An individual-based dynamic model to assess interventions to mitigate opioid overdose risk.

BACKGROUND: Illicit opioid overdose continues to rise in North America and is a leading cause of death. Mathematical modeling is a valuable tool to investigate the epidemiology of this public health issue, as it can characterize key features of population outcomes and quantify the broader effect of structural and interventional changes on overdose mortality. The aim of this study is to quantify and predict the impact of key harm reduction strategies at differing levels of scale-up on fatal and nonfatal overdose among a population of people engaging in unregulated opioid use in Toronto. METHODS: An individual-based model for opioid overdose was built featuring demographic and behavioural variation among members of the population. Key individual attributes known to scale the risk of fatal and nonfatal overdose were identified and incorporated into a dynamic modeling framework, wherein every member of the simulated population encompasses a set of distinct characteristics that govern demographics, intervention usage, and overdose incidence. The model was parametrized to fatal and nonfatal overdose events reported in Toronto in 2019. The interventions considered were opioid agonist therapy (OAT), supervised consumption sites (SCS), take-home naloxone (THN), drug-checking, and reducing fentanyl in the drug supply. Harm reduction scenarios were explored relative to a baseline model to examine the impact of each intervention being scaled from 0% use to 100% use on overdose events. RESULTS: Model simulations resulted in 3690.6 nonfatal and 295.4 fatal overdoses, coinciding with 2019 data from Toronto. From this baseline, at full scale-up, 290 deaths were averted by THN, 248 from eliminating fentanyl from the drug supply, 124 from SCS use, 173 from OAT, and 100 by drug-checking services. Drug-checking and reducing fentanyl in the drug supply were the only harm reduction strategies that reduced the number of nonfatal overdoses. CONCLUSIONS: Within a multi-faceted harm reduction approach, scaling up take-home naloxone, and reducing fentanyl in the drug supply led to the largest reduction in opioid overdose fatality in Toronto. Detailed model simulation studies provide an additional tool to assess and inform public health policy on harm reduction.

Barriers to, and Facilitators of, Checking Drugs for Adulterants in the Era of Fentanyl and Xylazine: Qualitative Study.

BACKGROUND: Overdose deaths continue to reach new records in New York City and nationwide, largely driven by adulterants such as fentanyl and xylazine in the illicit drug supply. Unknowingly consuming adulterated substances dramatically increases risks of overdose and other health problems, especially when individuals consume multiple adulterants and are exposed to a combination of drugs they did not intend to take. Although test strips and more sophisticated devices enable people to check drugs for adulterants including fentanyl and xylazine prior to consumption and are often available free of charge, many people who use drugs decline to use them. OBJECTIVE: We sought to better understand why people in the New York City area do or do not check drugs before use. We plan to use study findings to inform the development of technology-based interventions to encourage consistent drug checking. METHODS: In summer 2023, team members who have experience working with people who use drugs conducted 22 semistructured qualitative interviews with a convenience sample of people who reported illicit drug use within the past 90 days. An interview guide examined participants' knowledge of and experience with adulterants including fentanyl, xylazine, and benzodiazepines; using drug testing strips; and whether they had ever received harm reduction services. All interviews were audio recorded, transcribed, and analyzed for emerging themes. RESULTS: Most participants lacked knowledge of adulterants, and only a few reported regularly checking drugs. Reasons for not checking included lacking convenient access to test supplies, or a place to check samples out of the public's view, as well as time considerations. Some participants also reported a strong belief that they were not at risk from fentanyl, xylazine, or other adulterants because they exclusively used cocaine or crack, or that they were confident the people they bought drugs from would not sell them adulterated substances. Those who did report testing their drugs described positive interactions with harm reduction agency staff. CONCLUSIONS: New forms of outreach are needed not only to increase people's knowledge of adulterated substances and awareness of the increasing risks they pose but also to encourage people who use drugs to regularly check their substances prior to use. This includes new intervention messages that highlight the importance of drug checking in the context of a rapidly changing and volatile drug supply. This messaging can potentially help normalize drug checking as an easily enacted behavior that benefits public health. To increase effectiveness, messages can be developed with, and outreach can be conducted by, trusted community members including people who use drugs and, potentially, people who sell drugs. Pairing this messaging with access to no-cost drug-checking supplies and equipment may help address the ongoing spiral of increased overdose deaths nationwide.

