Evaluation of a fentanyl drug checking service for clients of a supervised injection facility, Vancouver, Canada

The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder

The American Society of Addiction Medicine/American Academy of Addiction Psychiatry (ASAM/AAAP) Clinical Practice Guideline on the Management of Stimulant Use Disorder provides guidance on evidence-based strategies for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use. The Clinical Guideline Committee (CGC) comprised experts from ASAM and AAAP representing a range of clinical settings and patient populations. The guideline was developed following modified GRADE methodology. The process included a systematic literature review as well as several targeted supplemental searches. The CGC utilized Evidence to Decision tables to review available evidence and rate the strength of each recommendation. The clinical practice guideline was revised based on external stakeholder review. Key takeaways included: Contingency management represents the current standard of care for treatment of StUDs; Pharmacotherapies may be utilized off-label to treat StUDs; Acute stimulant intoxication can result in life-threatening complications that should be addressed in an appropriate level of care; Secondary and tertiary prevention strategies should be used to reduce harms related to risky stimulant use.

Implementation opportunities and challenges to piloting a community-based drug-checking intervention for sexual and gender minority men in Vancouver, Canada: a qualitative study

BACKGROUND

In response to the overdose crisis, a collaborative group of two community-based organizations, a health authority and a research institute in Vancouver, Canada, implemented a pilot community-based drug checking (CBDC) intervention for sexual and gender minority (SGM) men. This study identified key factors that influenced the implementation of the CBDC intervention, including opportunities and challenges.

METHODS

We conducted semi-structured interviews with seven pertinent parties involved in the CBDC, including policymakers, researchers and representatives from community-based organizations. These interviews were coded and analyzed using domains and constructs of the Consolidated Framework for Implementation Research.

RESULTS

While drug-related stigma was identified as a challenge to deliver drug checking services, participants described the context of the overdose crisis as a key facilitator to engage collaboration between relevant organizations (e.g., health authorities, medical health officers, community organizations) to design, resource and implement the CBDC intervention. The implementation of the CBDC intervention was also influenced by SGM-specific needs and resources (e.g., lack of information about the drug supply). The high level of interest of SGM organizations in providing harm reduction services combined with the need to expand drug checking into community spaces represented two key opportunities for the CBDC intervention. Here, SGM organizations were recognized as valued partners that fostered a broader culture of harm reduction. Participants' emphasis that knowing the composition of one's drugs is a "right to know", particularly in the context of a highly contaminated illicit drug market, emerged as a key implementation factor. Lastly, participants emphasized the importance of involving SGM community groups at all stages of the implementation process to ensure that the CBDC intervention is appropriately tailored to SGM men.

CONCLUSIONS

The context of the overdose crisis and the involvement of SGM organizations were key facilitators to the implementation of a drug checking intervention in SGM community spaces. This study offers contextualized understandings about how SGM knowledge and experiences can contribute to implement tailored drug checking interventions.

Characterising differences between self-reported and wastewater-identified drug use at two consecutive years of an Australian music festival

BACKGROUND

In the context of drug prohibition, potential adulteration and variable purity pose additional health risks for people who use drugs, with these risks often compounded by the outdoor music festival environment. Ahead of the imminent implementation of drug checking services in Queensland, Australia, this study aims to characterise this problem using triangulated survey and wastewater data to understand self-reported and detected drug use among attendees of a multi-day Queensland-based music festival in 2021 and 2022.

METHODS

We administered an in-situ survey focusing on drug use at the festival to two convenience samples of 136 and 140 festival attendees in 2021 and 2022 respectively. We compared survey findings to wastewater collected concurrently from the festival's site-specific wastewater treatment plant, which was analysed using Liquid Chromatography Tandem Mass Spectrometry.

RESULTS

Most survey respondents (82 % in 2021, 92 % in 2022) reported using or intending to use an illicit drug at the festival. Some respondents reported potentially risky drug use practices such as using drugs found on the ground (2 % in 2021, 4 % in 2022). Substances detected in wastewater but not surveys include MDEA, mephedrone, methylone, 3-MMC, alpha-D2PV, etizolam, eutylone, and N,N-dimethylpentylone.

CONCLUSION

Many substances detected in wastewater but not self-reported in surveys likely represent substitutions or adulterants. These findings highlight the benefits of drug checking services to prevent harms from adulterants and provide education on safer drug use practices. These findings also provide useful information on socio-demographic characteristics and drug use patterns of potential users of Queensland's future drug checking service.

Volatile drug use and overdose during the first year of the COVID-19 pandemic in the United States

BACKGROUND

Overdose deaths in the United States rose substantially during the COVID-19 pandemic. Disruptions to the drug supply and service provision introduced significant instability into the lives of people who use drugs (PWUD), including volatility in their drug use behaviors.

METHODS

Using data from a multistate survey of PWUD, we examined sociodemographic and drug use correlates of volatile drug use during COVID-19 using multivariable linear regression. In a multivariable logistic regression model, we assessed the association between volatile drug use and past month overdose adjusting for sociodemographic and other drug use characteristics.

RESULTS

Among participants, 52% were male, 50% were white, 29% had less than a high school education, and 25% were experiencing homelessness. Indicators of volatile drug use were prevalent: 53% wanted to use more drugs; 45% used more drugs; 43% reported different triggers for drug use, and 23% used drugs that they did not typically use. 14% experienced a past-month overdose. In adjusted models, hunger (β=0.47, 95% CI: 0.21-0.72), transactional sex (β=0.50, 95% CI: 0.06-0.94), and the number of drugs used (β=0.16, 95% CI: 0.07-0.26) were associated with increased volatile drug use. Volatile drug use was associated with increased overdose risk (aOR=1.42, 95% CI: 1.17-1.71) in the adjusted model.

CONCLUSIONS

Volatile drug use during the COVID-19 pandemic was common, appeared to be driven by structural vulnerability, and was associated with increased overdose risk. Addressing volatile drug use through interventions that ensure structural stability for PWUD and a safer drug supply is essential for mitigating the ongoing overdose crisis.

The availability of fentanyl test strips in Georgia community pharmacies

BACKGROUND

Fentanyl test strips (FTS) are increasingly being used to test counterfeit pharmaceuticals and illicit drugs for fentanyl before consumption. On July 1, 2022, Georgia legalized the distribution of FTS. One strategy for expanding FTS distribution in the community involves leveraging community pharmacies. However, less is known about FTS distribution through community pharmacies.

