“Don Julio.” “AT&T.” “Ruby Tuesday.” “Call of Duty.” These are among the stamps on small bags of street drugs that Dalton Barrett has recently gathered.
“Frosted Flakes.” “Megamind.” “American Greed.” The “Monopoly” logo has been around for a year and a half now, Barrett said, but the ingredients within it have changed substantially.
In fact, while most people may have a rough idea of what they’re purchasing within each of these packets, the full composition is far from certain. Street drugs are an unregulated market.
Ingredients aren’t printed on the package.
With the proliferation of prescription pills came the first wave of the opioid overdose epidemic. Then, with the crackdown on the overprescribing of those pills: heroin. Fentanyl followed. As a synthetic, it’s much cheaper and easier to produce.
The fourth wave has been the ubiquity of polysubstance: fentanyl – almost always fentanyl – in combination with any number of other substances. These include methamphetamine, cocaine, carfentanyl (a synthetic used to anesthetize elephants that can be 100 times as potent as fentanyl), xylazine (or “tranq,” another animal sedative that can cause frightful skin ulcers when injected), and, increasingly, medetomidine (yet another animal sedative, much more potent than xylazine).
The inventory is ever-changing, and the consequences can be lethal.
Which is why Barrett has collected these packages. He’s the program manager for the Edgecombe County EMS Post Overdose Response Team, or PORT, which has been offering outreach services since May of 2023. Edgecombe is a largely rural county in the northeastern region of North Carolina.
Barrett recalled incidents in which he would respond to an overdose and would be told heroin or fentanyl was involved. What he’d learned from his textbooks to expect with these drugs was constricted pupils, a slow heart rate.
“But what we were seeing was they might have dilated pupils, they may have an increased heart rate, which didn’t make sense for these types of drugs,” he said. “The paramedic in me was like, ‘Why is that?’”
These questions led to the launch of PORT’s street drug testing initiative. The PORT team collects drug samples from folks who want to know what exactly they’re using. The samples are then sent to the Street Drug Analysis Lab at the University of North Carolina at Chapel Hill.
This initiative has been “the cornerstone of any type of drug education that we do here in the county,” Barrett said. “It’s all based upon what we’re actually seeing in the supply.”
It has “changed the game for us,” he said.
‘You Really Must Care’
Nab Dasgupta is a luminary in the drug-testing world, a pioneering expert in the study of the U.S. street drug supply. He oversees the lab that the PORT team partners with. Last fall, Dasgupta was recognized for his work with a MacArthur Fellowship – the vaunted “genius grant.”
Barrett learned of the lab, commonly known as “Nab’s Lab,” and that health departments and harm reduction agencies could send drug samples to determine their contents. How about an EMS team? He applied. Dasgupta’s response, Barrett recalled, was, “‘Absolutely.” EMS was an ideal untapped resource.
The lab provides guidance and support, but leaves it to each community-based program to apply the tools as they see fit.
First order of business: Building trust among people who use drugs. Pulling up in an EMS vehicle and asking for drug samples was, initially, Barrett said, “kind of weird.”
Helping facilitate that trust is the array of other harm reduction services the PORT team provides. They offer naloxone. They provide hepatitis C testing and wound care. They exchange clean syringes for used ones. Their mobile outreach unit is regularly stocked with flashlights, batteries, hand warmers, energy bars, and ramen noodles. They provide referrals for other services available in the community.
The team does point-of-care drug testing using test strips for some commonly found substances, including benzodiazepines, fentanyl, xylazine, and medetomidine. Those will produce a “yes” or a “no” for that particular substance. Dasgupta’s lab provides a detailed accounting.
Freedom Hill Community Health Center is another partner in this initiative. Savannah Junkins is a physician associate and Freedom Hill’s director of integrated behavioral health. The health center provides medication for opioid use disorder and other substance use-related services.
Junkins had heard about Nab’s Lab and thought it was a great idea. But the health center itself collecting samples was “a bridge too far.” Partnering with the PORT team was a perfect fit.
Learning the extent and variety of additives has been a revelation. A recently analyzed pressed pill, for example, was found to include fentanyl, lidocaine, caffeine, carfentanyl, xylazine, and levamisole, a medication primarily used to treat worm infestation in animals.
Barrett produced handouts with recent analysis results, which Freedom Hill helps circulate.
