Your Captain Speaking: Fentanyl Test Strips for EMS

“Samantha, it’s not often that I can’t decide what we should do with a new test available to EMS, but maybe we can sort out if we should have fentanyl test strips in our ambulances.”

“Let’s figure this out, Dick. What do the test strips tell us, how do they work, and what are the pros and cons for EMS?”

It was not that many years ago that we first heard about fentanyl in EMS, both for pain management and, sadly, as an abused drug. Today there are a shocking number of fentanyl overdoses in the US. The numbers are not pure and accurate, but we can easily agree there are too many. Fentanyl can be mixed with other drugs. Many nonfatal adverse events are either not reported or never identified.

Multiple states are considering legislation making it legal to possess or buy fentanyl test strips for personal use. Several states consider these “drug paraphernalia” and illegal, while others consider them a “harm reduction” tactic, as Kaiser Health News put it, “to help prevent overdose deaths from illicit drugs that users may not know are laced with fentanyl.”¹

So what do fentanyl test strips (FTS) do? They are much the same size as a urine test strip and relatively inexpensive at about $1 apiece. An important takeaway is that they only indicate if fentanyl is present in the sample—not how much, its strength, or its purity. The test does have pretty good accuracy. The strips also detect analogs of fentanyl such as carfentanil; however, they will show a negative result for other opiates such as heroin.

Opinions differ whether the public should be allowed to possess and use fentanyl test strips. Whatever risks they assume, drug users might wish to know if their illegal drugs contain fentanyl that may kill them rather than just getting them high. They can certainly avoid fentanyl overdose by not taking illegal drugs, but this implies the use of fentanyl test strips would perhaps increase the use of illegal drugs. There is no empirical evidence that FTS increase or facilitate illegal drug use.

EMS Use

We know when we encounter a narcotic overdose that if fentanyl is involved, we will very likely use more naloxone with a patient. Your local procedures must be followed, but generally start with higher doses of naloxone and keep them coming. Are the results of a fentanyl test beneficial to a patient’s immediate treatment and important to have in an EMS setting? You be the judge. There was a time when we did not check patients’ blood sugar routinely, and for a long time we did not have the capacity to do so. The same with pulse oxygen saturation, which is ubiquitous now.

The process of conducting a test presents obvious problems for us in EMS. A publication from the New York City Health department outlines 3 ways to run a test:²

1. First, dissolve all the drugs you plan to use in water. The PDF states to use 1 teaspoon of water for every 10 mg of meth or ecstasy and half a teaspoon for all other drugs. Mix up the solution and test it.
2. Finely crush the drugs on a clean surface and place them in a small plastic bag and shake the bag to mix them. Not all fentanyl is evenly distributed in a pill. Empty the bag and retain it for later use. A small amount of the drug residue will be left in the bag. Add water to the residue and test.
3. Put 10 mg of the drugs (enough to cover Abraham Lincoln’s hair on a penny) in a clean, dry container. Add water and test.

For EMS this assumes there is some of the drug available to collect and test. Option No. 2 is likely the best bet for field collection. There might be enough in a syringe used by the patient, perhaps on a flat surface nearby where drugs were present, pill bottles, or even on the patient’s face. A cotton swab is effective for collecting these samples.

Determining 10 mg of product is difficult and most likely needs to be done on the scene and not later in the ambulance. The good news is that measuring a teaspoon or half a teaspoon of water is easy for EMS, as a teaspoon is almost exactly 5 mL, so we could draw up in a syringe either 5 or 2.5 mL of water. Unless the manufacturer specifies use of normal saline, it has to be water. Most of our water bottles in ambulances are for personal use, so this needs to be planned for. A medicine cup is a good container to run the test and already may be on many ambulances.

Documentation

Our patient care reports are important to the patient’s medical record and as a legal document. A patient, if their capacity allows, may object to the testing for several reasons. The suspected drugs or substance we want to test is their property and has value to them, and they don’t want it destroyed or wasted. The patient may fear that law enforcement may use the results as probable cause or evidence and decline, perhaps vigorously. If a patient is unresponsive and cannot grant permission, is consent implied? Clearly, it must be done through a well written and followed EMS protocol.

“Dick, I think adding FTS is something EMS agencies, EMTs, paramedics, and medical directors should discuss and decide for their own systems.”

What say you?

References

1. Miller A. As Overdoses Soar, More States Decriminalize Fentanyl Testing Strips. Kaiser Health News. Published May 5, 2022. https://khn.org/news/article/states-decriminalize-fentanyl-testing-strips/view/republish

2. NYC Health. How to Test Your Drugs Using Fentanyl Test Strips. New York City Health Department. www1.nyc.gov/assets/doh/downloads/pdf/basas/fentanyl-test-strips-brochure.pdf

Dick Blanchet, BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Missouri and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years. He is a graduate of the US Air Force Academy with an MBA from Golden Gate University.

Samantha Greene is a paramedic and field training officer for the Illinois Department of Public Health Region IV Southwestern Illinois EMS system, a paramedic and FTO for Columbia EMS in Illinois, and a full-time paramedic at the St. Louis South City Hospital emergency department.