Street level activists are leading the fight against fentanyl deaths — and it’s working

St. Ann’s Corner of Harm Reduction sits on a busy section of Westchester Avenue in the Bronx, in the shadow of an elevated train track. Inside the facility, patrons can come in from the cold, get a hot meal, and sit in a recliner watching TV or chatting with friends. In one corner, people can pump iron or do pull-ups in a makeshift gym.

The organization also offers a judgement-free space for people who use drugs to pick up sterile syringes, alcohol swabs, doses of the opioid-overdose-reversal drug naloxone, and other goods to help them reduce the risks inherent to intravenous drug use.

St. Ann’s operates around the model of harm reduction, which advocates argue is a pragmatic approach to preventing overdose and the spread of diseases by accepting that some people are going to do drugs, and it’s better to keep them alive and healthy than to demand they “just say no.” Harm reduction is not a silver bullet, and it’s not supposed to be. Instead, it focuses on meeting people who use drugs where they’re at and trying to keep them as safe as possible, according to Van Asher, a program manager at St. Ann’s.

“’Just say no’ hasn’t worked,” Asher said. “It didn’t work in the ‘80s, and it’s not working now.”

The sterile syringes and other products St. Ann’s passes out have long been a staple of harm reduction work. As the Bronx and much of the rest of the country began to see a surge of deaths from fentanyl, a powerful synthetic opioid 50 to 100 times more potent than morphine, St. Ann’s has been on the cutting edge of a new way of helping those who use drugs try to avoid overdoses.

In early 2017, Asher heard about a pilot project at Insite — a so-called safe-consumption site in Vancouver, Canada, which allows people to inject drugs in the presence of trained staff — which suggested that a brand of urine strips designed to test hospital patients for fentanyl could also be used to test for its presence in samples of addictive drugs including heroin and cocaine. Intrigued by the prospect of a new tool to add to his arsenal of harm reduction tactics, he ordered some strips, which retail for about $1 a pop, from Canadian company BTNX.

Asher is one of several street-level activists leading the fight against fentanyl deaths across the country. He has three goals: gathering data on the spread of fentanyl, giving people the ability to test their own drugs and take necessary precautions, and opening a dialogue with people who use drugs in an effort to help them develop ways for them to stay as safe as possible.

“We need to start having conversations with people about how do you safely use something once there’s fentanyl in it,” he said.

“We need all the tools in the toolbox”

A pair of recent scientific studies appear to support Insite’s findings suggesting that urine strips would be useful in detecting fentanyl and helping people make safer choices. In February, a team of researchers at Johns Hopkins University released the executive summary to a study that found that, compared with two types of more sophisticated lab equipment — which would be of little use to an everyday layperson — the urine strips from BTNX had the lowest detection limit and the highest sensitivity, meaning they’re highly accurate at picking up on traces of fentanyl. The team is still trying to publish their study in a medical journal, but they released the summary first due to what they felt was the urgency of the matter, according to Susan Sherman, a Johns Hopkins professor and one of the lead researchers on the study.

The study also consulted people who use drugs, and found them highly receptive to the idea of testing their drugs, with 86% of respondents saying they’d use the tests, and 70% saying they’d likely change their behavior if the the drugs tested positive.

While the strips are more immediately useful to those who use drugs than the machines, they only give a simple “yes” or “no” answer for whether the drugs contain fentanyl or any of three of its analogues. The strips cannot indicate which or how much of those substances may be present.

Still, Sherman said, the strips represent a positive step toward a more informed consumption, one among an array of services to help keep those who use drugs alive at a time where overdose deaths continue to take a toll on communities across the country.

“What more do we need to understand that there’s a crisis and that we need to respond with all the tools in the toolbox,” she said in an interview. “It takes a lot of different touch points for people who use drugs, engaging them at different points along the trajectory before they’re able to be stable enough or have the will to stop using.”

Another study, published in October by the North Carolina-based Research Triangle Institute, was even more encouraging. It found that people who use street opioids are five times more likely to engage in safer injection practices if their drugs test positive for fentanyl.

