By Bethany Romano, MBA'17
“So much of what we know about fentanyl is from autopsy reports,” laments Traci Green, professor and director of the Opioid Policy Research Collaborative (OPRC). What is known is frightening: Last fall, the Centers for Disease Control and Prevention (CDC) reported that nearly half of all overdose deaths from March 2018 to February 2019 were due to fentanyl and other synthetic opioids.
These data paint a desperate picture — and an incomplete one. Green and other public health experts combine numbers from autopsy reports, crime labs, poison control centers and 911 calls, but many of these datasets aren’t available until months or years after the data are collected.
These delays are deadly. “Every single time fentanyl enters the drug supply in a new city or town, overdose rates double. They double,” says Green. “We need to know where fentanyl is entering the market today — not two years ago — if we’re going to save any lives.”
Only a fraction of police-confiscated drugs gets tested for fentanyl or other cutting agents. Most are destroyed or kept in storage — often for years — while the few samples that become evidence in criminal cases go to crime labs for testing. “There’s so many different places where we could possibly collect data, but instead, it’s on a shelf. Or it’s trash.
“But it just so happens that epidemiologists really love trash,” she says with a grin. “Where some see trash, I see data.”
So Green and her colleagues are collecting trash — both untested drugs seized by police departments and drug packaging from active users — to test it for fentanyl and other cutting agents. They’re then providing that information in real time to public health officials and drug users to learn about the drug supply and help keep users safe.
Green’s goal is for this real-time testing, called “drug checking,” to stabilize fentanyl fluctuations in the market and empower users to know what is going into their bodies. “That level of autonomy is afforded to all other medical patients,” she says, “so why not people with opioid use disorder?”
Bridging Science and Creativity
The opioid crisis began in the 1990s with prescription painkillers whose addictive qualities were underplayed or denied by their manufacturers. Many people who became addicted eventually turned to heroin, as prescription painkillers grew more difficult to acquire. Fentanyl, a synthetic opioid often used as a cutting agent in street heroin, is so potent that minuscule amounts can result in a fatal overdose. In 2017, over 70,000 people died from drug overdoses in the U.S., 28,000 of them from fentanyl and its analogues.
That same year, the Heller School founded the Opioid Policy Research Collaborative to combat this growing epidemic. Green joined the OPRC as its director in January 2020. In her career as an epidemiologist, Green helped increase access to naloxone (an overdose antidote), co-led strategic planning for the Rhode Island Governor’s Task Force on opioids and overdose, and became an expert adviser for the CDC and the High Intensity Drug Trafficking Areas.
Over the last decade, she has developed deep roots in metro Boston, including critical partnerships with police departments, public health commissions and organizations focused on harm reduction for active users, like needle-exchange sites. Brittni Reilly of the Bureau of Substance Addiction Services at the Massachusetts Department of Public Health (DPH) says, “Traci and her team have national expertise in the topic of drug checking. We’ve been really honored to participate and support this emerging field.”
As a scientist, Green emphasizes the importance of creativity and interdisciplinary thinking in her work. “I think we get stuck in ruts as scientists if we stay only within our disciplines,” she says. “The surge in fentanyl overdoses really got me thinking that the tools we’re using are insufficient.”
In addition to seeking out stories from users and service providers, she pieces together stories from the data. “When I look at medical examiner cases, I try to reconstruct what happened and see opportunities for intervention. Where did we miss the chance to connect with this person? How could we have prevented that death?
“It’s one of the reasons I was so excited about coming to Heller: the opportunity to work with like-minded people who were willing to take the snow globe and shake it up a little bit.”
For Green, like many of the people working in this field, the urgency to solve the opioid epidemic feels personal. “I have loved many people who use drugs throughout my life. It’s devastating seeing communities you care about losing young people, or even losing older people who have used drugs for a long time but who aren’t able to navigate this terrain. Drug checking is our effort to set the scales. As scientists, we have other tools, and we should be using them.”
Prioritizing Drug User Safety
Drug checking is a consumer safety issue, according to Green: “With drug checking, we’re treating street drugs the same way we treat any other substance that someone consumes on a regular basis. We put public health first.”
In 2018, the Bloomberg American Health Initiative funded Green and collaborators from Johns Hopkins University and Rhode Island Hospital to determine which field-testing devices were best at detecting fentanyl in street drugs. The team partnered with police departments in Providence and Baltimore to blind test over 200 samples of confiscated drugs using three devices: an infrared spectrometer, a Raman spectrometer and simple fentanyl test strips. They determined that a two-pronged approach is best: the infrared spectrometer — which provides detailed chemical profile information — and fentanyl test strips — which are cheap, simple to use and highly sensitive to fentanyl.
