Drug checking to detect fentanyl and new psychoactive substances

National and regional trends in fentanyl seizures in the United States, 2017-2023

BACKGROUND

Rates of synthetic opioid-related deaths over time and across regions have been compared within the US, but other indicator data could help inform prevention and harm reduction as well. We compared regional trends in fentanyl seizures to examine potential shifts in illicit fentanyl availability.

METHODS

Annual trends in fentanyl seizures were examined using data from High Intensity Drug Trafficking Areas for the US overall and by region from 2017 through 2023. Multiple measures included the number of seizures, the number of powder seizures, the number of pill seizures, the total weight of seizures, the number of pills seized, and the percentage of the number of pill seizures relative to the number of total seizures.

RESULTS

The percentage of seizures in pill form in the US increased from 10.3 % in 2017 to 49.0 % in 2023 (adjusted annual percentage change [AAPC]=25.2, 95 % CI: 17.6, 33.2), with 115.6 million individual pills seized in 2023. Pill weight related to total seizure weight also increased from 0.4 % to 54.5 % (AAPC=112.6, 95 % CI: 78.6, 153.2). In 2023, the plurality of seizures was in the West, in seven out of eight of our measures, with 77.8 % of seizures in the West being in pill form. Although the Midwest had lower prevalence of seizures than the West, there were notable increases in the Midwest in the number of pill seizures (AAPC=142.2, 95 % CI: 91.9, 205.8) and number of pills seized (AAPC=421.0, 95 % CI: 272.7, 628.4). Total weight of fentanyl seized increased the most in the West (AAPC=84.6, 95 % CI: 72.3, 97.8).

CONCLUSIONS

The number and size of fentanyl seizures is increasing in the US, with the majority of seizures, especially in pill form, in the West. Continued monitoring of regional shifts in the fentanyl supply can help inform targeted prevention and public health response.

Systematic review of cognitive and behavioral strategies used in effective harm reduction interventions for people who use cocaine

OBJECTIVE

The aim of this systematic review is to identify cognitive and behavioral strategies that have been used in effective harm reduction interventions for people who use cocaine.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the search was performed on February 26, 2023 across databases including PsycInfo, PubMed, Scopus, and Web of Science. Studies were included if they (1) report the use of one cognitive or behavioral strategy, (2) have harm reduction as the objective, (3) involve participants who used cocaine as at least one of their substances, (4) be published within the last 10 years, and (5) have a randomized controlled trial design. The Cochrane RoB 2.0 Tool was used to assess risk of bias. The cognitive and behavioral strategies were extracted and organized based on their frequency of use in the studies and their corresponding outcomes.

RESULTS

The final synthesis included k = 10 studies with N = 3,567 participants. Psychoeducation strategies, influence on social norms, personalized feedback, increased self-efficacy and motivational interviewing were the most frequently used promising strategies across studies.

CONCLUSIONS

This review underscores the significance of incorporating cognitive and behavioral strategies within harm reduction interventions, as they represent a promising domain that could enhance the effectiveness of addressing cocaine use.

Enhancing drug checking services for supply monitoring: perspectives on implementation in syringe service programs in the USA

BACKGROUND

Shifts in the US drug supply, including the proliferation of synthetic opioids and emergence of xylazine, have contributed to the worsening toll of the overdose epidemic. Drug checking services offer a critical intervention to promote agency among people who use drugs (PWUD) to reduce overdose risk. Current drug checking methods can be enhanced to contribute to supply-level monitoring in the USA, overcoming the selection bias associated with existing supply monitoring efforts and informing public health interventions.

METHODS

As a group of analytical chemists, public health researchers, evaluators, and harm reductionists, we used a semi-structured guide to facilitate discussion of four different approaches for syringe service programs (SSPs) to offer drug checking services for supply-level monitoring. Using thematic analysis, we identified four key principles that SSPs should consider when implementing drug checking programs.

RESULTS

A number of analytical methods exist for drug checking to contribute to supply-level monitoring. While there is likely not a one-size-fits-all approach, SSPs should prioritize methods that can (1) provide immediate utility to PWUD, (2) integrate seamlessly into existing workflows, (3) balance individual- and population-level data needs, and (4) attend to legal concerns for implementation and dissemination.

CONCLUSIONS

Enhancing drug checking methods for supply-level monitoring has the potential to detect emerging threats in the drug supply and reduce the toll of the worsening overdose epidemic.

Perceptions of fentanyl among African Americans who misuse opioids: implications for risk reduction

BACKGROUND

Fentanyl is a powerful synthetic opioid that is 50 times more powerful than heroin and has become ubiquitous in the illicit drug supply in the USA. Studies show that among people who use drugs, fentanyl is sometimes viewed as a desirable substance due to its high potency and low cost, while others have an unfavorable perception because of its association with overdose. Unfortunately, studies on the perceptions of fentanyl are relatively rare and existing studies tend to rely on samples with little African American representation. The objective of this study, therefore, was to identify and describe perceptions of fentanyl among African Americans who misuse opioids, while capturing their motivations for seeking out or avoiding fentanyl.

METHODS

In-depth interviews (n = 30) were conducted with a sample of African American adults who misuse opioids in Southwest Florida between August 2021 and February 2022. Audiotapes of interviews were transcribed, coded, and thematically analyzed.

RESULTS

Analyses revealed the presence of three subtypes of fentanyl-related perceptions: (1) fentanyl as an avoided adulterant, (2) fentanyl as a tolerated adulterant, and (3) fentanyl as a drug of choice.

