SGEM#407: Here We Go Test Strips for Fentanyl

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Date: June 16, 2023

Reference: Reed et al. Pilot Testing Fentanyl Test Strip Distribution in an Emergency Department Setting: Experiences, Lessons Learned, and Suggestions from Staff. AEM June 2023

Guest Skeptic: Dr. Lauren Westafer is an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for Annals of Emergency Medicine.

Case: A 27-year-old right hand dominant patient presents to the emergency department (ED) with a 2.5 cm left forearm abscess. They have no fever, chills, or signs of compartment syndrome. You perform an incision and drainage of the abscess with significant improvement in pain. The patient reports injection use of opioids, last use was a few hours ago. The patient currently has no signs of withdrawal and is interested in potentially starting on methadone; however, the patient is not ready to start the medication right now.

Background: We have addressed the issue of substance use disorder a few times on the SGEM. This included looking at alcohol misuse and opioid misuse.

SGEM#55: Drugs in My Pocket (Opioids in the Emergency Department)
SGEM#241: Wake Me Up Before You Go, Go – Using the HOUR Rule
SGEM#264: Hooked on a Feeling – Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain
SGEM#313: Here Comes a Regular to the ED
SGEM#374: Bad Habits – Medications for Opioid Use Disorder in the Emergency Department

Rises in opioid overdose deaths have been attributed, at least in part, due to increases in fentanyl contaminating the illicit opioids in the United States. EDs are an important touch point for individuals with opioid use disorder (OUD), given the number of encounters for overdose and complications associated with drug use.

Although some patients may be ready for medication such as buprenorphine or methadone, which can be initiated in the ED, some patients may not be ready for either medication. In these cases, harm reduction practices, strategies that mitigate complications from drug use, are critical.

Fentanyl test strips (FTS) have been suggested as one harm reduction strategy to reduce opioid overdose deaths. The American College of Emergency Physicians (ACEP) endorses greater harm reduction education for emergency physician . Fentanyl test strips can be used by people who use drugs (PWUD), prior to use, to detect the presence of fentanyl. Individuals can then use that information to decide if or how much of the drug to use.

Clinical Question: What are the perspectives of clinicians and other staff distributing fentanyl test strips to people who use drugs in an ED setting?

Reference: Reed et al. Pilot Testing Fentanyl Test Strip Distribution in an Emergency Department Setting: Experiences, Lessons Learned, and Suggestions from Staff. AEM June 2023

Study design: This was a qualitative study assessing staff perceptions of a pilot of distribution of fentanyl test strips. Staff meeting inclusion criteria (below) were invited to participate and rec
Population: English speaking ED clinician (physician, nurse, advanced practice provider, technician, social worker, certified recovery specialist) distributing fentanyl test strips through the pilot program.
Intervention: Interviews at two points in time, three weeks and three months after distribution of FTSs began
Comparison: Not applicable

Megan Reed PhD

This is an SGEMHOP episode, and it is my pleasure to introduce Dr. Megan Reed. She is a PhD with a Master’s in Public Health. Megan currently works at the College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA.

Authors’ Conclusions: “Implementing FTS distribution may improve patient rapport while providing patients with tools to avoid a fentanyl overdose. Participants generally reported positive experiences distributing FTS within the ED but the barriers they identified limited opportunities to make distribution more integrated into their workflow. EDs considering this intervention should train staff on FTS, how to identify and train patients, and explore mechanisms to routinize distribution in the ED environment.”

Quality Checklist for Randomized Clinical Trials:

Was there a clear statement of the aims of the research? Yes
Is a qualitative methodology appropriate? Yes
Was the research design appropriate to address the aims of the research? Yes
Was the recruitment strategy appropriate to the aims of the research? Yes
Was the data collected in a way that addressed the research issue? Yes
Has the relationship between researcher and participants been adequately considered? No
Have ethical issues been taken into consideration? Yes
Was the data analysis sufficiently rigorous? Unsure
Is there a clear statement of findings? Yes
How valuable is the research? Valuable
Funding/COI: Funding from Bloomberg Philanthropies and the authors declare no potential conflict of interest.

Results: There were 21 ED staff who participated in the qualitative review (7 residents, 4 attendings, 6 nurses, 2 recovery specialists, 1 social worker and 1 technician). The mean age was 35 years, 57% were male and 76% were not at all familiar with FTS.

Key Result: All participants endorsed the utility of FTS distribution in the ED

Five Themes from the Interviews:

Strategies to approach patients about FTS
Patient reactions to FTS
Dynamics between patients and participants
Staff support and stigma
Challenges of FTS distribution in the ED

Listen to the podcast to hear Megan answer each our five nerdy questions. You can also click on the link to the YouTube video on How to Use FTS and How to Distribute FTS in the ED.

1. Reflexivity: Reflexivity is a key component of rigor in qualitative studies. Reflexivity involves a qualitative researcher examining their own judgments, practices, and belief systems during the data collection process to identify any personal biases that may have incidentally affected the research. In what was reflexivity addressed in the analysis?

2. Social Desirability Bias: We have talked often on the SGEM about various forms of bias. Bias being defined as something that systematically moves us away from determining the best point estimate of an observed effect size. In qualitative research, a major bias that is omnipresent is social desirability bias. This bias is when participants will often tell you what they think you want to hear. What degree do you think this might have been present? What efforts did you undertake to try to avoid this bias?

3. Qualitative Analytic Technique: There are several options for analysis in qualitative studies – grounded theory, thematic analysis, etc. Qualitative content analysis is less commonly used in healthcare and implementation research. Often then a manifest (what participants say) or latent (what participants intended to say) approach is chosen. How did you choose your approach?

4. Qualitative Rigor: Rigor in qualitative studies has been widely described based on the following criteria: credibility, dependability, transferability, and confirmability (instead of validity and generalizability). What did you do in this study to ensure qualitative rigor on these points?

5. Balancing Perspectives: In qualitative studies, participants will sometimes report the experiences or perspectives of others. Since this study did not interview the patients who were approached as potentially receiving fentanyl test strips, it is impossible to understand their perspectives. How do you balance this tension?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.

SGEM Bottom Line: Although the clinical impact of fentanyl test strips is uncertain, staff led distribution in the ED appears feasible.

Case Resolution: You prescribe antibiotics for the mild cellulitis around the abscess. You provide take home naloxone and discuss harm reduction techniques including rotating injection sites, where to access new needles, use of alcohol pads, and potential for fentanyl test strips.

Dr. Lauren Westafer

Clinical Application: Although the clinical utility of fentanyl test strips in an undifferentiated population of people who use drugs in the ED is unknown, there are several barriers to implementing this intervention in the ED.

What Do I Tell the Patient? Until you are ready to stop using drugs, there are several things you can do to reduce your risk of getting very sick, a bad infection, or dying. One of the things you may be interested in are test strips, which can detect fentanyl. If the drugs test positive for fentanyl, you are at increased risk of overdose.

Keener Kontest: Last weeks’ winner was John Carter. He knew etomidate was published as a novel hypnotic agent in 1965.Listen to the episode to hear this weeks’ question. If you think you know the answer then send an email to TheSGEM@gmail.com with “keener” in the subject line.

SGEMHOP: Now it is your turn SGEMers. What do you think of this pilot study of distributing FTS to OUD patients in the ED? Tweet your comments using #SGEMHOP. What questions do you have for Megan and her team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.