Abstract
Background
Illicitly manufactured fentanyl accounts for a majority of overdose fatalities in the US. Research has demonstrated that fentanyl test strips (FTS) help people who use drugs (PWUD) avoid unintended exposure to fentanyl and overdose. This study assesses characteristics associated with FTS use among PWUD in Rhode Island. Such findings may shed light on whether there are subgroups of PWUD who are less likely to be using FTS and therefore may benefit from their use.
Methods
From September 2020 - February 2023, participants were recruited to participate in RAPIDS, a clinical trial assessing whether FTS provision can reduce overdose rates. Baseline data were used to assess correlates of lifetime FTS use through bivariable and multivariable analyses. We also examined drug testing patterns relating to FTS use in the past month.
Results
Of 509 people enrolled, 376 (73.9%) had heard of FTS before enrollment. Among this group, 189 (50.3%) reported lifetime FTS use and 98 (26.1%) reported use in the last month. In bivariable analyses, lifetime injection drug use, responding to an overdose, and drug selling were associated with FTS use. Solitary drug use was not associated with FTS uptake. In the multivariable analysis, gender and lifetime naloxone administration were associated with FTS use. Of those who used FTS in the past month, 76.5% had at least one test that was positive for fentanyl.
Conclusions
We found high uptake of FTS use among PWUD in Rhode Island. Our results also suggest a need for targeted outreach to increase FTS uptake among sub-groups of PWUD.
Clinical trial registration:
The Rhode Island Prescription and Illicit Drug Study is a registered clinical trial, NCT043722838
Keywords: Fentanyl test strips, harm reduction, overdose prevention, poly-substance drug use
Introduction
Drug overdose rates continue to rise in the United States driven by illicitly manufactured fentanyl.(“Vital Statistics Rapid Release - Provisional Drug Overdose Data” 2023) This is both because of fentanyl’s increased potency relative to heroin and its spread in the nation’s unregulated drug supply. As a result of the increased pervasiveness of fentanyl in the drug supply, resulting in both intentional and unintentional fentanyl co-use (McKnight et al. 2023), fentanyl overdoses involving amphetamines, cocaine, and benzodiazepines have become increasingly common nationally (Park et al. 2022; Ciccarone 2021). In Rhode Island, from 2019 to 2021, 89% of fatal overdoses involved fentanyl or fentanyl-related analogues (Weidele et al. 2022), and from 2020 to 2021, 75% of all fatal overdoses involved more than one substance, most commonly, fentanyl, other opioids (including heroin and prescription opioids) and cocaine (“RIDOH Drug Overdose Surveillance SUDORS Dashboard,” n.d.). High levels of contamination and/or adulteration (Galust et al. 2024) in the drug supply present significant risks for people who use drugs (PWUD)(Bhuiyan, Tobias, and Ti 2023), as there is little certainty that the drugs they intend to use are in fact the ones they consume. Given that PWUD do not have control over the composition of their drugs, tools and interventions are needed in order to foster agency and provide people with more information about their drugs.
Fentanyl test strips (FTS) are an important tool that PWUD can use to assess whether their drugs contain fentanyl (Krieger et al. 2018), but their utility may be limited as the drug markets and contexts for drug use shift (Weicker et al. 2020). In some literature, PWUD have cited many motivations for using FTS including, but not limited to, their ease of use, their provision of information about the makeup of their drugs, and their ability to inform decisions around overdose prevention practices (Goldman, Waye, et al. 2019; Reed, Salcedo, Guth, et al. 2022; Tobias et al. 2024). However, as the drug market is increasingly saturated with fentanyl and new adulterants like xylazine (D’Orazio et al. 2023), many PWUD, particularly those who use fentanyl routinely from the same source, or access other methods for detecting fentanyl (Mars, Ondocsin, and Ciccarone 2018), may find FTS to be less useful (Reed, Salcedo, Hsiao, et al. 2022). Additional reluctance to FTS use and lower uptake of other harm reduction supplies (e.g., possessing naloxone) may be due to concerns of negative interventions with law enforcement (Victor, Ray, and Watson 2024; Hamilton et al. 2021), especially for PWUD who have been recently released from incarceration and/or are on probation/parole, despite the fact that recent release from incarceration is a risk factor for overdose (Victor et al. 2022). In contrast, people who do not regularly use fentanyl, heroin, or other opioids, those who buy diverted or counterfeit prescription pills, and PWUD who are otherwise not seeking out fentanyl may find utility in knowing whether their drugs contain fentanyl (Reed et al. 2021; Weicker et al. 2020). Additionally, FTS use may be more beneficial for those who use drugs in isolation (since bystanders are not present to administrator naloxone in the event of an overdose) or may not be engaged with other harm reduction services (Papamihali et al. 2020).
In 2018, Rhode Island decriminalized the distribution of FTS, paving the way for the scale-up of FTS programs across the state. As FTS become a ubiquitous harm reduction tool, and as PWUD gain increasing access to them, it is important to understand if there are behavioral or drug use characteristics that are correlated with FTS use. The objective of this study is to explore the correlates of FTS use among PWUD who have previous knowledge of FTS. The study may help to elucidate patterns of FTS use and shed light on categories of PWUD who are aware of FTS, and choose not to use them. This could inform if there are subgroups of PWUD who would benefit from targeted outreach and increased education regarding FTS use.
