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High willingness to use rapid fentanyl test strips among young adults who use drugs Krieger, Maxwell S; Yedinak, Jesse L; Buxton, Jane A; Lysyshyn, Mark; Bernstein, Edward; Rich, Josiah D; Green, Traci C; Hadland, Scott E; Marshall, Brandon D L Feb 8, 2018

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RESEARCH Open AccessHigh willingness to use rapid fentanyl teststrips among young adults who use drugsMaxwell S. Krieger1, Jesse L. Yedinak1, Jane A. Buxton2,3, Mark Lysyshyn2,4, Edward Bernstein5,6, Josiah D. Rich1,7,Traci C. Green1,5,6,7, Scott E. Hadland5,6 and Brandon D. L. Marshall1*AbstractBackground: Synthetic opioid overdose mortality among young adults has risen more than 300% in the USA since2013, primarily due to the contamination of heroin and other drugs with illicitly manufactured fentanyl. Rapid teststrips, which can be used to detect the presence of fentanyl in drug samples (before use) or urine (after use), mayhelp inform people about their exposure risk. The purpose of this study was to determine whether young adultswho use drugs were willing to use rapid test strips as a harm reduction intervention to prevent overdose. Wehypothesized that those who had ever overdosed would be more willing to use the test strips.Methods: We recruited a convenience sample of young adults who use drugs in Rhode Island from May to September2017. Eligible participants (aged 18 to 35 with past 30-day drug use) completed an interviewer-administered survey. Thesurvey assessed participant’s socio-demographic and behavioral characteristics, overdose risk, as well as suspectedfentanyl exposure, and willingness to use take-home rapid test strips to detect fentanyl contamination in drugs or urine.Participants were then trained to use the test strips and were given ten to take home.Results: Among 93 eligible participants, the mean age was 27 years (SD = 4.8), 56% (n = 52) of participants were male,and 56% (n = 52) were white. Over one third (n = 34, 37%) had a prior overdose. The vast majority (n = 86, 92%)of participants wanted to know if there was fentanyl in their drug supply prior to their use. Sixty-five (70%)participants reported concern that their drugs were contaminated with fentanyl. After the brief training, nearly allparticipants (n = 88, 95%) reported that they planned to use the test strips.Conclusions: More than 90% of participants reported willingness to use rapid test strips regardless of having everoverdosed, suggesting that rapid fentanyl testing is an acceptable harm reduction intervention among young peoplewho use drugs in Rhode Island. Study follow-up is ongoing to determine whether, how, and under what circumstancesparticipants used the rapid test strips and if a positive result contributed to changes in overdose risk behavior.Keywords: Overdose, Opioids, Fentanyl, Harm reduction, WillingnessBackgroundNorth America is in the midst of an unprecedentedoverdose epidemic. In 2016, provisional data indicatesthat overdose mortality increased over 20% from 2015 toreach a record high of 64,070 deaths [1, 2]. The opioidoverdose epidemic, once dominated by prescriptionopioid misuse, is now driven by the use of heroin andother illicit drugs [3–6]. Heroin-related deaths have qua-drupled since 2010, while prescription opioid deathshave increased only slightly [7, 8]. Although diversion ofpharmaceutical fentanyl, such as transdermal patches, isan ongoing problem, in recent years, illicitly manufac-tured fentanyl and related compounds have been regu-larly mixed into heroin, cocaine, and counterfeitprescription pills [9–13]. Since the widespread introduc-tion of illicitly manufactured fentanyl into the drugsupply in North America in 2013 [11], fentanyl-relateddeaths have sharply increased [8, 14]. In the UnitedStates (US), six states that publish data on fentanyl-related fatalities reported that the number of overdosedeaths attributable to fentanyl increased by over 350%between 2013 and 2014, from 392 to over 1400 [15]. In* Correspondence: brandon_marshall@brown.edu1Department of Epidemiology, Brown University School of Public Health, 121South Main Street, Box G-S-121-2, Providence, RI 02912, USAFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Krieger et al. Harm Reduction Journal  (2018) 15:7 https://doi.org/10.1186/s12954-018-0213-2British