The chocolate chip cookie theory of fentanyl distribution in counterfeit “pharmaceutical” pills holds that when the pills are pressed, the fentanyl is not evenly spread through the mixture. Pills, both counterfeit and pharmaceutical, have a substantial volume of filler material added to them. For counterfeit pharmaceuticals made with clandestine pill presses, it’s a legitimate concern. Between this and questions of human behavior, there has been discussion of whether or not fentanyl test strips are effective for potential and actual pill users.
It’s a question that really matters when youth overdose, in particular, has skyrocketed mostly due to counterfeit pills. While people who use powder opioids understand there is some level of risk, pills stamped with whatever it might be can lull someone into a false sense of security. Much of the pill market is people who knowingly and intentionally buy fentanyl pressed to look like 30 mg oxycodone. But when those same counterfeit pills trickle out into the hands of the unsuspecting, tragedy strikes.
The false reassurance of a negative could be worse than no test at all.
Some of those people intend to just swallow their pills (which is never advised when dealing with fentanyl) and may not wish to grind them into powder. Preferably, an entire pill will be ground up to be tested. For various reasons, not everyone is likely to do that. Yet the advice to “test a part of the pill,” even if more likely to be followed, seems potentially dangerous: If that segment of the pill does not contain fentanyl when it is present in the rest of the pill, the false reassurance of a negative could be worse than no test at all.
So what’s the right advice? I’ve often heard the chocolate chip theory repeated as a reason to be reluctant to use fentanyl test strips—inexpensive tools for getting a crude yes-or-not answer—for pills. On the other hand, people who are addicted to “Blues”—the pressed pills, ostensibly oxycodone but ubiquitously fentanyl, that have soared in popularity on the West Coast—will sometimes “go up” on a pill 50:50, splitting it in half. Drug users tend to know best: If there were a chance that a half-pill contained no fentanyl, I doubt that would be an acceptable practice.
My instinct was that fentanyl test strips should still hold value for anyone looking to use a pressed pill, but (obviously) above all for those who don’t intend to consume fentanyl. Familiarity with a supply doesn’t equal certainty. And it’s always better to have more information—even if important caveats should be emphasized and applied to the strips’ results.
I did a tiny and unscientific experiment: testing two different Blues that were different shades of blue.
I also understood that expecting someone to grind up their entire pill and add water to it might not always be realistic. That led me to wonder what happens when you test only a portion of a fentanyl pill.
So I did a tiny and unscientific experiment: testing two different Blues that were different shades of blue. (I’m unsure if that means they were from different suppliers, different batches, or simply ended up different hues.) An acquaintance made a donation to science, and our experiment was conducted at a syringe service program.
My first observation was that the Blues looked alarmingly like the oxycodone M30s they were alleged to be. They were very small, almost too small to get a good photograph. They were pressed densely, with clean lines and no obvious indication of their counterfeit status.
My next observation was that they were almost impossible to break. Later, I learned that people who regularly use them (again, the real experts) have figured out that you can set them on a Bic lighter and use its convex shape to then break them in half by pressing with your thumbs.
For the experiment, the harm reduction specialist I was working with brought out a mortar and pestle. We bashed the pill once, trying to split it without it pulverizing. My initial idea was to break the pill into quarters and test each quarter. Instead, it fractured into small bits.
We then picked up some of the tiny slivers we produced—four fragments from each pill, with a lot left behind that was never tested—and placed them into sterile cookers. We added some water, stirred them around, and then tested each sample using BTNX fentanyl test strips.
Of the eight fragments from two different pills we tested, every single one showed an obviously positive result. It did not seem to matter how little we mixed the samples—even the fragments that had dropped in like tiny rocks and were wholly undissolved produced glaring positives.
In these pills, it seemed that the fentanyl was distributed enough that testing any small sample would allow you to identify its presence. (This is not to say the chocolate chip cookie theory is incorrect. Due to the nature of clandestine pill press operations, it is unlikely the mixture of inert filler and fentanyl is ever homogenous. But even trace amounts of fentanyl in the tested portion result in a positive.)
For what it was worth, it strengthened my belief that fentanyl test strips could have value.
Needless to say, the findings of our mini-experiment are limited in all kinds of ways and should not be applied to any pills other than the two we tested. But for what it was worth, it strengthened my belief that fentanyl test strips could have value, even if caveats must apply to any negatives.
Oh and by the way, I conducted this experiment with my bare hands because I knew that fentanyl cannot practically be absorbed through skin contact. Just for the sake of it, I used a fentanyl test strip to test my urine (technically what they’re made for) that night and the next day. As expected, it was negative both times.
Counterfeit pills are a very American phenomenon. They cropped up to fill the void left after medical prescribing of opioids plummeted—it didn’t fall, it was pushed—though demand stayed the same. Ten times as many annual deaths are now linked to illicit opioids as were ever linked to prescription drugs. The danger pills pose to less experienced and knowledgeable people—who may not have opioid tolerance, might not recognize the signs of an overdose and are less likely to have naloxone—is acute.
Passing out fentanyl test strips does more than give people a drug testing tool. It serves as a tangible, physical reminder for why drugs need to be tested. They function as a conversation-starting, memory-jogging prop as well as a testing device. If you get someone to test their “oxy,” you’ve already won more than half the battle. You’ve moved risk from an unknown unknown into a known unknown, establishing in somebody’s mind the wildly uncertain risk level of what they purchased.
We have shifted risk to a known unknown. Once it enters that category, all harm reduction practices are on the table.
If someone intending to swallow their “oxy” orally struggles to break it in pieces and therefore opts to not test it all, that’s a big issue. But again, if you have the person thinking about the presence of fentanyl, via the physical embodiment of fentanyl test strips, I believe we are winning.
The test strip represents their knowledge that risk exists. Other precautions may occur to people who use the strips, or curiosity may lead them to look them up. They may be more likely to have naloxone on hand and to not use alone. We have shifted risk to a known unknown. Once it enters that category, all harm reduction practices are on the table.
Photographs by Morgan Godvin