Methods
Procedure
The Rhode Island Prescription and Illicit Drug Study (RAPIDS) recruited PWUD to participate in a randomized control trial to assess if the provision of FTS, along with a behavioral intervention involving motivational interviewing, can reduce the rate of nonfatal overdose within the sample. Eligibility criteria included being between 18 and 65 years of age; living in Rhode Island; and reporting using heroin, cocaine (powder or crack), any kind of methamphetamine, or nonmedical prescription opioids, or reporting drug injection in the 30 days before enrollment. A longer description of the protocol and recruitment methods are detailed elsewhere (Jacka et al. 2020); in brief, participants were recruited through targeted internet-based outreach, flyering, bus advertisements, and canvassing of areas where PWUD are known to gather (such as in bus hubs, and street corners near direct services providers), as well as directly recruited from two different syringe services programs outside of the state’s urban core. Participants were administered surveys at months 1, 2, 3, 6 and 12 post baseline and were thus retained in the study for up to a year (Jacka et al. 2020). Surveys were administered verbally by trained research assistants and participants were able to see response options for questions in order to increase ease of taking surveys. Select questions from the survey have been published in Appendix 1. While RAPIDS is a longitudinal study, this analysis utilizes data from the baseline assessment. The final outcomes of the RAPIDS study are not yet published, however, there will be exploration of whether the RAPIDS intervention did successfully reduce rates of non-fatal overdose among PWUD in Rhode Island. This analysis represents a sub-study of the larger RAPIDS study. This study was approved by the Brown University IRB.
Materials and Measures
From September 2020 to February 2023, 509 participants were eligible and completed baseline assessments. At each assessment, participants were asked questions about demographics, housing and carceral history, current and past drug use, drug selling, overdose history, and engagement in harm reduction services and substance use disorder treatment. Participants could provide more than one response for recruitment source; responses were aggregated into four categories: Syringe services programs, participant referral, bus ad, and other methods, which includes Craigslist, flier posted outside, another study, family member, and free text responses that were not SSP/HR orgs. Drug social patterns were categorized as using drugs alone exclusively, using alone and with others, and using with others exclusively. Regular drug use was defined as use of a specific drug totaling four or more days in the past month regardless of the modality of use. This definition comes from past literature that defines regular drug use as occurring once a week or more (Lubomir Okruhlica 2006). Given that participants were asked how many of the past 30 days they used drugs, it was determined that regular drug use would be defined by 4 or more days of use. Preference for fentanyl was asked on a 5-point likert scale, where a neutral or negative response was classified as not preferring fentanyl or drugs that have fentanyl in them.
FTS knowledge and use were assessed through asking participants if they had heard or or used FTS before enrollment. The primary analysis was restricted to participants who had ever heard of FTS, and the outcome was reported use of FTS before enrollment. Additional questions were asked of participants who indicated that they had used FTS in the 30 days prior to enrollment. For participants who responded affirmatively, a following set of questions assessed FTS positivity, steps that participants took following a FTS result, if participants engaged in treatment because of fentanyl and where FTS were ascertained. Many of these questions were asked in ways where participants could indicate multiple response options.
Analyses
Bivariable analyses were completed to examine the correlates of previous FTS use. Descriptive statistics were generated for demographic factors, such as age, race, gender identity, ethnicity, homelessness and incarceration status, as well as drug use characteristics such as drug selling, regular drug use patterns in the past 30 days, and overdose history. Likert scale questions were dichotomized in order to have sufficient power for analyses where neutral and negative responses were categorized together. We conducted a secondary analysis examining correlates of knowledge of FTS in the full sample. Chi-square tests, Fisher’s exact test, and Wilcoxon Rank sum tests were used in bivariable analyses.
A group LASSO (Least Absolute Shrinkage and Selection Operator) regularization method was employed to identify the most important predictors of FTS use and reduce overfitting, with an 80/20 split for training and testing the model and a k-fold cross-validation technique to determine the optimal tuning parameter value. Logistic regression was used on the final model to estimate adjusted odds ratios and 95% CI.
Finally, we conducted a sub-group analysis of descriptive characteristics for people who reported recent FTS use (i.e., in the 30 days prior to enrollment) such as how FTS were used, FTS positivity, and how fentanyl’s presence or absence has impacted drug use.
Two sided P-values were used for all variables and were considered statistically significant at p=0.05.
Results
Of the full sample of 509, 376 people (73.9%) had previously heard of FTS and are thus included in the primary analytic sample for this sub-study. Of this sample, half had used FTS before enrollment (n = 189, 50.3%) and half had heard of FTS, but had not used them (n = 187, 49.7%). Behavioral and drug use characteristics of the sample are summarized in Table 1. The sample was predominantly male (64.0%), white (59.2%), non-Hispanic (79.9%), and the mean age was 42.1 years (SD = 10.8). Close to 80% of the sample had a history of incarceration, and 75.4% had lifetime experiences of probation and parole.
Table 1.
