The potential impacts of community drug checking within the overdose crisis: qualitative study exploring the perspective of prospective service users

The emergence of fentanyl in a stimulant landscape: Un/intentional use, social relations, and developing communities of care

BACKGROUND

The introduction of fentanyl into the unregulated drug supply has drastically altered drug landscapes across the United States and increasingly contributed to overdose. As part of a larger study about opioid overdose, we assessed how the emergence of fentanyl has shaped health outcomes and social relations in an underserved region of California.

METHODS

From 2022-2024, we engaged in ethnographic fieldwork, surveys, and qualitative interviews with people 18+ years old and reporting opioid or stimulant use in the prior three months. We generated descriptive statistics and examined un/intentional fentanyl use among people using opioids (regardless of stimulant use) compared to those exclusively using stimulants. Qualitative interviews were thematically coded to lend insight into the social contexts of fentanyl use.

RESULTS

Of 195 survey participants, 31 % were women, and 60 % identified as racialized groups, with an average age of 43; the qualitative sub-sample (n = 53 interviews) was similar. People using opioids were often initially unintentionally exposed to fentanyl through the heroin supply or prescription pills, but shifted to intentional use. People using stimulants attributed unintentional fentanyl use to adulterated methamphetamine, mistaking fentanyl for other drugs, and sharing smoking tools. Socially, fentanyl heightened overdose risk and fueled community stigma, while paradoxically instantiating forms of community care (i.e., overdose response, warning those experimenting with fentanyl).

CONCLUSION

Our research calls for evidence-based education about fentanyl, expanded access to harm reduction services, including community drug checking and safer smoking supplies, and low-barrier drug treatment as part of broader efforts to promote community care.

Not just fentanyl: Understanding the complexities of the unregulated opioid supply through results from a drug checking service in British Columbia, Canada

INTRODUCTION

This study examines illicit opioid samples submitted to a drug checking service in British Columbia, Canada. By employing a method capable of identifying and quantifying compounds at low concentrations, the analysis focused on identifying trends in notable compounds such as fentanyl, its analogues, and benzodiazepines. The findings aim to address gaps in supply monitoring and inform public health and drug policies.

METHODS

Opioid samples were collected and analyzed over three years using fentanyl and benzodiazepine test strips, Fourier-transform infrared (FTIR) spectroscopy and Paper-Spray Mass Spectrometry (PS-MS). PS-MS was employed to conduct trace-level analysis, provide targeted composition results, and quantify notable ingredients within the samples. The concentrations of fentanyl and benzodiazepines, among other components, were examined.

RESULTS

The dataset includes 8122 opioid samples analyzed from January 2021 to December 2023. Analysis revealed that heroin was replaced by fentanyl and its analogues in the opioid supply, as heroin was detected in only 4 % of opioid samples while fentanyl and analogues were detected in 88 %. Fluorofentanyl was found in 70 % of opioid samples, occasionally in combination with fentanyl. Benzodiazepines and their analogues were detected in 49 % of opioid samples, with a notable shift from etizolam to bromazolam. The median fentanyl concentration was 10.6 % (weight/weight), ranging from less than 0.1 % to over 80 %. The median bromazolam concentration was 3.2 %, with a range of less than 0.1 % to over 25 %.

CONCLUSION

The study highlights the volatility in the supply and mentions the necessity for a safer opioid supply and robust drug checking methodologies to address the challenges posed by the heterogenous market.

Opioid Education and Naloxone Distribution by Occupation: A Scoping Review

BACKGROUND

In the U.S., opioid-involved overdose deaths rose dramatically from 21,089 in 2010 to 108,000 in 2022. Opioid use and overdoses are increasingly occurring outside clinical settings, necessitating the need for workplace-based interventions. Various industries, including hospitality and service, have reported increased naloxone training to combat workplace overdoses. This study explores the literature on Opioid Education and Naloxone Distribution (OEND) training by occupation and identifies areas for future intervention through an occupational health lens.

METHODS

This scoping review followed the PRISMA-ScR guidelines and utilized Arksey and O'Malley's five-step framework. A comprehensive literature search was conducted across multiple databases, covering publications from January 1, 2011, to December 31, 2023. Studies were included if they reported on the occupational demographics of OEND program participants and the impact of these programs on knowledge, attitudes, and overdose response.

RESULTS

Seventy-five studies met the inclusion criteria. Most OEND training targeted healthcare providers (71%) and first responders (24%). Other occupational groups, such as service industry workers, construction workers, and librarians, were underrepresented. The review highlighted the need for tailored OEND training in these sectors, emphasizing pragmatic implementation measures.

CONCLUSIONS

Increased access to naloxone and comprehensive OEND training are crucial for reducing opioid-related overdose mortality, particularly in non-traditional occupational groups.

APPLICATION TO PRACTICE

Occupational health nurses should prioritize expanding OEND programs to underrepresented occupational groups. Tailored training and harm reduction strategies should be incorporated to address the unique needs of these workers and enhance the effectiveness of overdose response interventions in various workplace settings.

Welfare first: transforming harm reduction at UK festivals

BACKGROUND

A welfare-first approach to harm reduction at UK festivals is emerging as a critical strategy for enhancing festival safety. In particular, the implementation of anonymous, non-punitive drug-checking services is posited as essential for reducing drug-related harm by enabling informed decision-making. This empirical study examines the limitations of punitive drug policies and the associated risks to public health and explores the potential benefits of decriminalisation in fostering safer festival environments.