CONCLUSIONS

These findings show that African Americans' perceptions of fentanyl are not monolithic and suggest the distribution of fentanyl test strips and naloxone may be an effective risk reduction strategy. Given that most studies on fentanyl rely on quantitative data from drug seizures and death certificates, this study uniquely contributes to the literature by capturing the voices of African Americans who use drugs.

Trends in reported and biologically confirmed drug use among people who use ecstasy in the nightclub/festival-attending population, 2016-2022

Background

Nightclub/festival attendees are a population with high rates of party drug use, but research is needed to determine whether there have been shifts in unintended drug exposure in this population (e.g., via adulterants) to inform prevention and harm reduction efforts.

Methods

Adults entering nightclubs and festivals in New York City were asked about past-year drug use in 2016 through 2022, with a subset providing a hair sample for testing. We focused on the 1943 who reported ecstasy use (of which 247 had a hair sample analyzed) and compared trends in self-reported drug use, drug positivity, and adjusted prevalence (adjusting for unreported use).

Results

MDMA positivity decreased from 74.4 % to 42.3 %, and decreases occurred regarding detection of synthetic cathinones ("bath salts"; a 100.0 % decrease), MDA (a 76.9 % decrease), amphetamine (an 81.3 % decrease), methamphetamine (a 64.2 % decrease), and ketamine (a 33.4 % decrease) (ps < .05). Although prevalence of MDA and synthetic cathinone use was comparable between self-report and adjusted report in 2022, gaps in prevalence were wider in 2016 (ps < .01). Adjusted prevalence of synthetic cathinone use decreased more across time than prevalence based on self-report (a 79.4 % vs. 69.1 % decrease) and adjusted report for MDA use decreased more than prevalence based on self-report (a 50.6 % vs. 38.9 % decrease).

Conclusions

Combining self-report and toxicology tests helped us determine that decreases in drug use/exposure were steeper regarding adjusted prevalence. Underreported drug exposure-possibly due to exposure to adulterants-appears to have had less of an effect on prevalence in 2022 than it did in 2016.

Detection of fentanyl, synthetic opioids, and ketamine in hair specimens from purposive samples of American and Italian populations

With the current crisis related to the diffusion of fentanyl and other novel opioids in several countries and populations, new and effective approaches are needed to better elucidate the phenomenon. In this context, hair testing offers a unique perspective in the investigation of drug consumption, producing useful information in terms of exposure to psychoactive substances. In this research, we applied targeted ultra-high performance liquid chromatography tandem mass spectrometry (UHPLC-MS/MS) analytical methods to detect novel synthetic and prescription opioids and other common controlled psychoactive drugs in the keratin matrix. A total of 120 hair samples were analyzed from the United States (US) and Italy, segmented when longer than 6 cm, and then analyzed. In the 60 samples (83 segments in total) analyzed from a purposive sample of data collected in the US, fentanyl was detected in 14 cases (16.9%), with no detection of nitazens or brorphine. We also detected fentanyl metabolites, despropionyl-p-fluorofentanyl, and prescription opioids. In the 60 samples collected in Italy (91 segments in total), ketamine was the most prevalent compound detected (in 41 cases; 45.1%), with ketamine demonstrating a strong correlation with detection of amphetamines and MDMA, likely due to co-use of these substances in recreational contexts. Several common drugs were also detected but no exposure to fentanyl or its analogs were detected. Results of this retrospective exploration of drug use add to increasing evidence that hair testing can serve as a useful adjunct to epidemiology studies that seek to determine biologically confirmed use and exposure in high-risk populations.

Drug checking in the fentanyl era: Utilization and interest among people who inject drugs in San Diego, California

BACKGROUND

In North America, overdose rates have steeply risen over the past five years, largely due to the ubiquity of illicitly manufactured fentanyls in the drug supply. Drug checking services (DCS) represent a promising harm reduction strategy and characterizing experiences of use and interest among people who inject drugs (PWID) is a priority.

METHODS

Between February-October 2022, PWID participating in a cohort study in San Diego, CA and Tijuana, Mexico completed structured surveys including questions about DCS, socio-demographics and substance use behaviors. We used Poisson regression to assess factors associated with lifetime DCS use and characterized experiences with DCS and interest in free access to DCS.

RESULTS

Of 426 PWID, 72% were male, 59% Latinx, 79% were experiencing homelessness and 56% ever experienced a nonfatal overdose. One third had heard of DCS, of whom 57% had ever used them. Among the latter, most (98%) reported using fentanyl test strips (FTS) the last time they used DCS; 66% did so less than once per month. In the last six months, respondents used FTS to check methamphetamine (48%), heroin (30%) or fentanyl (29%). Relative to White/non-Latinx PWID, those who were non-White/Latinx were significantly less likely to have used DCS [adjusted risk ratio (aRR): 0.22; 95% CI: 0.10, 0.47), as were PWID experiencing homelessness (aRR:0.45; 95% CI: 0.28, 0.72). However, a significant interaction indicated that non-White/Latinx syringe service program (SSP) clients were more likely to have used DCS than non-SSP clients (aRR: 2.79; CI: 1.09, 7.2). Among all PWID, 44% expressed interest in free access to FTS, while 84% (of 196 PWID) expressed interest in advanced spectrometry DCS to identify and quantify multiple substances.

CONCLUSIONS

Our findings highlight low rates of DCS awareness and utilization, inequities by race/ethnicity and housing situation, high interest in advanced spectrometry DCS versus FTS, and the potential role of SSPs in improving access to DCS, especially among racial/ethnic minorities.

