Pill testing or drug checking in Australia: Acceptability of service design features

Comparison of strength and adulteration between illicit drugs obtained from cryptomarkets versus off-line

BACKGROUND AND AIMS

Drugs sold on cryptomarkets are thought to have lower levels of adulteration and higher strength compared with those sourced off-line. The present study aimed to determine whether cryptomarket and off-line-sourced 3,4-methylenedioxy-N-methamphetamine (MDMA), cocaine, amphetamine, methamphetamine and lysergic acid diethylamide (LSD) differed in adulteration and strength.

DESIGN AND SETTING

A between-groups design was used to compare cryptomarket versus off-line-sourced drugs. Regression analyses controlling for year and service were conducted. Drug-checking services were conducted in Spain (Energy Control) and the Netherlands (Drugs Information and Monitoring System).

CASES

The cases comprised drug samples that underwent drug checking between 2016 and 2021 and were expected to contain MDMA (tablets; n = 36 065; powder: n = 6179), cocaine (n = 11 419), amphetamine (n = 6823), methamphetamine (n = 293) and LSD (n = 1817).

MEASUREMENTS

Drugs were measured for (1) matching the advertised substance (i.e. containing any amount of the expected substance); (2) strength; (3) presence of adulteration; and (4) number of adulterants.

FINDINGS

The expected drug was more likely to be identified when sourced from cryptomarkets versus off-line for MDMA tablets [adjusted odds ratio (AOR) = 2.10, 95% confidence interval (CI) = 1.28-3.43], MDMA powder (AOR = 2.64, CI = 1.55-4.51), cocaine (AOR = 3.65, CI = 1.98-6.71) and LSD (AOR = 1.75, CI = 1.13-2.72). Cryptomarket-sourced MDMA powder (β = 0.03, P = 0.012), cocaine (β = 0.08, P < 0.001) and methamphetamine (β = 0.15, P = 0.028) were statistically significantly higher in strength than substances from off-line sources. Conversely, MDMA tablets (β = -0.01, P = 0.043) and amphetamine (β = -0.07, P < 0.001) from cryptomarkets were statistically significantly lower in strength than from off-line sources. MDMA powder (AOR = 0.53, CI = 0.33-0.86) and cocaine (AOR = 0.66, CI = 0.55-0.79) were statistically significantly less likely to be adulterated if sourced from cryptomarkets. However, amphetamine (AOR = 1.54, CI = 1.25-1.90) and LSD (AOR = 1.31, CI = 1.00-1.71) were found to be more likely to be adulterated when purchased from cryptomarkets. Cocaine from cryptomarkets exhibited fewer adulterants (incidence rate ratio = 0.71, CI = 0.60-0.85).

CONCLUSION

The relationship between on-line drug market-places and substance quality varies depending on both the specific substance and the dynamics of the cryptomarket.

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.

Harm reduction behaviours and harm experiences of people who use 3,4-methylenedioxymethamphetamine (MDMA) in Aotearoa New Zealand

BACKGROUND

3,4-Methylenedioxymethamphetamine (MDMA) is drug of high prevalence in Aotearoa New Zealand and is the primary drug analysed by legal drug checking services. We aimed to address the gap in literature pertaining to MDMA-related harm reduction behaviour and harm experiences within the country.

METHODS

An online survey was used to assess the harm reduction behaviours (e.g., limiting consumption, planning use, seeking information) of people who use MDMA, in addition to their use of reagent testing and the major national drug checking and harm reduction service, KnowYourStuffNZ.

RESULTS

In total, 915 people completed the survey (60.7% females, aged 18-65, median = 24, IQR = 20-28). Frequency of various MDMA-related harm reduction behaviours differed, although these were carried out relatively frequently by most participants. Those who reported experiencing harm (physical, psychological, spiritual, social) from MDMA, or another drug presumed to be MDMA, reported less frequent harm reduction behaviours than non-harmed consumers. Reagent testing of MDMA had been conducted by 42.3% of the sample. Approximately 27% of the sample had used KnowYourStuffNZ services. Of KnowYourStuffNZ clients, 95.9% reported learning about harm reduction, and 53.3% reported changing their behaviour because of the service. Reasons for not using the KnowYourStuffNZ service were primarily lack of availability in local area (32.8%) or at relevant events (51.8%), and lack of concern with substance quality (29.8%). MDMA harm was reported by 14.4% of the sample, whilst reported harm was more common from consumption of presumably non-MDMA substances, self-reported as being mistaken for MDMA. Harm was primarily physical or psychological. Potential MDMA dependence was apparent in 6.9% of the sample.

CONCLUSIONS

The findings highlight potential targets for harm reduction education and interventions and emphasize the need for greater availability of readily accessible drug checking services in Aotearoa New Zealand.

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.

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.

