Brian: It's The Brian Lehrer Show on WNYC. Good morning again, everyone. Parents in Brooklyn, maybe you've heard about this story reported by Curbed few months ago. The Brooklyn Waldorf School, a private preschool and elementary school, distributed an alarming notice to parents apparently children had found a full fentanyl capsule, as they called it, a full fentanyl capsule on the Crispus Attucks Playground. Given its candy-colored nature, they wanted to take it home.

While the candy-colored canisters found at the park eventually tested negative for traces of fentanyl, you can imagine the frenzy that resulted from the school's notification after all, it came just a month after a one-year-old passed away at a preschool in the Bronx, remember that, due to exposure to fentanyl. All this to say, it feels like fentanyl is everywhere and it's seemingly unavoidable. Bars are stocking fentanyl test strips. The City Council just passed a bill making Narcan available at elementary and middle schools, and such a measure begs the question just how prevalent is fentanyl in the illicit drug supply in New York City.

According to a study published by researchers at NYU School of Global Public Health, more than 80% of people who inject drugs test positive for fentanyl, but only 18% intend to take it. How do we keep our loved ones or even ourselves safe when a drug that's 50 to 100 times more potent than morphine is laced in so much of our street drugs? Joining us now to try to answer these questions and more is one of the researchers in the study, Courtney McKnight, clinical assistant professor of epidemiology at the NYU School of Global Public Health. Professor McKnight, thank you so much for joining us. Welcome to WNYC.

Professor McKnight: Thank you.

Brian: I just read this statistic, but I'll repeat it because it's so shocking, over 80% of those who inject drugs in New York City test positive for fentanyl despite only 18% intending to take it. Can you take us into the research behind this stat, how it is that so many people are accidentally taking fentanyl and not even realizing?

Professor McKnight: Sure. We started doing this research in about 2016, 2017. We were seeing that really a lot of people did not want to be taking fentanyl, were trying to avoid it, but really had no way to determine whether or not they were using it. Now, many years later, we see that fentanyl test strips are widely available. We wanted to revisit whether or not people knew that they were using fentanyl, if they were using fentanyl. We're testing people's urine for the presence of fentanyl. We found that 83% of our study participants tested positive for fentanyl.

When we asked them about their drug use in the last 30 days, only 18% reported that they had intentionally used it. We say intentional because a lot of people, most people in our sample knew that fentanyl was in the drug supply but most of them didn't think that it was in their drug supply. This 18% of people was really the people that were seeking it out knew they were using it.

Brian: Who are your study participants and what drugs did they think they were ingesting instead?

Professor McKnight: They're people who inject drugs that live in any of the five boroughs in New York City, and 99% of our sample reported heroin use, and that is really the drug that they were seeking, and that they prefer to use. I wanted to also just provide some context for among those people that are now using fentanyl, even intentionally, what they do report is that their now intentional use really developed out of unintentional exposure.

Just like that 83% that didn't know that they were using it, though some of those people over time they have an increased tolerance due to the increased potency of the drug. Now, they're using fentanyl because if they use heroin, they start to get sick and go through withdrawal.

Brian: Some listeners may be thinking, well, we're already talking about people who use heroin, so they're already taking their lives into their hands. Would that be an accurate assumption? Or is fentanyl much more hazardous, as an opioid than heroin is?

Professor McKnight: It is much more potent and I think one of the biggest issues that we're dealing with is we have an unregulated supply. The variability in the amount of fentanyl or any other drug in illicit drug supply is unknown. While we have things like fentanyl test strips to help people determine whether fentanyl is in their drug, from those test strips, we don't know how much, we just know that it's present.

Brian: We've also heard stories where people have died from fentanyl overdoses while using cocaine on a night out and maybe they didn't realize that that was laced. Should casual drug users, including those perhaps who purchased just marijuana illegally, that is not from the dispensaries, assume that fentanyl may be present in whatever they're consuming?

Professor McKnight: I think in terms of fentanyl laced cannabis, at this time, there's really no concrete data to support this claim but it continues to be circulated, it remains a concern for people understandably, but I think we really need to look to the evidence. Around 2021, there was a report of a cluster of about 40 cases of overdoses in Connecticut that were, at the time, believed to be linked to fentanyl laced cannabis. The Department of Health there did a detailed investigation. They found that only one case could have potentially been fentanyl laced cannabis.

