Cam died from an overdose in his home office. His fiancée, Chelsie, found his body there, in their Austin apartment, beside a long list of personal goals he’d written out in blue ink. There were only a few nights left in 2020, and the new-year resolutions included “stop wasting $” and “research party health.”
Chelsie also found text messages on Cam’s phone. The night he died, Cam had texted the man who sold him what Cam believed were a pair of thirty-milligram tablets of oxycodone—a safe dose of the drug that can produce pain-killing, euphoric effects. Cam wanted to know why the pills were pale blue. He thought they were supposed to be darker. His dealer texted back, telling Cam to put the pills on a white piece of paper. If they looked sky-blue against that, Cam was told, he’d bought the right pills.
But the pills had been altered—broken down into powder form before being mixed with fentanyl, a cheaper but significantly more potent synthetic opioid than oxycodone. The mixture was pressed back into pill shape and stamped with an official-looking identifier. Such counterfeits are known as “pressed” pills, and they’ve been killing Texans, along with many other Americans, at an alarming rate.
There were about 107,000 drug-overdose deaths nationally last year, a record high and a jump of more than 7 percent from the year before, according to an estimate from the Centers for Disease Control and Prevention. Fentanyl is thought to be the leading cause of overdose deaths—and overall deaths—for Americans ages 18 to 45. Texas has seen an even larger increase, with 4,813 overdose deaths in 2021, up nearly 16 percent compared to 2020.
Recent studies suggest that a fentanyl test strip—a detection tool that looks and functions much like over-the-counter tests for COVID-19—could reduce the rising number of fentanyl-related fatalities. The strips, dipped in water along with a bit of residue of the drug, will show one line if fentanyl is present and two if it is not. Still, as simple as that is, some Texans who have dealt with the same kind of severe addictions that led to Cam’s death say they’re not sure whether illicit drug users could make themselves test illegally obtained opioids before taking them. But even if they could, there’s another problem: Those tests are illegal in Texas.
Fentanyl test strips are one aspect of a controversial approach to treating addiction called harm reduction. The approach doesn’t attempt to stop people from taking drugs. It’s concerned with preventing them from hurting themselves when they do.
The most widely embraced method of harm reduction is offering users naloxone, known by the brand name Narcan, an easy-to-use medication capable of reversing the effects of an opioid overdose. All U.S. states, including Texas, have relaxed restrictions on access to naloxone amid the opioid epidemic’s “third wave,” which began in 2013 with the rise of fentanyl’s presence on the black market. A less-popular harm-reduction method is the creation of government-approved, supervised sites where users can get clean syringes and take drugs in the presence of a health-care worker. Just two such sites in the nation have been authorized—both in New York City.
Fentanyl test strips fall somewhere in the middle in terms of their acceptance. The strips have become easier to access, as several states, including Tennessee and New Mexico, have recently decriminalized their possession. But they remain illegal in about half the states, including in Texas, where the strips are considered “drug paraphernalia,” meaning they fall into the same category as bongs and blunt papers. Since the passage of the 1973 Controlled Substances Act, Texas has banned any material intended for use in testing for or “analyzing” a controlled substance.
During the last legislative session, amid a growing number of deaths attributed to fentanyl, there was an effort to change that. State representative Jasmine Crockett, a Dallas Democrat now running for Congress, introduced a bill that would have made fentanyl test strips legal. The bill had some bipartisan support and passed in a House committee by a 6–3 vote, but it didn’t make it to the House floor. Representative Donna Howard, a former critical-care nurse whose district encompasses Austin’s western edge, said she and representative Gina Hinojosa, whose west-central Austin district abuts Howard’s, are looking to introduce legislation similar to Crockett’s during the next session. “We need do all we can to keep people alive so that we can actually help them get into recovery,” Howard said.
Top state officials may not agree. Senator Ted Cruz has glibly dismissed the concept of harm reduction to fight against fentanyl. In response to the Biden administration’s announcement that its 2022 National Drug Control Strategy was “the first-ever to champion harm reduction” and would put $30 million toward such efforts, Cruz tweeted: “Biden crime policy: Crack pipes for all. What could go wrong?” And in the Texas House, the response to the growing fentanyl crisis has so far focused on punitive measures. In July 2021, Governor Greg Abbott signed legislation that increased the penalties for the manufacturing and distribution of fentanyl. Abbott’s office proudly announced in April that the Texas Department of Public Safety had seized more than 300 million “lethal doses” across the state.
But if Texas is waging war on fentanyl, it’s losing. In Austin, overdose deaths associated with fentanyl increased 237 percent from 2020 to 2021, and accidental overdose became the leading cause of death, according to the Travis County Medical Examiner Annual Report. Travis County Judge Andy Brown declared it a public health crisis. Fentanyl-related overdoses have also risen in Houston’s Harris County, where deaths involving fentanyl increased 341 percent from 2019 to 2021. In the Dallas–Fort Worth area, fentanyl-related deaths jumped by 400 percent since 2017, according to one report. And in El Paso, four people each month die from overdoses involving fentanyl, on average. (It’s possible those dire numbers might be even higher if there were a more accurate database of overdoses involving fentanyl—something University of Texas researchers are now working to develop.)