Development of a neural network model to predict the presence of fentanyl in community drug samples

INTRODUCTION

Increasingly, Fourier-transform infrared (FTIR) spectroscopy is being used as a harm reduction tool to provide people who use drugs real-time information about the contents of their substances. However, FTIR spectroscopy has been shown to have a high detection limit for fentanyl and interpretation of results by a technician can be subjective. This poses concern, given that some synthetic opioids can produce serious toxicity at sub-detectable levels. The objective of this study was to develop a neural network model to identify fentanyl and related analogues more accurately in drug samples compared to traditional analysis by technicians.

METHODS

Data were drawn from samples analyzed point-of-care using combination FTIR spectroscopy and fentanyl immunoassay strips in British Columbia between August 2018 and January 2021. We developed neural network models to predict the presence of fentanyl based on FTIR data. The final model was validated against the results from immunoassay strips. Prediction performance was assessed using F1 score, accuracy, and area under the receiver-operating characteristic curve (AUROC), and was compared to results obtained from analysis by technicians.

RESULTS

A total of 12,684 samples were included. The neural network model outperformed results from those analyzed by technicians, with an F1 score of 96.4% and an accuracy of 96.4%, compared to 78.4% and 82.4% with a technician, respectively. The AUROC of the model was 99.0%. Fentanyl positive samples correctly detected by the model but not by the technician were typically those with low fentanyl concentrations (median: 2.3% quantity by weight; quartile 1-3: 0.0%-4.6%).

DISCUSSION

Neural network models can accurately predict the presence of fentanyl and related analogues using FTIR data, including samples with low fentanyl concentrations. Integrating this tool within drug checking services utilizing FTIR spectroscopy has the potential to improve decision making to reduce the risk of overdose and other negative health outcomes.

Insights from Drug Checking Programs: Practicing Bootstrap Public Health Whilst Tailoring to Local Drug User Needs

The year 2021 was the most deadly year for overdose deaths in the USA and Canada. The stress and social isolation stemming from the COVID-19 pandemic coupled with a flood of fentanyl into local drug markets created conditions in which people who use drugs were more susceptible to accidental overdose. Within territorial, state, and local policy communities, there have been longstanding efforts to reduce morbidity and mortality within this population; however, the current overdose crisis clearly indicates an urgent need for additional, easily accessible, and innovative services. Street-based drug testing programs allow individuals to learn the composition of their substances prior to use, averting unintended overdoses while also creating low threshold opportunities for individuals to connect to other harm reduction services, including substance use treatment programs. We sought to capture perspectives from service providers to document best practices around fielding community-based drug testing programs, including optimizing their position within a constellation of other harm reduction services to best serve local communities. We conducted 11 in-depth interviews from June to November 2022 via Zoom with harm reduction service providers to explore barriers and facilitators around the implementation of drug checking programs, the potential for integration with other health promotion services, and best practices for sustaining these programs, taking the local community and policy landscape into account. Interviews lasted 45-60 min and were recorded and transcribed. Thematic analysis was used to reduce the data, and transcripts were discussed by a team of trained analysts. Several key themes emerged from our interviews: (1) the instability of drug markets amid an inconsistent and dangerous drug supply; (2) implementing drug checking services in dynamic environments in response to the rapidly changing needs of local communities; (3) training and ongoing capacity building needed to create sustainable programs; and (4) the potential for integrating drug checking programs into other services. There are opportunities for this service to make a difference in overdose deaths as the contours of the drug market itself have changed over time, but a number of challenges remain to implement them effectively and sustain the service over time. Drug checking itself represents a paradox within the larger policy context, putting the sustainability of these programs at risk and challenging the potential to scale these programs as the overdose epidemic worsens.

Feasibility study of using mobile phone-based experience sampling to assess drug checking by opioid street drug users

BACKGROUND

To date, evaluations of take-home fentanyl (and/or benzodiazepine) test strip use - the most common form of drug checking services - and potential effects on overdose risk have relied on retrospective accounts for some preceding time period, usually a week to several months. Such accounts, however, are subject to recall and memory biases. This pilot study assessed the feasibility of using experiential sampling to collect daily information in situ on drug checking and associated overdose risk reduction - the primary outcomes - among a sample of street opioid users and compared the results to retrospective reports.

METHODS

We recruited 12 participants from a Chicago-based syringe services program. Participants were 18 years of age or older, reported using opioids purchased on the street 3 + times per week in the past month, and had an available Android mobile phone. A phone-based app was programmed to collect daily drug checking information and provided to each participant along with a supply of fentanyl and benzodiazepine test strips and instructions for use over 21 days. Comparable retrospective data were collected via follow-up in-person surveys at the conclusion of daily report collection.

RESULTS

We found a reasonably high rate of daily reporting (63.5%) with participants submitting reports on 160 "person-days" out of 252 possible days. Participants submitted daily reports an average of 13 of 21 days. Reports of test strip use frequency varied between the retrospective and daily reports with a relatively higher percentage of days/time using test strips obtained from the daily reports. We also found higher proportions reporting overdose risk reduction behaviors on the daily reports compared with the retrospective reviews.

CONCLUSIONS

We believe the results support using daily experience sampling to collect information on drug checking behaviors among street drug users. Although resource intensive in comparison to retrospective reports, daily reporting potentially provides more detailed information on test strip use and its association with overdose risk reduction and, ultimately, fewer overdoses. Needed are larger trials and validation studies of daily experience sampling to identify the optimum protocol for collecting accurate information on drug checking and overdose risk reduction behavior.

The Future of the United States Overdose Crisis: Challenges and Opportunities

Policy Points People are dying at record numbers from overdose in the United States. Concerted action has led to a number of successes, including reduced inappropriate opioid prescribing and increased availability of opioid use disorder treatment and harm-reduction efforts, yet ongoing challenges include criminalization of drug use and regulatory and stigma barriers to expansion of treatment and harm-reduction services. Priorities for action include investing in evidence-based and compassionate policies and programs that address sources of opioid demand, decriminalizing drug use and drug paraphernalia, enacting policies to make medication for opioid use disorder more accessible, and promoting drug checking and safe drug supply.

