Fentanyl Test Strips Valued in Rural Appalachia Where Naloxone and EMS Fall Short

People in rural Appalachian Kentucky who use drugs and are involved with the criminal-legal system have shared their experiences with a harm reduction intervention that distributes fentanyl test strips, according to a qualitative study published in Harm Reduction Journal. The research, conducted across six rural Appalachian Kentucky counties, explored how participants viewed the education and distribution program and how they used the strips in their daily lives.

The study enrolled 28 criminal-legal-system-involved people who use drugs in the intervention and interviewed them one-on-one using semi-structured interviews. The interviews covered participants’ prior experiences with fentanyl test strips, their experience of the intervention and their use of the strips, their responses to positive test results, and how the strips spread through their communities. Researchers analyzed the transcripts using hybrid thematic analysis methods.

Knowledge of the tool was limited before the program: just seven of the 28 participants had heard of fentanyl test strips before taking part in the intervention. This gap reflects the study’s background observation that while fentanyl overdose rates are high in rural Appalachia, access to the strips and related research remains nascent.

Participants nonetheless deemed the strips essential. In their view, the strips were a harm reduction option controlled by people who use drugs themselves, one that could prevent overdoses from occurring at all. The researchers report that this feature mattered greatly in an environment where naloxone access was suboptimal and where poor cell service, long travel distances, and unmapped substance-use sites made emergency medical services unreliable. In other words, the strips offered a layer of protection that participants could deploy themselves before an overdose ever happened, rather than relying on a response system that might not reach them in time.

The interviews also captured what happened after participants received alarming results. Of the 11 participants who reported receiving a positive fentanyl test result, all but one reported engaging in at least one behavior to reduce their overdose risk. This suggests that, among those interviewed, a positive result commonly prompted some form of risk-reducing action rather than being ignored.

The strips did not stay with their original recipients. Eleven participants disseminated fentanyl test strips to others, extending the intervention’s reach beyond the people directly enrolled. The researchers attribute this diffusion to strong social networks, which they describe as a well-documented local strength in the region. Based on their findings, they conclude that future interventions should leverage these networks to extend reach further.

The study’s conclusions tie the intervention’s appeal directly to local conditions. Suboptimal naloxone access and unreliable emergency medical response in this rural Appalachian environment enhanced interest in fentanyl test strips, while strong social networks supported their spread. The authors frame these two factors, the gaps in existing overdose response and the density of community ties, as the key contextual features shaping how the intervention was received.

The work was registered as a clinical trial on ClinicalTrials.gov under identifier NCT04134767, with registration dated October 19, 2019. The article was published open access on October 6, 2026, and was shared early to provide faster access to the peer-reviewed, accepted research; this version is subject to further edits and will be replaced by the final Version of Record.

Subject of Research: Experiences of criminal-legal-system-involved people who use drugs in rural Appalachian Kentucky with a fentanyl test strip education and distribution intervention

Article Title: A qualitative study with criminal-legal-system-involved rural Appalachians who use drugs about experiences with a harm reduction intervention

Article References: Fadanelli, M., Jahangir, T., Kesich, Z., Lane, K., Young, A. M., & Cooper, H. L. F. (2026). A qualitative study with criminal-legal-system-involved rural Appalachians who use drugs about experiences with a harm reduction intervention. Harm Reduction Journal. https://doi.org/10.1186/s12954-026-01555-2

Image Credits: AI Generated

DOI: 10.1186/s12954-026-01555-2

Keywords: fentanyl test strips, harm reduction, rural Appalachia, overdose prevention, people who use drugs, criminal-legal system, naloxone, qualitative research, Kentucky, emergency medical services, social networks, thematic analysis