Comparison of demographic and behavioral characteristics of those who have used FTS and those who have heard of them, but have not used FTS previously (n= 376)
| Characteristic | Overall n=376 | Have used FTS before baseline n=189, 50.3% | Have not used FTS before baseline n= 187 (49.7%) | P-value |
|---|---|---|---|---|
| Demographics: | ||||
| Age | <0.001 | |||
| Mean (SD) | 42.1 (10.8) | 40.4 (9.7) | 43.9 (11.5) | |
| Current Gender identity | 0.190 | |||
| Man (cisgender) | 240 (64.0) | 118 (62.8) | 122 (65.2) | |
| Woman (cisgender) | 119 (31.7) | 65 (34.6) | 54 (28.9) | |
| Trangender/Other | 16 (4.3) | 5 (2.7) | 11 (5.9) | |
| Race | 0.120 | |||
| White | 222 (59.2) | 118 (62.8) | 104 (55.6) | |
| Black | 61 (16.3) | 22 (11.7) | 39 (20.9) | |
| Mixed, bi-racial, multi-racial | 54 (14.4) | 28 (14.9) | 26 (13.9) | |
| Other | 38 (10.1) | 20 (10.6) | 18 (9.6) | |
| Ethnicity | 0.640 | |||
| Non-Hispanic | 304 (80.9) | 151 (79.9) | 153 (81.8) | |
| Hispanic | 72 (19.1) | 38 (20.1) | 34 (18.2) | |
| Current relationship status | 0.770 | |||
| Spouse/partner whom living with | 87 (23.3) | 45 (24.2) | 42 (22.5) | |
| Regular partner whom not living with | 27 (7.2) | 14 (7.5) | 13 (7.0) | |
| Dating/seeing someone | 47 (12.6) | 26 (14.0) | 21 (11.2) | |
| Single | 212 (56.8) | 101 (54.3) | 111 (59.4) | |
| Year of enrollment | 0.485 | |||
| 2020 | 29 (7.7) | 13 (6.9) | 16 (8.6) | |
| 2021 | 145 (38.6) | 72 (38.1) | 73 (39.0) | |
| 2022 | 167 (44.4) | 86 (45.5) | 81 (43.3) | |
| 2023 | 35 (9.3) | 18 (9.5) | 17 (9.1) | |
| Recruitment Source * | 0.119 | |||
| Syringe services program | 138 (36.7) | 74 (39.2) | 64 (34.2) | |
| Participant referral | 79 (21.0) | 44 (23.3) | 35 (18.7) | |
| Bus ad | 38 (10.1) | 13 (6.9) | 25 (13.4) | |
| Other | 77 (20.5) | 36 (19.0) | 41 (21.9) | |
| Lifetime history of incarceration | 0.170 | |||
| Yes | 297 (79.6) | 155 (82.4) | 142 (76.8) | |
| No | 76 (20.4) | 33 (17.6) | 43 (23.2) | |
| Currently on probation or parole | 0.030 | |||
| Yes | 133 (35.8) | 77 (41.2) | 56 (30.4) | |
| No | 238 (64.2) | 110 (58.8) | 128 (69.6) | |
| Drug use characteristics: | ||||
| Lifetime history of injection drug use | 0.012 | |||
| Yes | 231 (61.4) | 128 (67.7) | 103 (55.1) | |
| No | 145 (38.6) | 61 (32.3) | 84 (44.9) | |
| Drug use social patterns ** | 0.239 | |||
| Use alone exclusively | 64 (18.1) | 26 (14.7) | 38 (21.5) | |
| Use alone and with others | 118 (33.3) | 60 (33.9) | 58 (32.8) | |
| Use with others exclusively | 172 (48.6) | 91 (51.4) | 81 (45.8) | |
| Regular use of heroin | <0.001 | |||
| Yes | 139 (37.0) | 85 (45.0) | 54 (28.9) | |
| No | 237 (63.0) | 104 (55.0) | 133 (71.1) | |
| Regular use of powder cocaine | 0.017 | |||
| Yes | 99 (26.3) | 60 (31.7) | 39 (20.9) | |
| No | 277 (73.7) | 129 (68.3) | 148 (79.1) | |
| Regular use of crack cocaine | 0.410 | |||
| Yes | 231 (61.4) | 120 (63.5) | 111 (59.4) | |
| No | 145 (38.6) | 69 (36.5) | 76 (40.6) | |
| Regular use of crystal meth | 0.022 | |||
| Yes | 74 (19.7) | 46 (24.3) | 28 (15.0) | |
| No | 302 (80.3) | 143 (75.7) | 159 (85.0) | |
| Regular use of benzodiazepines | 0.005 | |||
| Yes | 94 (25.0) | 59 (31.2) | 35 (18.7) | |
| No | 282 (75.0) | 130 (68.8) | 152 (81.3) | |
| Lifetime history of drug selling | 0.008 | |||
| Yes | 269 (72.3) | 146 (78.5) | 123 (66.1) | |
| No | 103 (27.7) | 40 (21.5) | 62 (33.9) | |
| Fentanyl use: | ||||
| Use of fentanyl or drugs that contained fentanyl in the last month *** | 0.001 | |||
| Yes | 120 (31.9) | 77 (40.7) | 43 (23.0) | |
| No | 243 (64.6) | 106 (56.1) | 137 (73.3) | |
| Don’t know/Prefer not to answer | 13 (3.5) | 6 (3.2) | 7 (3.7) | |
| Preference for using fentanyl or drugs that have fentanyl in them | 0.371 | |||
| Yes | 67 (17.8) | 37 (19.6) | 30 (16.0) | |
| No | 309 (82.2) | 152 (80.4) | 157 (84.0) | |
| Score of fentanyl awareness questions **** | 0.017 | |||
| 0–3 correct | 27 (7.2) | 9 (4.8) | 18 (9.6) | |
| 4–5 correct | 200 (53.2) | 93 (49.2) | 107 (57.2) | |
| 6 correct | 149 (39.6) | 87 (46.0) | 62 (33.2) | |
| Treatment, harm reduction engagement and overdose: | ||||
| Lifetime history of drug or alcohol treatment | 0.145 | |||
| Yes | 313 (83.5) | 163 (86.2) | 150 (60.6) | |
| No | 62 (16.5) | 26 (13.8) | 36 (19.4) | |
| Lifetime history of administering naloxone to someone experiencing an overdose | <0.001 | |||
| Yes | 259 (68.9) | 157 (83.1) | 102 (54.5) | |
| No | 117 (31.1) | 32 (16.9) | 85 (45.5) | |
| Lifetime history of witnessing an overdose | <0.001 | |||
| Yes | 331 (88.5) | 179 (94.7) | 152 (82.2) | |
| No | 43 (11.5) | 10 (5.3) | 33 (17.8) | |
| Lifetime history of experiencing an overdose | 0.015 | |||
| Yes | 218 (58.8) | 122 (64.9) | 96 (52.5) | |
| No | 153 (41.2) | 66 (35.1) | 87 (47.5) |
Responses are not mutually exclusive; therefore, counts will not sum to overall and group totals.