But it was likely through their investigation, they found that it was really an isolated incident was likely due to accidental contamination from a dealer who may not have clean the surfaces in between packaging different types of drugs. There were a couple of other reports in Vermont where there were fentanyl laced cannabis. Those have also been proven to not be the case. I think we need to guess. Fentanyl has been seen in cocaine and has led to overdose fatalities of people that thought they were using cocaine. It is definitely impressed because we know that from the evidence. It's definitely in heroin.

It has also been shown to be in methamphetamine, but in terms of cannabis, I think we need to remember that that is the most widely used illicit, in New York, it's licit, but drug, 52 and a half million people use cannabis in 2021. If we were seeing fentanyl in cannabis, we would likely see much higher rates of overdose mortality.

Brian: A listener text, "What about ketamine and Molly? Added two other particular drugs, and whether they're laced with fentanyl, whether there's any evidence that that's been happening."

Professor McKnight: There is evidence to show that it has been mixed into, not to the same extent even that cocaine-- really, the primary drug is heroin and pressed pills or what sold is heroin because even some of what's sold is heroin is really just fentanyl. Then there have been incidents of methamphetamine, cocaine as well as other white powder substances, such as ketamine, and MDMA, Molly. This is why fentanyl test strips can be really useful, especially when the white powder drugs.

Brian: We'll get more into the test strips in a minute. On the heroin users who you were studying, the study reports that nearly one quarter of participants had overdosed at least once in the previous six months. I wonder if that indicates something about the increased danger of fentanyl in New York City as illicit drug supply, particularly heroin supply? Or if you could pick apart, what percentage of those overdoses were just from the heroin?

Professor McKnight: We see from the New York City mortality data that fentanyl in 2022 was present in 81% of overdose deaths. Overdose used to be a relatively rare event. We're seeing an increased frequency of overdoses among people in our studies. Again, that's about the potency of fentanyl and the instability of the drug supply. Fentanyl continues to be the reason we're seeing rates of overdose that we've never seen before, overdose fatalities that we've never seen before.

Brian: Listeners, we can take some phone calls for Courtney McKnight, epidemiologist from NYU on this study, which is one of the indications recently of just how much fentanyl is in the supply of other drugs and how many New Yorkers may be taking fentanyl and endangering their lives thereby without realizing it. 212-433-WNYC. Does anyone have a story? Help us report this story. Does anyone have a question about prevention or anything else? 212-433-WNYC, 433-9692.

It's not like fentanyl is brand new, so why is this happening so commonly now, and how does fentanyl get laced into other substances? Who is putting it in there and why?

Professor McKnight: Sure. It can be added to other drugs. Intentionally, as we know is the case with heroin and pressed pills, and those pills being sold as things like oxycodone, but it's also possible that there is accidental fentanyl contamination as in the case of the one potential marijuana or cannabis fentanyl case in Connecticut. That again is really about the packaging and same surfaces. It's not entirely clear why fentanyl would be added to drugs, including things like stimulants, methamphetamine, or cocaine that have very different effects.

Some people have made the argument that this is a way to increase the consumer base and their dependence on multiple drugs, but the other side of the argument is that for people who are opioid naïve, this can also lead to death which really runs counter to the notion of expanding your consumer base. Really, the only way for us to know is to talk with people who are selling drugs at all levels of the supply chain, and that's a challenging task. It's not really the focus of my research, but that is how we understand the motivation.

Certainly, there's an economic motivation. Fentanyl, it's much more potent so you can use less of it, so it's much cheaper. You can use a little bit of it and use a lot more filler and therefore increase your profit. There's certainly an economic motivation there.

Brian: Maryanne in Manhattan, you're on WNYC. Hi, Maryanne.

Maryanne: Hi, there. I have some videos that I've seen that have been put out by law enforcement, and I don't know whether I'm being irrational when I get angry at them. There are multiple instances that I've seen of this, where an officer will do something like open a trunk and the trunk has fentanyl inside, and the officer immediately passes out. That's one that I've seen. There are others like it. Doctors have weighed in and said, "This is misinformation, this is false." My worry is that people will equate these things and think like, "Well, my work built must not have any fentanyl in it because I would know right away, I would feel the ill effect just like that officer is."

I was wondering, one, am I just making this hypothetical leap? Or two, are these not faked videos that I'm seeing? Can an officer actually pass out just from opening a car trunk that contains fentanyl inside?

Brian: Maryanne, thank you. Do you know the answer to that question? Are you familiar with those videos?