OBJECTIVES

This preliminary study aimed to assess the availability of FTS in Georgia community pharmacies and examine pharmacists' knowledge and attitudes regarding FTS provision.

METHODS

This study used a cross-sectional design. A randomized telephone survey of 700 pharmacies, stratified by pharmacy type, was carried out from September 2022 to January 2023. Survey questions assessed FTS stock status, pharmacists' awareness of Georgia's FTS legalization, willingness to receive FTS information, and comfort in providing FTS education. Descriptive statistics and multivariate logistic regression analyses were used to analyze the data.

RESULTS

Of the 376 survey respondents, the vast majority were not aware of the Georgia FTS legalization (82.71% [n = 311]) and did not have FTS stocked in their pharmacies (94.91% [n = 354]). While most participants were willing to receive FTS information (70.21% [n = 264]), only slightly over half reported feeling comfortable providing FTS education (54.70% [n = 205]). Multivariate analyses showed that female participants were less likely to feel comfortable providing FTS education to patients/clients at the pharmacy (adjusted odds ratio: 0.58; confidence interval: 0.36 to 0.92).

CONCLUSION

Findings suggest that Georgia community pharmacies may not stock FTS and that pharmacists may be unaware of the state's FTS legalization, but they are willing to receive information about FTS. Future studies should use a representative sample to design and implement strategies to support pharmacists' provision of FTS, including a destigmatization approach for those not comfortable discussing FTS.

A qualitative assessment of tablet injectable opioid agonist therapy (TiOAT) in rural and smaller urban British Columbia, Canada: Motivations and initial impacts

BACKGROUND

The evolving and unpredictable unregulated drug market has driven an unprecedented overdose crisis that requires effective intervention. Growing evidence suggests that novel opioid agonist treatments, such as tablet injectable opioid agonist therapy (TiOAT), have potential to prevent overdoses and other drug-related harms. More evidence is needed to characterize their utility in achieving these outcomes. The current article is an analysis of two TiOAT programs implemented in British Columbia, Canada, to assess impact on health and well-being, including overdose risk. Moreover, we explored participants' enrollment goals and if they were achieved.

METHODS

The study employed qualitative methods to evaluate the TiOAT program in two sites between October 2021 and April 2022. We developed a semi-structured interview tool to guide in depth interviews. All interviews (n = 32) took place on teleconference software or in person. Thematic analysis allowed for the emergence of themes associated with TiOAT participation.

RESULTS

Participants discussed various motivations for enrolling in TiOAT, which included gaining financial stability, reducing or eliminating drug use, addressing withdrawal symptoms, wanting to work, and improving social circumstances. An assessment of initial programmatic impacts revealed that many participant-identified motivators were achieved. Participants also reported fewer or no overdoses since starting TiOAT, and many reported switching from injecting to smoking drugs. Some challenges included adequate dosing as evidenced by ongoing withdrawal and pain. Some participants requested additional opioids, such as diacetylmorphine, to aid in reducing illicit drug use.

CONCLUSION

Participants described how TiOAT helped them to achieve many of their goals. Suggested programmatic improvements include enhanced patient-provider co-design with respect to dosing to address ongoing withdrawal and pain. As the unpredictability the unregulated drug market worsens, novel options, such as TiOAT, ought to be implemented broadly to reduce overdose events and improve quality of life for people who use drugs.

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.

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.

Longitudinal polysubstance use patterns and non-fatal overdose: A repeated measures latent class analysis

BACKGROUND

Polysubstance use (PSU) is common among people who use opioids (PWUO) and has been associated with drug-related harms. We aimed to identify latent longitudinal PSU classes among a cohort of PWUO and characterize non-fatal overdose risks among different sub-classes over time.

METHODS

We used longitudinal data (2005-2018) from three ongoing prospective cohorts of people who use drugs in Vancouver, Canada. The primary outcome of interest was self-reported non-fatal overdose during the past six months. The primary exposure of interest was longitudinal PSU patterns among PWUO, obtained from repeated measures latent class analysis (RMLCA) of weekly substance use-related outcome indicators. Multivariable generalized estimating equations models were built to assess the association between latent PSU class membership and non-fatal overdose, adjusting for potential sociodemographic, behavioural, and structural confounders.

RESULTS

2627 PWUO were included in the analysis, and 1094 (41.6 %) had experienced at least one non-fatal overdose during the study period. RMLCA revealed five distinct latent longitudinal PSU classes, including low/infrequent use (Class 1; 30 %), primarily opioid and methamphetamine use (Class 2; 22 %), primarily cannabis use (Class 3; 15 %), primarily opioid and crack use (Class 4; 29 %), and frequent PSU (Class 5; 4 %). In comparison with Class 1 (low), membership in all latent PSU classes except Class 3 (cannabis) was associated with increased odds of non-fatal overdose: Class 2 (opioids + meth) vs. Class 1 (Adjusted odds ratios [aOR] = 2.20, 95 % confidence intervals [CI]: 1.51-3.22), Class 4 (opioids + crack) vs. Class 1 (aOR = 1.06, 95 % CI: 0.85-1.33), and Class 5 (frequent) vs. Class 1 (aOR = 2.39, 95 % CI: 1.92-2.97).

CONCLUSION

Our findings highlighted the heterogeneous characteristics of PWUO in terms of patterns of PSU and non-fatal overdose risk. The diverse nature of PWUO and the potential additive or multiplicative impact of using several substances on overdoses should be reflected across the substance use treatment continuum and care provision.

Fentanyl Concentration in Drug Checking Samples and Risk of Overdose Death in Vancouver, Canada

INTRODUCTION

The proliferation of fentanyl and its analogs in illegal, unregulated drug markets remains a major driver of the overdose crisis in North America. Drug checking services have been implemented as a harm reduction strategy to address the crisis. However, little is known about their potential utility as a mechanism for monitoring population-level risk of overdose stemming from changing fentanyl concentration in unregulated drugs over time. Therefore, this study assessed the relationship between median fentanyl concentration in expected opioid drug checking samples and the death rate due to illicit drug toxicity over time in Vancouver, Canada.

METHODS

Monthly population-based rates of death due to illicit drug toxicity were drawn from provincial coroner records. Monthly median percent fentanyl concentration was calculated using a validated quantification model from point-of-care Fourier-transform infrared spectra among expected opioid samples that tested positive for fentanyl at community drug checking services. A time-series analysis using generalized additive modeling was conducted to examine the association between monthly median fentanyl concentration and monthly death rate due to illicit drug toxicity, controlling for calendar month. Analyses were conducted in 2021-2022.

