Law Enforcement and Community Provision of Fentanyl Test Strips to People Who Use Drugs for Engagement and Referral to Services

Abstract

Use of fentanyl test strips (FTS) to test illicit drugs has been shown to be an effective harm-reduction tool for raising awareness of fentanyl risks, increased self-efficacy to prevent overdose, and safer use behavior changes. From March to June 2020, a total of 6 Massachusetts municipal police departments piloted FTS kit distribution during post–overdose outreach visits, community outreach, and related programming. The Police Assisted Addiction and Recovery Initiative developed the kits, trained departments, and oversaw implementation. The pilot evaluation involved site observations, process measures, and interviews with staff and kit recipients. For every kit distributed, there was approximately 1 health or support service or referral provided; 320 kits were distributed. Key themes from interviews were conceptualizing FTS as a tool, collaborations, and adaptations. Police departments that partnered with community programs amplified project reach. FTS distribution is a simple yet powerful tool that community providers and police can offer alongside linkage to care services and engagement with people who use drugs and their family and friends.

The drug supply is in enormous flux, with illicitly manufactured fentanyl (IMF) creating a deadly environment for people who use drugs (PWUD). IMF is sold as heroin and counterfeit prescription opioids and found as contaminant in cocaine and other drugs.1 PWUD report relying on smell, taste, color, and word of mouth to determine fentanyl presence, but these approaches are not foolproof and detection errors come at great risk.2 Use of immunoassay fentanyl test strips (FTS) by PWUD has been shown to increase fentanyl awareness and is associated with greater self-efficacy to prevent overdose and safer use behavior changes.3–7 The easy-to-use, inexpensive FTS require minimal sample preparation and rapidly produce valid results.8 Many syringe service programs (SSPs) and other community initiatives distribute FTS.3,9 Although public safety outreach efforts offer naloxone, provide referrals to treatment and mental health care, and extend other local resources,10 there are no known examples of FTS distribution by police. We conducted a pilot to evaluate implementation and feasibility of a police-led FTS kit distribution program in 6 Massachusetts municipalities.

Methods

The Massachusetts Department of Public Health oversaw a multisite FTS pilot project that was independently evaluated by Brandeis researchers and implemented by the Police Assisted Addiction and Recovery Initiative (PAARI), a nonprofit organization that provides training, support, and resources regarding nonarrest pathways to treatment and recovery to police departments. Municipal police departments were invited to apply to pilot FTS distribution, aligning with the Massachusetts Harm Reduction Commission recommendations.11 To pilot departments, PAARI provided trainings, conducted regular check-ins, and fostered a learning community through peer-enhanced communications and ongoing supports. A series of technical assistance videos on how to distribute kits and fentanyl safety awareness were created and shared publicly (https://paariusa.org/rollcallvideos/).

Data collected included monthly reports of kits distributed, manner of distribution (via outreach, other mechanism), and services provided or referrals made at kit distribution. Mid-pilot, small cups and instructions to dilute suspected methamphetamine samples were added to kits to improve test validity12 along with masks and hand sanitizer for COVID-19 safety. Midpoint and final convenings gathered agencies to share successes and challenges.

To track implementation and evaluate intervention feasibility, a mixed-methods approach was undertaken. Methods included analysis of monthly service reports, site observations, confidential interviews with recipients and program implementers, and an anonymous exit survey of piloting agencies.

A semistructured interview guide for pilot partners and FTS recipients covered a range of topics: experiences supporting public health and public safety efforts, with overdose, and in providing harm-reduction tools; perceptions and familiarity with FTS; implementation and distribution experiences; and COVID-19 adaptations and impacts. Interview topics for FTS recipients also covered the following: experience with overdose, harm reduction, interactions with community agencies; familiarity in receiving and using FTS; peer education; and secondary distribution. A Textual Analysis framework was applied to identify, contextualize, and report the most saliently semantic themes.13

Finally, all participating agencies were invited to complete an anonymous online exit survey that assessed their opinions and knowledge regarding FTS, syringes, naloxone, and Massachusetts laws relevant to FTS. Descriptive statistics were used to analyze all survey data and services reported.

Results

After an application period, 6 pilot police departments were selected on the basis of geographic considerations and overdose burden. Unpredictably, the project timeline collided with the start of the COVID-19 pandemic (see Supplemental Digital Content Figure 1, available at http://links.lww.com/JPHMP/A999): from April to June, 320 kits were distributed, leading to provision of 318 referrals or follow-up services.

Three implementation models emerged. Three departments employed a police department–led model of distribution that relied upon community outreach by officers and civilian staff and involved community partners in no or limited ways. Two departments employed a community program–led distribution model by working with existing community partners, such as SSPs, treatment programs, and hospitals, to assist in distribution; police supported but had little direct involvement in this model. One department adopted a hybrid model of police- and community-led kit distribution, wherein police fostered new collaborations with local treatment programs to augment the pilot's reach. The highest volume of kits and services provided was from community programs that received kits from police department partners. There were 97, 115, and 108 kits, respectively, distributed through the 3 models, and 65, 206, and 47 associated referrals and services provided (Table). Most services or referrals provided encompassed harm-reduction materials (eg, syringes, naloxone), drug treatment, counseling services, wound care, food, or housing. For every 1 kit distributed, there was approximately 1 service or referral provided.

TABLE 1. Fentanyl Test Strip Kits Distributed and Services and Referrals Provided by Each of 3 Main Models of Kit Distribution.

