Enacting Fentanyl Tests Strips for Overdose Prevention: The Socio-Material Transformation of “Suspect Technologies” into “Technologies of Solidarity”

Cultivating the “Serological Touch”: From the Wasserman Test to Fentanyl Testing Strips

Facts first, for facts “represent a stylized signal of resistance in thinking” in Genesis and Structure of a Scientific Fact (Fleck, 1979, p. 98). In Fleck’s comparative epistemology, a fact goes through several incarnations before becoming consolidated as an “immediately perceptible object of reality (Fleck, 1979, p. 125).” This reality-constituting perceptual work has been subsumed within garden variety social construction, but “our interpretative webs, spun to capture features of the world, are necessarily shaped by our agency within it. This agency is socially as well as materially engaged. Scientific facts, as the outcome of these interactions, represent specific worldly features in a way that is necessarily influenced by social interests and values. The opposing view, objectivism about worldly facts or truths, conceives epistemic agency as passive [and] facts/truths [as] (largely) independent of our beliefs (Fagan, 2010).” Grounded in concrete “worldly features,” socio-materialities are not merely evidential but agentically produced and animated by beliefs that deeply influence the shape that artifacts assume in relation to worldly materialities and epistemic agencies. Specific temporalities and spatialities—sets and settings—condition enactments in ways that embed belief within artifacts. Facts, then, represent specific worldly features in ways that are motivated by material interests and moral values but also have acquired that stylized resistance to thinking to which Fleck referred. I refer to these as artifacts in order to recognize that aspect of conditioned enactment.

Among the very earliest diagnostic technologies developed, the Wasserman test was the fussy test for syphilis that sparked Fleck’s thinking about facts. The artifact was notoriously indecipherable: it caught other autoimmune diseases in its net, yielded false positives, failed to detect nascent disease, and required expert interpretation. Yet it translated unreadable bloody materialities into facts recorded as permanent, reliable, consolidated, and stable enough to be inscribed into matters of state record with life and death consequences. Subscribing to facts enabled forgetting critical insights into the sociomaterial process of their production, including the interpretive work and epistemic agency that goes into making them. Habits of mind and body, material and symbolic, enact facts and artifacts within realist registers—no common sense can afford not to recognize the legitimacy of facts and artifacts. The capacity to reason with facts, to stick to “just the facts, ma’am”—never mind how or by whom or by what sociomaterial agency they are produced—is naturalized by “healthy reasoners” (Schillmeier, 2014, p. 33) as the central form of agency grounding thought and action in an evidence-based era. ¹

Subjects of harm reduction are depicted as active, agentic, healthy reasoners who rationally embrace all tools on offer in the interests of keeping themselves healthy and alive. FTS materialize bodily, mental, cognitive, but above all moral and ethicopolitical, capacities of healthy reasoners. Although these thin blue reeds are barely strong enough to bear the weight of a theory of socio-materiality, they are simpler to handle than was the Wasserman reaction. Somehow related to the presence of syphilis, the Wasserman reaction’s fuzzy results were similar to FTS, which can only signal presence or absence of fentanyl but not the degree to which it is present. Although FTS can detect many fentanyl analogs, manufacturers maintain denial in the face of potential liability concerns (Stewart, 2017). Harm reduction organizations instruct workers not to signal to PWUDs that their supply is “safe.” As with the home pregnancy test (Layne, 2009; Leavitt, 2006; Robinson, 2016), healthy reasoners confront desired or undesired results, depending on sociomaterial conditions, as well as emotional elements such as “mood.”

It was the “disciplined, shared mood of scientific thought” that compelled incorporation of consolidated fact into thought system, according to Fleck (1979, p. 145). His social account of the genesis of fact within the reified structures of scientific knowledge production acknowledged that cognition resulted from a “socially conditioned” process, activity, or relation (Fleck, 1979, pp. 38, 42). Thinking was a “supremely social activity which cannot by any means be completely localized within the confines of the individual” (Fleck, 1979, p. 98). Mood grounded science in ways that were social, material, and collective—and in that “special mood” of scientific thought collectives, Fleck heard echoes of a fervid, even emotional, tone (1979, pp. 44, 49, 54). Shared affect remains palpable within the global health equity and harm reduction movements, which sometimes tip into “collective effervescence” (Collins, 2004; Durkheim, 1912/1965). Plenty of this psychoactive substance is evident in the enthusiasms of harm reduction trainings, workshops, websites; assembly of kits and educational materials for overdose prevention; and in swag, promotional materials, and fundraising addresses. Harm reduction’s moods and sociomaterialities are digitally apparent on Instagram accounts like those of Heather Edney or Greg Ellis at @Ward_5B, which circulate emotionally potent “outsider art” from 'zines, flyers, playbills, stamped and branded glassine bags used for heroin and fentanyl; Chicago Recovery Alliance’s garden project through which harm reduction staples like naloxone and needles mix with food distribution efforts; or Homeless Health Care Los Angeles’ emphasis on building non-public housing or “Skid Rover” pet care; or accounts on Overdoselifesavers.org, which seeks to “support people affected by opioid overdose and thinking about using take-home naloxone.”