RESULTS

Between January 2019 and October 2020, 577 deaths due to illicit drug toxicity occurred in Vancouver, and the observed monthly rate ranged from 1.75 to 7.65 deaths per 100,000 population. A significant, positive association was observed between monthly median fentanyl concentration and monthly death rate due to illicit drug toxicity, adjusting for calendar month (chi-square=52.21, p<0.001).

CONCLUSIONS

Findings suggest a role for point-of-care drug checking as a tool for monitoring evolving overdose risk at the population level.

Motivators of and barriers to drug checking engagement in British Columbia, Canada: Findings from a cross-sectional study

OBJECTIVE

Responding to increasing rates of illicit drug toxicity mortality in British Columbia, regional health authorities introduced various types and models of drug checking services starting in 2016. Uptake has been gradual yet consistent, but motivators and barriers of service use have not been well-described.

METHODS

The British Columbia Harm Reduction Client Survey is a cross-sectional survey conducted at harm reduction sites across British Columbia. Data for the present findings were collected between March 2021 and January 2022. Participants (n = 537) were asked about their use of drug checking services and what prevented them from using available services. Responses were analyzed with descriptive statistics and multivariable logistic regression.

RESULTS

Of all participants, 519 (96.6 %) answered the survey question on drug checking with 144 (27.7 %) reporting having used services within six months. Participants highlighted barriers such as not knowing where to access services (21.0 %), or not having services in their area (10.0 %). Among people who did not report recent use of fentanyl, 49.6 % stated they would not use their drugs if they tested positive for fentanyl. Other harm reduction behaviors were positively associated with drug checking, such as use of overdose prevention sites (adjusted odds ratio [AOR]: 2.75, 95 % confidence interval [CI]: 1.65, 4.59) and having a naloxone kit (AOR: 2.67, 95 %CI: 1.14, 6.28). Receipt of opioid agonist therapy in the previous six months was also positively associated with drug checking (AOR: 1.72, 95 %CI: 1.05, 2.83).

DISCUSSION

Drug checking uptake remains low in British Columbia, however this study identified desire for services among participants, suggesting a need for expanded drug checking services. Behavioral change was reported among a high proportion of people who said they would not use their drugs if they tested positive for fentanyl, meaning that immunoassay strips alone have utility in the context of a pervasive fentanyl supply.

"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.

First drug-checking study at an electronic festival and fentanyl detection in the central region of Mexico

BACKGROUND

Perception of drug adulteration has increased in Mexico, but there is little research on adulterants and toxicity. The aim of this study was to identify drug composition in an electronic music outdoor festival nearby Mexico City.

METHODS

The participants completed a questionnaire with demographic data, harm reduction strategies, drug-use patterns, history, and the drug they expected to find. We took a small sample of each substance and prepared it for drug checking. A two-section drug testing station was placed within the grounds of the festival. Interaction with participants occurred at the front part. Drug checking was conducted at the rear part. The service was free of charge, voluntary and confidential. Forty persons aged 22 to 48 years participated (mode = 28), of which 92.5% were male, most (82.5%) were single. Through the Substance Analysis Program of "ReverdeSer Collective," we conducted the testing with the attendants that provided 51 drug samples, following ethical and biosafety protocols. We used colorimetry, Fourier Transform Infrared Spectroscopy, and fentanyl immunoassay strips for sample analysis.

RESULTS

Substances of choice among attendants were psychostimulants (MDMA and other amphetamine-like drugs) and hallucinogens. Most samples contained what the users expected plus adulterants. Main adulterants were methylene-dioxy-ethyl-amphetamine, methylene-dioxy-propyl-amphetamine, hydroxyamphetamine, and the selective serotonin reuptake inhibitor venlafaxine. Fentanyl was present in 2 out of 4 cocaine samples and in 14 of the 22 confirmed MDMA samples.

CONCLUSIONS

Some of the adulterants found pose serious health risks, especially fentanyl, amphetamine-like substances, and venlafaxine. Therefore, it is urgent to monitor these adulterants at electronic music festivals and to implement prevention, treatment, and harm reduction public policies. Naloxone distribution and drug-assisted therapies should be part of government programs in Mexico.

How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: a systems perspective

BACKGROUND

The intersection of dual public health emergencies-the COVID-19 pandemic and the drug toxicity crisis-has led to an urgent need for acute care based harm reduction for unregulated opioid use. Emergency Departments (EDs) as Complex Adaptive Systems (CASs) with multiple, interdependent, and interacting elements are suited to deliver such interventions. This paper examines how the ED is organized to provide harm reduction and identifies facilitators and barriers to implementation in light of interactions between system elements.

METHODS

Using a case study design, we conducted interviews with Emergency Physicians (n = 5), Emergency Nurses (n = 10), and clinical leaders (n = 5). Nine organizational policy documents were also collected. Interview data were analysed using a Reflexive Thematic Analysis approach. Policy documents were analysed using a predetermined coding structure pertaining to staffing roles and responsibilities and the interrelationships therein for the delivery of opioid-specific harm reduction in the ED. The theory of CAS informed data analysis.

RESULTS

An array of system agents, including substance use specialist providers and non-specialist providers, interacted in ways that enable the provision of harm reduction interventions in the ED, including opioid agonist treatment, supervised consumption, and withdrawal management. However, limited access to specialist providers, when coupled with specialist control, non-specialist reliance, and concerns related to safety, created tensions in the system that hinder harm reduction provision with resulting implications for the delivery of care.

CONCLUSIONS

To advance harm reduction implementation, there is a need for substance use specialist services that are congruent with the 24 h a day service delivery model of the ED, and for organizational policies that are attentive to discourses of specialized practice, hierarchical relations of power, and the dynamic regulatory landscape. Implementation efforts that take into consideration these perspectives have the potential to reduce harms experienced by people who use unregulated opioids, not only through overdose prevention and improving access to safer opioid alternatives, but also through supporting people to complete their unique care journeys.

Contextual factors affecting the implementation of drug checking for harm reduction: a scoping literature review from a North American perspective

BACKGROUND

The opioid epidemic continues to be a significant cause of morbidity and mortality in the US. In 2020, 83% of opioid-related overdose deaths were due to synthetic opioids, such as fentanyl. Drug checking services have been widely implemented as a harm reduction intervention to facilitate the identification of substances in a drug sample. There is a need to inform decision-making on drug checking technologies and service implementation. This research aims to outline contextual considerations for the implementation of a drug checking service.

