Stacey Andrews, the harm reduction coordinator for the AIDS project of the Ozarks (APO), walked through their downtown Springfield office and pointed out some of what the facility offers.
APO provides HIV and STI testing, small counseling areas, dozens of types of condoms organized into plastic bins, as well as information about HIV and STI prevention.
But suddenly she stopped and whispered, “Take a look. He’s going to the box.”
Just outside the door, a man leaned over an old newspaper box and grabbed harm reduction supplies.
These “porch boxes,” which have been converted from newspaper boxes, are located throughout APO’s 29-county region in southwestern Missouri.
There’s 18 porch boxes, as well as nine vending machines, that provide free, anonymous harm reduction supplies to anyone who needs them.
Supplies such as different types of naloxone – a medication that reverses opioid overdoses – containers for "sharps," or used needles, wound care kits, and packs of fentanyl test strips.
“Month over month, we are busier and busier and busier,” Andrews said. “I mean, it definitely, the demand for the services and the supplies has done nothing but increase, at least since I started tracking what we're doing.”
According to the Missouri Department of Health & Senior Services, nearly 2,000 Missourians died from drug overdoses in 2023.
Andrews said, on average, APO is distributing 1,000 units of naloxone a month and about 350 packs of fentanyl test strips. Each of these packs includes 10 single-use fentanyl tests strips and directions of how to use them.
Fentanyl test strips allow drugs to be tested for the presence of fentanyl, which is an incredibly potent opioid drug that can be deadly in relatively small quantities.
They’ve been officially legal in Missouri for a little more than a year, but – unlike the rapid acceptance of overdose reversal medications such as naloxone — the uptake of fentanyl test trip use has been a bit slower.
The Missouri Institute for Mental Health (MIMH) at the University of Missouri - St. Louis is the centralized distributor for free naloxone and fentanyl test strips in the state.
So far in 2024, they’ve sent harm reduction resources have been sent to more than 2,000 different organizations, but only about 400 of those requested fentanyl test strips.
“I don't think it's fair to compare the utilization of fentanyl test strips to the utilization of naloxone,” Casey Johnson, MIMH’s assistant director of harm reduction and drug user wellness, said. “Because naloxone is useful in any and every kind of environment, right?”
Johnson said that fentanyl test strips are “just more delicate” and are harder to use correctly. The strips contain very specific directions that have to be followed precisely to get an accurate result, and they require a non-contaminated environment to test in.
The tests also only confirm the presence of fentanyl, not the amount – which means they aren’t always helpful to those using opioids already.
Johnson also noted the strips can’t directly save lives like naloxone can, but they can help people using drugs make more informed decisions about what they are using.
“A fentanyl test strip is a tangible harm reduction tool designed to help you test your drugs to confirm either the presence of fentanyl or the lack of fentanyl we've seen as the volatile drug supply has continued to evolve and change,” Johnson said.
She added that the test strips can also help people using stimulants, such as cocaine, methamphetamine, and some prescription pills – who aren’t expecting to encounter opioids in the first place.
According to the Missouri Department of Health & Senior Services, there were 635 fatal overdoses in 2023 that involved both stimulants and opioids.
Rithvik Kondai, the senior overdose prevention coordinator for MIMH, said they distributed about 600,000 fentanyl test strips throughout the state between January and August 2024.
He said most of their funding comes from the state of Missouri and the federal government’s Substance Abuse and Mental Health Services Administration.
“Fentanyl test strips,” Kondai said, “have a role. They have a place and for people who are already using fentanyl… it might not be for them. It might be for the people who are only trying to use stimulants and then try to stay away from the fentanyl, or just using press pills and trying to stay away from fentanyl.”
Back in Springfield, Stacey Andrews and APO are still trying to expand the office’s offerings. They recently received a $15,000 grant from MIMH and are purchasing winter supplies such as sleeping bags and socks for unhoused people in the region.
And, as the drug supply continues to change, they’re trying to find more ways to assist people using drugs, such as distributing wound care kits and some xylazine test strips by request.
"It's a lot easier to utilize drugs in the state of Missouri than it is to find childcare, keep your family fed, be meaningfully employed."Casey Johnson, Assistant Director of Harm Reduction and Drug User Wellness at the Missouri Institute of Mental Health
These xylazine strips test for the presence of another potentially fatal drug whose consumption can lead to large, infected wounds and even amputation. Like fentanyl several years ago, xylazine has begun to pop up in the drug supply in Missouri.
But the strips to test for it? "Technically, in Missouri, they're still considered paraphernalia,” Andrews said.
She said she hopes policy and state laws will remove these barriers to access – just like it eventually did for fentanyl test strips.
But, Andrews added, she hopes this time the decision is made much quicker – before more Missourians die from using tainted drugs.
“You are worth every, every minute of time that you can invest into your health and safety. We know that you don't want to die just because you're taking a pill,” Andrews said. “So, what can we do to keep you here tomorrow, so that you can continue to work on those things.”
