Here at “Addressing Fentanyl- #harmreduction strategies to reduce overdose” featuring @DanCiccarone @jondocsin and Jon Zibbell w Maya Doe Simmons as moderator. 
Ciccarone’s talking about the triple wave epidemic, starting with prescription opioids, then shifting to heroin, and this third wave with synthetics and fentanyl. #HarmRed18
The fentanyl problem is regional particularly on the east coast. His study was conducted in Baltimore MD, Lowell & Lawrence MA, Chicago IL, and WV. Their interviews and data collection was trying to treat it like a new drug, exploratory. #HarmRed18
They did in-depth interviews treating people like experts, how do you use it, what does it look like and how was it changed (powder form vs liquid), and how does it feel? #HarmRed18
Major themes: 1) Devastation (telling anecdote of a key informant in WV who went to his 10 yr HS reunion and half of his class had passed from OD) #HarmRed18
2) changes in heroin in ways that no one was prepared for. They didn’t have slang or idioms for this new substance and it was happening high up in change. #HarmRed18
3) variation and unpredictability of the substance was alarming. So much change it’s hard to predict or find consistent stories. How could people stay safe? #HarmRed18
Colors are all over the place and inconsistent with historical trends we’ve seen with heroin. In solution form they can be milky or other shades. Look at these swatches! #HarmRed18
4) inconsistentency in whether users find this new substance desirable.
5) people think they can discern using cues from effects, taste on tongue, solution and powder color.
6) generational changes between what older users know about how to be safe vs the younger users who are trying to figure things out for themselves. Older cultural norms don’t apply anymore.
Ciccarone giving @bmore_POWER a shout out because going slow is a huge #HarmReduction strategy. They have started a “Go Slow” campaign that is really great. #HarmRed18
Now @jondocsin speaking further about this study bit specifically on what they learned abt the “Tools, Tastes, and Tester Shots: Sampling Strategies Used By People who Inject Heroin” #HarmRed18
Personal or friends’ experience w overdose motivated many of their informants to try testing substances by sampling first with small amounts. #HarmRed18
People talked about injecting partial dose- “slow shot” where the needle remains in vein and a little bit injected first, or tester shot where solution divided between two syringes. #HarmRed18
Other non-injecting and techniques here on slide #HarmRed18
Dealer-specific #harmreduction was inconsistent. Some felt keeping same dealer kept them safer. Other said it didn’t matter because dealers didn’t know what was in their drugs either. #HarmRed18
This is an older seasoned injector who never ODd who discussed combination shot approach. (Sounds really intelligent!) #HarmRed18
Another strategy is snorting “tooting” and a lot of information provided abt it based on how it feels when snorted, what the post-nasal drip tastes like, and how the feeling comes on. #HarmRed18
But it must be considered that these strategies are still potentially risky for these reasons: #HarmRed18
Even people who tried to be safe report overdosing and this is a reality for many. We are really facing something that is hard to adjust or predict for. Especially regions where fentanyl may have completely replaced heroin. #HarmRed18
Now Jon Zibbell starting “Risk in the age of illicitly manufactured fentanyls: use of fentanyl test strips” talking about the importance of working directly w PWUD. #HarmRed18
Zibbell saying that PWUD are actually great at adapting to drugs but how do people adapt to such a rapidly changing substance that is a moving target? That is the challenge we are facing right now. #HarmRed18
Zibbell now talking smack about that awful SAMHSA blog that further stigmatizes people who use drugs as being incapable of changing behavior w information through fentanyl test strips. These myths are false.
He’s also giving Sherman’s FORECAST study about the real promise of fentanyl strips and their accuracy as well as people’s willingness to use them. #HarmRed18
Zibbell along with @nc_usu decided to do a Fentanyl test strip study to help build evidence. They worked with 100+ people and 60+% had fentanyl positive result and 40+% of those people w pos results said they changed behavior. #HarmRed18
People said they used less, made tested shot, or they slowly pushed the plunger. People w positive fentanyl test strip were FIVE TIMES MORE LIKELY TO CHANGE THEIR BEHAVIOR!!! #HarmRed18
Even people with negative fentanyl results were more likely to change their behavior too!!! Amazing! It slowed them and got them to think about their actions. #HarmRed18
Most of these people said even the act of testing made them feel safer. It was a form of prevention and perhaps created a false sense but it’s interesting to think about. #HarmRed18
Another aspect of the study was asking people what they felt like and what they discerned, comparing to the test strips results. #HarmRed18
They found that 80% of ppl w positive fentanyl result said it was white powder. 73% said solution was clear. 62% said cloudy or milky. 40% said a little brown. 85% has more intense rush. 87% said shorter length of euphoria. 83% said unusual sensations (pins/needles) #HarmRed18
Other unusual effects include lightheaded ness, shortness of breath, rigid chest syndrome that can even impact absorption of nasal naloxone spray. #HarmRed18
All of this to say that we need fentanyl test strips accessible in needle exchanges. What if we had mass spectrometers at a needle exchanges? Yes, it would take long but we could learn a lot. Often bags have so many things in them. #HarmRed18
Now @maiasz asking what about the impact of these new substances on tolerance? Zibbell saying that some people may be seeking rush or ppl have become fentanyl dependent bc it has taken over their market. #HarmRed18
Audience member asking what they know about fentanyl adulterated cocaine- @DanCiccarone speaking about 3 things 1) speedballs, 2) sloppy production and cutting practices, and 3) it is possibly deliberate (but he doubts it is a major player). #HarmRed18