Point-of-care community drug checking technologies: an insider look at the scientific principles and practical considerations

Drug checking is increasingly being explored outside of festivals and events to be an ongoing service within communities, frequently integrated within responses to illicit drug overdose. The choice of instrumentation is a common question, and the demands on these chemical analytical instruments can be challenging as illicit substances may be more complex and include highly potent ingredients at trace levels. The answer remains nuanced as the instruments themselves are not directly comparable nor are the local demands on the service, meaning implementation factors heavily influence the assessment and effectiveness of instruments. In this perspective, we provide a technical but accessible introduction to the background of a few common drug checking methods aimed at current and potential drug checking service providers. We discuss the following tools that have been used as part of the Vancouver Island Drug Checking Project in Victoria, Canada: immunoassay test strips, attenuated total reflection IR-absorption spectroscopy, Raman spectroscopy from powder samples, surface-enhanced Raman scattering in a solution of colloidal gold nanoparticles, and gas chromatography-mass spectrometry. Using four different drug mixtures received and tested at the service, we illustrate the strengths, limitations, and capabilities of such instruments, and expose the scientific theory to give further insight into their analytical results. Each case study provides a walk-through-style analysis for a practical comparison between data from several different instruments acquired on the same sample. Ideally, a single instrument would be able to achieve all of the objectives of drug checking. However, there is no clear instrument that ticks every box; low cost, portable, rapid, easy-to-use and provides highly sensitive identification and accurate quantification. Multi-instrument approaches to drug checking may be required to effectively respond to increasingly complex and highly potent substances demanding trace level detection and the potential for quantification.

Substances from unregulated drug markets - A retrospective data analysis of customer-provided samples from a decade of drug checking service in Zurich (Switzerland)

BACKGROUND

Drug checking services (DCS) are harm reduction interventions for people who consume illicit substances. Unregulated drug markets lead to samples with unexpected and variable contents. A retrospective data analysis of Zurich's DCS was performed to determine the nature of these samples.

METHODS

This study aims to investigate the qualitative and quantitative properties of 16,815 customer-provided psychoactive drug samples analyzed chemically through the DCS in Zurich from 1^st January 2011 to 31^st December 2021. The main analytical method utilized for characterizing these substances was high-performance liquid chromatography and gas chromatography-mass spectrometry. Data sets are summarized using descriptive statistics.

RESULTS

There was a 2.5-fold increase in the number of tested samples over the past decade. An overall proportion of 57.9% (weighted mean) of samples within our database demonstrates unexpected analytical findings and additional low sample contents during the observation period. Substantial differences in quality and quantity between substance groups were detected and an increase of sample quality and content over time was demonstrated.

CONCLUSIONS

Chemical analysis reveals that over half of substances acquired from unregulated drug markets analyzed through DCS in Zurich are with low qualitative and quantitative properties, which may expose users to risks. Based on longitudinal analyses over a decade, this study contributes to the body of evidence that DCS may potentially manipulate unregulated drug markets towards providing better quality substances, as well as may stabilize these markets over time. The necessity for drug policy changes to make this service accessible in further settings was highlighted, as DCS still often take place in legal grey zones.

FUNDING

None to declare.

Feasibility Study of Using Mobile Phone-Based Experience Sampling to Assess Drug Checking by Opioid Street Drug Users

Background: To date, evaluations of take-home fentanyl (and/or benzodiazepine) test strip use - the most common form of drug checking services - and potential effects on overdose risk have relied on retrospective accounts for some preceding time period, usually a week to several months. Such accounts, however, are subject to recall and memory biases. This pilot study assessed the feasibility of using experiential sampling to collect daily information in situ on drug checking and associated overdose risk reduction - the primary outcomes - among a sample of street opioid users and compared the results to retrospective reports. Methods: We recruited 12 participants from a Chicago-based syringe services program. Participants were 18 years of age or older, reported using opioids purchased on the street 3+ times per week in the past month, and had an available Android mobile phone. A phone-based app was programmed to collect daily drug checking information and provided to each participant along with a supply of fentanyl and benzodiazepine test strips and instructions for use over 21 days. Comparable retrospective data were collected via follow-up in-person surveys at the conclusion of daily report collection. Results: We found a reasonably high rate of daily reporting (63.5%) with participants submitting reports on 160 "person-days" out of 252 possible days. Participants submitted daily reports an average of 13 of 21 days. Reports of test strip use frequency varied between the retrospective and daily reports with a relatively higher percentage of days/time using test strips obtained from the daily reports. We also found higher proportions reporting overdose risk reduction behaviors on the daily reports compared with the retrospective reviews. Conclusions: We believe the results support using daily experience sampling to collect information on drug checking behaviors among street drug users. Although resource intensive in comparison to retrospective reports, daily reporting potentially provides more detailed information on test strip use and its association with overdose risk reduction and, ultimately, fewer overdoses. Needed are larger trials and validation studies of daily experience sampling to identify the optimum protocol for collecting accurate information on drug checking and overdose risk reduction behavior.