The role of on-site drug analysis within supervised injecting facilities: A case presentation of an adverse event highlighting need.

INTRODUCTION: The Sydney Medically Supervised Injecting Centre provides a safe, non-judgemental space where people can inject pre-obtained substances under the supervision of trained staff. This article describes an unusual incident occurring at the Medically Supervised Injecting Centre in January 2023. CASE PRESENTATION: Two regular male clients attending the Medically Supervised Injecting Centre injected a substance they believed to be cocaine. Both clients experienced adverse reactions; one was transported to hospital, while the other became extremely distressed and agitated. Paraphernalia sent for testing returned a result of tiletamine (a dissociative used in veterinary medicine) and no cocaine, 30 h after the incident. DISCUSSION AND CONCLUSIONS: Where substances are novel or unknown, adverse events are often unexpected and may be more difficult to prepare for. Substance-induced acute agitation can be alarming and hazardous for people consuming drugs and those around them and may pose challenges for staff. There is a substantial evidence base for the benefits of on-site drug analysis and drug checking in reducing harms related to drug use, and in enhancing drug market monitoring. This incident was successfully managed by Medically Supervised Injecting Centre and hospital staff, with no major consequence, however clinical management could have been improved using point of care drug testing.

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.

Broad evidence of xylazine in the UK illicit drug market beyond heroin supplies: Triangulating from toxicology, drug-testing and law enforcement.

BACKGROUND AND AIMS: Xylazine is a non-opioid sedative which has spread rapidly throughout the US illicit drug supply. This study aimed to describe the spread of xylazine throughout the UK illicit drug supply. METHODS: Xylazine detections in human biological samples were collated from toxicology laboratories operating in the United Kingdom with the date, location, case type, xylazine concentration and co-detected drugs (with quantifications where performed) detailed, where permitted, by the corresponding coroner. Drug-testing cases positive for xylazine were collated from the Welsh Emerging Drugs and Identification of Novel Substances (WEDINOS) drug-testing postal service with the date, location, purchase intent and co-detected drugs detailed. Drug seizures made by UK law enforcement were communicated by the Office for Health Improvement and Disparities with the date and location detailed. RESULTS: By the end of August 2023, xylazine was detected in 35 cases from throughout toxicology, drug-testing and drug seizure sources covering England, Scotland and Wales. There were no cases reported from Northern Ireland. Xylazine was detected in biological samples from 16 people. In most cases where full toxicology results were provided, xylazine was detected with heroin and/or a strong opioid (n = nine of 11), but this polydrug use pattern was not evident in all cases (n = two of 11), suggesting a wider circulation of xylazine in the UK illicit drug market beyond heroin supplies. Evidence from WEDINOS supports this claim, as all 14 drug samples (100%) submitted from across the UK contained xylazine; however, in none of these cases was heroin the purchase intent but rather counterfeit prescription medication tablets (n = 11 of 14), tetrahydrocannabinol (THC) vapes (n = two of 14) or white powder (n = one of 14). Additional evidence for the spread of illicit xylazine comes from five drug seizures made by law enforcement. CONCLUSIONS: Xylazine has penetrated the UK illicit drug market and is not limited to heroin supplies.

Preventing Overdoses Involving Stimulants: The POINTS Study Protocol.