METHODS

The study employed qualitative methodologies, including semi-structured interviews and questionnaires with festival attendees at three major UK festivals. This empirical data was supplemented by a review of recent studies (Ivers et al. in Ir J Med Sci 191(4):1701-1710, 2022. https://doi.org/10.1007/s11845-021-02765-2 ; Palmer Maynard in Harm Reduc J 19(1):81, 2022. https://doi.org/10.1186/s12954-022-00662-0 ; Cooney and Measham. in Drug Sci Policy Law 9, 2023. https://doi.org/10.1177/20503245231211444 ) and relevant policy documents, in order to evaluate current harm reduction practices and identify key barriers, such as stigma, social control, and criminalisation.

RESULTS

Analysis revealed that integrated harm reduction measures, comprising drug-checking services, welfare support, and early intervention initiatives, significantly enhance safety by empowering individuals with timely, accurate substance information. A majority of participants expressed a clear preference for drug-checking services, underscoring their willingness to engage when these services are provided in a supportive, non-punitive environment. However, persistent challenges related to punitive drug policies and gaps in public education about harm reduction continue to impede optimal service delivery. Evidence further suggests that a shift towards decriminalisation and welfare-based approaches could mitigate these risks and foster more trusting engagement with harm reduction initiatives.

CONCLUSIONS

The findings indicate that prioritising welfare-first harm reduction strategies, particularly the implementation of anonymous drug-checking services, can create safer festival environments and inform broader public health policies. The study underscores the need for policy reforms that move away from punitive approaches, suggesting that festival-based interventions can serve as scalable models for reducing drug-related harm across diverse community settings.

Is fentanyl in everything? Examining the unexpected occurrence of illicit opioids in British Columbia's drug supply

BACKGROUND

Illicit opioids, including fentanyl, are linked to unprecedented levels of overdose in Canada and elsewhere. The risks associated with illicit opioids can include high potency, unpredictable concentration and the unexpected presence in other drugs. Within this context, we examine drug checking data to better understand the presence of illicit opioids such as fentanyl in other drugs and possible ways to interpret these results.

METHODS

Three years (2021-2023) of data (18,474 samples) from Substance Drug Checking in British Columbia, Canada were examined to investigate the risks associated with the detection of opioids in other drugs such as cocaine and methamphetamine, as well as in other drug categories. Samples were tested by paper spray mass spectrometry (PS-MS), fentanyl test strips and Fourier-Transform infrared spectroscopy (FTIR). We examine the 8889 samples not expected to include fentanyl to confirm; if the expected drug was detected, if unexpected opioids were detected, and when the unexpected opioids are in trace concentration.

RESULTS

Unexpected opioids were rarely detected (2%) in other drugs (189 of 8889 samples) with most (61.4%) detected at trace concentration levels. Unexpected opioids are far more likely to be found in samples that did not contain the expected drug than in samples that were confirmed to contain the expected drug. The least common scenario (below 1%) were substances that included the expected drug plus unexpected opioid above trace concentration. These findings raise questions on how to interpret and communicate the detection of fentanyl and related opioids in other drugs. We present three potential interpretations: (1) mistaken and misrepresented samples where the expected drug was never detected, (2) cross contamination when opioids were at trace concentration levels, or (3) adulteration as the least frequent scenario where opioids were detected above trace concentrations in combination with the expected drug.

CONCLUSIONS

In a region where fentanyl is associated with extreme rates of overdose, it remains rare to find such opioids in other drugs. However, the risk of fentanyl in other drugs remains an ongoing threat that warrants responses by individuals and public health. We provide possible interpretations to inform such responses. Our data raises questions on how to interpret and communicate the detection of fentanyl and other opioids in other drugs.

The prevalence of fentanyl in New York City's unregulated drug supply as measured through drug checking offered at syringe service programs

BACKGROUND

Drug checking is a harm reduction strategy that provides people who use drugs (PWUD) information about the composition of a substance. Drug checking has been identified as a key public health response to the continually evolving overdose crisis.

METHODS

The New York City Health Department of Health and Mental Hygiene (DOHMH) partnered with existing syringe programs to launch a drug-checking pilot study. The study offered multiple point-of-care drug-checking technologies including fentanyl test strips (FTS) and Fourier-transformed infrared (FTIR) spectrometry, as well as secondary laboratory testing. Fentanyl positivity in major drug types was assessed for each drug-checking technology.

RESULTS

Between November 2021 and December 2023, a total of N = 397 unique participants and drop-off samples contributed a total of N = 1644 samples for drug checking. The majority of samples were sold as opioids (n = 908), with fewer sold as cocaine (n = 314) and methamphetamine (n = 62). 95.3 % (852/894) of opioid samples produced positive FTS. FTIR and secondary laboratory testing resulted in a similarly high prevalence of fentanyl in opioid samples at 84.7 % (769/908) and 89.3 % (519/581), respectively. We did not observe the unexplained presence of fentanyl in samples sold as cocaine or methamphetamine. Further, we describe instances where discussions between technicians and PWUD provided important context that explained the presence of fentanyl in non-opioid samples.

CONCLUSION

The majority of opioid samples submitted to DOHMH's drug-checking pilot study contained fentanyl. Comparatively, there was little evidence suggesting fentanyl in samples sold as cocaine and methamphetamine. The drug-checking pilot study's point-of-care service delivery model was effective in providing information to PWUD.

Strategies used to reduce harms associated with fentanyl exposure among rural people who use drugs: multi-site qualitative findings from the rural opioid initiative

AIM

Illicitly manufactured fentanyl and its analogs are the primary drivers of opioid overdose deaths in the United States (U.S.). People who use drugs may be exposed to fentanyl or its analogs intentionally or unintentionally. This study sought to identify strategies used by rural people who use drugs to reduce harms associated with unintentional fentanyl exposure.

METHODS

This analysis focused on 349 semi-structured qualitative interviews across 10 states and 58 rural counties in the U.S conducted between 2018 and 2020. Interview guides were collaboratively standardized across sites and included questions about drug use history (including drugs currently used, frequency of use, mode of administration) and questions specific to fentanyl. Deductive coding was used to code all data, then inductive coding of overdose and fentanyl codes was conducted by an interdisciplinary writing team.

