Editor’s Note: Today’s guest post comes from Bilal Abbas, MPA, MSW. Bilal graduated with the MPA from Rutgers University in Newark and the MSW from Columbia University in New York City in 2018. He works at the Albert Einstein College of Medicine/Montefiore Medical Center as a Research Coordinator, facilitating research related to heroin or opioid use treatment.
For over half a century in New York City, heroin bags have been distinctly branded with unique markings, including with rubber stamps. From the seller’s viewpoint, stamps create brand loyalty and identify a superior product that yields more psychoactive effects. Heroin-using communities also utilize stamps to identify potentially lethal supplies and raise awareness through word-of-mouth messaging. In the 1990s, users identified and alerted others about supplies, which had caused a number of overdoses and which they suspected to be contaminated with lethal adulterants including scopolamine. [1-3]
Fentanyl has been of increasingly paramount importance in tens of thousands of preventable deaths among Americans since 2013. Fentanyl seizures in the US increased 7-fold from 2012 to 2014, while overdose deaths involving fentanyl and its analogs increased almost 47 percent from 2016 to 2017.  A 55 percent increase in fatal overdose was observed in New York City (NYC) between 2015-2017, and in 2017, 55 percent of overdose deaths involved fentanyl. 
Due to the availability of rapid fentanyl test-strips, the novel study described in this post, Exploring fentanyl prevalence in New York City, used an exploratory framework to examine and understand the fentanyl contamination in NYC stamped heroin. Examining fentanyl prevalence in NYC heroin by stamp or “brand” can raise awareness about tainted supplies and can help to reduce opioid overdoses. My team collected samples of used and discarded heroin glassine bags in NYC neighborhoods known for heroin use and sealed them within a separate plastic bag to avoid cross-contamination.
We then used fentanyl test strips, which use immunoassay technology to quickly and reliably detect the presence of fentanyl and its analogs, to test trace amounts of heroin in each bag. According to the American College for Medical Toxicology (ACMT), it is a near scientific impossibility to overdose on fentanyl from airborne or transdermal exposure. Therefore, there were no safety risks involved in executing this study. 
We tested 35 bags each from a total of 16 different stamps, including “Empire,” “Ultimate Level,” “The Reaper,” “Batman,” “CIROC,” “Toro,” “W,” “Kiss Me,” “Knock Out,” “Breaking Bad,” “Dirty Harry,” “Truth or Dare,” “Black Jack,” “Blue Skull,” “Sweet,” and “Time Out.” We also collected examples of 3 unstamped but uniquely packaged bags with distinct blue, white, or pink colors. The study similarly tested 35 bags of each color. Table 1 describes the frequency of stamped and unstamped bags that tested positive for fentanyl.
Past investigations have reported more than 400 different heroin stamps in NYC, and this study only included a small fraction of that number. More comprehensive research would be necessary to precisely identify, collect, test, and report on all stamps in the city.4 This study tested a total of 665 used heroin bags, of which 78% tested positive for fentanyl; 20% did not test positive for fentanyl; and 2.4% were inconclusive.
But there was a difference between the sample of uniquely stamped heroin bags, of which 76% tested positive for fentanyl, and the unstamped, distinctly colored bags, of which more than 88% tested positive for fentanyl. The percentage of uniquely stamped bags adulterated with fentanyl ranged from 71% to 82%—but bags for each stamp were less likely to be contaminated than any of the distinctly colored bags.
Public Health Implications
The majority of heroin in NYC is now adulterated with fentanyl—but the unstamped, distinctly colored bags were more likely to test positive for fentanyl. Why might that be? Unstamped bags might allow sellers to circumvent criminal liability in the event of a fatal overdose, and sellers not using distinct brands might be less cautious about mixing fentanyl with unmarked product.
Raising awareness about the dangers of fentanyl contamination among heroin using communities might improve harm reduction among at-risk communities. Fentanyl test-strips are a practical and cost-effective method to test for tainted supplies of not only heroin, but other street-obtained drugs including crack (freebase), cocaine, PCP, and marijuana. Improved test-strip access and distribution could boost harm reduction efforts.
This study calls the attention of policy makers to the need for enhancing current harm reduction approaches with implications for public health. Recent policy changes that facilitate access to the overdose reversal antidote naloxone and increased efforts to initiate buprenorphine uptake following opioid overdose-related emergency department visits are deliberate strategies to decelerate the opioid overdose epidemic. Co-dispensing fentanyl test-strips with naloxone and sterile injecting equipment, which might raise awareness about overdose potential prior to drug ingestion, can potentially become a first-line prevention intervention.
Author’s Note: This was a personal initiative without IRB approval and does not fall under any institutional affiliation. I conducted this study purely for acquiring preliminary knowledge and truths about the current status of heroin use and the extent of fentanyl contamination in NYC by studying the uniquely branded bags.
 Paul J. Goldstein, Douglas S. Lipton, Edward Preble, et al, “The Marketing of Street Heroin in New York City,” Journal of Drug Issues 14, no. 3(1984): 553–66.
 Centers for Disease Control and Prevention, “Scopolamine Poisoning among Heroin Users—New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996,” Morbidity and Mortality Weekly Report (MMWR) vol. 45 no. 22 (Junw 7, 1996): 457.
 Travis Wendel and Ric Curtis, “The Heraldry of Heroin: ‘Dope stamps’ and the Dynamics of Drug Markets in New York City,” Journal of Drug Issues 30, no. 2 (2000): 225–59.
 Centers for Disease Control and Prevention, “Opioid Overdose,” accessed Jan. 31, 2021.
 Cody Colon-Berezin, Michelle L. Nolan, Jaclyn Blachman-Forshay, Denise Paone, “Overdose Deaths Involving Fentanyl and Fentanyl Analogs—New York City, 2000–2017,” Morbidity and Mortality Weekly Report (MMWR) 68, no. 2 (Jan. 18 2019): 37.
 Michael J. Moss, Brandon J. Warrick, Lewis S. Nelson, et al., “ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders,” Clinical Toxicology (Phila). 56, no. 4 (April 2018): 297–300.