Assessed through the question, “in the last month, who’s usually around when you’re using drugs?” Response options included “I use alone”, “A close friend”, “A casual friend or acquaintance”, “A sex partner”, “An immediate family or household member”, “An extended family member”, “A dealer”, “Strangers/people I don’t know”, “don’t know/refused”, which were collapsed into three mutually exclusive categories.
Assessed through the question, “In the last month, how often have you used fentanyl or drugs you were confident contained fentanyl” to which participants could indicate: “never”, “once or a couple of times”, “about once a month”, “at least every week”, “everyday” or “don’t know/refused”, which were collapsed into mutually exclusive categories.
Included 6 questions consisting of true/false statements items such as, “Fentanyl is an opioid”, “Fentanyl is not as strong as heroin”, “Fentanyl acts more quickly than heroin”, “Drugs that are mixed with fentanyl look different than drugs that are not mixed with fentanyl”, “Someone is more likely to overdose when using drugs that contain fentanyl than when using drugs that do not contain fentanyl”, “In Rhode Island, fentanyl now causes more overdoses than heroin”, which were scored and categorized based on the number of correct responses.
Bivariable analyses yielded a number of findings related to having used FTS before baseline (Table 1). Those who had previously used FTS before baseline were younger, and more likely to be currently on probation or parole (p<0.001, p=0.030 respectively). Being enrolled in RAPIDS at an SSP was not associated with FTS use before the study. Year of enrollment was not associated with FTS use (p=0.485) and a histogram of FTS use patterns before enrollment can be found in Figure 1. Participants who had used FTS were more likely to have a history of drug selling (p=0.008). While preference for using fentanyl was not associated with using FTS, having ever administered naloxone to someone overdosing, and ever witnessing an overdose were associated with using FTS (p<0.001, p<0.001, respectively). Having more general knowledge about fentanyl was associated with using FTS (p=0.017). Of note, exclusive solitary drug use (i.e. only using drugs alone) was not associated with a lifetime history of FTS use (p=0.239).
Figure 1:
Use of fentanyl test strip (FTS) over study enrollment period.
Drug use characterics had varying levels of significance when examining differences between those who had and had not used FTS before baseline. Those that had used FTS were more likely to have a lifetime history of injection drug use (p=0.012). Use of FTS before baseline was associated with regular use of heroin, powder cocaine, crystal methamphetamine, and benzodiazepines (p<0.001, p=0.017, p=0.022, and p=0.005, respectively).
Characteristics relating to FTS use in the month before enrollment can be found in Table 2. A total of 98 (26.1%) participants used FTS in the month before enrollment. A majority of those who had used FTS in the month before enrollment, 87.8%, completed the test on their own. When asked how fentanyl’s presence in the drug supply changed their drug use, 45.9% said they were more likely to use their drugs slowly, 39.8% said they were more likely to use in public, and 33.7% said they were more likely to carry a naloxone kit - which could have been given to the participant at an SSP or other community organization, purchased at a pharmacy. These responses are not mutually exclusive. Only 3.1% of people said that their use has not changed at all. A majority (76.5%) had at least one positive FTS in the past 30 days, and about half (52.0%) had at least one negative FTS. When asked how a positive test impacted drug use, 41.3% of those with a positive test responded that they used their drugs faster, 22.7% said they used faster, 20% used less, and 18.7% said that they used more after a positive FTS. When asked how having a negative FTS impacted their drug use practices, a majority 76.5% reported that their use did not change, whereas only 10.7% of those who had a positive FTS result stated that their use did not change.
Table 2.