RESULTS

Participants described being concerned that fentanyl had saturated the drug market, in both stimulant and opioid supplies. Participants utilized strategies including: (1) avoiding drugs that were perceived to contain fentanyl, (2) buying drugs from trusted sources, (3) using fentanyl test strips, 4) using small doses and non-injection routes, (5) using with other people, (6) tasting, smelling, and looking at drugs before use, and (7) carrying and using naloxone. Most people who used drugs used a combination of these strategies as there was an overwhelming fear of fatal overdose.

CONCLUSION

People who use drugs living in rural areas of the U.S. are aware that fentanyl is in their drug supply and use several strategies to prevent associated harms, including fatal overdose. Increasing access to harm reduction tools (e.g., fentanyl test strips, naloxone) and services (e.g., community drug checking, syringe services programs, overdose prevention centers) should be prioritized to address the polysubstance-involved overdose crisis. These efforts should target persons who use opioids and other drugs that may contain fentanyl.

Mobile addiction treatment and harm reduction services as tools to address health inequities: a community case study of the Brockton Neighborhood Health Center mobile unit

Opioid overdose deaths continue to increase in the US. Recent data show disproportionately high and increasing overdose death rates among Black, Latine, and Indigenous individuals, and people experiencing homelessness. Medications for opioid use disorder (MOUD) can be lifesaving; however, only a fraction of eligible individuals receive them. Our goal was to describe our experience promoting equitable MOUD access using a mobile delivery model. We implemented a mobile MOUD unit aiming to improve equitable access in Brockton, a racially diverse, medium-sized city in Massachusetts. Brockton has a relatively high opioid overdose death rate with increasingly disproportionate death rates among Black residents. Brockton Neighborhood Health Center (BNHC), a community health center, provides brick-and-mortar MOUD access. Through the Communities That HEAL intervention as part of the HEALing Communities Study (HCS), Brockton convened a community coalition with the aim of selecting evidence-based practices to decrease overdose deaths. BNHC leadership and coalition members recognized that traditional brick-and-mortar treatment locations were inaccessible to marginalized populations, and that a mobile program could increase MOUD access. In September 2021, with support from the HCS coalition, BNHC launched its mobile initiative - Community Care-in-Reach® - to bring low-threshold buprenorphine, harm reduction, and preventive care to high-risk populations. During implementation, the team encountered several challenges including: securing local buy-in; navigating a complex licensure process; maintaining operations throughout the COVID-19 pandemic; and finally, planning for sustainability. In two years of operation, the mobile team cared for 297 unique patients during 1,286 total visits. More than one-third (36%) of patients received buprenorphine prescriptions. In contrast to BNHC's brick-and-mortar clinics, patients with OUD seen on the mobile unit were more representative of historically marginalized racial and ethnic groups, and people experiencing homelessness, evidencing improved, equitable addiction care access for these historically disadvantaged populations. Offering varied services on the mobile unit, such as wound care, syringe and safer smoking supplies, naloxone, and other basic medical care, was a key engagement strategy. This on-demand mobile model helped redress systemic disadvantages in access to addiction treatment and harm reduction services, reaching diverse individuals to offer lifesaving MOUD at a time of inequitable increases in overdose deaths.

How do we understand the value of drug checking as a component of harm reduction services? A qualitative exploration of client and provider perspectives

BACKGROUND

Mortality related to opioid overdose in the U.S. has risen sharply in the past decade. In California, opioid overdose death rates more than tripled from 2018 to 2021, and deaths from synthetic opioids such as fentanyl increased more than seven times in those three years alone. Heightened attention to this crisis has attracted funding and programming opportunities for prevention and harm reduction interventions. Drug checking services offer people who use drugs the opportunity to test the chemical content of their own supply, but are not widely used in North America. We report on qualitative data from providers and clients of harm reduction and drug checking services, to explore how these services are used, experienced, and considered.

METHODS

We conducted in-depth semi-structured key informant interviews across two samples of drug checking stakeholders: "clients" (individuals who use drugs and receive harm reduction services) and "providers" (subject matter experts and those providing clinical and harm reduction services to people who use drugs). Provider interviews were conducted via Zoom from June-November, 2022. Client interviews were conducted in person in San Francisco over a one-week period in November 2022. Data were analyzed following the tenets of thematic analysis.

RESULTS

We found that the value of drug checking includes but extends well beyond overdose prevention. Participants discussed ways that drug checking can fill a regulatory vacuum, serve as a tool of informal market regulation at the community level, and empower public health surveillance systems and clinical response. We present our findings within three key themes: (1) the role of drug checking in overdose prevention; (2) benefits to the overall agency, health, and wellbeing of people who use drugs; and (3) impacts of drug checking services at the community and systems levels.

CONCLUSION

This study contributes to growing evidence of the effectiveness of drug checking services in mitigating risks associated with substance use, including overdose, through enabling people who use and sell drugs to test their own supply. It further contributes to discussions around the utility of drug checking and harm reduction, in order to inform legislation and funding allocation.

Beyond a spec: assessing heterogeneity in the unregulated opioid supply

BACKGROUND

Drug checking services aim to provide compositional information for the illicit drug supply and are being employed in public health responses to extreme rates of overdose associated with fentanyl within street opioids. The technologies used within these services range from basic qualitative tests, such as immunoassay test strips, to comprehensive quantitative analyses, such as mass spectrometry. In general, there is concern that heterogeneity of a drug mixture adds significant uncertainty when using drug checking results based on a small subsamples. The presence of hot spots of active drug components in this context is often termed the 'chocolate chip cookie effect'. Establishing the limitations of the service are essential for interpretation of the results.