A Systematized Review of Drug-checking and Related Considerations for Implementation as A Harm Reduction Intervention

Drug-checking services (DCS) provide people who use drugs (PWUD) the opportunity to have their substances tested before consumption. Though some suggest they may have adverse consequences, DCS have been introduced as a harm reduction (HR) strategy. A systematized review of the literature regarding drug checking (DC) methods and testing locations, advantages and disadvantages, and legal frameworks with an emphasis on HR was conducted referencing PRISMA guidelines. The primary search of PsychInfo, PubMed, Medline, CINHAL, CORE, and Web of Science was conducted between the 4^th and 10^th of September 2020, and 51 literature pieces were included in the final article. Most of the literature focuses on the benefits of currently available DCS. The services identified varied significantly in terms of testing methods, location of operation, primary goal, and the surrounding legal framework. The results suggest using multiple DC methods to be most beneficial. Further, DCS and the personalized interventions they provide can positively influence behavior change, minimize harm, and reduce mortality. DCS are a viable public health intervention that requires cross-sector support beyond the legal frameworks and testing methods. Services will need to be tailored to meet the needs of their chosen setting, local drug market, and target audience.

Exploring Potential Bellwethers for Drug-Related Mortality in the General Population: A Case for Sentinel Surveillance of Trends in Drug Use among Nightclub/Festival Attendees

Background: Drug-related deaths in the US continue to increase. Sentinel surveillance of high-risk populations can provide early warning for shifts in trends. Nightclub/festival attendees have high levels of drug use, so we explored whether use among this population can serve as a potential bellwether or indicator for use-related mortality in the general population.Methods: Trends in past-year cocaine and methamphetamine use were estimated from nightclub/festival attendees in New York City (NYC) and among NY residents, and trends were estimated for related death rates in NYC (2014/15-2019/20). Using national data from England and Wales (2010-2019), trends in past-year cocaine and ecstasy use (among the full population and among nightclub attendees) and related deaths were also estimated.Results: In NY/NYC, cocaine use remained stable in the general population, but use among nightclub/festival attendees and cocaine-related deaths doubled. Methamphetamine use among nightclub/festival attendees and death rates also more than doubled while use among the general population remained stable. In UK countries, increases in cocaine and ecstasy use were larger for infrequent/frequent nightclub attendees than in the general population, with 3.6- and 8-fold increases in related deaths, respectively. In UK countries, the association between nightclub attendance and death rates increased in a dose-response-like manner with larger associations detected when death rates were lagged by one year.Conclusions: Patterns of use among nightclub/festival attendees, more so than patterns in the general population, were similar to patterns of drug-related deaths. Use among this subpopulation could possibly serve as a bellwether for use-related outcomes. Continued surveillance is recommended.

Evaluating new simplified assays for harm reduction from methanol poisoning using chromotropic acid kits: An analytical study on Indian and Iranian alcoholic beverages

Background

Ingestion of methanol can result in severe irreversible morbidity, and death. Simple and easy methods to detect methanol and other hazardous additives prior to consumption can prevent fatalities. This form of harm reduction is analogous to the widely practiced "pill testing" of recreational drugs in various countries. We aimed to evaluate the performance of two qualitative and quantitative kits to simultaneously identify the presence of methanol and formaldehyde in alcoholic beverages, and compare this to the standard gas chromatographic (GC) method.

Methods

Two-hundred samples of Indian and Iranian alcoholic drinks were examined by two new qualitative and quantitative chemical kits designed based on a modified chromotropic acid (CA) method, as well as a gold standard GC method.

Results

Methanol levels were similar when evaluated by GC and quantitative method (Z = - 0.328, p = 0.743). The 75th percentile of methanol level detection was 4,290 mg L^-1 (range; 0-83,132) using GC compared to that of 4,671 mg L^-1 (range; 0-84,960) using the qualitative kit (predefined color intensity reflecting the methanol/ethanol ratio). The quantitative kit was able to detect all methanol-contaminated and non-contaminated samples (110 and 60 cases, respectively: 100% sensitivity). In 25 samples, GC analysis showed no methanol; but the qualitative kit detected possible toxic substances. Formaldehyde measurement by UV/Vis analysis showed the presence of formaldehyde in 23 samples (92%) with a median 912 [IQR 249, 2,109; range 112-2,742] mg L^-1.

Conclusion

Methanol and formaldehyde can be easily detected using these simple CA chemical kits. Qualitative positive results may indicate the risk of poisoning if the beverage is consumed. CA kits can be used in community setting by public health units and community organizations to monitor for methanol contamination and inform a public health response to reduce methanol-related harms to the public.

A century of research on psychedelics: A scientometric analysis on trends and knowledge maps of hallucinogens, entactogens, entheogens and dissociative drugs

A scientometric analysis was realized to outline clinical research on psychedelics over the last century. Web of Science Core Collection was searched up to March 18, 2022, for publications on psychedelics. Network analyses and bibliometrics were combined, to identify research themes and trends with Bibliometrix and CiteSpace. The primary aim was to measure research trends evolution over time, and the secondary aims were to identify bibliometric performance and influence networks of publications, authors, institutions, and countries. Sensitivity analyses were conducted for 2016-2022, and 2021 time periods. We included 31,687 documents (591,329 references), which aggregated into a well-structured network with credible clustering. Research productivity was split into an early less productive period mainly focusing on safety issues, and a "psychedelic renaissance" after the 1990s. Major trends were identified for hallucinogens/entheogens, entactogens, novel psychoactive substances (NPS), and on dissociative substances. There was a translational evolution from the bench to the bedside, with phase 2 and 3 trials and/or evidence synthesis in particular. The most recent trends concerned NPS, ketamine-associated brain changes, and ayahuasca-assisted psychotherapy. The USA and Canada were the most productive settings for the research overall, and more recently this geographical distribution became more prominent, reflecting legislative context/policy making. A translational evolution of psychedelics has been occurring, that has brought approval of esketamine for depression and will likely lead to approval of additional psychedelics across mental and physical conditions. Toxicology screening tools for NPS are urgently needed, which in turn might follow the same translational evolution of psychedelics in the future.