METHODS

A scoping review was conducted using a structured search strategy in PubMed and EMBASE. Articles were independently screened by two reviewers, and included if they were primary literature and reported on an actionable consideration(s) for drug checking services. Data elements were extracted using a standardized form, and included study design, study population, drug checking technology utilized or discussed, and main findings.

RESULTS

Twenty-nine articles were selected for inclusion, and four primary areas of consideration were identified: drug checking technologies, venue of a drug checking service, legality, and privacy. Technological considerations include the need for highly accurate, quantitative results which appeal to both populations of people with drug use disorder and recreational users. Accessibility of services was identified as an important factor that may be impacted by the location, integration with other services, how the service is provided (mobile vs. fixed), and the hours of operation. Maintaining plausible deniability and building trust were seen as important facilitators to service use and engagement. Issues surrounding legality were the most frequently cited barrier by patrons, including fear of criminalization, policing, and surveillance. Patrons and stakeholders identified a need for supportive policies that offer protections. Maintaining anonymity for patrons is crucial to addressing privacy-related barriers.

CONCLUSION

This review highlights the need to understand the local population and climate for drug checking to implement a drug checking service successfully. Common themes identified in the literature included considerations related to the choice of technology, the type of venue, and the impact of legality and privacy. We intend to utilize these considerations in future research to help guide discussions with US-based stakeholders.

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.

'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.

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.

Evaluating Technologies to Identify Fentanyl and Adulterants in Street Drug Paraphernalia: Qualitative Perspectives of Service Providers and Their Clientele

Background: Opioid overdose deaths continue to present major public health challenges in the U.S. Harm reduction agencies have begun using drug checking technologies to identify adulterants in the local drug supply and reduce overdose risk among people who use drugs (PWUD). Through qualitative and ethnographic methods, we assess the use of portable mass spectrometers at a harm reduction agency in a Northeastern U.S. city. Methods: We conducted participant observation, and on-the-spot qualitative interviews with harm-reduction staff members (n = 10) and their clientele (n = 17) between May 2019 and December 2020. Interviews explored emic views on drug checking (process, logistics, technology), and perceived benefits and challenges. We used thematic content analysis techniques to code and analyze interview transcriptions. Results: Implementation and use of drug checking devices were not free of challenges and malfunctions, often delaying drug checking opportunities and increasing suspicions and distrust among clients. Yet, staff members perceived that when working properly, or in conjunction with an additional device, they offered information about purchased drugs that could empower clients and potentially lead to positive behavior change. Use of these devices also enhanced engagement between harm reduction staff and PWUD, facilitating meaningful conversations around self-advocacy and harm reduction engagement. Conclusion: We report qualitative findings on the experiences and perceptions of drug checking devices among harm reduction staff and PWUD. Our findings indicate that use of this technology has the potential to decrease risk behaviors, expand health promotion services, and help reduce high rates of fentanyl-related overdose.

Mortality among individuals prescribed opioid-agonist therapy in Scotland, UK, 2011-20: a national retrospective cohort study

BACKGROUND

Drug-related death (DRD) rate in Scotland, UK, has increased rapidly to one of the highest in the world. Our aim was to examine the extent to which opioid-agonist therapy (OAT) in Scotland is protective against drug-related mortality and how this effect has varied over time.

METHODS

We included individuals in Scotland with opioid use disorder who received at least one OAT prescription between Jan 1, 2011, and Dec 31, 2020. We calculated drug-related mortality rates and used Quasi-Poisson regression models to estimate trends over time and by OAT exposure, adjusting for potential confounding.

FINDINGS

In a cohort of 46 453 individuals prescribed OAT with a total of 304 000 person-years of follow-up, DRD rates more than trebled from 6·36 per 1000 person-years (95% CI 5·73-7·01) in 2011-12 to 21·45 (20·31-22·63) in 2019-20. DRD rates were almost three and a half times higher (hazard ratio 3·37; 95% CI 1·74-6·53) for those off OAT compared with those on OAT after adjustment for confounders. However, confounder adjusted DRD risk increased over time for both people off and on OAT.

INTERPRETATION

Drug-related mortality rates among people with opioid use disorders in Scotland increased between 2011 and 2020. OAT remains protective but is insufficient on its own to slow the increase in DRD risk for people who are opioid dependent in Scotland.

FUNDING

Scottish Government Drug Deaths Taskforce, Public Health Scotland, and National Institute for Health and Care Research.

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.

Validated method for the analysis of 22 illicit drugs and their metabolites via liquid chromatography tandem mass spectrometry (LC-MS/MS) in illicit drug samples collected in Chicago, IL

Drug checking services are being utilized worldwide to provide people who use drugs information on the composition and contents of their drugs as a tool for harm reduction and accidental overdose prevention. Existing drug checking services use a variety of techniques including immunoassay strips and spectroscopic techniques like FTIR and Raman. Few services utilize LC-MS based methods for primary or secondary analysis and few methods exist for direct analysis of illicit drugs. To address this, an LC-MS/MS method was developed for 22 illicit drugs and cutting agents using LC-MS/MS with application to 124 illicit drug samples that were collected from Chicago, IL. Samples were also analyzed using fentanyl and benzodiazepine immunoassay test strips. Fentanyl test strips gave a positive result for 86% of samples with only one sample showing a positive result on a benzodiazepine test strip. LC-MS/MS analysis of samples show that opioids were the most commonly quantified in 96% of samples, followed by stimulants at 12% and benzodiazepines at 1%. Fentanyl was measured in 91% of samples, co-occurring with heroin in 58% of opioid-containing samples. A comparison of the gold-standard LC-MS/MS results to fentanyl test strips shows a high level of accuracy for the fentanyl test strips, with just 5% of samples being classified as false negatives and no false positives. These results demonstrate the strengths and benefits of LC-MS/MS when incorporated as a secondary analysis tool for drug checking.

Monitoring for fentanyl within Australian supervised injecting facilities: Findings from feasibility testing of novel methods and collaborative workshops

BACKGROUND

Australia is yet to see widespread fentanyl-contaminated heroin, despite the established presence of fentanyl in other countries. International mortality trends alongside a local cluster of fentanyl-related deaths prompted interest in developing methods to monitor for fentanyl and other potentially harmful novel psychoactive substances (NPS) in Australia.