Columbia, Canada, fentanyl-related overdosedeaths increased over 600% from 2014 to 2016, with fen-tanyl being detected in 67% of all overdose-relateddeaths in 2016 compared to 25% in 2014 [16].Young adults have experienced the greatest increasesin fentanyl overdose mortality as heroin and counterfeitpill use has surged over the last decade [17, 18]. InRhode Island, a state with the fifth highest overdose ratein the US, over half of all fentanyl overdose deaths in2014 and 2015 were among individuals under the age of35 [19]. Drug-using young adults may have less experi-ence with overdose prevention strategies and may en-gage in drug-using behaviors that put them at higherrisk for overdose, such as polysubstance use or com-bined alcohol and drug use [14]. Moreover, harm reduc-tion services such as needle distribution programs arecurrently underutilized by the majority of young adultswho use drugs, due in part to the stigma associated withusing such services [20, 21].People who use drugs may not know if fentanyl is beingcut into their drugs and might rely on ineffectual informa-tion regarding smell, taste, color, and word of mouth todetermine the presence of fentanyl [22]. To address thealarming public health challenges associated with illicitlymanufactured fentanyl, recent innovations in rapid drugtesting technology may promote risk reduction behaviorsamong young adults who are at high risk of fentanyl over-dose. Rapid fentanyl test strips, such as those recentlypiloted at a supervised injection facility (SIF) in Vancou-ver, Canada, are used to detect the presence of fentanyl indrug samples or urine [23, 24]. A pilot study at the Van-couver SIF found a high positivity rate of fentanyl-contaminated drugs and that clients who used the stripsprior to consumption reduced their dose and decreasedthe risk of overdose [24]. In this study, we sought to deter-mine whether young people (aged 18 to 35) who use drugsin Rhode Island were willing to use take-home rapid fen-tanyl test strips as a harm reduction intervention to pre-vent accidental overdose due to fentanyl contamination.We hypothesized that young adults would report highinterest in and willingness to use rapid fentanyl testingand that those who had ever overdosed would be morewilling to use rapid fentanyl test strips than young adultswith no prior overdose experience.MethodsStudy designThis pilot study was conducted to determine the feasibil-ity, acceptability, and behavioral outcomes associatedwith take-home rapid fentanyl tests as a harm reductionintervention to prevent accidental overdose amongdrug-using young people. Our study was guided by theinformation-motivation-behavioral (IMB) skills model ofengagement in health behaviors [25]. The IMB modelhypothesizes that if a person possesses the information,motivation, and behavioral skills to act, there is an in-creased likelihood that she/he will fulfill and maintainthe desired behaviors [25, 26]. The combination of in-creased information, motivation, and behavioral skills isnecessary to produce desired behavior change (in thiscase, overdose risk reduction practices). We hypothe-sized that having experienced an overdose would lead toincreased behavioral skills to avoid an overdose (seeFig. 1) and would thus be associated with an increasedwillingness to use fentanyl testing strips. The IMB modelinformed the questions included on the interviewer-Fig. 1 Selected information, behavior skills, and motivation questions with behavioral change outcomesKrieger et al. Harm Reduction Journal  (2018) 15:7 Page 2 of 9administered survey, which assessed participant know-ledge about fentanyl and overdose prevention (informa-tion), desire to increase their knowledge of fentanyl orconcern about overdose (motivation), and overdoseprevention skills based on experience with overdose (be-havioral skills) [25]. We also included questions asses-sing socio-demographic characteristics, overdose risk,fentanyl exposure, and willingness to use take-homerapid test strips to detect fentanyl contamination in par-ticipant’s drug supply or urine.Survey questions were further informed by ourprevious 2015 study, the Rhode Island Young AdultPrescription and Illicit Drug Study (RAPIDS), whichdemonstrated that non-pharmaceutical fentanyl expos-ure was a significant problem for young people who usedrugs in Rhode Island [27].Recruitment and eligibility criteriaBeginning in May 2017, we recruited participants fromthe 2015 RAPIDS study, 61% of whom previously agreedto be contacted for future research studies. The eligibil-ity criteria for RAPIDS included being aged 18 to 29,residing in Rhode Island, not currently being in alcoholor substance abuse treatment programs, and reportingpast 30-day non-medical use of prescription opioids.From May to September 2017, we recruited additionalyoung adults who use drugs in Rhode Island throughinternet advertisements (e.g., Craigslist and Reddit),digital bus advertisements, public canvassing, and wordof mouth. Eligibility criteria for the current study in-cluded (1) living in Rhode Island at the time of enroll-ment, (2) aged 18 to 35 at the time of enrollment, and(3) self-reported past 30-day heroin or cocaine use, in-jection drug use, or having purchased prescription pillson the street. We expanded the age and drug use eligi-bility criteria created based on our recent research of thefentanyl overdose epidemic in Rhode Island [19].Survey and fentanyl test strip protocolsSurveys were administered by a professionally trained re-search assistant using a Qualtrics web-based survey toolafter obtaining written consent. The surveys took anaverage of 1 h to complete. Research assistants weretrained in harm reduction techniques such as recogniz-ing and responding to overdose and administering na-loxone. Research assistants were also trained on how touse and interpret rapid fentanyl test strips. Based onprior research at an SIF in Vancouver, we purchasedrapid fentanyl urine test strips, which have a detectionlevel of 20 ng/ml [28]. The rapid fentanyl test strips aresingle-use immunoassay tests for the qualitative detec-tion of fentanyl and norfentanyl [29]. The tests are ad-vertised as being able to detect fentanyl analogs suchcarfentanil, acetyl fentanyl, and butyryl fentanyl, but fur-ther research is needed to determine if the tests are ableto detect other novel fentanyl analogs [30]. We pur-chased the strips in bulk for approximately $1 USD for asingle, individually packaged fentanyl test strip.Once the primary survey was complete, participantsthen received a brief in-person one-on-one training onhow to use rapid fentanyl test strips. During the firstpart of the training, participants viewed a short instruc-tional video of heroin being tested for fentanyl and an-other video on how to interpret test strip results. Thenext part of the training included a plain language hand-out on how to test urine, powdered drugs, and pillsusing the test strips. In order to determine the feasibilityof both urine and drug sample testing, the first 40 par-ticipants were instructed to test their urine (after druguse) to detect the presence of fentanyl, while theremaining participants were instructed to test a sampleof their drugs or residue (before consumption). Partici-pants were instructed that a negative result could stillmean their drugs contained other fentanyl analogs ordrug contaminants and that the tests did not reveal thequantity of fentanyl, only its presence or absence. Partic-ipants were asked if they had any questions regardingthe videos or handout. Participants were then asked sev-eral brief questions about the training, including “I feelconfident in my ability to test my own drugs/urine forfentanyl,” and “I feel confident in my ability to read theresults of the fentanyl testing strips.” The primary out-come (willingness to use the fentanyl test strips) wasassessed with the question, “I plan to use the testingstrips,” with response options offered on a 4-point Likertscale of strongly agree to strongly disagree. Participantswere then provided with ten strips to take home and aprintout of what a positive or negative result looked like.Participants also received resources which included fen-tanyl harm reduction suggestions, instructions on howto recognize an opioid overdose, and information onlocal resources. At the end of the study visit, participantswere compensated $25 USD for their time.We report here the results of the baseline survey andthe outcomes of the fentanyl strip test training and re-ceipt of the take-home tests. Data from the participants’follow-up visits, which surveyed whether participantsused the fentanyl rapid test strips and if the interventionresulted in overdose risk behavior