METHODS

This study assesses the consequence of drug heterogeneity and sampling of consumer level opioid purchased in Victoria, British Columbia ( n = 21 , 50-100 mg each) on quantitative fentanyl results determined from testing with paper spray mass spectrometry.

RESULTS

Using descriptive statistics, such as relative standard deviation and interquartile range, the results demonstrate varied distributions of fentanyl concentrations within a single drug batch. However, the presence of hot spots, defined as outliers, were relatively rare.

CONCLUSIONS

This study found that the variability in fentanyl concentration from drug heterogeneity and sampling is greater than that attributed to the analytical technique. On a practical level, this provides data to help guide communication of limitations of drug checking services, supporting the aim of trust and transparency between services and people who use drugs. However, if drug checking services continue to be restricted from fully engaging with the reality of manufacturing, buying, selling, mixing and dosing practices, the accuracy, usefulness, and impact will always be limited.

Recommendations from people who use drugs in Philadelphia, PA about structuring point-of-care drug checking

BACKGROUND

Adulterants, such as fentanyl and xylazine, among others, are present in a high percentage of the illicit drug supply, increasing the risk for overdose and other adverse health events among people who use drugs (PWUD). Point-of-care drug checking identifies components of a drug sample and delivers results consumers. To successfully meet the diverse needs of PWUD, more information is needed about the utility of drug checking, motivations for using services contextualized in broader comments on the drug supply, hypothesized actions to be taken after receiving drug checking results, and the ideal structure of a program.

METHODS

In December 2021, semi-structured interviews were conducted with 40 PWUD who were accessing harm reduction services in Philadelphia, PA. Participants were asked about opinions and preferences for a future drug checking program. Interviews were audio recorded, transcribed and coded using content analysis to identify themes.

RESULTS

Participants were primarily White (52.5%) and male (60%). Heroin/fentanyl was the most frequently reported drug used (72.5%, n = 29), followed by crack cocaine (60.0%, n = 24) and powder cocaine (47.5%, n = 19). Emerging themes from potential drug checking consumers included universal interest in using a drug checking program, intentions to change drug use actions based on drug checking results, deep concern about the unpredictability of the drug supply, engaging in multiple harm reduction practices, and concerns about privacy while accessing a service.

CONCLUSIONS

We offer recommendations for sites considering point-of-care drug checking regarding staffing, safety, logistics, and cultural competency. Programs should leverage pre-existing relationships with organizations serving PWUD and hire people with lived experiences of drug use. They should work with local or state government to issue protections to people accessing drug checking programs and ensure the service is anonymous and that data collection is minimized to keep the program low-threshold. Programs will ideally operate in multiple locations and span "atmosphere" (e.g., from clinical to a drop-in culture), offer in-depth education to participants about results, engage with a community advisory board, and not partner with law enforcement.

Planning and implementing community-based drug checking services in Scotland: a qualitative exploration using the consolidated framework for implementation research

BACKGROUND

Drug checking services (DCS) provide harm reduction support and advice to individuals based on chemical analysis of submitted substances of concern. Whilst there are currently no DCS in Scotland, community-based services are being planned in three cities.

METHODS

In this paper, we report qualitative findings based on interviews with 43 participants, focused on perceptions of DCS and their implementation. Participants were relevant professionals, those with experience of drug use, and family members of those with experience of drug use. The Consolidated Framework for Implementation Research (CFIR) was used to inform data collection and analysis. We report findings under nine constructs/themes across the five CFIR domains.

RESULTS

Participants noted the importance of DCS being implemented in low-threshold, trusted services with a harm reduction ethos, and outlined a range of further service design considerations such as speed of testing, and information provided through the analysis process. In relation to the 'inner setting', a key finding related to the potential value of leveraging existing resources in order to expand both reach and effectiveness of drug trend communication. The approach of local and national police to DCS, and the attitudes of the public and local community, were described as important external factors which could influence the success (or otherwise) of implementation. Bringing together a range of stakeholders in dialogue and developing tailored communication strategies were seen as ways to build support for DCS. Overall, we found high levels of support and perceived need for DCS amongst all stakeholder groups.

CONCLUSIONS

Our findings present initial implementation considerations for Scotland which could be further explored as DCS are operationalised. Further, our focus on implementation contexts is relevant to research on DCS more generally, given the minimal consideration of such issues in the literature.

Harm reduction in undergraduate and graduate medical education: a systematic scoping review

BACKGROUND

Substance use increasingly contributes to early morbidity and mortality, which necessitates greater preparation of the healthcare workforce to mitigate its harm. The purpose of this systematic scoping review is to: 1) review published curricula on harm reduction for substance use implemented by undergraduate (UME) and graduate medical education (GME) in the United States and Canada, 2) develop a framework to describe a comprehensive approach to harm reduction medical education, and 3) propose additional content topics for future consideration.

METHODS

PubMed, Scopus, ERIC: Education Resources Information Center (Ovid), and MedEdPORTAL were searched. Studies included any English language curricula about harm reduction within UME or GME in the United States or Canada from 1993 until Nov 22, 2021. Two authors independently reviewed and screened records for data extraction. Data were analyzed on trainee population, curricula objectives, format, content, and evaluation.

RESULTS

Twenty-three articles describing 19 distinct educational programs across the United States were included in the final sample, most of which created their own curricula (n = 17). Data on educational content were categorized by content and approach. Most programs (85%) focused on introductory substance use knowledge and skills without an understanding of harm reduction principles. Based on our synthesis of the educational content in these curricula, we iteratively developed a Harm Reduction Educational Spectrum (HRES) framework to describe curricula and identified 17 discrete content topics grouped into 6 themes based on their reliance on harm reduction principles.

