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Expanding harm reduction to include fentanyl urine testing: results from a pilot in rural British Columbia Mema, Silvina C; Sage, Chloe; Popoff, Serge; Bridgeman, Jessica; Taylor, Deanne; Corneil, Trevor Apr 6, 2018

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BRIEF REPORT Open AccessExpanding harm reduction to includefentanyl urine testing: results from a pilotin rural British ColumbiaSilvina C. Mema1,2*, Chloe Sage3, Serge Popoff3, Jessica Bridgeman1, Deanne Taylor1,4 and Trevor Corneil1,2AbstractBackground: Harm reduction has been at the forefront of the response to the opioid overdose public healthemergency in British Columbia (BC). The unprecedented number of opioid overdose deaths in the province calls foran expansion of harm reduction services. The purpose of this study was to determine the acceptability of a fentanylurine drug test among people who use drugs (PWUD) and explore whether testing introduced any changes inparticipants’ attitudes and behaviors towards their drug use.Methods: A pilot of fentanyl urine testing was implemented in partnership with an outreach harm reduction programin rural BC. Participants were PWUD who had consumed within the last 3 days prior to the test. Participants filled out asemi-structured questionnaire at the time of the test and were invited for a follow-up interview 2 to 4 weeksafter the test. Urine samples were tested with BNTX Rapid Response™ fentanyl urine strip test at a detection levelof 20 ng/ml norfentanyl.Results: Of the 24 participants who completed the urine test and first interview, 4 had a positive fentanyl urinetest. Fifteen clients completed the second questionnaire, 10 of whom reported introducing a behavior changeafter testing and the remaining 5 indicated being already engaged in harm reduction practices. All four clientswho tested positive completed the second questionnaire; all but one indicated adopting behaviors towardsoverdose prevention.Discussion: Fentanyl urine testing appealed to illicit opioid users and may have contributed to adopting behaviorstowards safer drug use. A relationship of trust between tester and client seemed important for clients who expressedconcerns with privacy of the urine test results. Post-consumption urine testing could complement the use ofpre-consumption drug checking in the context of harm reduction services.IntroductionA public health emergency was declared in BritishColumbia in April 2016 due to the unprecedented numberof deaths from opioid overdoses. Causality assessmentsuggests fentanyl as the principal driver of the overdosedeath epidemic. While in 2012, fentanyl was implicated in5% of drug overdose deaths; the proportion has increasedto nearly 80% in 2017 [1].The overdose public health emergency calls to expandthe suite of harm reduction services to include fentanyldrug checking and urine testing. It is plausible that inthe wake of an unexpected positive fentanyl drug checkor urine test, clients will adopt harm reduction practicesto reduce their overdose risk.In a recent urine screen study in British Columbia,Amlani et al. demonstrated that about a third of clientshad a positive fentanyl urine test. Among those whotested positive, 73% were not aware of their fentanylexposure [2].Amlani et al.’s findings suggest that a substantialproportion of illicit fentanyl consumption in BC is unin-tentional. The authors, however, fell short of exploringwhether the positive fentanyl urine test result led clientsto change their attitude and/or behavior towards drugconsumption. It could be hypothesized that upon the* Correspondence: Silvina.Mema@interiorhealth.ca1Interior Health Authority, Kelowna, British Columbia, Canada2School of Population and Public Health, University of British Columbia,Vancouver, CanadaFull 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.Mema et al. Harm Reduction Journal  (2018) 15:19 https://doi.org/10.1186/s12954-018-0224-z“eye opening” positive fentanyl urine test result revealingtheir unintentional fentanyl consumption, a client maychoose to adopt a harm reduction strategy to reducetheir overdose risk. Harm reduction strategies includetesting a small amount of drug before using their usualdose, using under supervision, or acquiring a naloxonekit. Furthermore, the change in behavior could extend tothe client’s network and influence their behavior towardsillicit drug use.The purpose of this study was to twofold: first, todetermine the acceptability of fentanyl urine testingamong PWUD as part of harm reduction program inrural British Columbia, and