Mood and materiality hold us together; semiosis calls “us” into activity and symbolic forms prolong mood beyond its otherwise ephemerally precarious existence (Collins, 2004, p. 37; Durkheim, 1912/1965, p. 265). Social movements seeking new relations to technoscience cultivate an “active, concrete awareness of the very special and demanding character of their knowledge, and the way its reliability depends on the distribution between what they define as mattering and what can be ignored” (Stengers, 2018, pp. 149–150). Mood matters for how sociomaterial enactments take practical shape in the practical experiments in the arts of harm reduction, where being experienced means “feeling one’s way” (Rheinberger, 1997, p. 77). ² Being experienced entails being able to attach consciousness or awareness to artifacts that may be worn, “liked,” carried, circulated, or transmitted in ways that enable others to incorporate the “special and demanding character of their knowledge” into everyday life.

Without access to experiential knowledges, people could develop neither the “serological touch” to make their interpretations reproducible and practical (Fleck, 1979, pp. 96–98). Packaged as a test strip or home pregnancy test, the “serological touch” makes convenient and transmissible facts for healthy reasoners. FTS are produced by a biotechnology corporation outside of Toronto, Canada. Initially developed to detect the presence of fentanyl and metabolites in urine samples, they were made to give rapid results upon which physicians and drug treatment providers could act to enforce compliance. Since 2016 harm reduction practitioners have animated FTS in unlicensed, non-compliant, or “off-label” ways across North America. A mood of life-affirming empowerment is evident in online training and promotional videos showing activists taking FTS distribution into their own hands, using the readily available material culture of opioid injection such as cookers. This life-affirming affect may be counterpoised to affective styles mobilized in relation to grief and loss. The next sections examine the moral and political landscape in which “off-label” strategies emerged to offer agency and hope of ensuring safer drug supply. Although circulation of FTS in the social infrastructures developed and maintained by harm reductionists is an innovative redeployment of a drug surveillance technology, the next section describes proto-formations used to ensure safer drug supplies emerged from illicit producers and suppliers.

Evolution of the “Bummer Squad”: Drug Checking as a Safety Strategy

Early drug-checking operations or bummer squads responded to people freaking out in public spaces, particularly concerts and festivals (Chapman et al., 1982). Physicians Sidney Schnoll and Stuart James brought massive gas chromatography mass spectrometers for toxicological testing of bodily fluids and solid dose forms of drugs in a trailer on-site at the 600,000 participant Watkins Glen Summer Jam Rock Concert on July 28–29, 1973 (James et al., 1975). Attention focused on “street deception” and “look-alikes,” pills that were clandestinely produced, diverted, adulterated, or unintentionally tainted:

[W]e would post a list on the trailer describing a drug and saying whether it was good or bad or whatever. People would come up and look at the list, and they’d look at their handful of drugs. They’d put the good ones back in their pocket, and some they would throw on the ground. The bad ones they’d throw on the ground. And there were people who would stand around and pick up the ones that were thrown on the ground. So we would watch out for those people showing up later on. (Sidney Schnoll, personal communication with author and Joseph F. Spillane, June 19, 2008, pp. 18–23)

The newly formed National Institute on Drug Abuse (NIDA) and the Drug Abuse Council convened a symposium on December 10, 1973, and published Medical Care at Large Youth Gatherings: A Manual Based on Experiences in Rock Concert Medicine (Dubin, 1976). Although the manual indicated that response to drug-related events was integral to the general practice of medicine, “rock concert work” was its focus: “It is the basic feeling of the authors…that proper medical care is a basic human right and should be available at large youth gatherings, notwithstanding the broad moralistic attitudes which customarily surround these events. It is felt that toxicologists have a responsibility to uphold in the proper planning of medical care at these large youth gatherings (James et al., 1975, p. 47).” The Watkins Glen crew was recognized as a first-US instance of this kind of roving toxicology laboratory (their “laboratory” was a folding card table that shook when people entered or exited the trailer, or when helicoptors landed or took off nearby). The manual also described a 200-person medical team that included 30 Navy medics at an Oakland Coliseum event for which the PharmChem Research Group was trained and provisioned by the Haight-Ashbury Free Medical Clinic, having assembled a “compact, readily assembled analytical laboratory” for rapid analysis. Later associated with the campaign to end Paraquat spraying in Mexico by the US-based National Organization for the Reform of Marijuana Laws (NORML), PharmChem provided an Analysis Anonymous service for street drugs. ⁴

These earlier episodes are worth recalling in terms of the socio-material infrastructure assembled pre-COVID-19 to make naloxone more systemically available by local, municipal, and state governments in the United States. Public provision occurred only because the harm reduction movement made naloxone synonymous with drug safety and integral to overdose death prevention while also using it as a “technology of solidarity” around which to consolidate a social movement that enacts resistant practices as biopolitical expertise (Campbell, 2020a, 2020b). The complex circuitry of relays enacted in the face of fentanyl built upon the sociomaterial infrastructures of a harm reduction responsive to and enacted in coordination with other economic, legal, and political forces. Whether or not FTS will reach even naloxone’s degree of intermittent availability remains to be seen. The two technologies differ from one another. Naloxone is unequivocally an opioid overdose reversal agent and was FDA approved for that indication in 1971. FTS require interpretation and are not licensed or approved for harm reduction purposes.