CONCLUSIONS

Harm reduction is under-represented in published medical curricula. Because the drug supply market changes rapidly, the content of medical curricula may be quickly outmoded thus curricula that include foundational knowledge of harm reduction principles may be more enduring. Students should be grounded in harm reduction principles to develop the advanced skills necessary to reduce the physical harm associated with drugs while still simultaneously recognizing the possibility of patients' ongoing substance use. We present the Harm Reduction Educational Spectrum as a new framework to guide future healthcare workforce development and to ultimately provide the highest-quality care for patients who use drugs.

"It would really support the wider harm reduction agenda across the board": A qualitative study of the potential impacts of drug checking service delivery in Scotland

Drug checking services (DCS) enable individuals to voluntarily submit a small amount of a substance for analysis, providing information about the content of the substance along with tailored harm reduction support and advice. There is some evidence suggesting that DCS may lead to behaviour and system change, with impacts for people who use drugs, staff and services, and public health structures. The evidence base is still relatively nascent, however, and several evidence gaps persist. This paper reports on qualitative interviews with forty-three participants across three Scottish cities where the implementation of community-based DCS is being planned. Participants were drawn from three groups: professional participants; people with experience of drug use; and affected family members. Findings focus on perceived harm reduction impacts of DCS delivery in Scotland, with participants highlighting the potential for drug checking to impact a number of key groups including: individual service users; harm reduction services and staff; drug market monitoring structures and networks; and wider groups of people who use and sell drugs, in shaping their interactions with the drug market. Whilst continued evaluation of individual health behaviour outcomes is crucial to building the evidence base for DCS, the findings highlight the importance of extending evaluation beyond these outcomes. This would include evaluation of processes such as: information sharing across a range of parties; engagement with harm reduction and treatment services; knowledge building; and increased drug literacy. These broader dynamics may be particularly important for evaluations of community-based DCS serving individuals at higher-risk, given the complex relationship between information provision and health behaviour change which may be mediated by mental and physical health, stigma, criminalisation and the risk environment. This paper is of international relevance and adds to existing literature on the potential impact of DCS on individuals, organisations, and public health structures.

Prevalence of xylazine among people who inject drugs seeking medical care at a syringe services program clinic: Miami, Florida, 2023

Background

We aimed to report the preliminary xylazine prevalence among people who inject drugs (PWID) treated at a student-run free clinic in Miami, FL, USA and to identify characteristics associated with screening positive for xylazine.

Methods

A retrospective chart review of 59 patients presenting to a syringe services program (SSP) clinic in was conducted between April 27th and August 17th, 2023. We measured presence of xylazine with rapid visual immunoassay strips on patient urine samples.

Results

Xylazine was present in 55.9 % (33/59) of urine samples including 2 without detected opioids. Xylazine presence was significantly associated with unsheltered homelessness (p = 0.018), presence of wound(s) (p = 0.008), and testing positive for hepatitis C antibody (p = 0.014), fentanyl (p = 0.005) and MDMA (p = 0.002).

Conclusions

A high prevalence of xylazine in the Southeastern United States furthers evidence of the geographical spread of xylazine and rapidly evolving illicit drug supply. Widespread xylazine screening is urgently needed to inform people who inject drugs and to studyinterventions to minimize harms associated with xylazine.

A rapid review of current engagement strategies with people who use drugs in monitoring and reporting on substance use-related harms

BACKGROUND

The Canadian drug supply has significantly increased in toxicity over the past few years, resulting in the worsening of the overdose crisis. A key initiative implemented during this crisis has been data monitoring and reporting of substance use-related harms (SRH). This literature review aims to: (1) identify strategies used for the meaningful engagement of people who use drugs (PWUD) in local, provincial, and national SRH data system planning, reporting, and action and (2) describe data monitoring and reporting strategies and common indicators of SRH within those systems.

METHODS

We searched three academic and five gray literature databases for relevant literature published between 2012 and 2022. Team members who identify as PWUD and a librarian at Public Health Ontario developed search strings collaboratively. Two reviewers screened all search results and applied the eligibility criteria. We used Microsoft Excel for data management.

RESULTS

Twenty-two articles met our eligibility criteria (peer-reviewed n = 10 and gray literature reports n = 12); most used qualitative methods and focused on the Canadian context (n = 20). There were few examples of PWUD engaged as authors of reports on SRH monitoring. Among information systems involving PWUD, we found two main strategies: (1) community-based strategies (e.g., word of mouth, through drug sellers, and through satellite workers) and (2) public health-based data monitoring and communication strategies (e.g., communicating drug quality and alerts to PWUD). Substance use-related mortality, hospitalizations, and emergency department visits were the indicators most commonly used in systems of SRH reporting that engaged PWUD.

CONCLUSION

This review demonstrates limited engagement of PWUD and silos of activity in existing SRH data monitoring and reporting strategies. Future work is needed to better engage PWUD in these processes in an equitable manner. Building SRH monitoring systems in partnership with PWUD may increase the potential impact of these systems to reduce harms in the community.

A survey of North American drug checking services operating in 2022

BACKGROUND

Drug overdose deaths have reached record-breaking levels in North America. Drug checking services (DCS) provide localized information on the contents of drugs to individuals and communities. Depending on the design, individuals can submit drug samples for onsite "real-time" testing or offsite testing. The results can shed light on emerging drugs in the community and support ongoing prevention and surveillance efforts. We sought to describe and report aggregate outcomes of DCS operating in North America.

METHODS

The North American Drug Checking Survey was launched in 2022 to characterize and monitor DCS operating in the region. Sixteen organizations from the US (n = 9), Canada (n = 5), and Mexico (n = 2) responded to the survey. Each organization reported on their program's operations and provided service delivery outcomes (site- or program-level) in the aggregate.

