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

BACKGROUND: Mortality related to opioid overdose in the U.S. has risen sharply in the past decade. In California, opioid overdose death rates more than tripled from 2018 to 2021, and deaths from synthetic opioids such as fentanyl increased more than seven times in those three years alone. Heightened attention to this crisis has attracted funding and programming opportunities for prevention and harm reduction interventions. Drug checking services offer people who use drugs the opportunity to test the chemical content of their own supply, but are not widely used in North America. We report on qualitative data from providers and clients of harm reduction and drug checking services, to explore how these services are used, experienced, and considered. METHODS: We conducted in-depth semi-structured key informant interviews across two samples of drug checking stakeholders: "clients" (individuals who use drugs and receive harm reduction services) and "providers" (subject matter experts and those providing clinical and harm reduction services to people who use drugs). Provider interviews were conducted via Zoom from June-November, 2022. Client interviews were conducted in person in San Francisco over a one-week period in November 2022. Data were analyzed following the tenets of thematic analysis. RESULTS: We found that the value of drug checking includes but extends well beyond overdose prevention. Participants discussed ways that drug checking can fill a regulatory vacuum, serve as a tool of informal market regulation at the community level, and empower public health surveillance systems and clinical response. We present our findings within three key themes: (1) the role of drug checking in overdose prevention; (2) benefits to the overall agency, health, and wellbeing of people who use drugs; and (3) impacts of drug checking services at the community and systems levels. CONCLUSION: This study contributes to growing evidence of the effectiveness of drug checking services in mitigating risks associated with substance use, including overdose, through enabling people who use and sell drugs to test their own supply. It further contributes to discussions around the utility of drug checking and harm reduction, in order to inform legislation and funding allocation.

The North American opioid epidemic: current challenges and a call for treatment as prevention.

There is a need for creative, public health-oriented solutions to the increasingly intractable problems associated with the North American opioid epidemic. This epidemic is a fundamentally continental problem, as routes of migration, drug demand, and drug exchange link the USA with Mexico and Canada. The challenges faced throughout North America include entrenched prescribing practices of opioid medications, high costs and low availability of medication-assisted treatment (MAT), and policy approaches that present substantial barriers to care.We advocate for the scale up of a low-threshold treatment model for MAT that incorporates the best practices in addiction treatment. Such a model would remove barriers to care through widespread treatment availability and affordability and also a policy of decriminalization. Given that MAT reduces the frequency of drug injecting among opioid injectors, this treatment model should also be guided by an understanding of the socially communicable nature of injection drug use, such that increasing MAT availability may also prevent the spread of injecting practices to individuals at risk of transitions from non-injection to injection drug use. To that end, the "Treatment as Prevention" model employed to respond to the individual- and population-level risks for HIV/AIDS prevention could be adapted to efforts to halt the North American opioid epidemic.

Commentary on Vorobjov et al., "Comparison of injection drug users who obtain syringes from pharmacies and syringe exchange programs in Tallinn, Estonia".

Recent data suggest that globally, between 5% and 10% of all new HIV cases are the result of unsafe injecting practices, and experts agree that reducing these practices is key to tackling the spread of HIV. And yet, despite the overwhelming evidence that providing sterile syringes to injection drug users (IDU) through syringe exchange programs (SEPs) or other means is an effective way of reducing HIV transmission among high-risk subpopulations, IDU in most settings still do not have access to sterile injecting equipment or if they do, access remains too restricted to effectively reduce the risk of HIV transmission. Vorobjov and colleagues have presented in this journal an interesting and timely study from Estonia comparing individuals who obtain syringes from SEPs and those who obtain syringes from pharmacies. As the authors point out, Estonia faces an unacceptably high HIV incidence rate of 50 new HIV cases per 100,000, this rate driven primarily by injection drug use. As such, the authors argue that Estonia's SEP network does not have the capacity to serve a growing IDU population at risk of transmitting HIV and pharmacy dispensation of clean syringes may be one potential approach to decreasing syringe sharing among high-risk injectors. It may be overly optimistic to consider the impact of higher threshold interventions such as pharmacy-based SEPs, given that IDU populations that engage in HIV risk behaviours such as syringe sharing are often hidden or hard to reach. Despite the need for a cautious approach, however, the findings presented by Vorobjov et al. may chart one potential course towards a more comprehensive societal response to reducing the health harms associated with injection drug use.

Drug treatment courts in Canada: an evidence-based review.

Drug treatment courts (DTCs), which are judicially mandated treatment alternatives to the incarceration of illicit drug offenders, were introduced in Canada in late 1998. Recent announcements from the federal government suggest that the drug treatment court model will continue to operate and expand in a number of Canadian jurisdictions. Two major evaluations of these programs--in Vancouver and Toronto--have been conducted. In this article, D. Werb et al. analyze the results of these evaluations. Their analysis reveals that, despite the evaluations, little is known regarding the success of DTCs in contributing to the long-term reduction of drug use and recidivism among their participants; and that the cost-effectiveness of these programs requires further study. The authors conclude that further funding for DTCs in Canada should be dependent on the implementation of randomized controlled trials that measure the success of these programs in reducing drug use and recidivism in the long term; that measure the impact of DTCs on societal end-points such as rates of crime and incarceration of injection drug users; and that include components to measure the cost-effectiveness of DTCs compared with other interventions aimed at reducing the negative effects of problematic drug use and drug-related crime.