METHODS

We tested novel methods to monitor for fentanyl and other NPS. From 2017-2021, clients from supervised injecting facilities (SIFs) in Melbourne and Sydney, Australia, contributed urine screens (UDS) with BTNX Rapid Response™ fentanyl test strips (FTS) paired with surveys, and injecting equipment associated with opioid overdoses for laboratory analysis. A single site piloted drug checking using FTS with laboratory confirmation. Two workshops were conducted with SIF staff, content experts and people with lived experience to determine how results can inform practices within SIFs.

RESULTS

Of the 911 UDS with FTS conducted, less than 1% (n=8) yielded positive results that were not explained by self-reported pharmaceutical fentanyl use, with two laboratory confirmed fentanyl positive results. Injecting equipment from 59 overdoses was tested and neither fentanyl nor other NPS were identified. Drug checking with FTS (n=34) indicated the presence of fentanyl on three tests. Two specimens were subsequently sent for laboratory testing and classified as false positives as the presence of fentanyl was not confirmed. Workshop participants (n=21) felt routine monitoring with FTS currently had limited value. A process for using pre-defined signals to trigger surveillance was developed.

CONCLUSION

The high false positive rates with FTS, relative to the small number of positive results and potential for them to undermine confidence in FTS emphasised the need for confirmatory testing. The role of routine surveillance was unclear within the current low-fentanyl context, however, a process was developed to upscale testing should signals of increased fentanyl prevalence in the Australian heroin market emerge.

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.

Handheld Raman Spectroscopy in the First UK Home Office Licensed Pharmacist-Led Community Drug Checking Service

Across the world, the interest in point-of-care drug checking as a harm-reduction intervention is growing. This is an attempt to improve intelligence about current drug trends and reduce drug-related morbidity and mortality. In the UK, drug-related harm is increasing exponentially year after year. As such, specialist community treatment services are exploring new methods to improve engagement with people who use drugs (PWUD), who may require support for their problematic drug use. This need has driven the requirement to pilot an on-site, time-responsive, readily available drug-checking service at point-of-support centres. In this study, we piloted the UK's first Home Office-licensed drug-checking service that was embedded into a community substance-misuse service and had all on-site analysis and harm-reduction interventions led and delivered by pharmacists. We report on the laboratory findings from the associated confirmatory analysis (UHPLC-MS, GC-MS, and ¹H NMR) to assess the performance of the on-site hand-held Raman spectrometer and outline the challenges of providing real-time analysis of psychoactive substances in a clinical setting. Whilst acknowledging the limitation of the small sample size (n = 13), we demonstrate the potential suitability of using this technology for the purposes of screening substances in community-treatment services. Portability of equipment and timeliness of results are important and only very small samples may be provided by people who use the service. The challenges of accurately identifying substances from complex mixtures were equally found with both point-of-care Raman spectroscopy and laboratory confirmatory-analysis techniques. Further studies are required to confirm these findings.

Examining fentanyl and its analogues in the unregulated drug supply of British Columbia, Canada using drug checking technologies

INTRODUCTION

The emergence of fentanyl and its analogues have contributed to a drastic rise in overdose-related mortality in recent years. The objective of this study was to determine the number of drug checking samples containing fentanyl and fentanyl analogues using both point of care and confirmatory drug checking technologies.

METHODS

Point-of-care drug checking data, using a combination of fentanyl immunoassay strips and Fourier-transform infrared spectroscopy (FTIR), were collected at harm reduction sites in Vancouver and Surrey, British Columbia. Based on current recommendations from the British Columbia Centre on Substance Use Drug Checking Project, a subset of these samples was sent for confirmatory analysis using quantitative nuclear resonance spectroscopy, gas chromatography-mass spectrometry and/or liquid chromatography-mass spectrometry.

RESULTS

A total of 22,916 samples were tested using FTIR and fentanyl immunoassay strips, of which 6125 (29%) were positive for fentanyl and/or fentanyl analogues. FTIR identified a fentanyl analogue in five samples (all carfentanil). Of the 1467 samples sent for confirmatory analysis, fentanyl was identified in 855 (58%) and fentanyl analogues in 85 (6%), including: carfentanil (n = 56), acetyl fentanyl (n = 15), furanyl fentanyl (n = 9) and cyclopropyl fentanyl (n = 5).

DISCUSSION AND CONCLUSION

Our research found that FTIR does not consistently distinguish between fentanyl and its analogues at point of care and that highly sensitive confirmatory drug checking technologies are needed to identify fentanyl analogues. These findings underscore the limitations of current drug checking technologies and the importance of using both point of care and confirmatory drug checking initiatives for monitoring changes in the drug supply.

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.

Characteristics and context of fentanyl test strip use among syringe service clients in southern Wisconsin

BACKGROUND

Fentanyl adulteration of illicit drugs is a major driver of opioid-involved overdose in the USA. Fentanyl test strips are increasingly used by people who use drugs to check for fentanyl. However, little is known about factors that influence test strip use in this population.

METHODS

In this mixed-methods study employing semi-structured open-ended interviews (n = 29) and a structured survey (n = 341), we examined characteristics associated with test strip use, characteristics of test strip use, and situational, logistical and psychosocial factors influencing test strip use. Respondents were recruited from a syringe service program in southern Wisconsin. Bivariate tests of association and multivariable logistic regression examined the relationship between respondent characteristics and test strip use. Summary statistics were used to describe how situational, logistical and psychosocial factors impact test strip use.

RESULTS

Most respondents were male (59.6%), non-Hispanic white (77.4%), young (mean 35.7 years), reported heroin as their primary drug (70.7%), injection as their primary route (87.9%), and use ≥ 3 times daily (78.6%). In multivariable models, site, race and ethnicity, drug of choice, and seeking fentanyl were associated with test strip use. Among test strip users, 36.5% use them most of the time or more and 80.6% get positive results half the time or more. Among individuals reporting heroin, fentanyl, methamphetamine, or cocaine or crack cocaine at least once per month, 99.1%, 56.8%, 42.2%, and 55.7% reported testing these drugs, respectively. Test strip use is supported by information from suppliers, regular transportation, diverse distribution locations, recommendations from harm reduction staff, and having a safe or private place to use.

CONCLUSIONS

We found that individuals who use fentanyl test strips are more often non-Hispanic white, use heroin, and seek drugs with fentanyl relative to individuals without test strip use. Findings confirm high fentanyl penetration in the Wisconsin drug supply. Low rates of stimulant testing suggest inadequate awareness of fentanyl penetration. Findings support outreach to key populations, increased diversity of distributing locations, efforts to correct misperceptions about drug wasting, emphasis on pre-consumption testing, and the importance of adjunct behaviors to prevent overdose given high rates of intentional fentanyl use.