second, to explore whetherclients undergoing a fentanyl urine test had any changesin attitudes and behaviors towards illicit drug use 2 to4 weeks after testing.MethodsStudy designA two-phased mixed-methods study was designed togather information from PWUD about the acceptabilityand effectiveness of fentanyl urine testing as a harmreduction intervention: Phase one involved a short semi-structured questionnaire at the time of the fentanylurine test asking age range, gender, employment status,frequency of drug use, drug of choice, preferred mode/sof consumption, and when were illicit substances lastconsumed. Phase two was a semi-structured face-to-faceinterview delivered 2 to 4 weeks after the fentanyl urinetest. Phase two questions inquired about any behaviorchange towards illicit drug use potentially triggered bythe results of fentanyl urine testing [3–5].All information collected was anonymous and self-reported. An acronym was used to link phase one andphase two surveys. The semi-structured interviewscripts were developed based on an interview scriptfrom a provincial fentanyl and drug testing study [6]and amended by the Aids Network Outreach SupportSociety (ANKORS) Hepatitis C Project coordinator toreflect local language and context.The qualitative data were analyzed using contentanalysis and conducted separately by three of the re-searchers and then discussed as a group using consensuscoding techniques [7]. Final themes were presented to asmall group of harm reduction experts who had context-ual knowledge of the Interior region and harm reductioncontent expertise as a form of member checking [8].ParticipantsThe pilot was promoted via word of mouth and attractedmainly long-term clients who have a relationship of trustwith local harm reduction services. Occasional and fre-quent illicit drug users were recruited from among clientsof the mobile and fixed site harm reduction programoffered by ANKORS which delivers harm reduction sup-ply in West Kootenay Communities: Nelson, Castlegar,Trail, Salmo, Fruitvale, and Grandforks. ANKORS clientswere made aware of the dates, times, and locations of fen-tanyl urine testing opportunities through word of mouth.Clients interested in participating were informed of thestudy purpose, risks, and benefits, and were given theopportunity to ask questions before a team member askedfor consent.Participation in the research study was not a conditionto access fentanyl urine testing. To be eligible to partici-pate in this study, clients had to be 19 years of age orolder, able to provide informed consent, and self-identifyas illicit drug user. Given that fentanyl levels becomenegligible after 3 days, only clients who reported usingdrugs within this time frame were included. Fentanylurine testing was available between March 2017 andMay 2017. A $10 cash incentive was provided to studyparticipants in two allotments of $5 the day of the fen-tanyl urine test and the second $5 at the end of the sec-ond visit 2 to 3 weeks later.Urine testing protocolAfter giving consent to participate, clients were providedwith sterile urine containers and asked to provide aurine sample in a private location (i.e., washroom). Onceobtained, samples were left to cool to room temperaturewhile the client was being interviewed. Samples weretested with BNTX Rapid Response™ fentanyl urine striptest at a detection level of 20 ng/ml norfentanyl. Thestrips were placed into the urine for 15 s, and then letsit for 5 min before reading the result to the client. Assoon as the fentanyl urine test was complete, urine sam-ples were disposed of in a toilet and flushed. Clientswere then invited to return for the follow-up interviewin 2 weeks.Ethics approval and consent to participateHarmonized research ethics approval was obtainedfrom the Interior Health and University of BritishColumbia Ethics Review boards (Board of RecordApproval Reference #: 2016-17-060-I). Consent to par-ticipate in the research study was sought from eachparticipant who expressed interest in fentanyl urinechecking. Consent to participate was obtained verbally.Using a consent script (see supporting documents),staff explained the risks and benefits of the study (seeAdditional file 1).ResultsTwenty-four participants completed phase one interviewand the urine test. Demographic characteristics of the cli-ents showed that about half of participants were withinthe 50–59 years of age range. The sample had an evenMema et al. Harm Reduction Journal  (2018) 15:19 Page 2 of 5distribution of men and women. Most participants indi-cated Income Assistance as their major source of income.Drugs