Reaching Underserved Populations with FTS

Immigrant and refugee populations face a distinct constellation of barriers to accessing harm reduction services, including language barriers, fear related to immigration enforcement, cultural stigma around substance use, and unfamiliarity with the U.S. healthcare system. A scoping review published in 2023 found that language barriers are among the most significant obstacles preventing immigrants from accessing treatment for opioid use disorder, with mutual misunderstandings hindering medical consultations and nuanced instructions being lost even when translation services are available. For refugees specifically, the absence of culturally informed treatment models compounds the language barrier, and cultural beliefs about mental health care may discourage engagement with any substance-use-related service.

People leaving jails and prisons face an extraordinarily elevated overdose risk. Research shows that the first two weeks after release are 13 to 40 times riskier for fatal overdose compared to the general population, and the first 48 hours represent the single most dangerous period. Reduced tolerance from periods of abstinence during incarceration means that returning to pre-incarceration dosing levels with a drug supply now dominated by fentanyl is frequently fatal. Almost one-third of individuals in U.S.

Mobile outreach units are central to harm reduction delivery for populations that cannot or will not visit fixed-site services. These units take several forms, from converted vans and buses to full mobile clinics, and their accompanying staff can provide medical care, behavioral health services, HIV and hepatitis testing, naloxone distribution, and fentanyl test strip distribution in a single encounter. The operational model varies by context. In urban settings, mobile OUD care units (MOCUs) park in neighborhoods with high overdose burden and offer same-day access to buprenorphine alongside harm reduction supplies. Philadelphia\\

Peer-based distribution models tap into the social networks of people who use drugs to deliver harm reduction supplies, including fentanyl test strips, directly to individuals who may never interact with formal services. In compensated peer models, people who use drugs receive cash stipends to obtain naloxone, FTS, and other supplies from syringe service programs and distribute them within their networks. This approach has demonstrated feasibility in filling gaps in outreach to underserved minority communities in urban areas that have been historically underserved by harm reduction and high-quality treatment programs. The evidence supports both the practicality and the effectiveness of peer distribution.

Stigma operates at multiple levels to limit FTS access among underserved populations. At the structural level, stigma around drug use creates barriers that deter people from seeking or carrying harm reduction supplies. At the institutional level, healthcare and social service settings may communicate judgment through intake processes, staff attitudes, or physical environments that feel unwelcoming. At the interpersonal level, small-community dynamics in rural areas and tight-knit cultural communities amplify fear of being identified as a person who uses drugs.

Mail-based harm reduction platforms represent one of the most significant innovations in reaching underserved populations, particularly in areas with no physical harm reduction infrastructure. NEXT Distro, established in 2017, operates a confidential online and mail-order distribution system for naloxone, fentanyl test strips, syringes, and other harm reduction materials. The platform serves all 50 states and Puerto Rico through partnerships with over 30 harm reduction programs nationwide, and its anonymous, mail-based model has demonstrated particular effectiveness in reaching stigmatized groups in rural areas. In Wisconsin, NEXT Distro partnered with Vital Strategies to specifically address climbing overdose deaths in Indigenous and rural communities by mailing naloxone and harm reduction supplies statewide.

Fentanyl test strips are only effective if used correctly, and instructional clarity is a matter of life and death. A false-negative result caused by improper dilution, incorrect timing, or misreading the strip can provide dangerous reassurance that a drug supply is fentanyl-free when it is not. Yet a 2025 analysis in the Harm Reduction Journal found significant variability across FTS instructions from different sources, with no standardized instructional protocol for their use as a drug checking tool. Readability analyses using the Flesch-Kincaid scale reveal that many existing instructions are written at grade levels that exceed the literacy of the populations most in need.

Equity-focused FTS distribution requires systematic data collection that goes beyond counting strips distributed. Programs should track who is receiving strips, whether those recipients reflect the demographic composition of the populations most affected by overdose, and whether FTS use translates into behavior change and overdose reduction across all population segments. At minimum, programs should collect and report data disaggregated by race and ethnicity, geographic location (urban, suburban, rural, tribal), housing status, language preference, and history of criminal justice involvement. The CDC\\