Descriptive statistics for participants who reporting using FTSs in the 30 days before enrollment (n=98)
| Characteristic | Number (%) n=98 |
|---|---|
| Who performed the test? * | |
| Myself | 86 (87.8) |
| Close friend | 18 (18.4) |
| Stranger | 4 (4.1) |
| Dealer | 3 (3.1) |
| Immediate family/household member | 3 (3.1) |
| Casual friend/acquaintance | 2 (2.0) |
| Other | 2 (2.0) |
| Extended family member | 0 (0.0) |
| Don’t know/Refused | 0 (0.0) |
| Where did the test strip come from? * | |
| Project Weber/RENEW | 36 (36.7) |
| Another harm reduction organization | 32 (32.7) |
| Other** | 17 (17.3) |
| Uncertain | 9 (9.2) |
| AIDS Care Ocean State | 5 (5.1) |
| RAPIDS Clinical Trial | 1 (1.0) |
| Don’t know/Refuse | 1 (1.0) |
| Other research study | 0 (0.0) |
| In the last month, how many times have you tested your drugs for fentanyl? | |
| Median (IQR) | 4 (1,10) |
| Did any of the tests come back positive for fentanyl? | |
| Yes | 75 (76.5) |
| No | 20 (20.4) |
| Don’t know/Refuse | 3 (3.1) |
| Did any of the tests come back negative for fentanyl? | |
| Yes | 51 (52.0) |
| No | 43 (43.9) |
| Don’t know/Refuse | 4 (4.1) |
| Has fentanyl changed how you think about starting methadone/buprenorphine, or other forms of addiction treatment? | |
| Yes, I accessed addiction treatment because of concerns about fentanyl | 13 (13.3) |
| Yes, I am thinking about accessing treatment (but have not done so) | 18 (18.4) |
| Already in some kind of treatment | 25 (25.5) |
| No | 40 (40.8) |
| Don’t know/Refuse | 2 (2.0) |
| Has fentanyl changed how you use drugs? * | |
| More likely to inject slowly and/or taste drugs first | 45 (45.9) |
| More likely to use in public (outside) | 39 (39.8) |
| Less likely to use alone | 36 (36.7) |
| More likely to use where naloxone is available | 36 (36.7) |
| More likely to to carry take-home naloxone | 33 (33.7) |
| Using less often and/or using smaller amounts of a drug each time | 32 (32.7) |
| More like to use drugs unlikely to contain fentanyl | 30 (30.6) |
| Other | 18 (18.4) |
| Don’t know/Refused | 10 (10.2) |
| More likely to use with others | 7 (7.1) |
| Use hasn’t changed | 3 (3.1) |
| What did you do when you found out you had drugs containing fentanyl?* (n=75) | |
| Went slower | 31 (41.3) |
| Went faster | 17 (22.7) |
| Used less | 15 (20.0) |
| Used more | 14 (18.7) |
| Did a tester | 12 (16.0) |
| Used with someone else around | 12 (16.0) |
| Took drugs as usual | 8 (10.7) |
| Threw drugs out | 7 (9.3) |
| Sold drugs | 5 (6.7) |
| Got naloxone | 1 (1.3) |
| Other | 1 (1.3) |
| Don’t know/Refused | 0 (0.0) |
| What did you do when you found out you had drugs that did not contain fentanyl?* (n=51) | |
| Took drugs as usual | 39 (76.5) |
| Used more | 4 (7.8) |
| West faster | 3 (5.9) |
| Sold drugs | 2 (3.9) |
| Went slower | 2 (3.9) |
| Did a tester | 2 (3.9) |
| Don’t know/Refused | 2 (3.9) |
| Threw drugs out | 1 (2.0) |
| Used with someone else | 1 (2.0) |
| Other | 1 (2.0) |
| Used less | 0 (0.0) |
| Got naloxone | 0 (0.0) |
Responses are not mutually exclusive
Free text responses included:, Journey Clinic, methadone clinic, Providence Comprehensive Treatment Center, Scurvy Dog, someone on the street, and others
The group LASSO regularization method yielded a final model with 8 predictors of FTS use, found in Table 3. In the final adjusted logistic regression model, female gender identity (OR: 2.34; 95%CI: 1.26, 4.45) and having ever administered naloxone (OR: 2.60; 95% CI: 1.42, 4.86) were both independently and significantly associated with having ever used FTS.
Table 3.
Logistic regression model of correlates of FTS use with group LASSO regularization
| Characteristic | Adjusted Odds Ratio (95% Confidence interval) |
|---|---|
| Age | 0.97 (0.95 – 1.00) |
| Gender | |
| Man | Ref |
| Woman | 2.34 (1.26 – 4.45) |
| Transgender and other gender non conforming | 0.88 (0.17 – 3.65) |
| Probation status: | |
| Not currently on probation | Ref |
| Currently on probation or parole | 1.68 (0.95 – 3.02) |
| Regular use of powder cocaine: | |
| No regular use | Ref |
| Regular use | 1.63 (0.89 – 3.02) |
| Regular use of non - medical benzodiazepines | |
| No regular use | Ref |
| Regular use | 1.35 (0.71 – 2.57) |
| Lifetime history of drug selling: | |
| No history of drug selling | Ref |
| History of drug selling | 1.58 (0.85 – 2.98) |
| Lifetime history of administering naloxone to someone experiencing an overdose | |
| No | Ref |
| Yes | 2.60 (1.42 – 4.86) |
| Score of fentanyl awareness questions | |
| 0–3 Correct | Ref |
| 4–5 Correct | 0.71 (0.23 – 2.26) |
| 6 Correct | 1.41 (0.45 – 4.54) |
Differences between those who had heard of FTS before baseline and those who had not heard of FTS before baseline were assessed and can be found in Appendix Table 1. Use of fentanyl in the month prior to enrollment, lifetime history of naloxone administration, witnessing an overdose, and lifetime history of experiencing an overdose were associated with awareness of FTS before baseline (all p<0.05). Neither concern for personally using fentanyl nor concern for a friend using fentanyl were associated with awareness of FTS. Importantly, participants who reported exclusive solitary drug use were less likely to have ever heard of FTS compared to participants who reported using drugs with others around (p=0.024).