“The bottom line is that fentanyl test strips may represent a new technique to prevent opioid overdose by allowing people to check street drugs for fentanyl and modify consumption behavior accordingly,” Jon Zibbell, a public health researcher at RTI who worked on the study, wrote.

The strips are still not officially approved for use outside of a clinical setting, but BTNX has leaned into its role as a major supplier of harm reduction clinics. The company sent representatives to a recent conference in New Orleans organized by the Harm Reduction Coalition, and its website features information about harm reduction, including a pamphlet touting the results from the recent Johns Hopkins and RTI studies.

“It was in every bag, and people prefer it”

While Fentanyl has gotten a lot of press in recent years as its presence in street drugs has increased dramatically and it has played a role in celebrity deaths, it isn’t particularly new. A batch of heroin labelled “Tango and Cash” that was improperly cut with fentanyl sickened and killed numerous people in New York City in 1991. It reared its head again from 2005 to 2007, when fentanyl contamination killed more than 1,000 people in Illinois, New York, and several other states.

As overdoses have become the leading killer of people under the age of 50 in the United States, the number of deaths attributed to fentanyl has risen sharply. In 2017, 72,000 people died in America from all drugs. Fentanyl and its analogues were present in nearly 30,000 of those, according to provisional data from the National Institute on Drug Abuse.

In New York, fentanyl represents an even greater threat. In 2017, which saw 1,487 drug overdose deaths across the city, fentanyl was connected to 57% of those deaths, making it the most common substance, according to a report released in September.

Illicit fentanyl — which is now largely produced in labs in Mexico, according to the Drug Enforcement Administration — was likely introduced into the heroin supply because it’s easier to make than heroin and because it increases the potency of the product. The amount of fentanyl in a given bag is not always the same, so someone accustomed to a certain dose might accidentally misjudge if they happened to buy a dose with just a touch more fentanyl than they can handle.

But illicit drug supplies are not regulated, and fentanyl is much stronger than heroin. It’s essentially impossible to identify one or the other by eyeballing them — one bag sold on the street could be significantly more powerful than the next one, which can be a contributing factor to a potentially fatal overdose.

For a person using drugs, having an idea of what’s in your drugs can make the difference between life and death. Heroin and fentanyl are both opioids, which when taken in large enough doses, suppress heart rate and breathing. This can starve the brain of oxygen, killing the person or causing severe brain damage. An overdose is a race against time to administer naloxone, which is designed to revive the victim by blocking the brain’s opioid receptors from absorbing the drugs.

Fentanyl absorbs into a person’s system faster than morphine or heroin, and as a result, people who overdose are knocked flat far quicker. That makes it all the more urgent that anyone who could be using fentanyl take precautions like using with a friend and having naloxone on hand, according to Shawn Westfahl, a harm reductionist who works with vulnerable populations in Philadelphia.

Westfahl first trained as a street medic in 2011, and said he performed his first overdose reversal in Zuccotti Park in New York City during the Occupy Wall Street direct action. Since then, he says he’s administered naloxone dozens of times, which has given him a close-up view of the spread of fentanyl in the Northeast. Westfahl said he first started hearing about fentanyl in 2016, first as a dangerous adulterant to be avoided. But as the drug began to dominate the local street opioid market, that changed

“At the time, it was like ‘watch out, there’s fentanyl here and it’s putting people out,’” he said. “But eventually it came to the point where fentanyl was everywhere, it was in every bag, and people prefer it.”

According to multiple people familiar with opioid use in the Northeast, fentanyl has become so prevalent that many people now seek it out, including some who began injecting drugs well after fentanyl began to replace or heavily augment the heroin sold on the street. But even if someone prefers the quick, more intense high of fentanyl to heroin, the mechanics of an overdose remain the same, and the ability to know if the more powerful drug is present can mean the difference between life and death for people like James. James showed Mic how he typically prepares a shot of heroin and tests the drugs before using.

Taking a glassine envelope slightly larger than a postage stamp, James, who asked that his last name not be published, poured a small heap of off-white powder into a cooker, a sterile vessel used to mix drugs that resembles a soda cap. James measured out about 15 cubic centimeters of water in a sterile syringe, squirted it into the cooker, and mixed the heroin briefly over a flame before putting a filter into the mix, drawing it back into the syringe, and capping the needle so he could use it later, in private.