RESULTS

Participating organizations reported testing a total of 49,786 drug samples between 2014 and 2022. DCS were run by community-led organizations (44%), health departments (25%), universities (19%), or clinical/private laboratories (19%). The types of samples tested differed between programs (e.g., solids vs. liquids, drug paraphernalia accepted). While most organizations tested onsite using fentanyl test strips (88%) and Fourier-transform infrared (FTIR) spectroscopy (63%), many sent samples offsite for confirmatory testing (63%), most often with mass spectrometry. Common facilitators of operating a DCS included: interest of clients (69%), interest of service providers (63%), and receiving external technical assistance (63%). Barriers included: the lack of funding (81%) or staff (50%), gaps in technical expertise (38%), as well as laws banning the possession and/or distribution of illicit drug samples, drug paraphernalia, or drug checking equipment (38%).

CONCLUSION

DCS are scaling up in North America. Given the evolving and localized nature of illicit drug supplies, supporting the establishment and operations of DCS could enhance the public's understanding of local drug supplies to reduce drug-related harms over time.

'It's not going to be a one size fits all': a qualitative exploration of the potential utility of three drug checking service models in Scotland

BACKGROUND

Scotland currently has the highest rates of drug-related deaths in Europe, so drug checking services are being explored due to their potential role in reducing these deaths and related harms. Drug checking services allow individuals to submit presumed psychoactive drug samples for analysis, and then receive individualised feedback and counselling. This paper explores participants' views on the advantages and challenges of three hypothetical service models, to inform future service delivery in Scotland.

METHODS

Semi-structured interviews were conducted with 43 people: 27 professional stakeholders, 11 people with experience of drug use, and five family members across three cities. Vignettes were used to provide short descriptions of three hypothetical service models during the interviews. Interviews were audio-recorded, transcribed and analysed using thematic analysis.

RESULTS

Participants identified advantages and challenges for each of the three potential service models. The third sector (not-for-profit) model was favoured overall by participants, and the NHS substance use treatment service was the least popular. Participants also noted that multiple drug checking sites within one city, along with outreach models would be advantageous, to meet the diverse needs of different groups of people who use drugs.

CONCLUSIONS

Drug checking services need to be tailored to local context and needs, with a range of service models being possible, in order to meet the needs of a heterogeneous group of people who use drugs. Addressing issues around stigma, accessibility, and concerns about the potential impact of accessing drug checking on access to and outcomes of drug treatment, are essential for successful service delivery.

"A lotta people switched playing hard ball to playing Russian roulette": Experiences with rising overdose incidence caused by drug supply changes during the COVID-19 pandemic in the San Diego-Tijuana border metroplex

Background

People who use drugs (PWUD) in the San Diego, USA and Tijuana, Mexico metroplex face high overdose risk related to historic methamphetamine use and relatively recent fentanyl introduction into local drug supplies. The personal overdose experiences of PWUD in this region are understudied, however, and may have been influenced by the COVID pandemic.

Methods

From September-November 2021, we conducted 28 qualitative interviews among PWUD ≥18 years old sampled from an ongoing cohort study in the San Diego-Tijuana metroplex. Interviews explored overdose experiences and changes in the drug supply. Thematic analysis of coded interview transcripts explored overdose experiences, perspectives on drug supply changes, interactions with harm reduction services, and naloxone access.

Results

Among 28 participants, 13 had experienced an overdose. Participants discussed rising levels of fentanyl in local drug supplies and increasing overdose incidents in their social networks. Participants discussed a general shift from injecting heroin to smoking fentanyl in their networks. Participants' most common concerns included having consistent access to a safe and potent drug supply and naloxone.

Conclusion

Participants prioritized adapting to drug supply changes and preventing overdose compared to other health concerns, such as HIV and COVID-19. Efforts to address overdose in this region could benefit from drug checking services and expanded, equitable delivery of naloxone.

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.

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.

Co-designing drug alerts for health and community workers for an emerging early warning system in Victoria, Australia

BACKGROUND

Alerts about changes in unregulated drug markets may be useful for supporting health and community workers to anticipate, prevent, and respond to unexpected adverse drug events. This study aimed to establish factors influencing the successful design and implementation of drug alerts for use in clinical and community service settings in Victoria, Australia.

METHODS

An iterative mixed methods design was used to co-produce drug alert prototypes with practitioners and managers working across various alcohol and other drug services and emergency medicine settings. A quantitative needs-analysis survey (n = 184) informed five qualitative co-design workshops (n = 31). Alert prototypes were drafted based on findings and tested for utility and acceptability. Applicable constructs from the Consolidated Framework for Implementation Research helped to conceptualise factors that impact successful alert system design.

RESULTS

Timely and reliable alerts about unexpected drug market changes were important to nearly all workers (98%) yet many reported insufficient access to this kind of information (64%). Workers considered themselves 'conduits' for information-sharing and valued alerts for increasing exposure to drug market intelligence; facilitating communication about potential threats and trends; and improving capacity for effective responding to drug-related harm. Alerts should be 'shareable' across a range of clinical and community settings and audiences. To maximise engagement and impact, alerts must command attention, be easily recognisable, be available on multiple platforms (electronic and printable formats) in varying levels of detail, and be disseminated via appropriate notification mechanisms to meet the needs of diverse stakeholder groups. Three drug alert prototypes (SMS prompt, summary flyer, and a detailed poster) were endorsed by workers as useful for supporting their work responding to unexpected drug-related harms.

DISCUSSION

Alerts informed by coordinated early warning networks that offer close to real-time detection of unexpected substances can provide rapid, evidence-based drug market intelligence to inform preventive and responsive action to drug-related harm. The success of alert systems requires adequate planning and resourcing to support design, implementation, and evaluation, which includes consultation with all relevant audiences to understand how to maximise engagement with information, recommendations, and advice. Our findings about factors impacting successful alert design have utility to inform the development of local early warning systems.