Discussion
While many of the people in this sub-study had used FTS before study enrollment, we identified sub-groups of people who use drugs with different demographics, drug use, or harm reduction characteristics who are not using FTS. Future research should identify whether these specific populations may benefit from their use. FTS use varied widely in ways that are both consistent and inconsistent with past literature. The bivariable and multivariable analyses highlighted different results. Though gender was not associated with FTS use in the bivariable analysis, it was in the LASSO logistic regression. On the other hand, having administered naloxone previously was significant in both the bivariable and multivariable analysis. In terms of demographic characteristics, bivariable analyses demonstrated that those who used FTS before baseline tended to be younger. Additionally with regard to demographics, our LASSO logistic regression showed that women have higher odds of FTS use than men. While younger age has been associated with FTS use in past literature (Oh et al. 2020), gender has not consistently been found to be associated with FTS use (Alyssa Shell Tilhou et al. 2022; Krieger et al. 2018).
People who used FTS were also more likely to be currently on probation or parole. This is consistent with research that has shown that PWUD may use FTS in order to determine if they would have positive urinalysis results at probation appointments (Reed, Guth, et al. 2022). However, this finding is not consistent with other literature which has found that harm reduction uptake is lower among people who have been released from incarceration (Victor, Ray, and Watson 2024). Though motivations for FTS use were not assessed in this study, it is possible that probation and parole status was positively associated with FTS use due to concerns about positive urinalysis or perhaps because of recognition that recent release from incarceration is a risk for overdose (Victor et al. 2022); however, additional research is needed to understand the nuances and motivations for why participants with histories in incarceration in this population used FTS at higher rates. Consistent with other research, drug selling was also found to be associated with FTS use (Krieger et al. 2018; Weicker et al. 2020).
A number of drug use characterics were associated with FTS use before baseline. FTS use before baseline was associated with lifetime injection drug use, engaging in solitary drug use, regular use of heroin or powder cocaine, and having used fentanyl in the past month. While some research has found that people who exhibit these characteristics are more likely to use FTS because of awareness of increased fentanyl contamination in opioid and stimulant drug supplies (Weicker et al. 2020; Reed et al. 2021), others have found that people who inject drugs or use fentanyl or drugs that are likely to be contaminated with fentanyl do not use FTS because of the assumption that fentanyl is ubiquitous in the drug market (Reed, Salcedo, Hsiao, et al. 2022). Drug selling was also associated with FTS use, which has been also congruous with past literature (Krieger et al. 2018; Reed et al. 2021). Future studies could investigate whether those who sell drugs are able to provide harm reduction education to those who buy as many PWUD place high degrees of trust in those who they buy from (Bardwell et al. 2019).
While a history of experiencing, witnessing, or responding to an overdose was associated with FTS use, neither concern for fentanyl contamination nor solitary drug use were associated with FTS use. While past literature has found that past overdose, and engagement with harm reduction practices - like naloxone administration - are associated with FTS use (Goldman, Krieger, et al. 2019; Park et al. 2021; Alyssa S. Tilhou et al. 2023), the fact that concern about fentanyl was not associated with FTS use is inconsistent with past literature which has found that PWUD use FTS to avoid fentanyl and keep themselves safe when using drugs (Park et al. 2020; Reed et al. 2021).
Even though a majority of participants in this sample have used FTS, there were still sub-groups of PWUD enrolled who were less likely to report use, but could benefit from it. For example, almost half of participants who had ever experienced an overdose had never used a FTS. At time of baseline interview, we did not ascertain whether participants perceived that their overdoses had been attributed to either known or unknown fentanyl use. Though fentanyl had been pervasive in the Rhode Island drug supply as early as 2014 (Marshall et al. 2017), participants may not have known that their drugs contained fentanyl and therefore did not seek fentanyl-specific harm reduction resources. Given that research has found that FTS use leads to additional uptake of overdose prevention strategies (Tobias et al. 2024), it is important that PWUD who have previously experienced overdose, or are at higher risk for overdose, can access FTS, which may in turn lead to downstream uptake of additional overdose prevention practices. Further, it is essential that people who have experienced an overdose are able to access other tools (e.g., naloxone) to help mitigate future overdoses that are responsive to the ever-evolving drug use landscape.
We found that almost 20% of our sample reported exclusive solitary drug use, which was not associated with a lifetime history of FTS use. Furthermore, in secondary analyses, participants who reported exclusive solitary drug use were less likely to have ever heard of FTS. These findings demonstrate the urgent need for innovations to increase awareness and uptake of drug checking services among PWUD alone (and who are often not connected to existing harm reduction programs). Promising strategies include mail-order distribution programs, and engaging those who sell drugs to provide education to their clients. In addition to being identified as trusted sources for clients (Bardwell et al. 2019), past research has found that those who supply drugs have provided harm reduction education and resources to others in their networks (Hedden-Clayton et al. 2024). This is also consistent with our findings that those who sold drugs were more likely to have used FTS prior to enrollment. In Rhode Island, other programs to reach PWUD in private locations (often alone) include door-knocking programs that focus on ‘hotspot’ neighborhoods (i.e., those with high levels of overdose activity), and on-demand home delivery of harm reduction equipment (Brown et al. 2022).