Next, James dipped the strip into the water and waited counted out about 15 or 20 seconds as a small blueish coloring began to creep up the face of the strip. Slowly, a single line appears, indicating the presence of fentanyl.

The result is not a surprise to James. In New York, at least, every bag that he’s tested has come up positive for fentanyl, a prevalence that is backed up by Asher’s findings testing drugs in the Bronx. Still, knowing for sure that the dope he’s going to shoot in a fe minutes contains fentanyl, James said he’s able to take precautions to avoid an overdose. He can inject it more slowly

James said he’s never experienced an overdose, in part because he’s been able to test drugs as long as he’s been injecting them, which he said he only began doing several months ago.

“You just go slow, cause a certain amount will probably kill you,” he said.

“With every reform we get closer to the end goal”

Around the time Asher began experimenting with fentanyl test strips, others in the harm reduction world began to as well. Tino Fuentes, who formerly dealt drugs and used heroin, and now works as an independent harm-reduction advocate, rolled the strips into his daily outreach with people who use drugs in the Bronx. He has developed enough of a reputation for his drug testing that other harm reduction sites across the country began to bring him in to give trainings on how to use the strips.

Christopher Moraff, a journalist and former opioid user who began covering the drug scene in Philadelphia as an extension of his focus on the criminal justice beat, learned about the strips from Fuentes and began conducting extensive tests of samples from the open-air drug markets in the Kensington neighborhood. Over time, he also began using morphine strips, which test for the presence of heroin, and could tell him giving him an ability to identify whether a sample contained both heroin and fentanyl or solely one or the other. Over time, as fentanyl began to appear in nearly every dope sample, he began focusing on vials of crack-cocaine, in a quest to verify rumors that fentanyl was showing up in the city’s coke supply. No dice so far, he told Mic.

But even as the strips began to catch on across the country, organizations like St. Ann’s were largely barred from using public funding to pay for them. That’s begun to change in 2018, however, with city governments in Philadelphia, San Francisco and Burlington, Vermont, giving the green light for city-funded groups interested in distributing the strips.

“Philly is doing a really good job,” Moraff said. “With every reform we get closer to the end goal, which is safer use for everyone.”

Until June, St. Ann’s, which is funded in part by New York City, was barred from using public funding to buy test strips, so Asher was buying them with other grants and resources, he said. But this summer, the city quietly gave the go ahead to the 14 syringe access programs it funds, including St. Ann’s, to begin buying and distributing the strips, a department spokeswoman told Mic.

Officials with the Department of Health and Mental Hygiene were initially wary of giving the thumbs up for an off-label use of the strips. But as other cities started to see their potential, and particularly after reading the increasing scientific support of the strips as one more method of encouraging safer use, the agency relented, Denise Paone, who oversees research and surveillance in in the department’s Bureau of Alcohol and Drug Use, said in an interview.

“We had a concern in the context of us supporting and funding test strips was that there wasn’t enough scientific evidence,” Paone said. “We encourage the organizations to use them as an engagement tool.”

“The best possible ‘screw you’”

Like many who work in harm reduction, Asher has his own history with drugs. As a young punk living in a squat on the Lower East Side, he said he lived a wild life, fighting cops and landlords and doing a lot of drugs. He was never big into opioids, but his experiences with “a lot of crack and a lot of meth,” and his frustration at what he described as the government’s apathy toward the deaths by overdoses and HIV in marginalized communities, led him to harm reduction work.

“It bothered me enough that a group of people who had never met me had said it would be okay if I died,” he said, as he drove from St. Ann’s to nearby Patterson Park, where his team was doing outreach work on a recent weekday. “So doing this work was the best possible ‘screw you’ I could come up with for a group of people who said that

With the exception of some years he spent racing motorcycles, Asher has been saying that same “screw you” by working at needle exchange programs and other harm reduction providers since 1992.

“I’m going to keep myself, and my friends, my family, my loved ones alive, healthy and fighting you,” he said.

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