Some experts have found preliminary evidence suggesting those increases might not have been so steep if fentanyl test strips had been more widely available. Studies conducted in North Carolina, Rhode Island, and Baltimore have found that the strips do help illicit drug users assess the risk of accidental fentanyl poisoning when taking other substances.
That’s also what a faith-based nonprofit called Corazón San Antonio has found. In December 2021, the group launched a harm-reduction program using a two-year, $780,000 grant provided by the nonprofit Bexar Area Harm Reduction Coalition and UT Health San Antonio. Through both mobile outreach and an in-person center, Corazón offers the state’s only legal needle exchange program. In addition, it provides wound kits, condoms, and HIV testing. It also offers fentanyl test strips, although it does so illegally, a fact that only came to Corazón’s attention after a Texas Monthly inquiry.
Corazón had believed that it was operating within a loophole in Texas law. In 2007, the Texas Legislature passed a health-care benefit bill that included a tiny bit of broadly worded language. The bill granted Bexar County authority to set up a pilot program to reduce communicable diseases and said that the program “may include . . . the anonymous exchange of used hypodermic needles and syringes.”
That language sat on the books for fourteen years. Then, in November 2021, Corazón received a federal grant to offer harm-reduction services. Since the Legislature had made the nonprofit’s work technically legal in Bexar County, the group began training city workers to hand out clean needles. In the eight months since that work began, Corazón has worked with more than three thousand people and given out more than two thousand test strips. Claudia Delfin, Corazón’s assistant director for harm reduction, says the strips are being used and that many users have told Corazón they are testing several different drugs in hopes of avoiding accidental overdoses. “They know they are illegal,” Delfin said. But she says the number of people using the strips is “incredibly encouraging.”
Despite the fact that the strips are illegal in Texas, Corazón said it plans to continue distributing them. Delfin insisted that Corazón’s street-level harm-reduction strategy “takes away the stigma and judgment that they [drug users] assume we have. At some point, they’ll contact us and say, ‘I’m tired of this. I want help.’ ”
Still, some harm-reduction advocates say test strips alone won’t be enough to win the war on fentanyl. “It’s just not the silver bullet for overdose prevention,” says Cate Graziani, co–executive director of the Texas Harm Reduction Alliance, a nonprofit that has provided wound-care kits, hygiene kits, and safe-injection kits to drug users in Austin—apparently illegally—since 2019. “It won’t be an effective overdose-prevention tool for everybody.”
That’s because addiction is complicated, and some who are addicted to opioids may be willing to accept the risk of taking pills that contain unknown quantities of fentanyl. Cam’s fiancée, Chelsie, said that had been her experience. Cam started using narcotics after about a year of sobriety from heroin. When Chelsie found he’d fatally overdosed, she said she was “shocked but not surprised.”
Chelsie had been through the ringer before with Cam, whom she’d known since high school. In the past, she had obtained and later administered Narcan to Cam when he overdosed and went into sudden cardiac arrest. At one point, she even obtained fentanyl test strips, even though possessing them is a misdemeanor. It was a long way from years prior, when she had been appalled at the idea of organizations such as the Texas Harm Reduction Alliance giving out drug supplies like free needles even as she was helping Cam minimize the harm he was doing to himself. “It felt like I was enabling users,” Chelsie said.
That was before Cam’s intravenous heroin use led to his contracting hepatitis C. Before Cam overdosed, Chelsie went to a group for Nar-Anon, a twelve-step program for friends and family of those with addiction issues. “I learned,” she said, “that there’s literally nothing you can do for someone with substance-abuse disorder, except love them and be there for them and support them when they do want help.”
Mary, whose husband, Cody, fatally overdosed this past year, was equally sober about the realities of harm reduction. Cody’s drug of choice was oxycodone, what Cam had died trying to take. “I honestly don’t think fentanyl test strips would make a difference for” people like Cody, Mary said. “Cody knew that he was taking fentanyl, and he knew that he could die. And he still wanted to do it. Which is crazy for people . . . who don’t have a grasp of that kind of addiction.”
Juan (who, unlike others in this story, preferred his real name not be used) was dropping about $4,500 a month on illicit, often pressed, pills before cutting back to infrequent drug use. “I’ve still taken pills even knowing they have fentanyl,” Juan said. “I didn’t think twice about taking them. . . . It’s scary, but that’s just something you tell yourself: ‘Oh, it won’t happen to me.’ ” Juan still occasionally connects drug dealers with some of his friends. “I’ll tell them, ‘Hey, they’re probably pressed pills. Just be careful.’ ”
Even among advocates, the use of harm-reduction tools has required a more nuanced, less conventional way of thinking about substance abuse. Delfin said many of Corazón’s case managers and peer coaches—former users who provide support—come from programs that took abstinence-only approaches. “They had to warm up to the idea that ‘Hey, we’re going to be doing syringe exchange and teaching them how to inject properly,’ ” Delfin said. “But over time, they’ve been able to see how this approach works. Instead of pushing treatment down someone’s throat . . . it’s an opportunity to build a relationship, to build trust.”
Are Texans willing to put resources toward helping as many addicts as possible while understanding not all can be helped—and that some users, in fact, don’t want help? Answers to those questions may come soon. Graziani said Texas Harm Reduction Alliance is advising Texas Health and Human Services on recommendations for fentanyl test strips that will, eventually, be brought to the governor. But in a state not normally known for a subtle and considered approach to gray areas, those results are still pending.