Fentanyl itself is a medically necessary drug with a deathly diversion profile that participates in both pleasure and danger. Although consumers are assumed to avoid fentanyl, and are supposed to discard, slow the pace, or reduce dosage if they identify it in their supply, some seek experiences to which fentanyl allows access (Papamihali et al., 2020). As documented in Vancouver, British Columbia, a “significantly higher number of PWUD are using fentanyl knowingly in comparison with the past few years. We also found that known fentanyl use was considerable among people who used crystal meth. Our findings suggest that the landscape of the illicit drug supply in BC as well as PWUD’s attitude toward exposure to fentanyl may be changing (Karamouzian et al., 2020).” PWUDs cannot be assumed to entirely avoid experiences that others label harmful, as Schnoll’s interview indicated—indeed, we might ask, who defines what counts as harm, what pleasure, and what danger? The drug-checking model assumes that agency resides in the decision to abstain, to steer clear of known risks, to play it safe—and not to seek, prefer, or embrace fentanyl with or without other drugs.

The neutral vocabulary of “drug-checking services” refers to “promising” or “strategic” practices in the evidence-based scientific literature that has sprung up to evaluate them (Laing et al., 2018). Located as generative ground for drug-checking, the 1990s saw raves or large-scale dance parties occurring all over the world. As with naloxone, harm reduction advocates evaluated drug-checking practices in the process of establishing them, producing a substantial evidence base tracing the benefits of assessing quality or detecting adulterants via relatively simple chemical tests (Soukup-Baljak et al., 2015). Established in 1992, the Dutch Drug Information and Monitoring System (DIMS) was an early coordinated system for tracking substance characteristics by conducting laboratory analyses of submitted compounds (Brunt & Niesink, 2011). ⁵ Although drug-checking services were sometimes linked to public health surveillance (Barratt et al., 2018), many more were linked to needle and syringe programs or other harm reduction organizations that were quasi-legal (and treated as illegal) in the US. The latter moved in low-tech directions, employing bulletin boards, blackboards, or whiteboards that enabled users to track purity, potency, and, increasingly in the 2010s, presence of fentanyl. A global proliferation of such services has occurred in the past 5 years (Barratt et al., 2018).

Drug-checking services focus not only upon materialities such as chemical composition, but upon socialities of educating PWUDs to reduce risk by discarding drugs known or shown to be dangerous by changing suppliers, route of administration, or consumption practices. As of 2017, the United Nations Global Commission on Drug Policy included drug-checking services among recommended harm reduction measures that governments should take to “provide legal protection and support funding for rigorous evaluation of testing technologies in a range of settings, longitudinally. This process should be informed by ongoing consultation with community advisory groups, and by involving PWUD as key stakeholders in program design and implementation (Laing et al., 2018).” Nonprofit groups such as DanceSafe have become familiar presences at music festivals since the late 1990s, bringing less surveillant services, including free reagent testing, to attendees. The Spanish NGO Energy Control, officially named the Asociación Bienestar y Desarrollo (Association For Well Being and Development), earned drug user trust to such a degree they encountered complex relations with law enforcement and festival producers, who sometimes requested a reduced array of services on grounds that harm reduction promotes or condones illicit drug use. Energy Control supported by the Spanish Government Delegation to the National Plan on Drugs as part of the EU Early Warning System operated by the EMCDDA and Europol.

Arguments against scaling up drug-checking services typically assert that results provide false security or “false reassurance” (Schneider et al., 2016). Some argue that pill-checking “lacks evidence of efficacy sufficient to justify publicly funded national roll-out of on-site pill-testing programmes (Scott & Scott, 2020).” Concerns about “wasting of precious resources” have led to calls for “modest and selective implementation” until more research could be conducted on the “real-world effectiveness of DCTs [Drug Checking Technologies] (Bardwell & Kerr, 2018).” Political decisions to allocate public monies to harm reduction are typically contested in these terms, but FTS were also attributed a deceptive or superficial “shine of safety” (Winstock et al., 2001) that obscured the “unpredictable spectrum of effect” (Schneider et al., 2016) occurring once a substance is inside the body. Pharmacological effects have long been shown to vary with “set and setting”; they depend on socio-material context as well—and the latter is typically more thoroughly studied than the former. Although individual variation in pharmacodynamics would seem to argue against reliance upon FTS or other technologies that reduce the social meanings of harm by relying entirely upon chemical identification, intense variation in drug effects might also be useful support for building least-surveillant infrastructures attuned to the needs of drug users. Drug testing or checking may be infrastructured in ways that may be more or less attuned to the needs of those who comprise drug-using cultures (Zigon, 2019).

Arguably, Insite, the first legally sanctioned safe injection facility in North America, in Vancouver British Columbia’s Downtown Eastside, is a place where harm reduction has been structured into everyday life (Boyd et al., 2009; Lupick, 2017, 2018; Zigon, 2019, pp. 126–129). Proximity and a tight loop between practitioners and researchers led to the first use of FTS for harm reduction at Insite during a declared public health emergency in April 2016 (Karamouzian et al., 2018) and a study subsequently conducted there from July 7 to August 3, 2016 (Lupick, 2018; Tupper et al., 2018). ⁶ Popular and scientific literature on how FTS were deployed in this setting characterized it as an infrastructure built by harm reduction principles and government and community support. By contrast, U.S. harm reduction organizations have largely been left to their own devices, relying on individual capacity to obtain and distribute FTS (Stobbe, 2018). FTS materialize the tense relation between prevention oriented toward harm reduction versus prevention oriented toward abstinence and drug control, and in the tactic of adopting a technology developed for drug surveillance to make the unregulated drug supply safer (see Figure 1; Ivsins et al., 2020). Given the success of the regulated market in ensuring safe supply of so-called white market drugs (Herzberg, 2020), the importation of one of these mechanisms, the legal construct of “off-label use,” may be a harbinger of convergence between these once separated markets and their customer bases.