Background: In recent years, overdoses involving illicit cocaine, methamphetamine, and other stimulants have increased in the U.S. The unintentional consumption of stimulants containing illicit fentanyl is a major risk factor for overdoses, particularly in Massachusetts and Rhode Island. Understanding the drug use patterns and strategies used by people who use stimulants (PWUS) to prevent overdose is necessary to identify risk and protective factors for stimulant-involved overdoses. Mixed-methods research with people who distribute drugs (PWDD) can also provide critical information into the mechanisms through which fentanyl may enter the stimulant supply, and the testing of drug samples can further triangulate PWUS and PWDD perspectives regarding the potency and adulteration of the drug supply. These epidemiological methods can inform collaborative intervention development efforts with community leaders to identify feasible, acceptable, and scalable strategies to prevent fatal and non-fatal overdoses in high-risk communities. Methods: Our overall objective is to reduce stimulant and opioid-involved overdoses in regions disproportionately affected by the overdose epidemic. To meet this long-term objective, we employ a multi-pronged approach to identify risk and protective factors for unintentional stimulant and opioid-involved overdoses among PWUS, and use these findings to develop a package of locally tailored intervention strategies that can be swiftly implemented to prevent overdoses. Specifically, this study aims to [1] Carry out mixed-methods research with incarcerated and non-incarcerated people who use or distribute illicit stimulants to identify risk and protective factors for stimulant and opioid-involved overdoses; [2] Conduct drug checking to examine the presence and relative quantity of fentanyl and other adulterants in the stimulant supply; and [3] Convene a series of working groups with community stakeholders involved in primary and secondary overdose prevention in Massachusetts and Rhode Island to contextualize our mixed-methods findings and identify multilevel intervention strategies to prevent stimulant-involved overdoses. Discussion: Completion of this study will yield a rich understanding of the social epidemiology of stimulant and opioid-involved overdoses in addition to community-derived intervention strategies that can be readily implemented and scaled to prevent such overdoses in two states disproportionately impacted by the opioid and overdose crises: Massachusetts and Rhode Island.

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.

Beyond a spec: assessing heterogeneity in the unregulated opioid supply.

BACKGROUND: Drug checking services aim to provide compositional information for the illicit drug supply and are being employed in public health responses to extreme rates of overdose associated with fentanyl within street opioids. The technologies used within these services range from basic qualitative tests, such as immunoassay test strips, to comprehensive quantitative analyses, such as mass spectrometry. In general, there is concern that heterogeneity of a drug mixture adds significant uncertainty when using drug checking results based on a small subsamples. The presence of hot spots of active drug components in this context is often termed the 'chocolate chip cookie effect'. Establishing the limitations of the service are essential for interpretation of the results. METHODS: This study assesses the consequence of drug heterogeneity and sampling of consumer level opioid purchased in Victoria, British Columbia ( n = 21 , 50-100 mg each) on quantitative fentanyl results determined from testing with paper spray mass spectrometry. RESULTS: Using descriptive statistics, such as relative standard deviation and interquartile range, the results demonstrate varied distributions of fentanyl concentrations within a single drug batch. However, the presence of hot spots, defined as outliers, were relatively rare. CONCLUSIONS: This study found that the variability in fentanyl concentration from drug heterogeneity and sampling is greater than that attributed to the analytical technique. On a practical level, this provides data to help guide communication of limitations of drug checking services, supporting the aim of trust and transparency between services and people who use drugs. However, if drug checking services continue to be restricted from fully engaging with the reality of manufacturing, buying, selling, mixing and dosing practices, the accuracy, usefulness, and impact will always be limited.

Increases in the use of drug testing kits among nightclub and festival attendees in New York City who use ecstasy, 2017-2022.

INTRODUCTION: Ecstasy (3,4-methylenedioxymethamphetamine [MDMA]) is a drug commonly used by people who attend electronic dance music (EDM) events at nightclubs and dance festivals. Drug checking has gained popularity in recent years to test for adulterants, but epidemiology studies are needed to estimate potential shifts in prevalence of drug checking to further inform harm reduction efforts. METHODS: Adults entering randomly selected EDM events in New York City were surveyed in 2017 and 2022. Those reporting past-year ecstasy use were asked if they tested their ecstasy in the past year using a drug testing kit and whether they found out or suspected their ecstasy contained other drugs. We compared estimates between 2017 and 2022. RESULTS: In 2017, an estimated 23.1% had tested their ecstasy, and this estimate increased to 43.1% in 2022 (86.6% increase, p = 0.006). Among those who tested their ecstasy, in 2017, 31.2% always tested their drug, and this increased to 60.6% in 2022 (94.2% increase, p = 0.026). In 2017, 59.6% of those who tested their ecstasy reported finding out or suspecting their drug was adulterated, which decreased to 18.4% in 2022 (69.1% decrease, p < 0.001). Suspected methamphetamine adulteration in particular decreased, from 21.9% in 2017 to 3.6% in 2022 (83.6% decrease, p = 0.007). DISCUSSION AND CONCLUSIONS: The use of drug testing kits has increased among EDM event attendees who use ecstasy and, at the same time, among those who had tested their ecstasy, suspected adulteration has decreased. Continued interest in understanding ecstasy contents among this population suggests the need for formal drug checking services.