Limitations
This study has a number of limitations. This study relied on self-reported data, and is therefore subject to recall and information bias. Additionally, the surveys were researcher-administered to reduce information biases; thus, data may be subject to social desirability bias. Data were cross-sectional, and therefore, there is no way to deduce if FTS usage preceded or followed overdose experiences. A large number of participants were recruited directly from syringe services programs and therefore, results may not be generalizable to PWUD who are not engaged in harm reduction services. While all survey measures were administered by trained research assistants who actively clarified questions that were unclear, it is possible that some measures, such as drug selling, were interpreted in different ways by some participants, leading to possible measurement error. Finally, fentanyl use and other drug use were asked about separately. This seemed appropriate at the time of survey development when fewer people were knowingly and/or intentionally using fentanyl. However, the unregulated opioid supply has been increasingly contaminated with fentanyl since before and throughout the time of data collection, and thus there may be measurement error as it pertains to heroin and fentanyl use as captured by our data collection instrument.
Conclusion
In summary, there were important differences between PWUD who used FTS and those who had heard of them and had not used them previously. Though lifetime history of overdose, witnessing an overdose, and responding to an overdose were associated with FTS use, exclusive solitary drug use was not. There may be sub-populations of PWUD who are not currently using FTS, and future research is needed to determine if access to FTS or other drug checking services could benefit these individuals and help reduce overdose rates
Supplementary Material
Highlights.
Exclusive solitary drug use (i.e., only using drugs alone) was not associated with FTS use.
Witnessing and responding to an overdose were associated with FTS use.
Uptake of FTS is high among PWUD in Rhode Island.
History of experiencing an overdose or having administered naloxone to someone experiencing an overdose were associated with FTS use.
Acknowledgements:
The authors would like to acknowledge Andrew Gould, Cathy Lenox, Esther Moon, Michael Tan, Roxxanne Newman, Sari Greene, Tania Lobo Paz, and Tayla Giguere for performing data collection activities over the course of the RAPIDS study.
Funding source:
The RAPIDS project is supported by the US National Institute on Drug Abuse [R01-DA03447975].
Appendix Table 1.
Comparison of demographic and behavioral characteristics of those who have heard of FTS and those who have not heard of FTS at time of enrollment (n= 509)
| Characteristic | Overall n=509 | Have heard of FTS before baseline n=376, 73.9% | Have not heard of FTS before baseline n= 187 (49.%) | P-value |
|---|---|---|---|---|
| Demographics: | <0.001 | |||
| Age | ||||
| Mean (SD) | 43.3 (11.2) | 42.1 (10.8) | 46.6 (11.9) | |
| Current Gender identity | 0.644 | |||
| Man (cisgender) | 325 (64.1) | 240 (64.0) | 85 (64.4) | |
| Woman (cisgender) | 163 (32.1) | 119 (31.7) | 44 (33.3) | |
| Trangender/Other | 19 (3.7) | 16 (4.3) | 3 (2.3) | |
| Race | <0.001 | |||
| White | 281 (55.5) | 222 (59.2) | 59 (45.0) | |
| Black | 94 (18.6) | 61 (16.3) | 33 (25.2) | |
| Mixed, bi-racial, multi-racial | 66 (13.0) | 54 (14.4) | 12 (9.2) | |
| Other | 65 (12.8) | 38 (10.1) | 27 (20.6) | |
| Ethnicity | 0.108 | |||
| Non-Hispanic | 402 (79.1) | 304 (80.9) | 98 (74.2) | |
| Hispanic | 106 (20.9) | 72 (19.1) | 34 (25.8) | |
| Current relationship status | 0.338 | |||
| Spouse/partner whom living with | 125 (24.7) | 87 (23.3) | 38 (28.6) | |
| Regular partner whom not living with | 36 (7.1) | 27 (7.2) | 9 (6.8) | |
| Dating/seeing someone | 57 (11.3) | 47 (12.6) | 10 (7.5) | |
| Single | 288 (56.9) | 212 (56.8) | 76 (57.1) | |
| Year of enrollment | 0.045 | |||
| 2020 | 37 (7.3) | 29 (7.7) | 8 (6.0) | |
| 2021 | 209 (41.1) | 145 (38.6) | 64 (48.1) | |
| 2022 | 224 (44.0) | 167 (44.4) | 57 (42.9) | |
| 2023 | 39 (7.7) | 35 (9.3) | 4 (3.0) | |
| Recruitment Source * | 0.978 | |||
| Syringe services program | 189 (37.1) | 138 (36.7) | 51 (38.3) | |
| Participant referral | 110 (21.6) | 79 (21.0) | 31 (23.3) | |
| Bus ad | 54 (10.6) | 38 (10.1) | 16 (12.0) | |
| Other | 108 (21.2) | 77 (20.5) | 31 (23.3) | |
| Lifetime history of incarceration | 0.110 | |||
| Yes | 394 (77.9) | 297 (79.6) | 97 (72.9) | |