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.

Everywhere and for everyone: proportionate universalism as a framework for equitable access to community drug checking

BACKGROUND

Illicit drug overdoses have reached unprecedented levels, exacerbated by the COVID-19 pandemic. Responses are needed that address the increasingly potent and unpredictable drug supply with better reach to a wide population at risk for overdose. Drug checking is a potential response offered mainly within existing harm reduction services, but strategies are needed to increase reach and improve equitable delivery of drug checking services.

METHODS

The purpose of this qualitative study was to explore how to extend the reach of drug checking services to a wide population at risk of overdose. We conducted 26 in-depth interviews with potential service users to identify barriers to service use and strategies to increase equitable delivery of drug checking services. Our analysis was informed by theoretical perspectives on equity, and themes were developed relevant to equitable delivery through attention to quality dimensions of service use: accessibility, appropriateness, effectiveness, safety, and respect.

RESULTS

Barriers to equitable service delivery included criminalization and stigma, geographic and access issues, and lack of cultural appropriateness that deter service use for a broad population with diverse needs. Strategies to enhance equitable access include 1ocating services widely throughout communities, integrating drug checking within existing health care services, reframing away from risk messaging, engaging peers from a broad range of backgrounds, and using discrete methods of delivery to help create safer spaces and better reach diverse populations at risk for overdose.

CONCLUSIONS

We propose proportionate universalism in drug checking as a guiding framework for the implementation of community drug checking as an equity-oriented harm reduction intervention and as a population health response. Both a universal equity-oriented approach and multiple tailored approaches are required to facilitate drug checking services that maximize reach and appropriateness to respond to diverse needs.

Beyond co-production: The construction of drug checking knowledge in a Canadian supervised injection facility

Drug-checking is an ensemble of different harm reduction techniques providing people the ability to test illegally purchased drugs for strength, the presence of particular substances, and possible adulterants. Drug-checking research has primarily focused on nightlife and festival communities of people who use drugs and has overlooked how it functions as a knowledge forming process, particularly by people whose drug use is more stigmatized. The implementation of Fourier-Transform Infrared Spectroscopy (FTIR) in Vancouver, Canada's Downtown Eastside in response to the overdose crisis has made it possible for people who use drugs to receive information about the drugs that they are consuming. Using insights developed from the 'ontological turn' and approaches to co-production from public health and science and technology studies, we explore the multiple relations that come to produce and contest drug-checking knowledge in this setting. We look at how knowledge is produced by and for people who use drugs, including people who use drugs operating the FTIR. Using rapid ethnographic assessment and semi-structured interviews, participants were recruited from a low-barrier supervised injection facility to explore their experience of drug-checking. Data were coded in NVivo 12 using an initial coding scheme, as well as an iterative coding scheme as the data were explored. We find that the traditional demarcation between lay and expert, or peer and professional, which co-production idioms often rely on, creates barriers to seeing the different knowledge formations of drug-checking knowledge, and instead offer up a new idiom, trans-production, to explore how knowledge and harm reduction services are mutually enacted.

Substance Use Stigma and Community Drug Checking: A Qualitative Study Examining Barriers and Possible Responses

BACKGROUND

Community drug checking is an emerging response to the overdose crisis. However, stigma has been identified as a potential barrier to service use that requires investigation.

METHODS

A qualitative study explored how best to implement drug checking services to the wider population including those at risk of overdose. A secondary analysis of 26 interviews with potential service users examine how stigma may be a barrier to service use and strategies to address this. A Substance Use Stigma Framework was developed to guide analysis.

RESULTS

Drug checking is operating in a context of structural stigma produced by criminalization. People fear criminal repercussions, anticipate stigma when accessing services, and internalize stigma resulting in shame and avoidance of services. A perceived hierarchy of substance use creates stigma results in stigma between service users and avoidance of sites associated with certain drugs. Participants frequently recommended drug checking to be located in more public spaces that still maintain privacy.

CONCLUSIONS

Criminalization and societal views on substance use can deter service use. Strategies to mitigate stigma include employment of people with lived and living experience from diverse backgrounds; public yet private locations that preserve anonymity; and normalization of drug checking while decriminalization could address the root causes of stigma.

A Realist Review of How Community-Based Drug Checking Services Could Be Designed and Implemented to Promote Engagement of People Who Use Drugs

With rising numbers of drug-related deaths in the UK and globally, exploration of interventions that seek to reduce drug-related harm is essential. Drug checking services (DCS) allow people to submit drug samples for chemical analysis and receive feedback about the sample, as well as harm reduction advice. The use of DCS is often linked to festival and/or nightlife settings and to so-called 'recreational' drug use, but research has also shown the potential of community-based DCS as an intervention serving more varied demographics of people who use drugs, including more marginalised individuals and those experiencing drug dependence. Whilst there is a growing evidence base on the effectiveness of drug checking as a harm reduction intervention, there is still limited evidence of the underlying mechanisms and processes within DCS which may aid implementation and subsequent engagement of people who use drugs. This presents a challenge to understanding why engagement differs across types of DCS, and how best to develop and deliver services across different contexts and for different populations. To explore the contexts and mechanisms which impact engagement in community-based DCS, a realist review was undertaken to synthesise the international evidence for the delivery and implementation of DCS. There were 133 sources included in the review. From these sources the underlying contexts, mechanisms, and outcomes relating to DCS implementation and engagement were developed and refined into seven programme theories. The findings of this review are theoretically novel and hold practical relevance for the design of DCS, with implications for optimisation, tailoring, and implementing services to reach individuals in different settings.