Exploring the use of infrared absorption spectroscopy and two-trace two-dimensional correlation analysis for the resolution of multi-component drug mixtures

Community drug checking provides an essential service that responds to the unpredictable and variable supply of illicit drugs. Point of care detection of trace components using portable infrared spectrometers is a harm reduction measure to prevent overdose. This study investigates the ability of weighted subtraction and two-trace two-dimensional (2T2D) correlation analysis to reveal the presence of heroin in an opioid mixture that contains heroin and fentanyl mixed with caffeine as a cutting agent. In both methods, a spectral trace was identified that provided reasonably high correlation scores to heroin when compared to entries in drug libraries. The two-trace correlation analysis produced a higher match score, suggesting that future improvements in spectral unmixing methods may enhance the reliability of detecting trace components in drugs.

Pilot testing fentanyl test strip distribution in an emergency department setting: Experiences, lessons learned, and suggestions from staff

OBJECTIVES

Fentanyl test strips (FTSs) are increasingly used to address fentanyl contamination of the illicit drug supply by testing a drug for the presence of fentanyl, allowing people who use drugs (PWUD) to engage in overdose prevention. While emergency departments (EDs) have implemented various harm reduction strategies for PWUD, to date distribution of FTSs in EDs is limited and not evaluated. Thus, we sought to explore ED staff experiences distributing FTSs.

METHODS

Twenty-one staff serving different roles (e.g., physician, nurse, technician, social worker, certified recovery specialist) within two urban EDs in a major metropolitan area were enrolled in a pilot study to distribute FTS to patients who use drugs. Participants were interviewed about their experience at 3 weeks and again at 3 months. Interviews were recorded, transcribed verbatim, and coded using a conventional content analysis approach.

RESULTS

All participants endorsed the utility of FTS distribution in the ED. Across 42 interviews, participants discussed evolving strategies to approach patients about FTS, primarily favorable patient reactions to FTSs, improved dynamics between participants and patients, mixed intervention support from other staff, and named challenges of FTS distribution and recommendations to make FTS distribution in the ED widespread. Recommendations included medical records prompts to offer FTS, offering via different types of staff, and offering FTS during triage.

CONCLUSIONS

Implementing FTS distribution may improve patient rapport while providing patients with tools to avoid a fentanyl overdose. Participants generally reported positive experiences distributing FTSs within the ED but the barriers they identified limited opportunities to make distribution more integrated into their workflow. EDs considering this intervention should train staff on FTSs and how to identify and train patients and explore mechanisms to routinize distribution in the ED environment.

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.

Knowledge, attitudes, and behaviors related to the fentanyl-adulterated drug supply among people who use drugs in Oregon

INTRODUCTION

Nonpharmaceutical fentanyl has reconfigured the U.S. illicit drug market, contributing to a drastic increase in overdose drug deaths. While illicit fentanyl has subsumed the drug supply in the Northeast and Midwest, it has more recently reached the West. For this study, we explored knowledge, attitudes, and behaviors among people who use drugs in Oregon in the context of the emergence of fentanyl in the drug supply.

METHODS

We conducted in-depth interviews by phone with 34 people who use drugs in Oregon from May to June 2021. We used thematic analysis to analyze transcripts and construct themes.

RESULTS

People who use drugs knew about fentanyl, expressed doubt that fentanyl could be found in methamphetamine; believed those who were younger or less experienced were at higher risk for harm; and received information about fentanyl from drug dealers, syringe service programs, or peers (other people who use drugs). Preference for fentanyl's presence in drugs like heroin or methamphetamine was mixed. Some felt that their preference was irrelevant since fentanyl was unavoidable. Participants reported engaging in harm reduction practices, including communicating about fentanyl with dealers and peers, testing for fentanyl, using smaller quantities of drugs, switching from injecting to smoking, and using naloxone.

CONCLUSION

People who use drugs are responding to the rise of fentanyl on the West Coast and are concerned about the increasing uncertainty and hazards of the drug supply. They are willing and motivated to adopt harm reduction behaviors. Harm reduction promotion from syringe service programs and public health agencies is essential to reduce injury and death from nonpharmaceutical fentanyl.

Overdose Prevention and Housing: a Qualitative Study Examining Drug Use, Overdose Risk, and Access to Safer Supply in Permanent Supportive Housing in Vancouver, Canada

The majority of overdose deaths in British Columbia (BC) occur among people using illicit substances alone in private residences. Some supportive housing in BC includes on-site access to a variety of health and substance use-related services. More recently, a number of supportive housing locations have started offering prescribed safer supply medications to people at high overdose risk, though these remain limited and under-evaluated. In this study, we describe the drug use practices - including access to and use of on-site supervised consumption, OAT, and prescribed safer supply medications - of study participants living in permanent supportive housing with integrated primary care, substance use treatment services, and supervised consumption spaces. Qualitative interviews were conducted with 30 residents of a permanent supportive housing site in Vancouver, Canada. Data were analyzed using a sequential process to identify both a priori (e.g., low-barrier substance use treatment, pandemic effects on service access) and emerging themes (e.g., using alone). Most (N = 27) study participants reported using alone in their rooms, despite having access to an on-site supervised consumption area. Reasons for using alone include the following: preference for being alone, discretion/stigma, and restrictive housing policies. Less than half (N = 12) of the study participants accessed on-site prescribed safer supply medications. Participants receiving on-site prescribed safer supply described positive benefits including reduced use of illicit opioids, and less reliance on illicit income generation activities. On-site prescribed safer supply programs within supportive housing environments are an important tool in addressing overdose risk.

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.

Navigating Opioid Agonist Therapy among Young People who use Illicit Opioids in Vancouver, Canada

BACKGROUND

Opioid agonist therapy (OAT) has been shown to reduce opioid use and related harms. However, many young people are not accessing OAT. This study sought to explore how young people navigated OAT over time, including periods of engagement, disengagement, and avoidance.

METHODS

Semi-structured, in-depth qualitative interviews were conducted between January 2018 and August 2020 with 56 young people in Vancouver, Canada who reported illicit, intensive heroin and/or fentanyl use. Following the verbatim transcription of longitudinal interviews, an iterative thematic analysis was used to extrapolate key themes.

RESULTS

Young people contemplating OAT expressed fears about its addictiveness. Many experienced pressure from providers and family members to initiate buprenorphine-naloxone, despite a desire to explore other treatment options such as methadone. Once young people initiated OAT, staying on it was difficult and complicated by daily witnessed dosing requirements and strict rules around repeated missed doses, especially for those receiving methadone. Most young people envisioned tapering off OAT in the not-too-distant future.