Validation of a lateral flow chromatographic immunoassay for the detection of fentanyl in drug samples

BACKGROUND

Drug overdose deaths remain the primary cause of unintentional injuries in the United States. We examined the validity of a fentanyl test strip (FTS) in detecting fentanyl and its related analogs in water-based illicit drug solutions.

METHODS

Illicit drugs obtained from law enforcement (N = 343) were tested using a lateral flow chromatographic immunoassay FTS (BTNX Rapid Response) and Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) at a clinical chemistry laboratory in Baltimore, Maryland.

RESULTS

The FTS assay detected fentanyl at 200 ng/ml in water, and 13 additional fentanyl analogs, but failed to detect carfentanil and furanyl fentanyl at or below 1000 ng/ml. Overall sensitivity and specificity for detecting fentanyls was 98.5 % and 89.2 %; and the false negative and positive rate was 1.5 % and 10.9 %. False negatives (n = 2) occurred in fentanyl and a fentanyl precursor. False positives (n = 23) occurred in the presence of other illicit drugs and compounds (56.5 %) or when fentanyls were present below 40 ng/ml (43.5 %). False positive/negative rates remained low when testing cocaine and prescription opioid (PO) samples.

CONCLUSIONS

FTS is a valid drug checking tool, however, rapid immunoassays and other drug checking instruments that can detect a wider range of fentanyl analogs including carfentanil need to be prioritized to minimize accidental exposure to the full spectrum of fentanyls.

Trends in characteristics of fentanyl-related poisonings in the United States, 2015-2021

Background: Fentanyl-related deaths continue to increase in the United States; however, most national studies focus on fatal overdose. More research, including data on nonfatal overdose, is needed.Objective: We examined trends in characteristics of fatal and nonfatal fentanyl-related poisonings ("exposures") in the US.Methods: National Poison Control data were examined to estimate trends in characteristics of reported exposures between 2015 and 2021 (N = 15,391; 38.7% female). We also delineated correlates of experiencing a major adverse effect or death.Results: The proportion of exposures increased among all age groups between ages 13 and 39 (ps < .05) with the largest increase among those age 13-19 (a 127.8% increase). With respect to reasons for use, the proportion of cases involving fentanyl "abuse" increased by 63.8% (p < .001). The proportion involving fentanyl inhalation increased 427.6% from 5.7% to 29.9% and injection increased from 6.7% to 9.6%, a 42.3% increase (ps < .01). The proportion also increased for co-use of methamphetamine (by 669.0%), cocaine (by 374.0%), and heroin (by 159.5%). The proportion of major adverse effects increased from 15.5% to 39.6% (p < .001). In the multivariable model, "abuse", suspected suicide attempts, and use via inhalation were risk factors for experiencing a major effect or death, and misuse, ingestion, dermal use, and co-use of methamphetamine were associated with lower risk.Conclusion: Poison Control data suggest that characteristics of individuals exposed to fentanyl continue to shift, with use via inhalation increasing and medical outcomes of nonfatal poisonings becoming more severe. These results complement mortality data and inform prevention and harm reduction efforts.

Trends in seizures of powders and pills containing illicit fentanyl in the United States, 2018 through 2021

BACKGROUND

Prevalence of fentanyl-laced counterfeit prescription pills has been increasing in the US, possibly placing a wider population at risk for unintentional exposure. We aimed to determine whether there have been shifts in the number of fentanyl seizures and in the form of fentanyl seized in the US.

METHODS

We examined quarterly national seizure data from High Intensity Drug Trafficking Areas to determine the number of drug seizures in the US containing fentanyl from January 2018 through December 2021. Generalized additive models were used to estimate trends in the number and weight of pill and powder seizures containing fentanyl.

RESULTS

There was an increase both in the number of fentanyl-containing powder seizures (from 424 in 2018 Quarter 1 [Q1] to 1539 in 2021 Quarter 4 [Q4], β = 0.94, p < 0.001) and in the number of pill seizures (from 68 to 635, β = 0.96, p < 0.01). The proportion of pills to total seizures more than doubled from 13.8% in 2018 Q1 to 29.2% in 2021 Q4 (β = 0.92, p < 0.001). Weight of powder fentanyl seizures increased from 298.2 kg in 2018 Q1 to 2416.0 kg in 2021 Q4 (β = 1.12, p = 0.01); the number of pills seized increased from 42,202 in 2018 Q1 to 2,089,186 in 2021 Q4 (β = 0.90, p < 0.001).

CONCLUSIONS

Seizures of drugs containing fentanyl have been increasing in the US. Given that over a quarter of fentanyl seizures are now in pill form, people who obtain counterfeit pills such as those disguised as oxycodone or alprazolam are at risk for unintentional exposure to fentanyl.

New Psychoactive Substances Consumption in Opioid-Use Disorder Patients

Simple Summary

We applied a toxicological screening on 187 urine samples collected from patients with opioid-use disorder treated with opioid agonists in Barcelona and Badalona addiction care services, Spain. We found that 27.3% of urine samples were positive for any type of new psychoactive substance and 8.6% of samples were positive for a new synthetic opioid (NSO). These results show a new trend of consumption in patients with opioid-use disorder that requires social and political actions to stem associated health threats.