change (as hypothe-sized by the IMB conceptual model), is being analyzedand will be discussed in a subsequent study.Statistical analysesFirst, response options to the primary study outcomes(e.g., willingness to use the fentanyl testing strips) werere-coded into three categories: “agree” (for answersKrieger et al. Harm Reduction Journal  (2018) 15:7 Page 3 of 9Table 1 Selected socio-demographic and substance use characteristics of participants who have overdosedCharacteristic Overalln (%)n = 93Never overdosedn (%)n = 59Have overdosedn (%)n = 34p valueGenderMale 52 (56%) 33 (55%) 19 (56%) 0.842Female 37 (40%) 24 (41%) 13 (38%)Something else 4 (4%) 2 (4%) 2 (6%)RaceBlack 13 (14%) 10 (17%) 3 (9%) 0.369White 52 (56%) 30 (51%) 22 (65%)Mixed or other 28 (30%) 19 (33%) 9 (26%)Homeless everYes 55 (59%) 30 (51%) 25 (74%) 0.034No 38 (41%) 29 (49%) 9 (26%)Homeless last 6 monthsYes 17 (18%) 12 (20%) 5 (15%) 0.521No 76 (82%) 47 (80%) 29 (85%)Ever arrestedYes 68 (73%) 37 (63%) 31 (91%) 0.004No 25 (27%) 22 (37%) 3 (9%)Arrested last 6 monthsYes 16 (17%) 6 (10%) 10 (29%) 0.025No 77 (83%) 53 (90%) 24 (71%)Ever incarceratedYes 36 (39%) 19 (32%) 17 (50%) 0.098No 57 (61%) 40 (68%) 17 (50%)Ever purchased fentanyl online or the “dark web”Yes 5 (5%) 2 (3%) 3 (9%) 0.510No 88 (95%) 57 (97%) 31 (91%)Regular Heroin Use aYes 34 (37%) 16 (27%) 18 (53%) 0.015No 59 (63%) 43 (73%) 16 (47%)Regular cocaine useaYes 34 (37%) 19 (32%) 15 (44%) 0.263No 59 (63%) 40 (68%) 19 (56%)Regular non-medical prescription opioid usea,bYes 50 (54%) 26 (44%) 24 (71%) 0.015No 43 (46%) 33 (56%) 10 (29%)Ever been prescribed fentanylYes 4 (4%) 2 (3%) 2 (6%) 0.931No 89 (96%) 57 (97%) 32 (94%)Ever been in alcohol or drug treatment programYes 62 (67%) 33 (56%) 29 (85%) 0.004No 31 (33%) 26 (44%) 5 (14%)Ever injectedYes 45 (48%) 20 (34%) 25 (74%) < 0.001Krieger et al. Harm Reduction Journal  (2018) 15:7 Page 4 of 9strongly agree or agree), “disagree” (for answers stronglydisagree or disagree), and “do not know/refuse” (for an-swers do not know or refuse). We then stratified theparticipants based on the responses to the question,“Have you ever overdosed?” to determine whetherpeople who had ever overdosed were more or less likelyto be willing to use take-home fentanyl test strips com-pared to those who had never overdosed. Respondentswho answered “yes” to a lifetime history of overdosewere compared to those who answered “no” or “do notknow.” We used Pearson’s chi-square test to comparecategorical variables and Fisher’s exact test when a cellcount was ≤ 5. Two-sided p values were used for all vari-ables and were considered statistically significant at 0.05.ResultsSocio-demographic and substance use characteristics ofstudy participants are summarized in Table 1. A total offour participants were recruited from RAPIDS. Among93 participants who completed the survey, the mean agewas 27 years (SD = 4.8). More than half (56%) of thestudy participants were male and 56% were white,followed by mixed race (30%) and black (14%). Over halfreported that they had ever been homeless (59%), and al-most three quarters (73%) reported a lifetime history ofarrest. Over half of the participants reported regularnon-medical use (defined as at least once a week orevery day) of prescription opioids (54%), while approxi-mately one third reported heroin (37%) and cocaine use(37%). Almost half had injected drugs (ever in lifetime48%, in last 6 months: 42%). Of the 93 participants inthis study, 34 (37%) reported that they had ever over-dosed. Among the participants who had ever overdosed,18 (53%) reported ever overdosing on a drug which theythought might have been contaminated with fentanyl. Asshown in Table 1, socio-demographic and drug use fac-tors that were significantly associated with having everoverdosed included having ever been arrested, havingregular non-medical prescription opioid use, havingregular heroin use, having ever injected, having been inan alcohol and drug treatment program, and having everseen someone overdose (all p < 0.01).Information, motivation, and behavioral skills-relatedfactors, stratified by history of overdose, are summarizedin Table 2. Almost half of all study participants reporteda concern about overdosing (48%), with those who hadever overdosed being significantly more likely to report aconcern about overdosing (74%, p < 0.01). Nearly threequarters