Identification of three unexpected new psychoactive substances at an Australian drug checking service.

Drug checking is a harm reduction measure that provides people with the opportunity to confirm the identity and purity of substances before consumption. The CanTEST Health and Drug Checking Service is Australia's first fixed-site drug checking service, where clients can learn about the contents of the samples they provide while receiving tailored harm reduction and health advice. Three samples were recently presented to the service with the expectation of 4-fluoromethylphenidate (4F-MPH) 1, methoxetamine (MXE) 2 and 3-methylmethcathinone (3-MMC) 3. The identity of all three samples did not meet these expectations and remained unknown on-site, as no high confidence identifications were obtained. However, further analysis by nuclear magnetic resonance spectroscopy, high resolution gas chromatography-electron ionisation-mass spectrometry and liquid chromatography-electrospray ionisation-mass spectrometry at the nearby Australian National University allowed for the structure elucidation of the three samples as 4-fluoro-α-pyrrolidinoisohexanophenone (4F-α-PiHP) 4, 1-(4-fluorobenzyl)-4-methylpiperazine (4F-MBZP) 5 and N-propyl-1,2-diphenylethylamine (propylphenidine) 6, respectively. Given all three samples were not of the expected identity and have not yet been described as new psychoactive substances in the literature, this study presents a full characterisation of each compound. As exemplified by this rapid identification of three unexpected new psychoactive substances, drug checking can be used as an effective method to monitor the unregulated drug market.

Factors associated with obtaining prescribed safer supply among people accessing harm reduction services: findings from a cross-sectional survey.

BACKGROUND: With growing rates of unregulated drug toxicity death and concerns regarding COVID-19 transmission among people who use drugs, in March 2020, prescribed safer supply guidance was released in British Columbia. This study describes demographic and substance use characteristics associated with obtaining prescribed safer supply and examines the association between last 6-month harm reduction service access and obtaining prescribed safer supply. METHODS: Data come from the 2021 Harm Reduction Client Survey administered at 17 harm reduction sites across British Columbia. The sample included all who self-reported use of opioids, stimulants, or benzodiazepines in the prior 3 days (N = 491), given active use of these drugs was a requirement for eligibility for prescribed safer supply. The dependent variable was obtaining a prescribed safer supply prescription (Yes vs. No). The primary independent variables were access to drug checking services and access to overdose prevention services in the last 6 months (Yes vs. No). Descriptive statistics (Chi-square tests) were used to compare the characteristics of people who did and did not obtain a prescribed safer supply prescription. Multivariable logistic regression models were run to examine the association of drug checking services and overdose prevention services access with obtaining prescribed safer supply. RESULTS: A small proportion (n = 81(16.5%)) of the sample obtained prescribed safer supply. After adjusting for gender, age, and urbanicity, people who reported drug checking services access in the last 6 months had 1.67 (95% CI 1.00-2.79) times the odds of obtaining prescribed safer supply compared to people who had not contacted these services, and people who reported last 6 months of overdose prevention services access had more than twice the odds (OR 2.08 (95% CI 1.20-3.60)) of prescribed safer supply access, compared to people who did not access these services. CONCLUSIONS: Overall, the proportion of respondents who received prescribed safer supply was low, suggesting that this intervention is not reaching all those in need. Harm reduction services may serve as a point of contact for referral to prescribed safer supply. Additional outreach strategies and service models are needed to improve the accessibility of harm reduction services and of prescribed safer supply in British Columbia.

In Support of Community Drug Checking Programs: Position Statement of AMERSA, Inc. (Association for Multidisciplinary Education and Research in Substance use and Addiction).