OPEN IN VIEWER

Figure 1.

Originally intended for urine drug tests, fentanyl testing strips are being used as an off-label harm reduction approach to test the presence or absence of fentanyl and many fentanyl analogs (very closely related drugs) in the unregulated drug supply. Used with permission of Van Asher, Harm Reductionist.

Off-Label Use: The Symbolics of the “Right Tool” for the “Right” Job

Harm reduction networks redeployed urine testing strips by using them “off-label” to detect fentanyl, and getting users to pre-test drugs they intended to use. This resistant practice began at the Insite Safe Injection Facility in Vancouver, British Columbia, Canada, but has now been adopted widely in North America (Karamouzian et al., 2018; McGowan et al., 2018). FTS were intended neither for street use or for use in Safe Injection Facilities like Insite, where they are not dipped into urine but instead into solutions concocted from water and drug residue in bags or cookers. Initial press on FTS emphasized the original users as physicians checking the urine of patients to whom they had prescribed fentanyl for chronic pain, to ensure they were taking it as prescribed (Stobbe, 2018). “On-license” use only migrated to “off-label” when a “Canadian physician” undertook to dip the strips “into the residue of ‘cooker’ cups that heroin users employ to prepare their injections” at a “government-sanctioned facility in Vancouver that allows people to use drugs under medical supervision” (Stobbe, 2018). Early reporting emphasized that off-label use had not been evaluated for sensitivity or specificity, and questioned “whether the accuracy of fentanyl test strips might be mediated according to situated practices of use. We draw attention to the weak research evidence informing the use of fentanyl self-testing strips (McGowan et al., 2018).” Reportage implied that “on-label” use followed rigorous protocols, yet such studies were rarely conducted due to lack of resources or political will to fund and accomplish them according to scientific standards way beyond the reach of most harm reduction organizations. Researchers are caught in a series of double-binds when seeking to “evaluate” the application of licit technologies to illicit practices. Harm reduction workers simply move to pragmatics, rather than awaiting the official stamp of approval upon artifacts and practices they deem to save lives. They are “moving evidence” by attending to the “inseparability of the affective, epistemic, material, and temporal dimensions” of [] practices of enacting evidence and promoting [] research” (Linden, 2021, pp. 821–822). As in the case of beta blockers being used “off-label” for gynecological cancer prevention, pharmaceuticals are conscripted into the dynamic social processes and practices that social movements use to move.

As with other innovative harm reduction practices including needle and syringe programs and naloxone, when FTS were first adopted off-label, there was a chorus of calls to bolster the evidentiary base—in addition to generating new harm reduction markets; and innovations in drug education, public health research, advocacy, and prevention arenas (Rhodes & Lancaster, 2019). Emphasis on evidence-making and documenting successful evidence-based practices pervades the global harm reduction movement (Campbell, 2020b; Rhodes & Lancaster, 2019). Socio-material infrastructures developed to expand use of FTS in North America, with an eye to tracing, tracking, and forecasting implications of fentanyl expansion and heroin displacement, have been designated a “new normal” by the Harm Reduction Coalition (as depicted in Figures 1, 2, and 3).

OPEN IN VIEWER

Figure 2.

This Drug Overdose and Prevention Education (DOPE) Project flyer shows methamphetamine users how to test diluted residue for the presence of fentanyl. Used with the permission of DOPE as an example of early adaptation of FTS technology, this flyer is inaccurate in terms of current science.

OPEN IN VIEWER

Figure 3.

The DOPE Project and other harm reduction organizations have creatively adapted urine testing technologies. However, the website of BTNX, Inc., the Canadian diagnostics company that supplies FTS, does not plan to seek FDA approval for this indication: “With rising rates of drug abuse across the world the need for rapid and accurate drug testing has never been higher. Rapid Response^TM brand drug tests have a high sensitivity to aid in their detections of drugs in urine samples. These products are for screening purposes.”

The San Francisco DOPE Project bent both “on-label” and “off-label” FTS toward testing diluted methamphetamine or MDMA, an indication of fentanyl’s presence in less expected places, as depicted in Figure 2. These materials counter the oft-recycled differentiation of fentanyl as the world’s most dangerous drug, drawing continuities between FTS and other harm reduction protocols (Figure 3). Familiar with the cycle in which the “next” drug anchors new scares fusing the moral, political, social, and scientific aspects of everyday life (Reinarman & Levine, 1989), these organizations offer a different lexicon than those that position drugs as “richly functional scapegoats,” narrow the public “aperture of attribution,” and provide “elites with fig leaves to place over unsightly social ills that are endemic in the social systems over which they preside (Reinarman & Levine, 1989, p. 98).”