of choice were cocaine, crystal meth, methadone,fentanyl, heroin, carfentanil, marihuana, ketamine, mor-phine, and Percocet.The most popular mode of consumption was injectionreported by over 2/3 or respondents, followed by smok-ing and snorting. Only one client reported using oraldrugs. In terms of frequency of use, most responded thatthey used daily or every few days. A few clients re-ported using monthly and one reported using weekly.Most participants reported using more than one drugon a weekly basis.Four of the 24 clients enrolled in phase one had apositive fentanyl urine test. Of these four, only one indi-vidual was surprised by the positive result stating thatthe drugs they had done were “too weak to be fentanyl.”The remaining three participants’ responses to the posi-tive fentanyl urine test result varied from no commentto not being surprised either because they had boughtfentanyl and the test confirmed what they had purchasedor because they assumed fentanyl was in “everything,”referring to all illicit drugs.Of the 24 participants who completed phase one, 15returned to complete the phase two. Of these, 10reported a change in behavior after testing their urine,and the remaining 5 answered that they had not intro-duced any behavior change. All four clients whose urinetested positive in phase one returned for phase two,three of them reported adopting a harm reduction strat-egy after testing. Table 1 shows some quotes of threeparticipants who had a positive urine test result andreported introducing a behavior change. Of the 5 indi-viduals that answered not introducing any behaviorchange in phase two interview, all indicated that theywere already engaged in harm reduction practices.Table 2 outlines some of the answers of the 15 partici-pants who completed phase two, regardless of the posi-tive or negative test result.There were mixed results about whether expandingdrug checking and urine testing services would beuseful. Most participants were of the opinion such thatfentanyl drug checking and urine testing services wouldbe valuable as long as fentanyl analogues were included.Stigma was mentioned as a potential barrier to accessingservices, many of the respondents indicated that theywould either use this service in the privacy of theirhomes and/or from trusted harm reduction agencyworkers as evidenced by the following clients’ state-ments: “If you are looking for help, have more [help]available and less stigmatizing to get help there.” “Don’tfeel comfortable going anywhere else but in my home orwith [names harm reduction agency worker].”DiscussionThe objective of this study was to determine acceptabil-ity of fentanyl urine testing among PWUD in rural BCand determine any behavior changes introduced in the2 weeks after testing. The pilot project aimed to enhanceoutreach harm reduction services in smaller communi-ties in the context of a provincial overdose public healthemergency. It was hypothesized that a fentanyl drug test-ing program may be beneficial to PWUD in ruralcommunities by attracting people who would otherwisenot connect to harm reduction services, lead to behaviorchange through a meaningful interaction with staff, andTable 1 Responses given by clients who tested positive andintroduced a behavior changeAny behavior changes since receiving positive results?Made me more careful.Completely avoid fentanyl.I did not do the fentanyl we testedI don’t use alone and always carry NaloxoneI don’t use alone and injecting less now.Table 2 Behavior change as reported by the 15 participants inphase twoAny changes indrug use?CommentNo But got some naloxoneBut have more awareness to test my stuffBut I have been using less b/c out of moneyand no supplyDope is really weak here and I don’t use aloneI only use pharm morphine and I won’t buyanything elseTest was negative and always carefulUsually use alone. I use morphine cause I knowwhat I’m gettingCarry naloxone kit and worry all the timeDope is really weak here and I don’t use aloneYes Did it one more time. Starting treatmentDidn’t do the fentanyl we tested. Don’t usealone and injecting lessI haven’t done any drugs since. I got scared. Ihave a drug counsellor now.Yes - made me more careful. Completelyavoid fentanylMore careful about what I buy. But still useb/c I still have same problemsSlowed my useMema et al. Harm Reduction Journal  (2018) 15:19 Page 3 of 5normalize the conversation around drug use, and poten-tially lead to reducing stigma.Although preliminary, our results suggest that thereis a demand for fentanyl urine testing and provide anevidence base to support expansion