BACKGROUND: Position statements clarify key issues that are in alignment with the vision, mission, and values of the AMERSA, Inc. (Association for Multidisciplinary Education and Research in Substance use and Addiction). This Position Statement, endorsed by the AMERSA Board of Directors on October 3, 2023, amplifies the position of the organization, guides their activities, and informs the public and policymakers on the organization's stance on this issue. ISSUE: The unregulated drug supply in the United States evolves constantly, leaving those who use drugs potentially unaware of new adulterants in their drugs. Not knowing that information can leave people vulnerable to serious adverse events such as fatal overdoses, wounds, and other health consequences. Without real-time data on the composition of drugs available in a community, healthcare providers and public health practitioners are left with insufficient data, making it increasingly difficult to know how to best serve people who use drugs. In this context, community-based drug checking has become recognized as an important harm reduction strategy with the potential to provide those who use drugs with more information about their supply. RECOMMENDATIONS: It is imperative to expand funding and increase access to drug checking programs in communities across the United States. Key policy changes, such as those related to decriminalizing drug and drug paraphernalia possession, are needed to increase the utilization of drug checking programs. Protection of persons who use drugs through harm reduction strategies, including drug checking programs needs to be widely available and accessible.

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

BACKGROUND: Adulterants, such as fentanyl and xylazine, among others, are present in a high percentage of the illicit drug supply, increasing the risk for overdose and other adverse health events among people who use drugs (PWUD). Point-of-care drug checking identifies components of a drug sample and delivers results consumers. To successfully meet the diverse needs of PWUD, more information is needed about the utility of drug checking, motivations for using services contextualized in broader comments on the drug supply, hypothesized actions to be taken after receiving drug checking results, and the ideal structure of a program. METHODS: In December 2021, semi-structured interviews were conducted with 40 PWUD who were accessing harm reduction services in Philadelphia, PA. Participants were asked about opinions and preferences for a future drug checking program. Interviews were audio recorded, transcribed and coded using content analysis to identify themes. RESULTS: Participants were primarily White (52.5%) and male (60%). Heroin/fentanyl was the most frequently reported drug used (72.5%, n = 29), followed by crack cocaine (60.0%, n = 24) and powder cocaine (47.5%, n = 19). Emerging themes from potential drug checking consumers included universal interest in using a drug checking program, intentions to change drug use actions based on drug checking results, deep concern about the unpredictability of the drug supply, engaging in multiple harm reduction practices, and concerns about privacy while accessing a service. CONCLUSIONS: We offer recommendations for sites considering point-of-care drug checking regarding staffing, safety, logistics, and cultural competency. Programs should leverage pre-existing relationships with organizations serving PWUD and hire people with lived experiences of drug use. They should work with local or state government to issue protections to people accessing drug checking programs and ensure the service is anonymous and that data collection is minimized to keep the program low-threshold. Programs will ideally operate in multiple locations and span "atmosphere" (e.g., from clinical to a drop-in culture), offer in-depth education to participants about results, engage with a community advisory board, and not partner with law enforcement.

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

BACKGROUND: Drug checking services (DCS) provide harm reduction support and advice to individuals based on chemical analysis of submitted substances of concern. Whilst there are currently no DCS in Scotland, community-based services are being planned in three cities. METHODS: In this paper, we report qualitative findings based on interviews with 43 participants, focused on perceptions of DCS and their implementation. Participants were relevant professionals, those with experience of drug use, and family members of those with experience of drug use. The Consolidated Framework for Implementation Research (CFIR) was used to inform data collection and analysis. We report findings under nine constructs/themes across the five CFIR domains. RESULTS: Participants noted the importance of DCS being implemented in low-threshold, trusted services with a harm reduction ethos, and outlined a range of further service design considerations such as speed of testing, and information provided through the analysis process. In relation to the 'inner setting', a key finding related to the potential value of leveraging existing resources in order to expand both reach and effectiveness of drug trend communication. The approach of local and national police to DCS, and the attitudes of the public and local community, were described as important external factors which could influence the success (or otherwise) of implementation. Bringing together a range of stakeholders in dialogue and developing tailored communication strategies were seen as ways to build support for DCS. Overall, we found high levels of support and perceived need for DCS amongst all stakeholder groups. CONCLUSIONS: Our findings present initial implementation considerations for Scotland which could be further explored as DCS are operationalised. Further, our focus on implementation contexts is relevant to research on DCS more generally, given the minimal consideration of such issues in the literature.

Making Harm Reduction More Accessible: Fentanyl Test Strip Awareness and Attitudes among Emergency Department Patients Who Use Drugs.