Abstract

(1) Background: Since the beginning of the 21st century, the large number and wide chemical variety of new psychoactive substances (NPS) that enter the market every year has become a public health problem. Given the rapidity with which the drug market is changing, many NPS are not clinically investigated and their effects and health risks are unknown. Drug testing is a very useful tool for this purpose, but, unfortunately, it is not very widespread in individuals with opioid-use disorder under detoxification treatment. The aim of this study is to investigate the use of illicit drugs and NPS in opioid-use disorder (OUD) patients on opioid agonist treatment. (2) Methods: A multicenter, descriptive, cross-sectional study was conducted at two addiction care services in Barcelona and Badalona, Spain. Urine samples were collected from OUD individuals attending these two centers, who anonymously donated a urine sample at the time of a periodical visit. Samples were analyzed by high-sensitivity gas chromatography-mass spectrometry (GC-MS) and ultra-high-performance liquid chromatography-high –resolution mass spectrometry (UHPLC-HRMS). (3) Results: Out of the 187 collected and analyzed urine samples, 27.3% were positive for any type of NPS and 8.6% were positive for new synthetic opioids, including fentanyl and its derivatives (NSO). Other frequently detected substances were benzodiazepines in 46.0% of samples, antipsychotics in 27.8% of samples, or cocaine and cannabis in 23.5% of samples. (4) Conclusion: A wide number of NPS, including NSO, have been detected in urine samples from an OUD population. A lack of NPS detection in standard drug screening among drug users can hide the identification of a potential public health problem.

Portable gas chromatography-mass spectrometry in drug checking: Detection of carfentanil and etizolam in expected opioid samples

BACKGROUND

There has been a recent increase in adulteration of opioids with low concentration actives such as fentanyl analogues and benzodiazepines. As drug checking projects using vibrational spectroscopy continue to seek confirmatory lab-based testing, the concern and reality of missing these potentially harmful substances in point-of-care testing is prevalent.

METHODS

A portable GC-MS was used to analyze select opioid samples acquired at a drug checking service in Victoria, Canada (n=59). Certified reference standards of several fentanyl analogues and benzodiazepines were measured to guide targeted analysis of these samples. Results were compared with those obtained using a lab-based paper spray mass spectrometer.

RESULTS

Portable GC-MS was able to identify 62% of samples containing carfentanil and 36% of samples containing etizolam. In the case of etizolam, the success rate was higher for more potent samples: 78% of etizolam-containing samples were identified when the etizolam concentration was above 3% by weight. In comparison, infrared spectroscopy was able to detect etizolam in only 9% of the etizolam-containing samples, and is not sensitive enough to detect carfentanil at relevant concentrations.

CONCLUSIONS

Portable GC-MS has potential in identifying low concentration substances in a point-of-care setting, without relying on subsequent off-site confirmatory testing.

Safer Tripping: Serotonergic Psychedelics and Drug Checking. Submission and Detection Rates, Potential Harms, and Challenges for Drug Analysis

Purpose of Review

With the continuous emergence of new psychoactive substances, drug checking (DC) services are challenged by an increasingly complex drug market. Considering the resumed scientific and public interest in serotonergic psychedelics (SPs) like LSD, psilocybin, and 2C-B, we present the results of a literature search investigating the presence and proportion of SPs in DC samples.

Recent Findings

In 15 identified reports, submission and detection rates of SPs were comparably low, but increasing. Samples contained considerable amounts of adulterations or analogues, mostly novel SPs with unknown toxicological profiles and in some cases potentially life-threatening effects. The detection of SPs, however, requires advanced analysis techniques currently not available to most DC services.

Summary

Given the substantial proportion of novel SPs in DC samples and the associated risks, DC can be a valuable harm reduction and monitoring tool for SPs if analysis techniques with high sensitivity are employed.

The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis

PURPOSE OF REVIEW

This review provides an update on recently published literature on the rise of illicit fentanyls, risks for overdose, combinations with other substances, e.g. stimulants, consequences, and treatment.

RECENT FINDINGS

Overdose due to illicit synthetic opioids (e.g. fentanyl and fentanyl analogs) continues to rise in the US both preceding and during the COVID-19 pandemic. Fentanyl-related overdose is rising in new geographic areas e.g. the western USA. Stimulant-related overdose is also increasing nationwide driven by methamphetamine and cocaine. Polysubstance use, e.g. the use of a stimulant along with an opioid is driving stimulant-related overdose. Other medical consequences of injection drug use are rising including HIV and hepatitis C infections. Medication approaches to treating opioid use disorder remain the standard of care and there are new promising pharmacological approaches to treating methamphetamine use disorder.

SUMMARY

A 'fourth wave' of high mortality involving methamphetamine and cocaine use has been gathering force in the USA. Availability and use of illicit fentanyls are still the major drivers of overdose deaths and the current rise in stimulant-related deaths appears entwined with the ongoing opioid epidemic.

Drug checking at dance festivals: A review with recommendations to increase generalizability of findings

Dance festival attendees are at high risk for consuming adulterated drugs. In recent years, drug checking studies have been conducted at various dance festivals to provide valuable harm reduction information to attendees regarding drug content. We conducted a review of the literature to determine the generalizability of findings to the target population of interest-festival attendees at risk for using adulterated drugs. Six published studies involving drug checking at festivals were reviewed. All relied on self-selected samples and male attendees were overrepresented based on previous research. Test methods, drugs tested, definitions of adulteration, and prevalence of adulteration varied across studies. Prevalence of detection of adulterants ranged from 11% to 55%. While the drug checking services described appear to have been beneficial for participants, results have limited generalizability to the target population. We recommend that researchers expand beyond the self-selection model in future studies and utilize recruitment methods that involve random sampling techniques such as systematic random sampling, stratified random sampling, or time-space sampling within festivals. We also recommend that individuals approached are surveyed for demographic characteristics, planned drug use at the festival, and willingness to test their drugs. These methods would help determine how representative the sample is compared to the target population and allow for more generalizable estimates. In conclusion, as these valuable harm reduction services expand, it may be possible to reach a wider portion of the population at risk and to obtain more generalizable estimates of engagement, adulteration, and reactions to learning one possesses adulterated drugs. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Implementing an integrated multi-technology platform for drug checking: Social, scientific, and technological considerations