of harm reductionservices to include this service within the scope ofharm reduction services. Of note, during the studyperiod a police notification was released that carfentanilhad been detected in the community which may haveincreased interest in testing among clients, even thoughthe sensitivity and specificity of the fentanyl urine stripsto detect carfentanil is uncertain.It is important to differentiate between post-consumptionurine testing and pre-consumption drug checking [9].Clients indicated that their preference for checking drugsbefore consumption as opposed to getting a urine test afterconsumption. Drug checking for fentanyl may also posi-tively impact behavior change leading to a decrease inoverdose incidence, as suggested by a recent evaluationof a fentanyl drug checking program in a supervisedconsumption setting [10].Although generally acceptable, clients expressed thatthey would use a urine testing service as long as privacywas maintained and the test was delivered by a trustedperson. During this study, some clients expressed con-cerns around privacy and questioned whether the fen-tanyl urine test would become part of their medicalrecord. They only agreed to test after being reassuredthat participation in the study was anonymous. This sug-gests that a fentanyl urine test program may only appealto clients with a trusted relationship with harm reduc-tion providers such as ANKORS workers who havedelivered services in the area for over 20 years. Allowingusers to test themselves may be the way around this.However, the interaction with a harm reduction workermay create a "teachable moment" critical in effecting anybehavior change.The number of positive tests was approximately21%, slightly lower than expected given the evidencefrom Amlani et al.’s study which detected 29% positiv-ity. Furthermore, wide media coverage of the overdoseemergency has led to clients being aware that fentanylis ubiquitous in the illicit drug market. The positiveresult was unexpected to only one of the four, com-pared to most of participants in Amlani et al.’s study.Interestingly, a handful of clients were expecting apositive fentanyl test result but tested negative, whichcould be due to a limitation of the test in detectingsome of the fentanyl analogues that may be in circula-tion in the illicit market.Our results suggest that the impact of fentanyl urinetesting on behavior change is promising. Drawing fromhealth promotion constructs of behavior change [11], wehypothesize that a positive fentanyl urine test result willlikely increase clients’ perception of susceptibility ofbeing exposed to fentanyl because a positive urine testresult confirms fentanyl exposure almost unequivocally.We further hypothesize that changes in perceived sus-ceptibility may extend beyond clients who test to otherpeers who use with them or share the same dealer asthey become aware of the positive test through word ofmouth. Increased susceptibility by itself will not lead tobehavior change unless clients’ believe in the benefits ofchanging behavior (such as using less or not at all, usinga buddy system, and carrying naloxone) and any per-ceived barriers to taking action are overcome. The roleof harm reduction is to activate readiness to changeamong clients that, due to the positive test, feel suscep-tible to a fentanyl overdose. By providing awareness andsupport, this pragmatic approach increases clients’ confi-dence in their ability to take action, allowing clients totake control over their health to ultimately reduce theirrisk of a fatal overdose.These results should be interpreted with caution giventhat, as with other screening programs, it is possible thatfentanyl urine testing appeals to a health conscious,potentially more experienced population of people whouse drugs (PWUD). Clients included in this study werealready engaged in harm reduction practices throughANKORS services over several years in which may haveunderestimated the effect of the intervention on harmreduction uptake because they were already positivelyinfluencing behavior among clients in these areas. Inaddition, we could not determine whether any changesintroduced by the fentanyl drug testing were sustainedbeyond the study period. Future studies should use a lar-ger sample size to investigate if and if so how, thesechanges may be sustained.Limitations of this study include small sample size, andthe fentanyl urine test limitations to detect analogues offentanyl and an inability to detect fentanyl beyond the3 days due to renal clearance. It could be argued that inself-reporting behavior clients