Understanding drugs (and drug tests) as non-human socio-materialities attributed agentic powers positions FTS as standing in for an “off-label” chemical salvation, the worldly features of which include “health, well-being (that is, sufficient wealth, standard of living), security, protection against accidents” explored in “The Subject and Power” (Foucault, 1982, p. 784). Writing about the state’s exercise of new forms of pastoral power, Foucault portrayed individualization as an abstraction that could be refused in the struggle against the dividing and categorizing practices of power:

To sum up, the main objective of these struggles is to attack not so much “such or such” an institution of power, or group, or elite, or class but rather a technique, a form of power. This form of power applies itself to immediate everyday life which categorizes the individual, marks him by his own individuality, attaches him to his own identity, imposes a law of truth on him which he must recognize and which others have to recognize in him. It is a form of power which makes individuals subjects. (Foucault, 1982, p. 781)

Fentanyl kills—really—but it has also been demonized in the exaggerated form of a “killer opioid” (Bracken, 2016) and mischaracterized as a complexly racialized “chemical bogeyman” (Reinarman & Levine, 1989, p. 98). ⁷ As artifacts that detach the “bogeyman” semiotics from the socio-material pragmatics of harm reduction, FTS have been presented as if they are neutral tools for “savvier consumers” (Weicker et al., 2020). Lessening the deadly uncertainties and ignorances generated by the interpenetrated structures of licit and illicit opioid markets, FTS serve as “protective adaptations” beyond overdose prevention, helping PWUDs moderate use, avoid incarceration, and promote awareness. FTS are a “tangible and reliable tool (Weicker et al., 2020),” an artifact that counters what we might call a “futility narrative” that casts PWUDs as victims at the mercy of unpredictable and uncertain markets in which they have little control or agency. With artisanal flair, harm reduction organizations have produced brightly colored, attention-grabbing materials that speak plainly to practical interests in staying alive oneself and keeping others alive.

Cautiously keeping his company clear of legal liability for “off-label use,” the purveyor of this chemical salvation, Iqbal Sunderani, CEO of BTNX, Inc., has been cast as so caring as to be heartbroken and surprised at “off-license” interest in his product. “Parents who have lost their children to fentanyl overdoses ring up his biotechnology company on a regular basis.…desperate to get their hands on drug testing strips that can detect the powerful opioid, which could prevent other families from suffering the same loss” (Stewart, 2017). BTNX is subsumed into a “prevention imperative” that does not make strictly rational sense, but is a powerful pitch regularly used by parent groups allied with harm reduction in order to overcome objections. The “prevention imperative” situates an artifact or socio-material “tool”—naloxone, FTS, or clean needles—as a central socio-material fulcrum on which to hinge the transformation of loss into potential prevention of other people’s losses. Condensed into such artifacts is lament—if only parents, partners, siblings, or friends had had access to this tool, the overdosed decedent would be alive today. Friends and family are thereby rendered healthy reasoners, whose access to tools will reduce the suffering of others. The artifactual antidote performs an almost magical transformation of a technoscientific tool into an anticipatory one that enables a state of “certain uncertainty” (Fanon, 1967, p. 109). The once unknown, now increasingly predictable, presence of fentanyl in the illicit drug supply is thereby transformed into a knowable fact, but it has also been translated into affect.

FTS render fentanyl’s suspected presence “factual” just as the Wasserman test rendered the presence of syphilis “factual.” The BNTX Rapid Response^TM strips are thinly coated with an enzymatic dye and a protein antibody. When dipped into the liquid being tested, molecules in the sample may or may not bind to the antibody, which coats the strip in both mobile and immobile forms. To bind with the mobile antibodies, drug molecules “compete” for receptors. The results of this “competition” become available for interpretation: if present, fentanyl molecules bind with the mobile antibody and a positive line results. If fentanyl is absent, two lines result; if no lines result, the test strip itself is inert. ⁸ What, we might ask, is the social status of this fact? Riven by the fissures of pharmaceutical regulation and distribution, FTS neatly illustrate antagonism between corporate Big Pharma’s convergence with law enforcement’s evolution of tools to discipline and punish violators of drug laws, and the resistant infrastructures and solidarities of self-defined drug-user unions and harm-reduction organizations trying to gain for PWUDs some measure of personal control over social circumstances. Under cover of “off-label use,” practitioners of harm reduction remade technologies and practices once confined to the world of urine testing and drug control surveillance. Off-label use is legal in the United States, where medical personnel can prescribe a drug approved for one indication for another. As detection migrated away from detection of the user by technologies of suspicion and surveillance, it moved toward detection by the user via technologies of trust and solidarity. Rules, regulations, and the moral and social norms governing methods by which facts may be produced have an “epistemological duality” in which trust is covered over by the seeming unity and solidity implied in the word: “While for knowledge as regulation trust resides in the capacity to achieve order, for knowledge as emancipation trust resides in the capacity to achieve solidarity” (Santos, 2018, p. 41).

Off-label use is the orderly creature of U.S. regulatory law and policy. Allowing clinicians scope for clinical judgment despite the wholesale turn to evidence-based medicine, off-label use attests to tensions with “on-label use.” Fentanyl is a drug whose medicinal use is valued. Synthesized by Paul Janssen in 1960, fentanyl did not surface as a misused substance until the 1980s. When it surfaced, fentanyl misuse was largely confined to anesthesiologists and medical residents in anesthesia training programs (Armenian et al., 2017; Bryson & Silverstein, 2008; Kintz et al., 2005; Ward et al., 1983). Localized fentanyl overdose outbreaks occurred in the US and Europe in the 1990s; in Estonia it displaced heroin as early as 2003 (Gilbert & DasGupta, 2017; Uuskülaa et al., 2020). Once enclaved, it leaked (Ciccarone, 2017; Lovell, 2006). ⁹ Not until 2013 did it become more ubiquitous in North America, propelling fentanyl overdose deaths to become discernible against the backdrop of those involving other pharmaceutical opioids and heroin (Zoorob, 2019). Geographically segmented changes in drug supply explain the pattern of leakage. Fentanyl was initially concentrated in the Northeastern and Midwestern United States, and Canada’s westernmost province, British Columbia. Fentanyl was involved in 90% of Massachusetts overdose deaths—but less than a quarter in New Mexico from 2013 to 2020.

