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fentanyl, drug use: Eli Weinstock with his family at his high school graduation.The photograph on the website of BirdieLight, a nonprofit dedicated to spreading awareness of the dangers of fentanyl, shows Beth Weinstock, MD, and her daughter Olivia sporting smiles that cover their grief. Dr. Weinstock's son Eli died at his Washington, DC, home in March 2021 where the 20-year-old was a sophomore at American University and an intern at the Spanish Education Development Center. She does not know how Eli came into contact with fentanyl, but emphasized that he was unlikely to have known that whatever he took was laced with it. “We have a story to tell, and a promise to make. We've made that promise to Eli Weinstock and to our grieving hearts: a promise to build something good, true and honest atop this devastated landscape. Our job is to spread awareness around the dangers of fentanyl in drugs and distribute tools to prevent overdose, so you have the power to save your own life.” (BirdieLight. www.birdielight.org.) Eli was not alone. The Centers for Disease Control and Prevention's National Center for Health Statistics reported on May 11 that 107,622 people had died of overdoses in the United States in 2021, a 15 percent increase compared with 2020. (https://bit.ly/3w4FjZB.) An estimated 75 percent of those deaths were attributed to synthetic opioids or fentanyl, according to the CDC. The personal aspect and the enormity of the problem spurred the Weinstocks to act. “We formed BirdieLight as a nonprofit to educate young people,” Dr. Weinstock said. Their target demographic is ages 15 to 25. “The knowledge gap is so vast. A lot of people think about fentanyl only as it relates to the use of heroin.” They are trying to teach young people that fentanyl is found in heroin, cocaine, counterfeit Xanax and oxycodone, Adderall, methamphetamine, Ecstasy (Molly or MDMA), and popular party drugs as well. She also said she would like to eliminate the term “overdose.” “To many people, it implies that the person uses the drug daily or regularly. But it is more of a poisoning,” Dr. Weinstock said. “I get pushback on that, but wording is important. Many people die because they are not accustomed to opioids, and fentanyl is the most powerful opioid.” Testing for Safety She and her daughter make education about the risks of fentanyl their main purpose. One tool people can use to stay safe is fentanyl test strips, which can be 92 to 96 percent sensitive in picking up the presence of the drug. “They are very adept at identifying fentanyl, but they are not perfect,” Dr. Weinstock said. Several manufacturers make fentanyl test strips, but the most commonly used are those by BTNX, Inc., in Canada. They were originally designed as urine test strips, but they found that they can also pick up fentanyl before ingestion. “We always tell people they work if the substance you are taking is dissolved in water,” Dr. Weinstock said. If the person is taking a pill or powder, they should dissolve it in water and test that. Cocaine should be tested in multiple places in its container. That may mean using many test strips for a single bag of cocaine, she said. Whether people using the drugs will take the time to test is another issue, she said. People learned to use seatbelts and condoms as harm reduction, and they can do the same with the test strips. Some states approve of the strips, but others have lumped them in with illegal drug paraphernalia. Dr. Weinstock said she hoped that would change because of the current crisis of drug-related deaths. “Culturally we are trying to make them something standard that everyone talks about,” she said. That means making them more readily available. BirdieLight passes them out at colleges and hopes to make them available at all dormitories and student health centers. Unpredictable Overdose A study in a Baltimore emergency department found that four of five patients who reported opioid use had detectable levels of fentanyl in their urine. (Clin Toxicol [Phila]. 2020;58[6]:460.) “The majority of participants were aware of its high potency, dangers of use and risk of death from overdose,” the authors wrote. “However, approximately one in three subjects intentionally purchased fentanyl despite awareness of its dangers.” “I don't think we can say that patients were ‘sophisticated’ or familiar with the use of fentanyl to avoid overdose,” said Hong Kim, MD, MPH, an author of the study and an associate professor of emergency medicine and pharmacology at the University of Maryland School of Medicine. “Because fentanyl is mixed with heroin or adulterants, the dose of fentanyl from a sample purchased for misuse is unpredictable. Some samples may have a higher fentanyl dose while other samples can have low doses because of the inconsistency in mixing of fentanyl into the adulterants. So, the overdose event itself is unpredictable.” The study did not ask how patients use or avoid overdoses. “There is not one best way to decrease opioid/fentanyl use and overdose deaths,” Dr. Kim said. “There are socioeconomic, environmental, and individual factors that contribute to the development of substance use disorders. Therefore, local, state, and federal governments and NGOs have engaged in public health interventions and attempted to address the opioid use disorder from multiple angles. “Supervised injection sites can also help to recognize overdose events since the use of opioids is done under monitoring and it is possible to intervene (e.g., naloxone administration) to decrease overdose deaths. Select cities in Canada and Baltimore have distributed fentanyl test strips. I don't know how well they are accepted or used by opioid users.” The DOPE Project in San Francisco and the Syringe Access Collaborative there did a pilot giving test strips to syringe access sites. The strips were provided through a program supported by the California Department of Public Health. Syringe access providers worked with participants to test the drugs and complete a brief survey regarding the findings, including how finding out that a sample is positive or negative affected the participants' drug use. Providers used the strips to test drugs, and participants also received strips to test their own drugs. Seventy-eight percent of the speed and methamphetamine samples and 67 percent of the crack cocaine samples tested positive for fentanyl. “Providing the test strips, overdose prevention training and naloxone continue to honor the autonomy of people who use drugs, allowing them to make educated decisions with the most accurate information available to them and to prevent and respond to the overdoses,” wrote the DOPE project managers. (National Harm Reduction Coalition. https://bit.ly/3dsTlOk.) ‘Fentanyl is Everywhere’ Dr. Weinstock said she hopes to educate students before they have experimented with drugs that might be tainted with fentanyl. “The most powerful thing we do is we go to high schools and colleges,” she said. “We get in front of the students and talk about everything related to the process of experimentation and what it means in 2022 to use drugs recreationally. When we hand out strips, we like to sit down and talk about using drugs.” Getting into high schools and colleges can be difficult because of the stigma attached to drug use and institutional denial. “I think they don't want to admit that there are students doing drugs. But we try to push in,” Dr. Weinstock said. The current emphasis on the risks of fentanyl is hitting a nerve, she said, and their calendar of presentations is beginning to fill up. Educating the medical world about using test strips to identify fentanyl can also help. “I spoke recently to a group of physicians, hospitalists, nurse practitioners, and physician assistant students in southern Ohio. It was surprising how many of them had never seen or heard of a fentanyl test strip. I realized how much education we need to do in the health care community,” Dr. Weinstock said. She and her daughter Olivia started the project, but the rest of the family supports their activities. Her husband Michael is an emergency physician, Theo is 18, and Annie is 14. Their aim is simple: They want to lower the death toll of fentanyl. “Eli took risks like any other college kid—he didn't want to die. It takes one seemingly innocuous choice. Fentanyl is everywhere,” Olivia said on the BirdieLight website. Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, The Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.

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