| No | 112 (22.1) | 76 (20.4) | 36 (27.1) | |
| Lifetime history of probation or parole | 0.011 | |||
| Yes | 387 (76.5) | 296 (79.4) | 91 (68.4) | |
| No | 119 (23.5) | 77 (20.6) | 42 (31.6) | |
| Drug use characteristics: | ||||
| Lifetime history of injection drug use | ||||
| Yes | 280 (55.0) | 231 (61.4) | 49 (36.8) | <0.001 |
| No | 229 (45.0) | 145 (38.6) | 84 (63.2) | |
| Drug use social patterns ** | 0.024 | |||
| Use alone exclusively | 99 (21.0) | 64 (18.1) | 35 (29.9) | |
| Use alone and with others | 151 (32.1) | 118 (33.3) | 33 (28.2) | |
| Use with others exclusively | 221 (49.6) | 172 (48.6) | 49 (41.0) | |
| Regular use of prescription opioids | 0.048 | |||
| Yes | 124 (24.4) | 100 (26.6) | 24 (18.0) | |
| No | 385 (75.6) | 276 (73.4) | 109 (82.0) | |
| Regular use of heroin | <0.001 | |||
| Yes | 161 (31.6) | 139 (37.0) | 22 (16.5) | |
| No | 348 (68.4) | 237 (63.0) | 111 (83.5) | |
| Regular use of powder cocaine | 0.616 | |||
| Yes | 137 (16.9) | 99 (26.3) | 38 (28.6) | |
| No | 372 (73.1) | 277 (73.7) | 95 (71.4) | |
| Regular use of crack cocaine | 0.571 | |||
| Yes | 309 (60.7) | 231 (61.4) | 78 (58.6) | |
| No | 200 (29.3) | 145 (38.6) | 55 (41.4) | |
| Regular use of crystal meth | 0.001 | |||
| Yes | 83 (16.3) | 74 (19.7) | 9 (6.8) | |
| No | 426 (83.7) | 302 (80.3) | 124 (93.2) | |
| Regular use of benzodiazepines | 0.006 | |||
| Yes | 112 (22.0) | 94 (25.0) | 18 (13.5) | |
| No | 397 (78.0) | 282 (75.0) | 115 (86.5) | |
| Lifetime history of drug selling | 0.009 | |||
| Yes | 349 (69.1) | 269 (72.3) | 80 (60.2) | |
| No | 156 (30.9) | 103 (27.7) | 53 (39.8) | |
| Fentanyl use: | ||||
| Use of fentanyl or drugs that contained fentanyl in the last month *** | <0.001 | |||
| Yes | 140 (27.5) | 120 (31.9) | 20 (15.0) | |
| No | 337 (66.2) | 243 (64.6) | 94 (70.7) | |
| Don’t know/Prefer not to answer | 32 (6.3) | 13 (3.5) | 29 (24.3) | |
| Score of fentanyl awareness questions **** | <0.001 | |||
| 0–3 correct | 55 (10.8) | 27 (7.2) | 28 (21.1) | |
| 4–5 correct | 279 (54.8) | 200 (53.2) | 79 (59.4) | |
| 6 correct | 175 (34.4) | 149 (39.6) | 26 (19.5) | |
| Preference for using fentanyl or drugs that have fentanyl in them | 0.003 | |||
| Yes | 76 (15.0) | 67 (17.8) | 9 (6.9) | |
| No | 430 (85.0) | 309 (82.2) | 121 (93.1) | |
| Treatment, harm reduction engagement and overdose: | ||||
| Lifetime history of drug or alcohol treatment | 0.083 | |||
| Yes | 415 (81.7) | 313 (83.5) | 102 (76.7) | |
| No | 93 (18.3) | 62 (16.5) | 21 (23.3.) | |
| Lifetime history of administering Narcan/naloxone to someone experiencing an overdose | <0.001 | |||
| Yes | 307 (60.3) | 259 (68.9) | 48 (36.1) | |
| No | 202 (39.7) | 117 (31.1) | 85 (63.9) | |
| Lifetime history of witnessing an overdose | 0.002 | |||
| Yes | 434 (85.6) | 331 (88.5) | 103 (77.4) | |
| No | 73 (14.4) | 43 (11.5) | 30 (22.6) | |
| Lifetime history of experiencing an overdose | 0.001 | |||
| Yes | 273 (54.2) | 218 (58.8) | 55 (41.4) | |
| No | 231 (45.8) | 153 (41.2) | 78 (58.6) |
Responses are not mutually exclusive; therefore, counts will not sum to overall and group totals.
Assessed through the question, “in the last month, who’s usually around when you’re using drugs?” Response options included “I use alone”, “A close friend”, “A casual friend or acquaintance”, “A sex partner”, “An immediate family or household member”, “An extended family member”, “A dealer”, “Strangers/people I don’t know”, “don’t know/refused”, which were collapsed into three mutually exclusive categories.
Assessed through the question, “In the last month, how often have you used fentanyl or drugs you were confident contained fentanyl” to which participants could indicate: “never”, “once or a couple of times”, “about once a month”, “at least every week”, “everyday” or “don’t know/refused”, which were collapsed into mutually exclusive categories.
Included 6 questions consisting of true/false statements items such as, “Fentanyl is an opioid”, “Fentanyl is not as strong as heroin”, “Fentanyl acts more quickly than heroin”, “Drugs that are mixed with fentanyl look different than drugs that are not mixed with fentanyl”, “Someone is more likely to overdose when using drugs that contain fentanyl than when using drugs that do not contain fentanyl”, “In Rhode Island, fentanyl now causes more overdoses than heroin”, which were scored and categorized based on the number of correct responses.
Footnotes
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Declaration of interest: The authors have no interest to declare
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