CONCLUSIONS

Findings underscore the importance of working collaboratively with young people to develop treatment plans and timelines, and suggest that OAT engagement and retention among young people could be improved by expanding access to the full range of OAT; updating clinical guidelines to improve access to safer prescription alternatives to the increasingly poisonous, unregulated drug supply; addressing treatment gaps arising from missed doses and take-home dosing; and providing a clear pathway to OAT tapering.

Take-home drug checking as a novel harm reduction strategy in British Columbia, Canada

BACKGROUND

Drug checking is a harm reduction strategy used to identify components of illicitly obtained drugs, including adulterants, to prevent overdose. This study evaluated the distribution of take-home fentanyl test strips to people who use drugs (PWUD) in British Columbia, Canada. The primary aim was to assess if the detection of fentanyl in opioid samples was concordant between a take-home model and testing by trained drug checking staff.

METHODS

Take-home fentanyl test strips were distributed at ten sites providing drug checking services from April to July 2019. The fentanyl positivity of the aggregate take-home and on-site drug checking groups were compared by class of substance tested. An administered survey assessed acceptability and behaviour change.

RESULTS

1680 take-home results were obtained from 218 unique participants; 68% of samples (n=1142) were identified as opioids and 23% (n=382) were stimulant samples. During this period, 852 samples were tested using on-site drug checking. The fentanyl positivity of opioid samples was 90.0% for take-home samples and 89.1% for on-site samples (Difference 0.8% (95% CI -2.3% to 3.9%)). These results were not affected by previous experience with test strips. Fentanyl positivity of stimulants in the take-home group was higher than on-site (24.7% vs. 3.2%), but the study was underpowered to conduct statistical analysis on this sub-group. When fentanyl was detected, 27% of individuals reported behaviour change that was considered safer/positive. Greater than 95% of participants stated they would use fentanyl test strips again.

CONCLUSIONS

Take-home fentanyl test strips used by PWUD on opioid samples can provide similar results to formal drug checking services and are a viable addition to existing overdose prevention strategies. Use of this strategy for detection of fentanyl in stimulant samples requires further evaluation. This intervention was well accepted and in some participants was associated with positive behaviour change.

"It wasn't here, and now it is. It's everywhere": fentanyl's rising presence in Oregon's drug supply

Background

Illicit fentanyl has contributed to a drastic increase in overdose drug deaths. While fentanyl has subsumed the drug supply in the Northeastern and Midwestern USA, it has more recently reached the Western USA. For this study, we explored perspectives of people who use drugs (PWUD) on the changing drug supply in Oregon, experiences of and response to fentanyl-involved overdose, and recommendations from PWUD to reduce overdose risk within the context of illicit fentanyl’s dramatic increase in the recreational drug supply over the past decade.

Methods

We conducted in-depth interviews by phone with 34 PWUD in Oregon from May to June of 2021. We used thematic analysis to analyze transcripts and construct themes.

Results

PWUD knew about fentanyl, expressed concern about fentanyl pills, and were aware of other illicit drugs containing fentanyl. Participants were aware of the increased risk of an overdose but remained reluctant to engage with professional first responders due to fear of arrest. Participants had recommendations for reducing fentanyl overdose risk, including increasing access to information, harm reduction supplies (e.g., naloxone, fentanyl test strips), and medications for opioid use disorder; establishing drug checking services and overdose prevention sites; legalizing and regulating the drug supply; and reducing stigma enacted by healthcare providers.

Conclusion

PWUD in Oregon are aware of the rise of fentanyl and fentanyl pills and desire access to tools to reduce harm from fentanyl. As states in the Western USA face an inflection point of fentanyl in the drug supply, public health staff, behavioral health providers, and first responders can take action identified by the needs of PWUD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-022-00659-9.

Perspectives of people in Philadelphia who use fentanyl/heroin adulterated with the animal tranquilizer xylazine; Making a case for xylazine test strips

Background

Xylazine is an animal tranquilizer increasingly detected in those who have died of an opioid overdose in Philadelphia, PA and elsewhere. Despite an increasing presence of xylazine in the local fentanyl/heroin drug market and its association with ulcers, there are few perspectives about xylazine from people who use drugs and no data about the utility of a hypothetical xylazine test strip.

Methods

Between January to May 2021 in Philadelphia, PA, people who used fentanyl/heroin and had previously used fentanyl test strips were queried about xylazine and hypothetical xylazine test strips. Interviews were transcribed and analysis was conducted via conventional content analysis.

Results

Participants (7 spontaneously, 6 after probing, n = 13) discussed "tranq" (i.e., xylazine) in the fentanyl/heroin supply. None enjoyed tranq or wanted it in their fentanyl/heroin. Participants suspected xylazine saturation of the fentanyl/heroin market, disliked the sensation of the drug, and had safety concerns about xylazine exposure. Participants did not indicate concerns about overdose. All were interested in hypothetical xylazine test strips. While previous literature indicates that some people enjoy tranq in their fentanyl/heroin, our findings differed, with participants expressing concern about the consequences of undesired exposure. The interest expressed for xylazine test strips by people who use fentanyl/heroin is an important opportunity to center their voices in the development of innovations designed to mitigate the harms of unwanted adulterant exposure.

Conclusions

In the present study, people who use fentanyl/heroin indicated an interest to test their drug for the presence of xylazine prior to use.

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.

Development and validation of health system performance measures for opioid use disorder in British Columbia, Canada

BACKGROUND

Performance measurement provides an evidence-based means to inform development of interventions to improve the quality of care for people who use opioids. We aimed to develop and assess the predictive validity of health system performance measures for opioid use disorder (OUD) in British Columbia (BC), Canada.

METHODS

Performance measures were generated using retrospective population-level administrative datasets (both provincial and regional) and publicly-reported retrospective data according to four domains (care engagement, clinical guideline compliance, integration, and healthcare utilization). The adjusted odds ratio was estimated via generalized linear mixed models to determine predictive validity for all-cause hospitalization or mortality within 6 months of measurement.

FINDINGS

A total of 102 performance measures were constructed. We identified 55,470 diagnosed PWOUD, and 39,456 ever engaged in opioid agonist treatment (OAT). We found divergent rates of treatment for concurrent conditions (7.4% for alcohol use disorder to 80.1% for HIV/AIDS), low levels of linkage to OAT and other outpatient care following acute care, and increasing levels of service provision, including increases in OAT prescribers and pharmacies, naloxone kit distribution and overdose prevention site visitation. Our analyses on the predictive validity measures largely supported a priori hypotheses on the direction of effect on the outcome.