“We have patients who regularly ask, ‘Do you have any new results?’” Junkins said. “They recognize the stamps that Dalton includes on the documents. Even if they’re not currently using anything on those lists, they tend to know someone who is.”
There has been an encouraging response from people who deal drugs. “We know we have patients that are probably dealing,” Junkins said, “and they might recognize the stamp as something that’s passed through their hands.”
“People are very interested,” she said, “and they also really appreciate that someone is looking out for them. It’s kind of a next level of, ‘You really must care about me.’”
‘Engines of Ingenuity’
“Hey; it’s Dalton,” Barrett called out on a recent visit to a small encampment under a bridge in a commercial district. A couple of folks emerged from their tents. Barrett is a familiar face here. A major snow and ice storm was forecast for the following day. He supplied them with a few cold-weather provisions and some food and promised he would soon return. No drugs for testing today. But another productive encounter.
“Dalton’s done a lot of work in making EMS a trusted provider in the substance-use journey,” Junkins said, “instead of somebody who might have come with judgment when they respond to overdoses.” He’s been, she said, “a godsend.”
Having grown up in a rural community, Dasgupta said, “I see rural communities as often being engines of ingenuity.”
“I think our intention all along was to create a tool and a service that people could adapt for their own context without having someone external tell them how to do things,” he said of his lab. “We were there to give them tools, [share] knowledge and step away, and let them answer the questions that are important to them, and do it the way that is right in their communities.”
When Barrett met Christina Piscopo, she’d been more than two decades into addiction. While working as a manager at Home Depot, she was loading carpets when a chain-and-pulley system broke, the carpets fell upon her, and her back was broken. She was prescribed painkillers.
“One pill every six hours leads to two pills every six hours, leads to five pills every six hours, leads to I’m buying pills off the street,” Piscopo said. “I can’t afford to be pill sick and can’t afford to keep buying pills, so I switch to heroin.”
She began selling drugs. “You do whatever you have to do to maintain that drug habit.”
She was a patient of Junkins’, and was open with her about her drug use. Junkins asked Piscopo if she trusted her enough to let someone test her drugs. That’s when she met Barrett.
“She gave me his number, I called him, and he came,” she said. “I was still heavily selling and using, and I would have him come test my drugs for what I was putting into my body and what I was selling other people to put into their body.”
She had developed the wounds that often result from xylazine use. Barrett was able to present her with the analysis results confirming xylazine. “I think that started her wheels turning,” he said. Over the next couple of months, a “process for doing something different” took shape.
That level of trust is what Dasgupta considers “absolutely the central enabling factor of a program.”
Word Is Spreading
“I get very excited about rural innovation,” Dasgupta said. As the Trump administration has shared its antipathy toward harm reduction initiatives, and as federal funding for substance use disorder interventions is cut, he’s been encouraged to see more county-level funding of those initiatives using opioid settlement money. Such is the case in Edgecombe County: PORT has received $5 million to help fund the program for 18 years, though Barrett hopes to receive additional money from the Purdue Pharma settlement.
“And along with that,” Dasgupta added, “has come a huge explosion in the number of people who are interested in harm reduction at a county, local level.”
He recently delivered keynote speeches at opioid settlement conferences in North Carolina, Maine, and Kentucky, each with a substantial rural population.
He estimates that 90% of the attendees were “all in on harm reduction.” And street drug testing is increasingly an essential element of such initiatives.
When Piscopo learned what was in the drugs she was consuming and selling, “I was just amazed. I was, like, ‘Holy s**t. It’s almost pure xylazine; no dope in it.”
She then stopped selling, and she was soon ready to give it up herself. She’s been drug-free for more than a year and a half.
“He was somebody to talk to, first and foremost; somebody I can be honest with,” Piscopo said of Barrett.
Word is spreading. Barrett tells of being approached a while back by a guy who said, “Hey, man, you don’t know me, but I know you.” He went on to share how he’d gotten into treatment after overhearing conversations Barrett had with a friend that helped lead the friend to treatment. Barrett recently ran into the guy again at Lowe’s; both he and his friend are doing well.
“People will talk,” Barrett said, “‘Hey, this guy shows up. He can test our drugs. He can give us syringes and sterile injection supplies. He can help us into treatment.’
“That credibility goes a long way.”
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