A new federal grant is expected to fund 20 vending machines stocked with overdose-reversing drugs and later fentanyl test strips.

A powerful tool to help lower the number of fentanyl-related fatalities in Hawaii is now on Gov. Josh Green’s desk awaiting his approval.

The Hawaii Legislature unanimously approved Senate Bill 671 last month to decriminalize fentanyl test strips.

The bill’s passage is timely. Hawaii experienced a record number of drug overdose fatalities last year. A total of 320 people in Hawaii died from drug overdoses in 2022, up from 305 in 2021 and 266 in 2020, according to Gary Yabuta, executive director of Hawaii High Intensity Drug Trafficking Area. He cited new data from medical examiners and coroners across the islands.

Nationally, more than 106,000 people in the U.S. died from drug-involved overdose in 2021, including illicit drugs and prescription opioids, according to federal data.

Many expect Green to sign the legislation into law this summer. But his office told Civil Beat last week that there are hundreds of bill on his desk and it’ll take time to sort through them to ensure no unintended fiscal impacts or legal deficiencies exist.

Winners of the Bowl of Light award pose last week at the Hawaii Island Fentanyl Task Force Summit. (Paula Dobbyn/Civil Beat/2023)

The legislation exempts fentanyl test strips from the state’s drug paraphernalia law and removes the $500 fine associated with being caught with a strip. It also prevents an adult from being charged with a felony if they give a strip to a minor.

Hawaii is following in the footsteps of many other states that are quickly moving to legalize the strips as the rate of fatal opioid overdoses grows. According to the Network for Public Health Law, 16 states have legalized the strips since January 2022, bringing the total to 36 plus the District of Columbia.

At a summit of the Hawaii Island Fentanyl Task Force last week at a church in Waimea, the lawmaker who championed Hawaii’s test strip legislation was lauded for her efforts.

Sen. Joy San Buenaventura, who chairs the Health and Human Services Committee, received a Bowl of Light award for introducing the test strip bill and shepherding it through the legislative process.

State Sen. Joy San Buenaventura says the bill to decriminalize fentanyl test strips had bipartisan support.(Paula Dobbyn/Civil Beat/2023)

Addressing an audience of roughly 200 on Tuesday, San Buenaventura said bipartisan support for the legislation was strong, as evidenced by it sailing through both chambers without having to go to a conference committee.

“Even the conservatives supported it,” San Buenaventura said. “It’s wonderful.”

Fentanyl is a powerful synthetic opioid 50 times more potent than heroin and 100 stronger than morphine, according to the U.S. Drug Enforcement Administration. In hospital settings, it’s used to treat severe pain, often from advanced cancer. But fentanyl is increasingly showing up in street drugs.

On the Big Island, one person dies of a drug overdose every 11 days on average, and fentanyl is increasingly the cause, according to data from the Centers for Disease Control and Prevention and local authorities who spoke at the summit.

Fentanyl citrate in various forms prescribed by doctors, used illegally in overdose can cause death.
Fentanyl is being smuggled into Hawaii, resulting in a steady increase in the number of overdoses and deaths from the drug. (Getty Images/iStockphoto)

The Big Island is considered a hotbed of fentanyl distribution and use in the state.

While the island is home to 14% of the state’s population, 57% of fentanyl confiscated in Hawaii between 2016 and 2021 was on Hawaii island, according to a report by the Hawaii High Intensity Drug Trafficking Area initiative.

Given the scope of the problem, the Big Island’s fentanyl task force is beefing up its education and prevention work, trying to expand treatment services for drug addiction, advocating for harm reduction legislation and community initiatives, improving data collection and analysis and enhancing recovery support.

One of the task force’s partners is Honolulu-based Hawaii Health & Harm Reduction Center. Executive Director Heather Lusk, who spoke at the summit, said fentanyl test strips are incredibly useful when it comes to saving lives.

Heather Lusk says fentanyl test strips save lives. (Paula Dobbyn/Civil Beat/2023)

She sees the recently passed legislation decriminalizing them as an important step in helping Hawaii get a grip on preventing more drug overdose deaths.

At about one dollar a strip, the tests detect the presence of fentanyl when dipped into a solution of water mixed with a small amount of the drug in question. If two lines appear on the test strip, it means no fentanyl is present. A single line indicates a positive result.

Fentanyl test strips were recently identified by the Journal of the American Medical Association as a leading tool in the country’s fight against the opioid epidemic.

In the May issue of JAMA, the respected medical journal laid out four universal principles for helping reduce fatal overdoses.

Besides offering take-home fentanyl test strips, medical providers are advised to offer medications to treat people with opioid use disorder to reduce or manage their overdose risk. These medications include buprenorphine, methadone or extended-release naltrexone, according to the journal. 

Experts say making overdose-reversing drugs like naloxone can save lives. (Courtesy: Hawaii News Now)

Doctors should also provide overdose-reversing drugs like naloxone and training in how to use them. Finally, they should counsel people who use drugs to never use them alone, to start with a small amount to assess the drug’s potency and to avoid mixing opioids and other sedatives like alcohol and benzodiazepines, according to the journal.  

The medical community also has work to do to combat widespread stigma about opioid use disorder.

“Clinicians and health systems must address stigma against people who use drugs, recognize opioid use disorder as a medical illness, and view offering overdose prevention as central to care for people who use drugs,” the article says.

Applying these recommendations should promote needed culture change in medical and non-medical settings.

Lusk said she was very encouraged by JAMA’s guidance, applauding it for providing a community-oriented response that the medical community and general public can follow.

The Hawaii Health & Harm Reduction Center plans to stock vending machines with free naloxone, and later fentanyl test strips, in the coming months. This community-based harm reduction strategy has been deployed in at least seven European countries, starting with Denmark in 1987, according to medical literature. The first one in the U.S. was installed in Puerto Rico in 2009.

One of the vending machines that will be used to stock free Narcan and fentanyl test strips, assuming Gov. Josh Green signs legislation that decriminalizes the strips. (Courtesy: Heather Lusk)

With $200,000 in grant funds from the CDC, the organization will acquire 20 vending machines to be placed at various points around the Hawaiian islands, including prisons, where people can access naloxone, often referred to by the brand name Narcan, 24 hours a day, seven days a week.

Assuming Green signs the test strip bill into law, the vending machines will also offer strips in addition to naloxone kits.

Lusk hopes to see Hawaii implement another harm reduction strategy in the future: overdose prevention centers, also called safe injection sites.

Overdose prevention centers are community-based spaces where people who use drugs can do so more safely under the supervision of medically trained staff. The drugs can be injected, inhaled or otherwise consumed. The centers connect clients with drug treatment options, harm reduction, medical care, mental health treatment and social support.

Lusk is encouraged that a federally funded study was announced on Monday to examine the ability of overdose prevention centers to keep people alive.

An interdisciplinary team of researchers will assess the impact on public health of the first publicly recognized overdose prevention centers in the country. Two sites are in New York and one will open in Rhode Island next year, according to a news release from NYU Langone Health’s Center for Opioid Epidemiology and Policy.

The NYU researchers will partner with Brown University on the $5.8 million study. It will involve 1,000 study participants who will be tracked over four years.

Researchers will investigate whether the participants experience lower rates of overdoses, drug-related health problems, emergency-room visits and whether they’re more likely to enter treatment compared to people who use drugs but not at overdose prevention centers.

More than 200 overdose prevention centers operate in 14 countries globally, according to the news release. They are associated with “fewer overdoses, reductions in emergency department visits, increased access to addiction treatment, and improved public order,” researchers said.

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