CONCLUSIONS

We identified a range of priorities to improve the quality of care for PWOUD, with critical gaps in linkage to care through acute care settings and long-term engagement in OAT. The proposed measures can be derived for geographic and clinical subgroups and updated over time, providing a basis to monitor and evaluate efforts to address the public health burden of OUD.

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.

The Bronze Age of drug checking: barriers and facilitators to implementing advanced drug checking amidst police violence and COVID-19

OBJECTIVES

Unpredictable fluctuations in the illicit drug market increase overdose risk. Drug checking, or the use of technology to provide insight into the contents of illicit drug products, is an overdose prevention strategy with an emerging evidence base. The use of portable spectrometry devices to provide point-of-service analysis of the contents of illicit drugs been adopted by harm reduction organizations internationally but is only emerging in the United States. This study aimed to identify barriers and facilitators of implementing drug checking services with spectrometry devices in an urban harm reduction organization and syringe service program serving economically marginalized people who use drugs in Boston, Massachusetts (USA).

METHODS

In-vivo observations and semi-structured interviews with harm reduction staff and participants were conducted between March 2019 and December 2020. We used the consolidated framework for implementation research to identify implementation barriers and facilitators.

RESULTS

This implementation effort was facilitated by the organization's shared culture of harm reduction-which fostered shared implementation goals and beliefs about the intervention among staff persons-its horizontal organizational structure, strong identification with the organization among staff, and strong relationships with external funders. Barriers to implementation included the technological complexity of the advanced spectroscopy devices utilized for drug checking. Program staff indicated that commercially available spectroscopy devices are powerful but not always well-suited for drug checking efforts, describing their technological capacities as "the Bronze Age of Drug Checking." Other significant barriers include the legal ambiguity of drug checking services, disruptive and oppositional police activity, and the responses and programmatic changes demanded by the COVID-19 pandemic.

CONCLUSIONS

For harm reduction organizations to be successful in efforts to implement and scale drug checking services, these critical barriers-especially regressive policing policies and prohibitive costs-need to be addressed. Future research on the impact of policy changes to reduce the criminalization of substance use or to provide explicit legal frameworks for the provision of this and other harm reduction services may be merited.

Simulating the impact of Addiction Consult Services in the context of drug supply contamination, hospitalizations, and drug-related mortality

BACKGROUND

Illicitly manufactured fentanyl (IMF) is increasing in international drug supply chains, and IMF-related opioid overdose deaths are rising in North America. Hospitalizations among patients with opioid use disorder (OUD) are also rising; and, hospitalized patients are at increased risk of overdose and death following hospital discharge. Hospitalization is a key opportunity to engage patients with OUD. Addiction consult services (ACS) can provide effective treatment for patients hospitalized with OUD. This study aims to estimate the effect of increasing IMF contamination on drug-related death among patients hospitalized with OUD, and simulate the role of ACS expansion to mitigate these effects.

METHODS

We used a Markov model to mirror care systems for adult patients hospitalized with OUD in Oregon, from the time of hospital admission through 12-months post-discharge, and simulated patients through modeled care systems to evaluate the expansion of Addiction Consult Services in the context of increasing IMF in the drug supply.

RESULTS

In a simulated cohort of 10,000 patients, we estimate that 537 patients would die from drug-related causes within 12-months of hospital discharge. In the context of increased IMF in the drug supply, this estimate increased to 913. ACS referral at baseline was 4%; increasing ACS referral to accommodate 10%, 50%, or 100% of hospitalized OUD patients in the state reduces drug-related deaths to 904, 849, and 780, respectively. The number needed to treat for ACS to avoid one drug-related death in the context of increased IMF was 73.

CONCLUSIONS

Hospitals should expand interventions to help reduce IMF-related opioid overdoses, including through implementation of ACS. In the context of rising IMF-related deaths, ACS expansion could help connect patients to treatment, offer harm reduction interventions, or both, which can help reduce the risk of opioid-related death.

Time-Series Analysis of Fentanyl Concentration in the Unregulated Opioid Drug Supply in a Canadian Setting

North America has been contending with an unregulated street drug supply in which opioids are often adulterated with illicitly manufactured fentanyl. The unpredictability of composition may result in an increased risk of overdose due to unexpected elevated concentrations of the high-potency drug. Using data from a community-based drug-checking project, we evaluated trends in fentanyl concentration of illicit opioids in the context of an overdose epidemic. Using a quantification model for fentanyl hydrochloride, historical Fourier-transform infrared spectra from opioid drug-checking samples were analyzed to determine fentanyl concentrations. Median monthly fentanyl concentrations were plotted, and polynomial and autoregressive time-series analyses were performed to examine trends over time. A total of 3,621 fentanyl-positive samples were included in the study, spanning November 2017 to December 2019. Monthly median fentanyl concentrations ranged from 4.5% to 10.4%. Time-series analyses indicated that a third-degree polynomial model fit the data well (R2 = 0.639), suggesting a cyclical pattern in median concentration over time. Notably, absolute variance in fentanyl concentration decreased by an average 0.1% per month (P < 0.001). Future research should explore the relationship between fentanyl concentration and overdose to identify potential targeted harm-reduction interventions that can respond to changes in observed fentanyl concentration.

Invited Commentary: Drug Checking for Novel Insights Into the Unregulated Drug Supply

Tobias et al. (Am J Epidemiol. 2022;191 (2):241–247) present a novel analysis of time trends in fentanyl concentrations in the unregulated drug supply in British Columbia, Canada. The preexisting knowledge about unregulated drugs had come from law-enforcement seizures and postmortem toxicology. As both of these data sources are subject to selection bias, large-scale drug-checking programs are poised to be a crucial component of the public health response to the unrelenting increase in overdose in North America. As programs expand, we offer 2 guiding principles. First, the primary purpose of these programs is to deliver timely results to people who use drugs to mitigate health risks. Second, innovation is needed to go beyond criminal justice paradigms in laboratory analysis for a more nuanced understanding of health concerns. We provide examples of the role adulterants play in our understanding of drug harms. We also describe the applications and limitations of common laboratory assays, with implications for epidemiologic surveillance. While the research and direct service teams in British Columbia have taken groundbreaking steps, there is still a need to establish best practices for communicating results to sample donors in an approachable yet nonalarmist tone.