As Fentanyl Deaths Rise, Organizations in the Bronx Scramble to Find Solutions
Updated: Mar 15, 2018
Sam Santoscoy digs through a small pouch she carries with her on site visits, searching for her bottle of pharmaceutical fentanyl. Sitting in an outreach van in the Fordham Heights neighborhood of the Bronx, she carefully places the fentanyl on a makeshift table. Santoscoy then grabs a clean cooker - a tin apparatus akin to a tea-light candle holder - a vial of distilled water, and a packet of testing strips. After mixing the fentanyl into the water, Santoscoy dips a strip in the cooker, and a single red line appears.
"One line means that the sample is positive for fentanyl," explains Santoscoy, a drug-education specialist at the Washington Heights Corner Project, a harm reduction organization that works with drug users and sex workers. "Two means the sample is clean."
Sam Santoscoy, a drug education specialist at the Washington Heights Corner Project, carries out a fentanyl testing demonstration in the South Bronx. Photo: Zein Jardaneh
Fentanyl, a synthetic opioid, is 50 to 100 times more potent than morphine. Fentanyl is available on its own or cut in with other opioids such as heroin and illegally manufactured pain killers. It's also being mixed with non-opioid drugs such as cocaine.
In New York City, overdose deaths increased by 72% between 2014 and 2016 - a rise attributed to the infiltration of fentanyl in illicit drug supplies, and users' inability to detect its presence. Fentanyl was responsible for almost 46% of overdose deaths in the Bronx in 2016, the highest in any borough.
Desperate for solutions to mitigate the crisis, community organizations in the Bronx are willing to adopt many unorthodox methods, including fentanyl testing, to bring these numbers down.
St. Ann's Corner of Harm Reduction, an organization that's been working in the Bronx for 27 years, is no stranger to deploying such methods to save lives. "We've been on the front lines of addiction from day one," says Van Asher, who works with St. Ann's. "We were one of the first organizations to offer syringe-exchange programs. We did it illegally our first two years of operation."
Syringe-exchange programs provide free access to sterile needles and syringes. The first such programs appeared in Europe in the 1980s to help stem the spread of HIV/AIDS, hepatitis B and C, and other blood-borne illnesses among intravenous drug users. As the HIV/AIDS epidemic grew in the U.S., organizations like St. Ann began implementing the programs, often illegally, until studies demonstrated their efficacy in curbing the spread of HIV/AIDS.
Today, St. Ann's is again looking at models being used outside the U.S. to reduce the number of accidental overdose deaths.
After learning that safe-injection sites in Vancouver use fentanyl testing, Asher's organization began distributing the strips to users coming in to St. Ann's to exchange syringes. "Most of the users don't know what they're dealing with or what they're consuming," says Asher. "We've got to let them know what's out there."
Van Asher holds up a packet of fentanyl testing strips in his office at St. Ann's Corner of Harm Reduction. Photo: Zein Jardaneh
Other organizations that offer syringe exchanges, like the Corner Project, followed suit.
The process starts with demonstrations for drug users, so they can learn to test for fentanyl themselves. Legally obtained pharmaceutical fentanyl is used for the demonstrations, as New York drug possession laws prohibit organizations from having narcotics on their sites. Following the demonstration, users are provided with a clean cooker, water vials and testing strips.
The method has its limits. The strips produce a lot of false positives. Strips do not indicate the concentration of fentanyl or what fentanyl variant, which differ in potency, is present in the sample. Testing pills, as opposed to heroin, is even more complex, since the production is not well regulated, and fentanyl presence can vary widely among pills even in the same batch.
"Fentanyl testing is useful as an educational tool, but a bit gimmicky," says Mark Townsend, syringe access program director at the Corner Project. "It's a stepping stone towards achieving some sort of change, but not the main event.
"When users come back and tell you, 'Oh, I used it and made my buddy come and sit with me', it gives them an imaginary sense of control," he adds. "And maybe that'll give them the sense of empowerment to take the next steps to make things better, or just to feel like someone out there is looking out for them."
And, testing for fentanyl may inadvertently encourage users to proceed with using possibly lethal batches, rather than dispose of them.
"Fentanyl is short-acting with an immediate onset, whereas heroin lasts longer with a slower rush," explains Bethany Medley, the opioid program manager at the Harm Reduction Coalition, an advocacy group that focuses on health reform pertaining to drugs. "So, depending on a user's preference, they might actually want [fentanyl] in their stash."
"The majority of people who use heroin in the Bronx are too broke and get really sick during withdrawal, and you don't want to be dope sick," says Santoscoy. "It's unlikely to deter them from using completely. But, it's a conversation starter."
With that in mind, St. Ann's and the Corner Project use the demonstrations to educate users on how to "safely" use fentanyl. They encourage them not to shoot up alone, have narcan - an overdose reversing drug - close by, and take small doses of fentanyl-positive batches to minimize the risk of an overdose.
"We're giving them the strips, showing them how to use them, educating them, and then turning them loose," adds Asher. "But, there's no guarantee they'll actually do the test themselves."
How to test for fentanyl. Photo courtesy of the Washington Heights Corner Project.
Asher advocates for safe consumption spaces, like the one in Vancouver that inspired him to begin distributing fentanyl strips.
Safe sites provide drug users - who bring their own supplies - with a space to get high under the supervision of staff trained to respond to overdoses or other emergencies. Such facilities have opened in Canada, Australia and Europe, and studies conducted by European and American researchers demonstrate that they may help lower deaths and the spread of blood-borne illnesses.
But, these spaces remain highly controversial - and illegal - in the U.S. Opponents say they encourage drug use, and sites would attract drug dealers and increase crime. Advocates, like Asher and Townsend, argue that if addicts are going to continue using, they might as well be in environments where they can be saved.
"This is a preventable epidemic created through endemic neglect, racism and discrimination," says Asher. "Most people we serve overdose because of the stigma of using. They're using alone, recklessly and not reaching out for help because they feel the system is rigged against them."
"The narrative is still very much that we just need to clamp down on drugs," says Townsend - who ran the site in Vancouver that inspired Asher, before coming to the Corner Project. "But it's rubbish. It's never worked in the past. There's always going to be a drug that's causing problems, so you might as well start solving the problems instead of keep on fighting the drugs."
Some cities in the U.S., including San Francisco, Philadelphia and Seattle, have announced plans to open safe sites. In 2016, New York City allocated $100,000 to study the feasibility of opening such facilities, with Mayor de Blasio hinting in late January that the results would be released soon.
St. Ann's and the Corner Project are sticking to fentanyl-testing for now. Despite its limitations, initial results from a study by Johns Hopkins' Bloomberg School of Public Health and Rhode Island Hospital/Brown University tout the success of drug checking as a gateway to get treatment for substance abusers. Between April and November 2017, researchers evaluated drug checking technologies, and interviewed 335 users in Baltimore, Boston and Providence. The study shows that both users and agencies see the benefit of testing in curbing fentanyl-related deaths.
Even though St. Ann has been distributing fentanyl strips for over a year now, Asher says the organization hasn't kept track of what happens post-distribution. But, he's seen drug dealers use the strip to monitor the quality of their supply, and he said that some users say they've made more educated decisions about what they're consuming.
"Most of the time people are going to use regardless of what we tell them," says Asher. "But if one life is saved, one person starts using smartly, then this initiative has paid for itself a million times over."