Geography is useful for understanding the localized and uneven patterns of opioid use, which vary with changes in degree of interpenetration of licit drug diversion and illicit drug markets. A study conducted in Dayton, Ohio, a small Midwestern city from which heroin was displaced as early as 2013, referred to the emerging market as one of “erratic complexity” (Daniulaitytea et al., 2019). Skeptical about the utility of FTS, “Our findings indicate that unless such technologies can be reliable and specific in identifying emerging fentanyl analogues and other novel synthetic opioids, they can be of limited value in the context of current NPF epidemic with increased presence and diversification of fentanyl-type drugs and other novel opioids (Daniulaitytea et al., 2019, p. 8).” Non-pharmaceutical fentanyls (NPFs) include an array of analogues. In Dayton, obtaining opioids became as easy as ordering pizza (Quinones, 2015). Perhaps FTS and naloxone will soon be on the menu, as the COVID-19 pandemic shifts to “curbside” or “takeout”-style delivery, away from the educational model embraced by overdose prevention educators.

There is nothing inherently “harm reduction” about FTS as an artifact. Lawmakers have experimented with punitive uses of FTS, introducing drug-induced homicide laws intended to hold dealers accountable for fentanyl-related deaths. These attempts have largely failed in the face of fentanyl proliferation in the North American drug supply. They are opposed not only by drug users and dealers, but by parents and other family members of the dead (Peterson et al., 2019). The meaning and status of FTS as a socio-material tool remained up for grabs at the time of writing. The next section troubles the metaphoric baggage of the “toolkit” and the instrumentalism of the metaphor.

Troubling “Tools”: “As Fentanyl Deaths Rise, an Off-Label Tool Becomes a Test for the Killer Opioid”

Stories showing how FTS could be used as an “off-label tool” began to feature BNTX strips in 2017. For example, a Boston WBUR story centered Jess Tilley, a former opioid user from Massachusetts who founded the New England Drug Users Union. Represented as a highly trustworthy character—a role she has played in many media stories about fentanyl—Tilley is surrounded by women watching a tiny, dark pink, but difficult-to-decipher line appear on each test strip, indicating fentanyl presence (Bebinger, 2017). Interpretive difficulties were presented as material obstacles, undone science, lack of knowledge about whether all varieties of fentanyl show up in the same way, unclear reliability, and socio-legal concerns. The manufacturer refused at that time to stand behind the accuracy of test results due to fear of liability. Police refused to adopt a standard protocol to protect harm reduction “trainers” from being charged: “Police say for now it would be up to individual officers to decide whether to charge the person training drug users to check the contents of their drugs (Bebinger, 2017).”

This individualization extended not only to the police, but to harm reduction entrepreneurs and PWUDs. Animated educational videos appeared “because knowing is half the battle. An educated consumer is an empowered consumer.” St. Ann’s Corner of Harm Reduction in the Bronx credited staff member Van Asher with initiating FTS distribution out of “desperation” in stories that represented him as a harm reduction hero (see Campbell, 2020a), including the organization’s official website at: https://sachr.org/resources/). ¹⁰ On the Cover2 Resources podcast mentioned above, Asher self-identified as an epileptic who had relied on urine ketone test strips to manage his condition, and who had immediately seized upon the harm-reduction potential of FTS by analogy.

Researchers backed by high institutional prestige collaboratively studied FTS at two institutions historically well-situated to study the opioid crisis: Brown University in Providence, Rhode Island, a state contiguous with the Massachusetts southern tier, and Johns Hopkins University in Baltimore, Maryland (Campbell, 2007). Researcher Susan Sherman presented FTS as a tool that can be used even before stable equilibrium or the “will to stop using” have been reached: “What more do we need to understand that there’s a crisis and that we need to respond with all the tools in the toolbox? It takes a lot of different touch points for people who use drugs, engaging them at different points along the trajectory before they’re able to be stable enough or have the will to stop using” (Hurowitz, 2018). A news story on Bustle Media Group’s Mic.com, which focuses on Millenials and Gen Z, referred readers to the BTNX website, on which was posted the flyer that appears in Figure 4.

OPEN IN VIEWER

Figure 4.

BTNX flyer incorporating results of the Johns Hopkins Bloomberg School of Public Health study comparing three different testing technologies. Used with permission of BTNX, Inc.