Professor McKnight: I'm familiar with-- and maybe not that one in particular with the trunk, but yes, of the law enforcement videos and the concern about fentanyl overdose. I would characterize that as misinformation that I would not see as a threat. People are being exposed to fentanyl. We have people using fentanyl regularly, and granted they do have a tolerance, but people are also not overdosing every time they come into contact with it, even when they're injecting it right into their veins. I would say that is probably oversold.

Brian: Here's a related question that's about kids, not members of law enforcement because parents in Brooklyn, as I mentioned at the top of the segment, were sent into a frenzy after supposed fentanyl canisters were found at a playground in Bedford–Stuyvesant. While drug paraphernalia at playgrounds is hardly new, Curbed reported that parents' anxiety has heightened after a one-year-old passed away from exposure to fentanyl at that Bronx Daycare Center in September. How worried should parents be about their kids touching canisters or other types of trash drug paraphernalia at playgrounds? Can kids accidentally overdose that way?

Professor McKnight: I think what's important to note is that we're in the midst of an overdose epidemic, we have a very potent drug supply. Harm reduction programs are working very hard to keep people safe, including residents of communities in which they operate. As a parent, I understand the concern of feeling vulnerable, about keeping your children safe. I think it's unlikely that discarded paraphernalia could contain enough fentanyl to cause an overdose as the article reported that most of the canisters were empty, and did not test positive for fentanyl.

It is a possibility that if some paraphernalia contained enough of a drug and a child actually was able to open it and ingest it, it could lead to an overdose, but I do want to point out in that situation, I really want to highlight some of the parents of that community. They really tried to avoid a moral panic response and really took a much more practical approach to address the issue by going to one of the parks and doing a cleanup, and really learning more about the issue and Harm Reduction in general. I just want to applaud that response.

Brian: That's clarifying. Thank you very much. I think we're going to get a very sad story, but one that's important to this conversation from Jay in Brooklyn. Jay, you're on WNYC. Thank you for calling in.

Jay: Thank you. I lost my daughter three-and-a-half years ago to fentanyl. She thought she was using heroin, but she was given fentanyl. I'm part of a grief support group for parents and other people connected to loved ones who've died from overdoses. In our group, we have people who have lost loved ones, who had taken cocaine casually that turned out to have fentanyl in it, also that they thought they had bought Adderall or anti-anxiety medications, and it turned out to be laced with fentanyl and they died. I think this speaker may be underestimating the amount of the spread of it into the rest of the drug supply.

Secondly, I just wanted to say that the dealers may be businessmen, but they're also criminals, and they wouldn't be selling fentanyl if they cared at all. The fact that they can build their customer base by having an effective strong drug that is all that they care about, they figure they'll make up any losses by picking up new customers.

Brian: Jay, does your grief support group as a group recommend any policy actions or law enforcement actions to try to prevent deaths like that of your daughter?

Jay: Our main focus is on supporting people, who are in tremendous pain which will never end. We have different ideas about policy. Some people are very strong advocates of harsh prosecution of dealers. Other people think that's not the point. That the point is to focus on grief and recommendations to people not to buy from dealers because they're untrustworthy.

Brian: Jay, thank you. I'm so sorry for your loss. Thank you for an important addition to this segment. Now, let me ask you, Dr. McKnight about fentanyl testing strips. How do they work, and can they be used on all types of substances that are ingested in different ways? For example, can you test powders, plants? One of our listeners has written a text message asking, "Can you test pressed pills for fentanyl with a test strip? How would you get into a pill?" Any of the party drugs? How broadly applicable are these test strips?

Professor McKnight: Sure. I also just want to say I'm so sorry for Jay's loss, the loss of his daughter. Fentanyl test strips are being distributed throughout New York City at Harm Reduction and drug treatment programs as are Xylazine test strips which are related, but we don't matter. They're used by diluting some of the drug in water and inserting the test strip for about 15 seconds. The test strip will only provide whether or not fentanyl is present. It won't tell you the amount. They can't be used for cannabis.

Basically, you have to take a powder, add a little bit of water, and then you need to be able to put the test strip in the solution. They can be used with things like ketamine, with pressed pills, you do need to crush it in order to get a water solution in there to be able to test it. Those are some of the limitations after use.

Brian:  Kai in Amityville, you're on WNYC. Hello, Kai.