“When we finished that study and got that information out, other projects started using fentanyl test strips in the U.S. But to our knowledge, none took the next step of buying some of these more expensive devices,” says Green. The devices, which are already used around the world in countries like Australia, Canada and Germany, resemble a dark metal case the size of a piece of carry-on luggage.
Green partnered with Sam Tobias, senior drug-checking technician at the University of British Columbia in Vancouver, to train her team on the infrared spectrometer. “Drug checking could provide a modicum of regulation in an otherwise completely unregulated market,” notes Tobias. “For a long time, the drug market was kind of a black box. People just got what they got, and they didn’t really have answers to other questions, like, ‘What am I actually getting here?’”
The spectrometers Green uses are most frequently purchased by pharmaceutical companies to conduct quality-control testing. Each unit costs upward of $40,000. In addition to the cost and the novelty of using spectrometers on street drugs, the legal landscape is unclear at best. Each state differs, she says, but in some states, even fentanyl test strips can be seen as drug paraphernalia.
“There’s a gray zone, frankly. With the exception of police-confiscated substances, we can’t legally hold or test drugs. So we test remnant drugs, package materials, used cookers. It’s sometimes frustrating, because, of course, it’s best if we can test the drug before it’s used.”
Despite the convoluted legal issues, Green and her team conducted a pilot drug-checking program at Access, Harm Reduction, Overdose Prevention and Education (AHOPE), a harm reduction and needle-exchange site in the South End run by the Boston Public Health Commission. They’ve also provided drug checking on the CareZONE van, a mobile addiction-services program run by the Kraft Center for Community Health.
Jennifer Tracey, director of Boston Mayor Marty Walsh’s Office of Recovery Services, says, “The substance use crisis has devastating effects on individuals and families across our city. That is why the city of Boston continues to invest in providing the best and most effective harm-reduction and recovery services. We hope this technology and research will help us achieve our goal of reducing overdoses and saving lives.”
In addition to making the drug supply safer, these services reduce information lag for public health officials. “Fentanyl test strips take about five minutes, and spectrometers take about 40 seconds to scan and a few minutes for a technician to read the results. The full drug-checking experience could take about 15 minutes, start to finish, and then you have information that you can act on without anyone getting arrested or hurt,” Green says.
“This work is so innovative, but for a very simple reason,” says Constance Horgan, professor and director of Heller’s Institute for Behavioral Health, where OPRC is housed. “Almost everybody working to counter the opioid epidemic is focused on demand-side interventions: reducing demand for prescription opioids, for illicit opioids. Traci’s drug-checking work is one of the few supply-side interventions out there.
Reaching "the last 10%" in Boston and Beyond
Green intends to expand to provide drug-checking services in around a half-dozen communities in Boston this year. The CDC and the Massachusetts Department of Public Health are funding her team to build out drug-checking and drug-supply surveillance systems with spectrometers at multiple sites around the Bay State, including a key partnership with the New Bedford Police Department.
She is partnering with the Police Assisted Addiction and Recovery Initiative (PAARI) to distribute fentanyl test strips far and wide. “Unlike the spectrometers, test strips are inexpensive, easy to distribute and share; they can be used anywhere at any time, and they don’t require a ton of interpretation. And they’re great at detecting most of the major kinds of fentanyl, which could save lives.”
On all sides, Green is confronted with stakeholders who see the potential for drug checking to curtail the deadliest aspects of the opioid epidemic. “The overall impression we’re getting from people is that this is exciting and pretty groundbreaking, but also really frustrating that we aren’t yet able to offer these services regularly.
“Some of the providers we’re speaking with are trying to reach that last 10% of people who don’t want to come in for services. They may not be someone who injects drugs, or they may not see themselves as needing services. But maybe they went to a new dealer and their drug seemed different, and they want to make sure there’s no fentanyl in it. That person could come in for drug checking, and in addition to getting information about their drug that could be lifesaving, maybe they’ll also pick up clean syringes, get hiv tested, grab a few Narcan kits and some fentanyl test strips. This is a distribution pathway for tools that aren’t reaching other neighborhoods or spaces. And most importantly, it’s respecting the dignity of people who use drugs, and elevating their health and safety. That’s all for the better.”