too sensitive. One month, every time I tested a particular brand of powder cocaine, it came out positive. But no one seemed to notice. I saw numerous people with established opioid tolerance inject the powder, mainly as a component of speedballing, without overdose.

All the same, for people who use heroin or other drugs, test strips still represent a chance to make an informed choice. Test-strip provision, as with other harm reduction services, also provides an important opportunity for outreach workers to engage drug users in conversations about safer injection practices, and to dispel popular street myths—such as the widespread belief that if dope mixes up brown it’s heroin, not fentanyl. (In fact, the brown color many users associate with “real” heroin is easy to mimic, using rudimentary cutting techniques.)

Despite these positives, even if we place a test strip in the hand of every drug user in the city, they will be of little value if people don’t have the time and place to employ them.

While it only takes a few seconds to test a sample, street users often don’t have the leisure or safety from law enforcement scrutiny to inject a “tester” shot if the results are positive, as recommended by harm reductionists. And no homeless drug user in a state of withdrawal has the resources to discard a bag of something that will make them feel well simply because it tests positive for fentanyl.

A safer consumption site in Philly—preferably a number of them—could provide the space needed to empower drug users to use fentanyl test strips effectively. The campaign to make that happen is ongoing, though facing predictable obstacles. Better access to healthcare and treatment, including methadone and buprenorphine, is another part of the answer.

But as long as people are injecting furtively on public streets or along the edge of railroad tracks in a constant state of apprehension and fear of being arrested or harassed, there will be a disincentive to use fentanyl test strips as recommended.

The hard truth is that harm reduction resources like naloxone and fentanyl test strips—while incredibly important—can only partially offset the damage caused by systemic factors and policies that might as well have been designed to increase drug-related harms.

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Philadelphia photo by Fredy Martinez on Unsplash.

All other images: Christopher Moraff.

*For more on fentanyl-contaminated cocaine, check out part three of Narcotica’s series on stimulants: The Cocaine-Fentanyl Blues.