	Police Department–Led Model	Community Program–Led Model	Hybrid Police- and Community-Led Model
Number of fentanyl test strip kits distributed	97	115	108
Number of referrals/services	65	206	47
Types of referrals/services
Provision of harm-reduction servicesa	27	142	0
Drug treatment	13	19	20
Counseling	6	5	16
Wound care	4	13	0
Meals/food	3	10	0
Housing	9	3	0
Medical	0	5	0
Financial	0	3	0
HIV/HCV testing	3	0	11
Identification card support	0	3	0
Legal support	0	2	0
Drug-checking services	0	1	0

Abbreviations: HCV, hepatitis C virus; HIV, human immunodeficiency virus.

^aProvision of harm-reduction services included provision of overdose education and naloxone distribution, sterile syringes, and safe use supplies. More than 1 referral or service may have been provided.

Twenty-two interviews were conducted with recipients (n = 2) and implementers (n = 20), from which we identified 3 themes around implementation and feasibility: conceptualizing FTS as a tool, collaborations, and adaptations.

First, data suggested that police departments were willing to distribute FTS kits and found them useful to promote safety conversation:

It's the engagement. It's to get there and talk to ‘em. I have ... no skepticism now. I just see it as an engagement program. I mean, if somebody is taking the time to test, you know, that's great. You know? Maybe they won't take a pill that they think is.... Adderall and have it be pressed fentanyl, you know? If that's what they do, that's what they do, that's great. It'll probably save their life. But, you know ... as an engagement tool, I think it's great if you can stop and talk to somebody for a couple of minutes. And even if they throw the strip away behind your back when you walk away, then at least you talked to them and you maybe might have planted that seed.

Others saw utility in supporting engagement in preventive and harm-reducing behaviors for the person at risk and how FTS could be tools for caregivers they interact with too:

So, one mom was scared. She goes, “I don't know if I wanna give it to him,” 'cause now I'm giving him permission to use drugs. And she says, “You know, walk that through. What if he buys drugs and he passes away? That's gonna weigh heavy on you.” And she said, “You're right. Like, I can't control his outcome in regards to using or not using, but I can give him a prevention method which is handing him this kit.”

Second, linked to the pilot, we observed a strengthening of existing partnerships between community programs and police departments and the creation of new ones. Police officers were acutely aware of the value of relationships with community agencies, as one officer stated:

I tell you, I couldn't do what we do without the groups that we work with ... I mean, I think I said it on the last Zoom call, but they've been outstanding. They have done basically all the leg work for us and, you know, they are the ones that have the connections in the community. And they have been the ones that have, kind of, like, introduced us into that community.

Some community partners became involved in the intervention because they had existing relationships with the police, while other community connections evolved serendipitously: “A [police officer] in the Community Impact Unit asked if we were interested in providing these to people that we see inpatient or wherever I see them and we jumped on the idea.”

Third, adaptations to the kit and distribution approaches emerged. Both community partners and police departments innovated social media content (Facebook, Instagram, Twitter) to share about FTS availability in the community and were subsequently contacted requesting FTS delivery or pickup locations (during COVID-19 restrictions). Another adaptation requested the creation of trainings, materials, and kit instructions in other languages, especially Spanish. After the pilot end, Spanish language materials and videos were created for dissemination.

Finally, findings from the exit survey (n = 23 of 33; 70% response rate) suggested that participation in the pilot led to further interest in provision of other harm-reduction supplies. Respondents indicated interest in starting distribution of naloxone (2 police departments), sterile syringes (1 hospital, 1 police department), and personal syringe disposal units (4 police departments, 1 community partner). A majority agreed that they now consider FTS (89%), naloxone (94%), and sterile syringes (83%) as positive engagement and harm-reduction tools for PWUD. The only consistently named barrier from community partners was confusion over the legal status of FTS and concerns around their possession and distribution.

Implications for Policy & Practice

• FTS are an easy-to-use intervention that community partners and police can offer alongside linkage to treatment and recovery services.

• Police departments that partnered with or arranged for community partner programs to lead provision of FTS directly to people at risk of fentanyl use had greater subsequent distribution of harm-reduction supplies, referrals for medical and social support services, and other care connections than programs that relied only upon police-led FTS distribution points.

• It is important to provide tools that assist people in detecting fentanyl so that they can better care for themselves and others and reduce possible harms of fentanyl.

Discussion and Conclusion

In 90 days and amidst pandemic stay-at-home orders and suspension of all nonessential services, FTS pilot partners distributed hundreds of kits, leading directly to referrals for supporting services such as drug treatment, wound care, food, and housing. Regardless of the pandemic, PWUD and their social networks needed services and FTS pilot partners strived to meet those needs. In so doing, the intended goals to raise awareness of local supporting services and create additional pathways and linkages to services were met in the 6 municipalities.

Findings suggest that FTS, distributed through community agencies or partnerships with police, can be one, promising engagement tool set within the broader landscape of overdose awareness and as a complement to more comprehensive strategies for harm reduction, treatment, and recovery.

Clear need for FTS, financial support, legal clarity, and pilot examples can facilitate dissemination of public health innovations. As of April 2021, federal guidance explicitly permits FTS purchase with health and social service funds. A recent legal analysis explained the legality of possessing and distributing drug-checking equipment such as FTS in Massachusetts and other states.14 This pilot demonstrates several models of collaborations between public health and public safety entities to bridge access to lifesaving tools such as FTS. Additional study across more geographies is warranted and may provide further insights.