of all participants expressed concern about theirdrugs being contaminated with fentanyl (70%); however,expressing concern was not significantly associated withparticipants having ever overdosed. Almost half of theoverall sample (47%) was confident that (at some time inthe past) they used fentanyl-laced drugs. A greater num-ber of individuals who had ever overdosed (68% vs. 35%,p = 0.01) reported confidence that they had usedfentanyl-laced drugs. When asked “Do you know whereyou can buy or get Narcan/naloxone?”, more partici-pants who had ever overdosed reported “yes” (76% vs.46%, p = 0.01). As shown in Table 2, nearly all individ-uals reported that they wanted to know if fentanyl wasin their drugs before taking them (93%), which was notsignificantly associated with overdose history.After the brief training, overall willingness to use rapidfentanyl test strips was high among participants whohad ever overdosed and those who had not; overall, 95%agreed or strongly agreed that they planned to use theprovided rapid fentanyl take-home test strips. Almost allstudy participants (n = 92, 99%) reported that it wouldbe easy to use the fentanyl testing strips. Among the par-ticipants who were trained to use rapid fentanyl teststrips on their urine (n = 40), over half (56%) reportedthat they would prefer to use a test that could detectfentanyl in drugs dissolved in water before using them.Nearly three quarters of the overall sample (n = 66, 71%)endorsed “yes” when asked “Do you think your friendswould be interested in using the fentanyl testing strips?”.Table 1 Selected socio-demographic and substance use characteristics of participants who have overdosed (Continued)Characteristic Overalln (%)n = 93Never overdosedn (%)n = 59Have overdosedn (%)n = 34p valueNo 48 (52%) 39 (66%) 9 (26%)Injected last 6 monthsYes 39 (42%) 15 (25%) 24 (71%) < 0.001No 54 (58%) 44 (75%) 10 (29%)Ever seen someone overdoseYes 59 (63%) 29 (49%) 30 (88%) < 0.001No 34 (37%) 30 (51%) 4 (12%)aAt least once a week or every daybIncludes Percocet, Vicodin, tramadol, OxyContin, oxycodone, hydromorphone, hydrocodone, oxymorphone, or morphineKrieger et al. Harm Reduction Journal  (2018) 15:7 Page 5 of 9Table 2 Selected information-motivation-behavioral (IMB) skills model-related factors associated with overdose among young adultsCharacteristic Overalln (%)n = 93Never overdosedn (%)n = 59Have overdosedn (%)n = 34p valueInformationFentanyl acts more quickly than heroinAgree 50 (54%) 29 (49%) 21 (62%) 0.042Disagree 10 (11%) 4 (7%) 6 (18%)Neutral/do not know 33 (35%) 26 (44%) 7 (20%)I would like to be able to know if there is fentanyl in my drugs before I take themAgree 86 (93%) 56 (95%) 30 (88%) 0.070Disagree 5 (5%) 1 (2%) 4 (12%)Neutral/do not know 2 (2%) 2 (3%) 0 (0%)Heroin and other drugs that are mixed with fentanyl look different than drugs that are not mixed with fentanylTrue 25 (27%) 16 (27%) 9 (26%) 0.089False 40 (43%) 21 (36%) 19 (56%)Do not know 28 (30%) 22 (37%) 6 (18%)Have you ever heard of naloxone?Yes 82 (88%) 50 (85%) 32 (94%) 0.082No 10 (11%) 9 (15%) 1 (3%)Do not know 1 (1%) 0 (0%) 1 (3%)MotivationConcerned about overdosingAgree 45 (48%) 20 (34%) 25 (74%) < 0.001Disagree 42 (45%) 35 (59%) 7 (21%)Neutral/do not know 6 (6%) 4 (7%) 2 (6%)Concerned about drugs being contaminated with fentanylAgree 65 (70%) 41 (70%) 24 (70%) 0.686Disagree 17 (18%) 12 (20%) 5 (15%)Neutral/do not know 11 (12%) 6 (10%) 5 (15%)Confident have ever used a drug that was laced with fentanylAgree 44 (47%) 21 (35%) 23 (68%) 0.010Disagree 43 (46%) 34 (58%) 9 (26%)Neutral/do not know 6 (7%) 4 (7%) 2 (6%)Behavioral SkillsIn the last 6 months, who is usually around when you are using heroin?a,bI use heroin alone 32 (74%) 15 (79%) 17 (71%) 0.806A close friend 18 (42%) 7 (37%) 11 (46%) 0.573A casual friend or acquaintance 16 (37%) 7 (37%) 9 (38%) 0.969A sex partner 15 (35%) 6 (32%) 9 (38%) 0.704Other 13 (30%) 5 (26%) 8 (33%) 0.641What do you do to avoid an accidental overdose?aTake smaller amounts 56 (60%) 34 (58%) 22 (65%) 0.514Go slow 55 (59%) 31 (52%) 24 (71%) 0.094Avoid mixing with other drugs 46 (49%) 34 (58%) 12 (35%) 0.042Using with someone else 46 (49%) 26 (44%) 20 (59%) 0.180Avoid mixing with alcohol 39 (42%) 26 (44%) 13 (38%) 0.594Krieger et al. Harm Reduction Journal  (2018) 15:7 Page 6 of 9DiscussionContrary to our primary hypothesis, nearly all partici-pants