could have exaggerated anychanges to please the interviewer, overestimating the im-pact of the intervention. To overcome this bias, interviewswere carried out by harm reduction providers with longstanding relationship of trust with clients. We acknow-ledge these limitations and believe that they do not invali-date the results of this study in exploring acceptability anddemand for fentanyl urine testing.In summary, this study suggests that fentanyl urine test-ing is appealing to PWUD and that it may promote behav-ior change towards adoption or maintenance of harmreduction strategies among PWUD in rural BC. Furtherresearch should examine whether urine testing and drugchecking services may support the increased uptake ofharm reduction behaviors among different groups of peoplewho use illicit drugs.Mema et al. Harm Reduction Journal  (2018) 15:19 Page 4 of 5Additional fileAdditional file 1: Consent script. (DOCX 16 kb)AcknowledgementsNot applicable.FundingNot applicable.Availability of data and materialsThe data that support the findings of this study are available on requestfrom the corresponding author SCM. The data are not publicly available direto them containing information that could compromise research studyparticipants’ privacy.Authors’ contributionsSCM conceived of the study, participated in its design and coordination, anddrafted the manuscript. CS conceived of the study, participated in its design,and assisted with data collection and result interpretation. SP assisted withdata collection and result interpretation. JB participated in designing thestudy and assisted with result interpretation. DT carried out the data analysisand assisted with result interpretation. TC conceived of the study andassisted with result interpretation. All authors read and approved the finalmanuscript.Ethics approval and consent to participateHarmonized research ethics approval was obtained from the Interior Healthand University of British Columbia Ethics Review boards (Board of RecordApproval Reference #: 2016-17-060-I). Consent to participate in the researchstudy was sought from each participant who expressed interest in fentanylurine checking. Consent to participate was be obtained verbally. Using aconsent script (see supporting documents), staff explained the risks and ben-efits of the study (see Additional file 1).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 details1Interior Health Authority, Kelowna, British Columbia, Canada. 2School ofPopulation and Public Health, University of British Columbia, Vancouver,Canada. 3Aids Network Outreach Support Society, Nelson, British Columbia,Canada. 4Faculty of Health and Social Development, University of BritishColumbia, Vancouver, Canada.Received: 29 December 2017 Accepted: 20 March 2018References1. Fentanyl-Detected Illicit Drug Overdose Deaths January 1, 2012 toDecember 31, 2017. Coroners Service, British Columbia. https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/fentanyl-detected-overdose.pdf. Accessed 26 Mar 2018.2. Amlani A, et al. Why the FUSS (fentanyl urine screen study)? A cross-sectional survey to characterize an emerging threat to people who usedrugs in British Columbia, Canada. Harm Reduct J. 2015;12:54.3. Gubrium JF, Holstein JA. Narrative ethnography. In: Hesse-Biber SN, Leavy P,editors. Handbook of emergent methods. New York: The Guilford Press;2008. p. 241–65.4. Lincoln YS, Denzin NK. The seventh moment: out of the past. In: Denzin NK,Lincoln YS, editors. The landscape of qualitative research: theories andissues. Thousand Oaks: Sage; 2003. p. 611–40.5. Patton M. Qualitative research & evaluation methods (3rd ed.). ThousandOaks: Sage; 2002.6. Kerr, 2016 Refers to personal communications between Dr. Kerr and theresearch team.7. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol.2006;3(2):77–101.8. Creswell JW, Miller DL. Determining validity in qualitative inquiry. TheoryPract. 2000;39:124–30. https://doi.org/10.1207/s15430421tip3903_2.9. Drug Checking at Music Festivals: A How-To Guide. Chloe Sage and WarrenMichelow. http://michelow.ca/drug-checking-guide/. Accessed 26 Mar 2018.10. Lysyshyn M, Dohoo C, Forsting S, Kerr T, McNeil R. Evaluation of a fentanyldrug checking program for clients of a supervised injection site. Vancouver:Harm Reduction International; 2017.11. Strecher VJ, Rosenstock IM. “The health belief model”. Cambridge handbookof psychology, health and medicine; 1997. p. 113–7.•  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:Mema et al. Harm Reduction Journal  (2018) 15:19 Page 5 of 5

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