The illicit drug overdose crisis in North America continues to devastate communities with fentanyl detected in the majority of illicit drug overdose deaths. The COVID-19 pandemic has heightened concerns of even greater unpredictability in the drug supplies and unprecedented rates of overdoses. Portable drug-checking technologies are increasingly being integrated within overdose prevention strategies. These emerging responses are raising new questions about which technologies to pursue and what service models can respond to the current risks and contexts. In what has been referred to as the epicenter of the overdose crisis in Canada, a multi-technology platform for drug checking is being piloted in community settings using a suite of chemical analytical methods to provide real-time harm reduction. These include infrared absorption, Raman scattering, gas chromatography with mass spectrometry, and antibody-based test strips. In this Perspective, we illustrate some advantages and challenges of using multiple techniques for the analysis of the same sample, and provide an example of a data analysis and visualization platform that can unify the presentation of the results and enable deeper analysis of the results. We also highlight the implementation of a various service models that co-exist in a research setting, with particular emphasis on the way that drug checking technicians and harm reduction workers interact with service users. Finally, we provide a description of the challenges associated with data interpretation and the communication of results to a diverse audience.

Fentanyl and fentanyl analogs in the illicit stimulant supply: Results from U.S. drug seizure data, 2011-2016

BACKGROUND

U.S. research examining the illicit drug supply remains rare even though the information could help reduce overdoses. Relatively little is known regarding how often opioids are found in stimulants and whether temporal and geographic trends exist. We examined trends in fentanyl-cocaine and fentanyl-methamphetamine combinations in the national illicit drug supply.

METHODS

We analysed serial cross-sectional data from the National Forensic Laboratory Information System (NFLIS) collected between January 2011 and December 2016. We restricted the analysis to cocaine (N = 1,389,968) and methamphetamine (n = 1,407,474) samples and calculated proportions containing fentanyl (including 23 related analogs) over time.

RESULTS

The combined presence of fentanyl and cocaine steadily increased nationally between 2012-2016 (p = 0.01), and the number of such samples tripled from 2015 to 2016 (n = 423 to n = 1,325). Similarly, the combined presence of fentanyl and methamphetamine increased 179 % from 2015 to 2016 (n = 82-n = 272). Patterns varied widely by state; in 2016, fentanyl-cocaine samples were most common in New Hampshire (7.2 %), Connecticut (5.4 %), Ohio (2.6 %) and Massachusetts (2.1 %), whereas fentanyl-methamphetamine samples were most often in New Hampshire (6.1 %), Massachusetts (5.6 %), Vermont (2.4 %) and Maine (1.2 %).

CONCLUSIONS

Although relatively uncommon, the presence of fentanyl in the stimulant supply increased significantly between 2011 and 2016, with the greatest increases occuring between 2015-2016; the presence of these products was concentrated in the U.S. Northeast. Given these trends, strengthening community-based drug checking programs and surveillance within the public health infrastructure could help promote timely responses to novel threats posed by rapid shifts in the drug supply that may lead to inadvertent exposures.

Situating the Continuum of Overdose Risk in the Social Determinants of Health: A New Conceptual Framework

Policy Points This article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots. In order to successfully reduce drug-related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies.

CONTEXT

Drug overdose is the leading cause of injury-related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction.

METHODS

In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The "continuum of overdose risk" framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally.

FINDINGS

De-escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction.

CONCLUSIONS

Without recognizing the full drug-use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve.

Shifts in Unintentional Exposure to Drugs Among People Who Use Ecstasy in the Electronic Dance Music Scene, 2016-2019

BACKGROUND AND OBJECTIVES

Electronic dance music (EDM) party attendees who use ecstasy (3,4-methylenedioxymethamphetamine [MDMA], Molly) are at high risk for ingesting adulterant drugs, but little is known regarding trends in exposure. We sought to determine whether adulteration has shifted in recent years.

METHODS

Adults entering EDM events at nightclubs and dance festivals in NYC were surveyed in 2016 and 2019. We tested hair samples from a subsample of those reporting past-year ecstasy use using ultra-high performance liquid chromatography-tandem mass spectrometry. Differences in unreported drug exposure and suspected adulteration were compared between 2016 (n = 90) and 2019 (n = 72).

RESULTS

MDMA detection was stable at 72-74%. We detected decreases in unreported use of methamphetamine (from 22.2% to 5.6% [P = .003], an 74.8% decrease), new psychoactive substances (from 31.1% to 2.8% [P < .001], a 91.0% decrease), and synthetic cathinones in particular (from 27.8% to 2.8% (P < .001, an 89.9% decrease). Unreported ketamine exposure increased from 18.9% to 34.7% (P = .022, an 83.6% increase). We also detected decreases in participants' suspicion of their ecstasy being adulterated with methamphetamine (from 20.0% to 5.6% [P = .010], an 72.0% decrease) and "bath salts" (synthetic cathinones, from 8.9% to 1.4% [P = .044], an 84.3% decrease).

DISCUSSION AND CONCLUSIONS

Unknown exposure to adulterants among people who use ecstasy in the EDM scene is shifting. Monitoring of exposure to adulterants is needed to inform harm reduction.

SCIENTIFIC SIGNIFICANCE

This was among the first studies to examine unintentional exposure to drugs over time in this population and unintentional exposure to synthetic cathinones in particular appears to be declining. (Am J Addict 2021;30:49-54).