reported high willingness to use the fentanyl teststrips, regardless of previous overdose history. The ma-jority of the study participants reported wanting to knowif their drug supply was contaminated with fentanyl. Allstudy participants reported feeling confident in theirability to test their drugs or urine for fentanyl after abrief skill-based training. Nearly all participants reportedwanting to know if there was fentanyl in their drugs be-fore taking them, indicating a clear preference for testingtheir drugs or residue directly rather than testing theirurine after drug use. These findings suggest that rapiddrug testing is an acceptable, low threshold interventionthat could be used to address concerns associated withemerging adulterants (e.g., fentanyl) in the illicit opioiddrug supply.Despite the fact that reporting a history of overdosewas not associated with higher willingness to use thefentanyl testing strips, prior non-fatal overdose is amongthe strongest predictors of future overdose death [31,32]. In this study, young adults who had ever experi-enced an overdose were more likely to have been home-less, have an arrest history, and report more frequentand injection drug use, among other risk factors. If fen-tanyl rapid test strips are found to be an effective harmreduction intervention, making the technology readilyavailable to individuals who demonstrate these charac-teristics may be a high public health priority. Althoughoff-label use of fentanyl testing strips has not been ap-proved by the US Food and Drug Administration (FDA),they are already being used at syringe exchange pro-grams in areas with a high burden of fentanyl-relatedoverdoses, such as Vancouver, New York City, andBoston [33, 34]. Rapid fentanyl drug testing may also beincorporated into drug checking services provided atnightclubs and music venues seen in Europe [35].While there has been some concern raised about theability of the rapid fentanyl test strips to detect novelfentanyl analogs [34], the tests have been shown todetect the most common fentanyl analogs currently cir-culating in the illicit drug supply, such as carfentanil andacetyl fentanyl [29]. Further studies should examinewhich fentanyl analogs are able to be detected in urineor drugs and to what degree of sensitivity. Nonetheless,in light of concerns regarding false negatives, rapid fen-tanyl test strips should be distributed alongside informa-tion about what to do regardless of whether the drugtests positive for fentanyl, such as using with someonenearby who is capable of calling emergency medical ser-vices. In general, our results suggest that rapid drug testsmight be an acceptable intervention for young adultswho use drugs for identifying adulterants in the drugillicit supply.Future research is needed to determine if using fen-tanyl rapid testing strips will lead to desired behavioralchanges outlined in the IMB model, such as obtainingnaloxone and using drugs with others who can call anambulance if an overdose occurs [36, 37]. A futuremanuscript will discuss follow-up data and whetherknowledge of a drug being contaminated with fentanylwill encourage overdose risk reduction practices. Futureresearch is needed to determine if a higher level of con-cern about overdose will predict actual rapid test striputilization or more consistent use patterns. Research isalso needed to better understand the feasibility of usingthe rapid test strips among individuals who do not seethemselves as at risk for fentanyl overdose, such aspeople who buy pills on the street or people who use co-caine. Additional studies are also needed to determinethe sensitivity and specificity of using immunoassay testson drugs directly and in real-world, non-clinical settings.We are aware of a number of limitations to this study.This is a small pilot study which recruited a conveniencesample from a region highly impacted by the fentanyloverdose epidemic; therefore, this study may not begeneralizable to other settings. Additionally, in some re-gions, fentanyl contamination is widespread throughoutthe drug supply, and it has yet to be determined how thatmay affect uptake of rapid fentanyl test strips. Third, weTable 2 Selected information-motivation-behavioral (IMB) skills model-related factors associated with overdose among young adults(Continued)Characteristic Overalln (%)n = 93Never