Represented as “tools” for responding to the opioid crisis, FTS were designated as legally used “off-label.” Reasons that an “off-label tool” might be dis-used fall into two categories: inaccessibility and futility. The latter bears mention because is fentanyl is everywhere, efforts to confirm or disconfirm its presence are not worth time or money. Studies in rural West Virginia showed “willingness” to use FTS, but low awareness among PWUD (Allen et al., 2020). Other investigators encountered “commonly held perceptions that most drugs were fentanyl-contaminated, and therefore, participants did not need to confirm its presence (McGowan et al., 2018).” Studies that fall into the “ubiquitous” or “futility” category were connected to distrust of suppliers, in which consumers were making decisions based upon degree of trust or lack thereof, essentially based on degree of social familiarity with the supply situation. Although most participants preferred to test in private and make individual decisions to use or discard, one respondent claimed to have shown dealers positive results as a way to ensure a less “tainted” supply.

As in the early days of naloxone’s promotion as a “tool” of harm reduction, researchers assessed willingness based upon salient characteristics and perceptions of PWUDs themselves, including those of young adults (Goldman et al., 2019). Behavior changes responsive to the known presence of fentanyl included doing a “tester” shot, pacing or slowing ingestion, discarding supply, or testing supply in front of a dealer in order to encourage dealers to test their supplies before sale so as to avoid murder charges or life in prison. No studies reviewed for this article allowed for the possibility that some individuals seek fentanyl or viewed it as particularly pleasurable or desirable; fentanyl was always positioned as harmful, as something healthy reasoners would avoid. FTS were promoted as reducing overdose risk just as needles and syringes are promoted as reducing disease transmission (Peiper et al., 2019). Tools appeared as things that could be picked up and put down, selected as “the right tool for the job,” and subjected to individual pragmatic determinations rather than the structure of markets, uneven localization, or the bumpy terrain of access to harm reduction infrastructure.

Pragmatism is central to the Forecast Study project website, which emphasizes fentanyl’s dangers in the aesthetics of its design choices—black and the acid yellow of police tape—and indicated that fentanyl was “killing thousands of people who don’t even know they’ve taken it.” Performed in three U.S. cities with endemic opioid problems in Baltimore, Maryland (Dezman et al., 2020); Boston, Massachusetts; and Providence, Rhode Island, the Forecast Study tested street samples with BTNX FTS, the TruNarc Rayman spectroscopy machine, and the Bruker Alpha machine to “determine how well [testing] might work in real-world settings.” Each testing technology was determined to be accurate; ease of use of FTS was compared to the home pregnancy test; and a press release titled, “Low-Tech, Low-Cost Test Strips Show Promise for Reducing Fentanyl Overdose,” presented FTS as opening a window of metaphoric opportunity for a wholesale public health approach. The socio-materiality of these “thin blue lines,” seemingly insubstantial and promissory (Fortun, 2008), was represented as solidly effectuating a policy direction urged by the communities closest to the FTS off-label rollout.

Bright blue strips have come to signify science just as surely as do white lab coats. White-coated scientists are pictured with test tubes, blue-coated metal racks, eye droppers, and blue gloves. The color blue is associated not only with science, but with protection—and with the forces of social order, the police, an association solidified by the Blue Lives Matter reaction to the Black Lives Matter movement so prominent in the U.S. struggle against police violence in summer 2020. Clean, bright blue stands out in the photographs of laboratory procedures and the strips themselves; this blue is, in fact, a new, laboratory-borne blue chromophore (see Smith et al., 2009).

OPEN IN VIEWER

Figure 5.

Born in the laboratory of Mas A. Subramanian in 2009, “science blue” is a chromophore that has leaked into representations of the pharmaceutical sector. See Smith et al. (2009). Used with permission of Mas A. Subramanian.

Fittingly, “street samples,” were tested from the field by being brought into the lab despite provenance in the unregulated markets that produce, distribute, and deliver fentanyl on opioids and other street drugs, including those classed as stimulants. The gritty gray of “real-world spaces” contrasts to cleanly whitened and carefully sterilized laboratories reassuringly punctuated by strong spots of “science blue,” the synthetic color that has come to symbolize the top of a hierarchy of credibility. The blue signifies that science is being done, here and now—a science that can benefit drug users if deployed in a rational way.

Fentanyl, too, is a laboratory-based creature, borne without necessity for the social, human, and economic costs of agrarian poppy production. It is consistently marked as a foreign other within North America, originating from China or perhaps Russia, and trafficked across the U.S./Mexican border. Fentanyl is attributed threatening potency in relation to other opioids, just as was heroin. When a “profound point in the opioid crisis” was reached, researchers turned to epidemiological, forensic, and occasionally tools such as rapid ethnographic assessment in order to track fentanyl’s movement. The Forecast website casts them as compelled or even propelled out of the laboratory, pushed to go “where drug users are,” in mobile units. Documentary-style photographs convey respect between researchers and researched, an equal playing field on which, nonetheless, researchers had to ask “a lot of intense personal questions.” Community Partners raised calls for innovation. Even more diverse than the researchers (two white women and one Asian-American woman), the Community Partners witnessed behavior change in their clients using FTS, who came to a “different way of thinking” about risk, harm, and health. One, Andrew Bell, noted that “we often think that people who use drugs couldn’t care less about their health, and that couldn’t be further from the truth…the most important things [FTS] do is treat people like they’re people.” Similar to Green’s statement that FTS can open the door to a public health approach, or community partner Nicole Alexander-Scott’s statement that “low threshold drug checking means we can meet people where they are,” FTS materially embody far more than their slim profile could seem to contain. It is not the tools themselves, or the scientific evidence backing them, but their status as technologies of solidarity—they “treat people like they’re people”—and the mood that is made palpable in these exchanges. FTS signal safety, but the proximity of danger also marks them as a way for drug-using communities to deal positively and appropriately with real threats. Simultaneously instrumentalized and painted as useless because “fentanyl is everywhere,” FTS appear in some Forecast studies to mark fentanyl as a pervasive presence (Weicker et al., 2020).