Kai: Hey, Brian. Thanks for taking my call. I just want to call your attention and maybe the listener's attention to a really excellent article in The Atlantic. It was either, I read it yesterday or the day before, that talked about the fentanyl problem and drug problem in general. Even though this is a left-of-center publication, what they basically said is drugs are just not cool and we shouldn't make things so permissive. What we really should do is double down on the fact that drug use is not cool.

They use the cigarette smoking as an example of how public health has come a long way, how people have essentially stopped smoking, for the most part, because of societal view on smoking, and that we should take the same tack with with drugs. [crosstalk] Go ahead.

Brian: The other camp, if this is about camps, is the Harm Reduction camp that would say the war on drugs, the way it was fought with that central message and law enforcement for decades did not stop the spread of the deadly part of drug use, and so Harm Reduction, making it safer for people who are doing it is actually the more effective public health approach. I'm just saying that's the debate.

Kai: Right, it is a debate. Now, you invoked the police and law enforcement. I think the slant from The Atlantic wasn't so much police and law enforcement as family, friends, and society, that if you're going out with a bunch of people and somebody decides, "Hey, I got a fentanyl test strip here. How dangerous can this be? We'll be cool. We'll be safe." No, there should be pressure on, this is not a good idea. [crosstalk]

Brian: Go ahead, you can finish your thought.

Kai: Again, check out the article. It was brilliant.

Brian: In The Atlantic. Thank you very much. Any comment from you as an epidemiologist at NYU on that or is that a political conversation left to politicians?

Professor McKnight: I guess my only thought, I haven't read the article, but just in terms of the history of drug use in this country and globally, that would require a major cultural shift in the way that we think about drugs. I'm not saying it's not possible but it would require a massive shift in the way that people-- the reasons that people use drugs, and the way that people think about using drugs. I guess that would be where I would leave it.

Brian: Charles in the Bronx, one more call. You're on WNYC. Hi, Charles.

Charles: Hi, Brian. I was wondering whether Narcan is helpful for fentanyl overdose.

Brian: Professor?

Professor McKnight: Oh, yes, sure. Yes, Narcan or naloxone, Narcan is the brand name, but yes, it is an opioid antagonist, which means that it attaches to opioid receptors in the brain, and it blocks and reverses the effects of opioids. It's a very, very safe medication. It can be given to a person of any age, including infants, all the way up to the elderly. It has no effect if it's used on someone who does not have opioids in their system. Yes, it absolutely can be effective sometimes depending on the amount that someone has used, the potency of the drug it may require more than one dose, but yes, it's incredibly effective.

Brian: The New York City Council, as I mentioned earlier, just passed a bill last week that will make Narcan available in all public schools, and that includes elementary schools. Previously, Narcan was only kept in the high schools, but now, it'll be accessible for every grade level. Imagine, parents listening in with young children might be disturbed by the idea that their schools would need to keep a medication on hand that prevents overdoses. I'm curious what you would say to parents who think stocking Narcan in elementary and middle schools is either inappropriate or reflects really frightening, increasing danger to their young children.

Professor McKnight: I think it's highly unlikely for an elementary or middle school child to be exposed or to ingest fentanyl in a school setting in particular. If my child was accidentally exposed to fentanyl, I would want this life-saving medication on hand.

Brian: Would you recommend that parents attend Narcan trainings or even send their older children to Narcan trainings? Is Narcan something we should all keep stocked on our shelves or even in our day bags when we head out of the house?

Professor McKnight: Yes, absolutely. In New York City and similar places with high rates of overdose, having Narcan on hand is really, as I see it, a community service. I carry it in my bag all the time. I have two kids in college in Vermont and I was recently visiting them. I happened to be in a coffee shop when someone was unresponsive in one of the bathrooms in the coffee shop. I had my New York City Department of Health-issued naloxone kit in my bag and I was able to provide it to the staff to use. My kids also have naloxone kits that they carry with them.

Yes, I think this is our reality. We have incredibly high rates of overdose and a very potent drug supply, and overdoses and overdose fatalities are increasingly common and it's a way that you can save someone's life.

Brian: Well, more coverage of this is necessary because a lot is happening to people that they don't realize is about to happen to them as reflected by the NYU study that our guest was involved in that found many, many more people with fentanyl in their bloodstream than thought were taking fentanyl. That study was on heroin users, in particular, but there you go, more fentanyl out there and causing more deaths than even the number of people who think they're taking fentanyl. We leave it there with Courtney McKnight, clinical assistant professor of epidemiology at the NYU School of Global Public Health. Thank you so much.

Professor McKnight: Thank you.

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