overdosedn (%)n = 59Have overdosedn (%)n = 34p valueTake a tester 34 (37%) 21 (36%) 13 (38%) 0.800Keep Narcan/naloxone nearby 32 (34%) 14 (24%) 18 (53%) 0.006Do you know where you can buy or get Narcan/naloxone?cYes 53 (57%) 27 (46%) 26 (76%) 0.013No 29 (31%) 23 (39%) 6 (18%)aCategories are not mutually exclusivebRestricted to persons who reported heroin use in the past 6 months (n = 43)cAmong the participants who answered “yes” to “Have you ever heard of naloxone, a medication also known as Narcan?” (n = 82)Krieger et al. Harm Reduction Journal  (2018) 15:7 Page 7 of 9only assessed lifetime overdose history generally and didnot ask participants about their experiences with opioidoverdose specifically. It is possible that participants whohave previously experienced an opioid overdose, or had anoverdose they thought was caused by fentanyl, may bemore willing to use the fentanyl testing strips. Finally, thisstudy relied on self-report, which may be subject to so-cially desirable reporting. However, evidence has shown ahigh association between willingness to use a harm reduc-tion program and subsequent uptake of the interventionamong people who use drugs [38].ConclusionsIn summary, this study assessed the feasibility and ac-ceptability of take-home rapid fentanyl tests. We found ahigh willingness to use take-home rapid fentanyl teststrips among young people who use drugs and are at riskfor accidental fentanyl overdose. Initial results suggestthat rapid fentanyl test strips may be an acceptable harmreduction intervention for communities facing growingrates of fentanyl overdoses. Study follow-up is ongoingto determine whether, how, and under what circum-stances participants used these rapid test strips and ifpositive test results contribute to positive changes inoverdose risk behavior.AcknowledgementsWe would like to thank the study participants for their contribution to the research,as well as our researchers, students, and staff, including Conor Millard, Kobe Pereira,Giovannia Barbosa, Jacqueline Goldman, Esther Manu, and William Goedel.FundingThis pilot project was supported by Brown University’s Office of the VicePresident for Research through a Research Seed Grant. Dr. Rich is supportedthrough NIH grants K24DA022112 and P30AI042853.Availability of data and materialsThe data that support the findings of this study are available on requestfrom the corresponding author, BDLM. The data are not publicly availabledue to them containing information that could compromise researchparticipant privacy/consent.Authors’ contributionsMSK helped conduct the surveys, drafted the manuscript, and approved thefinal manuscript for submission. JLY and BDLM conceived the pilot study andapproved the final manuscript for submission. JLY, JAB, ML, EB, JDR, TCG, andSEH helped revise the manuscript and assist with critical interpretations of thefindings. BDLM planned the analyses and was the principal investigator of thepilot study. All authors read and approved the final manuscript.Ethics approval and consent to participateOur research was performed in accordance with the Declaration of Helsinki andreceived approval from the Brown University Office of Research Protections IRB,#1612001662. All participants provided written consent at the time of the survey.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Department of Epidemiology, Brown University School of Public Health, 121South Main Street, Box G-S-121-2, Providence, RI 02912, USA. 2School ofPopulation and Public Health, University of British Columbia, Vancouver,British Columbia, Canada. 3British Columbia Centre for Disease Control,Vancouver, British Columbia, Canada. 4Vancouver Coastal Health, Vancouver,British Columbia, Canada. 5Department of Emergency Medicine, GraykenCenter for Addiction, Boston University School of Medicine, Boston, MA, USA.6Department of Pediatrics, Grayken Center for Addiction, Boston MedicalCenter, Boston, MA, USA. 7Department of Emergency Medicine, WarrenAlpert Medical School of Brown University, Providence, RI, USA.Received: 7 December 2017 Accepted: 1 February 2018References1. 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Am J Drug AlcoholAbuse. 2012;38:55–62.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Krieger et al. Harm Reduction Journal  (2018) 15:7 Page 9 of 9

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