In the day room at St. Ann's Corner of Harm Reduction, which runs a needle exchange program in the Bronx, a group of guys are playing dominoes and listening to salsa music while they wait for lunch. And Van Asher, one of the staffers in charge of "transactions" — that means he gives out needles — is talking up his latest idea for how to keep the users here safe.
He wants to tell them what's really in their stash.
"If you're doing dope," he says to one client, "we'll give you a test strip so you can test and see if there's fentanyl."
Fentanyl is a synthetic opioid that is "similar to morphine but can be 50 to 100 times more potent," according to the National Institute on Drug Abuse. Increasingly, drug dealers have been using fentanyl to cut their heroin supply — which can be lethal for users. By using the same simple test a doctor would use to check for fentanyl in a patient's urine, Asher is now giving drug users in the Bronx a way to quickly find out what's in their syringe before they inject.
"I know what I'm getting is the raw," one client tells Asher, implying he knows his drugs are pure.
"That's what you think!" Asher tells him. "But how do you know? Are you buying it from, like, the FDA?" The client laughs.
Asher is the data manager here: He makes sure the Centers for Disease Control and Prevention and local health departments get the information they need about the drugs taken by the people who come here. But he started this project more out of his own feeling of desperation about the community he serves than out of a desire for official data collection.
He says the number of overdose deaths in the last year has been so overwhelming, he's tried to stop counting them. But the New York City Department of Health and Mental Hygiene says drugs killed more than 1,300 people in 2016 — the highest number on record. And public health officials say that rise has been driven, in large part, by fentanyl.
As Asher says, "You see someone, you go: 'I'll see you tomorrow.' And you never see them again."
Which is why he and St. Ann's Corner recently ordered a bunch of fentanyl test strips from Canada and started handing them out. The idea is that giving users information about what they're using could empower them make a better choice. If they know there's fentanyl in the mix, maybe they'll inject the drug more slowly. Maybe they'll use in a safer place. Maybe they won't use at all.
Now, Asher is working with needle exchanges around the country who are trying the same sort of thing. Dr. Alexander Walley, the director of the addiction medicine fellowship program at Boston Medical Center, has been tracking the use of these test strips since the idea first got started last year, at a needle exchange in Vancouver, called Insite.
"From what I've heard ... even when they know they're going to be positive for fentanyl, the experience of somebody testing their drugs and seeing that it's fentanyl has an impact," Walley says. "It really encourages them to use more safely."
Insite, which is funded by the Canadian government, is also the only "safe injection" site in North America. That means there's a key difference between what's happening there, and what's happening at needle exchanges in the U.S. In Canada, whether or not a user's drugs test positive for fentanyl, he or she can stay at Insite and inject under a nurse's supervision, which increases the chances that an otherwise lethal overdose could be reversed.
Walley thinks about these test strips the same way he thinks about a fire extinguisher or a seat belt: as a precaution. He's interviewed heroin users, and says while some users tell him they like fentanyl, and some don't, "the majority of people are agnostic. Because the people we interview, they have a daily opioid use disorder — and what they really care about is not being in withdrawal."
"At the end of the day," he continues, "I think giving people knowledge about what they're putting in their body is probably a good thing more than a bad thing."
But will these test strips help users in the Bronx avoid an overdose? Asher says the only way to know is to give them out and study what happens next.
His project is still very much a work in progress. Asher says that he's been giving out about 10-15 test strips a day, and is starting to run low. Each strip costs about a dollar, and the budget at St. Ann's, which is funded primarily by the city and state departments of health, is tight. Asher has tried handing out surveys with the strips, to figure out which brands might be more dangerous, or what a tainted batch might look like. But it's hard to get users to report back.
One thing he's already learned: Fentanyl has become a big part of the local drug supply in the Bronx. One user, Vincente Estepa, says all but one of the bags of heroin he tested came up positive for fentanyl.
When asked whether that will change the way he uses, though, he says no.
"At the end of the day an addict is an addict, Estepa says. "It's stronger! If it makes me feel the euphoria, I'm going to go for it."
Estepa says dependence on the drug means constantly looking to avoid "E." That stands for "empty," he explains — when the physical symptoms of opioid withdrawal kick in. And avoiding withdrawal can mean taking risks.
Using heroin has already taken a lot from him. Estepa has lost his job. He's homeless. But he's still alive. The people running this project want to keep it that way.