Indeed, Elinore McCance-Katz, assistant secretary at the federal Substance Abuse and Mental Health Services Administration (SAMHSA) during the Trump administration, argued in an October 3, 2018 SAMHSA blog post (later removed in early 2021 by the Biden administration), “The entire approach [of FTS] is based on the premise that a drug user poised to use a drug is making rational choices, is weighing pros and cons, and is thinking completely logically about his or her drug use. Based on my clinical experience, I know this could not be further from the truth. People who are addicted to opioids are not making a rational choice to continue their drug use. Addicted individuals whose bodies demand that they find their next opioid to stave off withdrawal symptoms are not in positions to weigh all options and to choose to not use the only opioid at their disposal.” Here the “non-rational” demands of drug-using bodies were depicted as in control—McCance-Katz argued that even if they were aware they were holding unsafe supply, users were going to “inject anyway,” as if they were placing themselves at risk rather than navigating a risky marketplace with uncertain information. McCance-Katz explained, “There is a chemical and not necessarily logical need for them to use. It is not inconceivable to think that people who are severely addicted will actually use the test strips to seek fentanyl, which might be able to give them the high that their current opioid no longer gives them—and which will place them at risk for overdose and death.” Her position presented an exemplary sample of the dominant necropolitical discourse against which harm reduction exerts the affective liveliness of its artifactual pragmatics.

Conclusion

Embedded in law as “moral hazard,” communities oriented toward preventing preventable deths from overdose have built an alterbiopolitics to contest ideas that seat belts, helmets, clean needles, naloxone (Campbell, 2020b, pp. 303–305), or FTS will be used by thrill-seekers to enhance risk rather than to proceed safely. Opposed by libertarian as well as harm reduction communities, a 2018 Cato Institute blog post by Jeffrey Miron castigated the Trump administration for distrusting drug users, a position that in effect meant that:

we have to outlaw drugs because people are not rational enough to use them safely;

And people wonder why we have an opioid epidemic (Miron, 2018). Moral hazard thinking makes unwarranted assumptions about separation between legal and illegal markets, trust and distrust, and on-label and off-label use. Such boundaries are artifactual to public policy, which actively produces and hardens such categories even as harm reduction activists, advocates, and researchers seek to undo them. The sociomaterialities that thwart such distinctions undermine the practices and meanings that dominant groups “continually prevail at embedding meanings that maintain their continued power within technologies. Public policy provides such groups with a massive engine for doing so and is replete with examples by which perennial social problems such as socially problematic drug use are translated into so-called scientific or technological problems subject to minute manipulations dictated by our understandings of the existing practical systems and structural contexts that render unjust outcomes more likely than not (Campbell, 2005).”

Fentanyl’s portrayal as “powerful” and “potent” relative to other opioids and, erroneously, as “resistant” to naloxone has heightened its aura of risk. This is not to say that fentanyl is not deadly or risky, but rather to say that risk is a cumulative outcome of supplier decisions in illicit markets and enforcement practices—rather than consumer preference or behavior. Fentanyl should be understood as a disruptive innovation relative to heroin, which it has displaced in many regions of North America (Pardo et al., 2019). Just as crack-cocaine was a disruptive innovation that decreased the price of cocaine, synthetic fentanyl is a disruptive innovation that not only moves opioids further away from poppy fields, but pervades the unregulated drug supply well beyond opioids. These sociomaterial disruptors pry fentanyl away from the social relations that comprise its cultural histories just as surely as they reconfigure the economics of opioids.

Questions arise as to whether consumer demand might have played a role in fentanyl’s increasing supply. Consumer “preferences” do not pre-exist the products that co-produce them but rather evolve and adapt depending on when and where first-use or overdose experiences occur, relative levels of experience with opioids prior to fentanyl, tolerance, and other factors such as age (Kline et al., 2020). Younger subpopulations lacked experience with opioids and overdose prior to fentanyl becoming ubiquitous (Rouhani et al., 2019). Yet few study participants had heard of FTS, much less used them. Drug control efforts that emphasize supply-side intervention may punish the powerless or make the already vulnerable even more so:

The population most harmed by the changing risk of the drug supply caused by supply shortages are those with the least power. People who use drugs often lack the knowledge, means or power to be informed consumers and are therefore at the whim of the changing market. Efforts to decrease the supply of opioids or to prosecute sellers will have little impact on the ongoing overdose crisis and instead will continue to end up largely hurting individuals who use drugs. (Wakeman, 2019)

But it is their sociomaterial flexibility that makes these artifacts move into new symbiotic relations that sustain the more creatively affectual forms of recognition that we might call an artisanal “otherwise.” Langdon Winner argued in “Upon Opening the Black Box and Finding It Empty,” that “interpretive flexibility soon becomes moral and political indifference” (1993, p. 372). Finding the box full of “science blue” FTS offers the artifactual means to craft moving responses counter to a spectrum running from moral and political indifference to mean-season necropolitics—with which so many drugs users were met until the advent of harm reduction and the multiplicity of modes of care and creativity generated by its affective and artisanal responses to current conditions.