BACKGROUND: Fentanyl test strips (FTS) are a harm reduction method for people to test their drugs for fentanyl. Ideal points for FTS distribution have not been identified. Many people who use drugs have frequent contact with the Emergency Department (ED). We piloted FTS distribution in two urban hospital EDs. METHODS: Between June-December 2021 in Philadelphia, PA, patients with past 30-day drug use completed a survey about drug use, fentanyl attitudes, and FTS; then offered FTS and a brief training. Survey data were analyzed using SPSS for bivariate statistics. RESULTS: Patients (n = 135) were primarily White (68.1%) and male (72.6%). Participants regularly interacted with substance use (57.8%) and benefits coordination (49.6%) services. The most common drugs used were heroin/fentanyl (68.9%), crack cocaine (45.2%) and cannabis (40.0%). Most (98.5%) had heard of fentanyl though few (18.5%) had ever used FTS. Across most drug types, participants were concerned about fentanyl. All accepted FTS training and distribution. Few (9.6%) were somewhat or very concerned about having FTS if stopped by police and this number varied by race (7.6% of White people were somewhat or very concerned, compared to 12.8% of Black people). Most participants were already engaged in risk reduction practices. DISCUSSION: FTS are a widely desired harm reduction tool to facilitate informed decision-making, and non-harm reduction locations are potentially feasible and acceptable distribution sites. Given regular contact with EDs and social services across the sample, FTS should be offered at non-harm reduction locations that come into frequent contact with people who use drugs.

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.

Testing the test strips: laboratory performance of fentanyl test strips.

BACKGROUND: The overdose crisis driven by synthetic opioids continues to escalate in the USA. We evaluated the efficacy of multiple manufacturing lots of a fentanyl test strip (FTS) to detect fentanyl and fentanyl analogs and assessed cross-reactivity with possible interferences. METHODS: Drug standards were dissolved in water in a laboratory setting and serially diluted. Drug dilutions were tested using five different manufacturing lots of BTNX Rapid Response (20 ng/mL cutoff) lateral flow chromatographic immunoassay strips to assess lot-to-lot variability for FTS sensitivity and cross-reactivity for the analytes of interest. RESULTS: All five manufacturing lots cross-reacted with fentanyl and eleven fentanyl analogs. Diphenhydramine, lidocaine, MDMA, and methamphetamine were found to cause false positives with the strips. There was notable lot-to-lot variability in the sensitivity of the strips for fentanyl, fentanyl analogs, and known interferences. DISCUSSION: FTS remains an important overdose prevention tool, but lot-to-lot variability in performance complicates robust instructions that balance the prevention of false positives and false negatives. Continued lot-to-lot performance assessment is recommended to ensure health education for FTS remains accurate. More sophisticated drug checking technologies and services are needed in the community landscape to augment personal FTS use to facilitate informed consumption and overdose risk mitigation.

Toward automated infrared spectral analysis in community drug checking.

The body of knowledge surrounding infrared spectral analysis of drug mixtures continues to grow alongside the physical expansion of drug checking services. Technicians trained in the analysis of spectroscopic data are essential for reasons that go beyond the accuracy of the analytical results. Significant barriers faced by people who use drugs in engaging with drug checking services include the speed and accuracy of the results, and the availability and accessibility of the service. These barriers can be overcome by the automation of interpretations. A random forest model for the detection of two compounds, MDA and fluorofentanyl, was trained and optimized with drug samples acquired at a community drug checking site. This resulted in a 79% true positive and 100% true negative rate for MDA, and 61% true positive and 97% true negative rate for fluorofentanyl. The trained models were applied to selected drug samples to demonstrate a proposed workflow for interpreting and validating model predictions. The detection of MDA was demonstrated on three mixtures: (1) MDMA and MDA, (2) MDA and dimethylsulfone, and (3) fentanyl, etizolam, and benzocaine. The classification of fluorofentanyl was applied to a drug mixture containing fentanyl, fluorofentanyl, 4-anilino-N-phenethylpiperidine, caffeine, and mannitol. Feature importance was calculated using shapely additive explanations to better explain the model predictions and k-nearest neighbors was used for visual comparison to labelled training data. This is a step toward building appropriate trust in computer-assisted interpretations in order to promote their use in a harm reduction context.