Variability in the unregulated opioid market in the context of extreme rates of overdose

BACKGROUND

Drug checking uses analytical chemistry technologies to report on the composition of drugs from the unregulated market to reduce substance use-related risks, while additionally allowing for monitoring and reporting of the supply. In the context of an overdose crisis linked to fentanyl, we used drug checking data to examine variability within the illicit opioid supply.

METHODS

In this time-series analysis, data was collected from a drug checking service in Victoria, Canada from November 2020 to July 2021. Drugs reported as opioids by participants of the service (N = 454) were analyzed to determine sample composition and paper spray mass spectroscopy was used to quantify low-concentration actives. Interquartile and statistical process control (SPC) analysis, namely standard deviation control charts, were used to examine the degree of variability among samples.

RESULTS

Fentanyl was found in 96% of samples reported to be opioids, with a median concentration of 9%. Concentrations varied significantly, with a standard deviation of 7% for fentanyl and where nearly 20% of data points fell outside the control limits. Over half of the samples contained an additional and unexpected active, most commonly etizolam (43% of samples). Etizolam also showed a large level of variability, uncorrelated to that of fentanyl.

CONCLUSIONS

Based on our chemical quantification and SPC analysis, a high degree of variability was found in opioid samples from the unregulated market in both the drugs detected and the concentrations of those drugs. This demonstrated the opioid crisis to be less attributable to a bad batch of drugs but rather the general variability found in the unregulated market.

Drug checking services for people who use drugs: a systematic review

BACKGROUND AND AIMS

Drug checking services provide people who use drugs with chemical analysis results of their drug samples while simultaneously monitoring the unregulated drug market. We sought to identify and synthesize literature on the following domains: (a) the influence of drug checking services on the behaviour of people who use drugs; (b) monitoring of drug markets by drug checking services; and (c) outcomes related to models of drug checking services.

METHODS

Systematic review. A systematic literature search was conducted in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, Web of Science and Dissertations and Theses Global. Eligible studies were peer-reviewed articles and conference abstracts or grey literature, published in any language since 1990 and including original data on the domains. We assessed risk of bias for quantitative peer-reviewed articles reporting on behaviour or models of drug checking services using National Institutes of Health tools.

RESULTS

We screened 2463 titles and abstracts and 156 full texts, with 90 studies meeting inclusion criteria. Most (n = 65, 72.2%) were from Europe and used cross-sectional designs (n = 79, 87.7%). Monitoring of drug markets by drug checking services (n = 63, 70%) was the most reported domain, followed by the influence of drug checking services on behaviour (n = 31, 34.4%), including intent to use, actual use and disposal of the drug, and outcomes related to models of drug checking services (n = 17, 18.9%). The most common outcome measures were detection of unexpected substances (n = 50, 55.6%), expected substances (n = 44, 48.9%), new psychoactive substances (n = 40, 44.4%) and drugs of concern (n = 32, 36.5%) by drug checking services.

CONCLUSIONS

Drug checking services appear to influence behavioural intentions and the behaviour of people who use drugs, particularly when results from drug checking services are unexpected or drugs of concern. Monitoring of drug markets by drug checking services is well established in Europe, and increasingly in North America. Concerns about drug contents and negative health consequences facilitate the use of drug checking services; lack of concern; trust in drug sellers; lack of accessibility of drug checking services; and legal and privacy concerns are barriers to use.

Rapid and accurate etizolam detection using surface-enhanced Raman spectroscopy for community drug checking

BACKGROUND

In British Columbia, Canada, illicit opioids have been increasingly combined with etizolam, a benzodiazepine analog, that continues to challenge popular portable drug checking technologies as it is often present in low concentrations as a result of its high potency. An unknown combination of opioids and benzodiazepines may have dangerous consequences due to unpredictable dosing, increased respiratory depression, and complicated overdose response measures.

METHODS

Surface-enhanced Raman spectroscopy (SERS) using a portable Raman spectrometer is used to establish a univariate model for the detection of etizolam in opioid drug mixtures (n=100) obtained from the Vancouver Island Drug Checking Project, where the presence of etizolam has been determined using paper-spray mass spectrometry. Benzodiazepine immunoassay test strips are also performed on all samples for comparison.

RESULTS

SERS is shown to detect etizolam with high sensitivity (96%) and specificity (86%). In contrast, benzodiazepine test strips demonstrate a low sensitivity (8%) for the detection of etizolam of the same samples (n=100), with only small improvements when studied over a larger subset of samples (n=506, sensitivity = 29%).

CONCLUSION

We have demonstrated the potential of SERS for trace detection of etizolam within complex sample matrices. Since SERS is one of the few portable technologies capable of trace detection, further studies on its ability for quantification and discrimination of trace adulterants in street samples is of significant interest for point-of-care applications.

Third party drug checking: accessing harm reduction services on the behalf of others

BACKGROUND

Drug checking uses chemical analytical technologies to analyze drugs from the unregulated market to reduce substance use-related risks. We aim to examine the frequency of third party use of a community drug checking service to explore the potential for harm reduction to extend beyond the individual into the community, increase service accessibility, and to contribute to upstream interventions in the supply.

METHODS

Over 31 months, data were collected from a point-of-care drug checking service operated in Victoria, Canada. Through the implementation of survey questions at the intake of the service, data were collected about whether the drug check was for the individual, to sell, and/or for others.

RESULTS

Just over half (52%) of service users were checking for reasons that extended beyond individual use. When checking for others, friends were the most common response, representing 52% of responses, and outreach/support workers checking for others was the second most at 32%. Twelve percent of service users reported checking to sell or for a supplier.

CONCLUSIONS

Third party checking is a frequent, and important aspect of drug checking services, which through facilitating community engagement and increasing accessibility, has expanded the reach of interventions beyond individuals to reduce risks within the unregulated market. Therefore, drug checking as an overdose response should be responsive and accessible for those using the service on the behalf of others.