Exploring the Decision-Making Process behind Illicit Drug Use at Music Festivals

Background: Illicit substance use is common at music festivals. One could question whether festival attendees deliberately plan to take drugs at such events or whether their illicit (poly)drug use is provoked by specific circumstances, such as the presence of peers or a general belief that others are using drugs at the festival. Objectives: The present study implemented the prototype willingness model, which is a model that assesses whether illicit drug use at music festivals is rather a rational or a more spontaneous decision-making process. Results: A three-wave panel survey was conducted, questioning festival attendees before (n = 304, 60.86% males), during, and after music festival visits. In total, 186 people (59.68% males) between 18 and 55 years (M = 27.80 years; SD = 8.19) completed all three surveys, of which 62.9% had taken one or more different illicit substances at the festival. Positive attitudes toward illicit drug consumption were most firmly related to attendees' intentions to take drugs at festivals. Additionally, the more festival visitors identified themselves with the prototype of an attendee using drugs, the more likely they were to be willing to use them. The perceived presence of illicit substances at such events was also strongly related to the actual behavior. Conclusion: The findings suggest that illicit drug use at music festivals relates to both a rational choice and an unplanned one.

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.

Exploring the subjective experience of rave party participants in Israel who consume psychedelic drugs: a qualitative inquiry

BACKGROUND

Rave music parties (RMP) are a world-wide socio-cultural phenomenon, where people listen to rave music while frequently consuming psychedelic drugs. Epidemiological studies have emphasized the hazardous consequences following the consumption of psychedelic drugs at RMP, and qualitative studies have shown social and psycho-spiritual experiences. Yet, phenomenological inquiry into subjective experiences of attendees is scant. This study aimed to examine physical, emotional, perceptual and social experiences of RMP participants in Israel, and their view on Israel's policy toward rave events. In addition, the study aimed to contribute useful information for policymakers and society on rave music and psychedelic drugs experiences at RMP.

METHOD

Interpretative phenomenological analysis was used to analyze transcriptions of semi-structured interviews with 27 individuals attending RMP regularly and consume psychedelic drugs.

RESULTS

Analysis revealed four significant themes: the first theme, the impact of Israel's drug policy on participants' sense of safety, relates to participants' sense of insecurity and anxiety at Israeli RMP due to government drug ban policy. The second theme, the stigma on rave culture, relates to participants' perception regarding the stigma on rave culture in law enforcement agencies and in society in general. The third theme, negative experiences, describes short-term experiences after consuming psychedelics at RMP, including hallucinations and disorientation. The fourth theme, positive experiences, describes positive sensory, emotional and self/world attitudinal aspects after consuming psychedelics at RMP. Sensory experiences included intensified auditory, visual and tactile experiences; emotional experiences included positive feelings toward others, reduced stress and ability to vent difficult emotions; self/world attitudinal aspects included self-acceptance, higher appreciation of life and connectedness to nature.

CONCLUSIONS

The study highlights RMP participants' sense of insecurity due to Israel's strict drug policy and absence of harm reduction strategies at rave scenes. The study also notes participants' experience of stigmatization as drug addicts by society and law enforcement agencies. Reducing police presence and adopting harm reduction policies at rave scenes in Israel may increase participants' sense of security, reduce stigmatization and decrease overdose risk. Hence, the findings may contribute to new knowledge useful for policymakers and society concerning RMP and the use of psychedelics.

A qualitative assessment of key considerations for drug checking service implementation

BACKGROUND

With many drug-related deaths driven by potent synthetic opioids tainting the illicit drug supply, drug checking services are becoming a key harm reduction strategy. Many drug checking technologies are available, ranging from fentanyl test strips to mass spectrometry. This study aimed to identify key considerations when implementing drug checking technologies and services to support harm reduction initiatives.

METHODS

Key informant interviews were conducted with harm reduction stakeholders throughout Illinois. Participants included members of existing drug checking services and recovery centers. Interviews were recorded, transcribed, and coded by two researchers using the framework method. Findings were contextualized according to micro (client)-, meso (organization)-, and macro (policy)-level themes.

RESULTS

Seven interviews were conducted with ten participants. Fourier transform infrared spectroscopy was consistently identified as a technology of choice given its accuracy, range of substance detection, portability, and usability. Recommendations included the use of confirmatory testing, which can help address the limitations of technologies and provide a mechanism to train technicians. Locations of drug checking services should maximize public health outreach and leverage existing harm reduction agencies and staff with lived experience, who are critical to developing trust and rapport with clients. Criminalization and loss of privacy were major concerns for clients using drug checking services. Additional issues included the need to raise awareness of the legitimacy of services through public support from governing bodies, and funding to ensure the sustainability of drug checking services.

CONCLUSIONS

This research facilitated the identification of issues and recommendations from stakeholders around key considerations for the adoption of drug checking technologies, which not only included the cost and technical specifications of instrumentation, but also broader issues such as accessibility, privacy, and well-trained personnel trusted by clients of the service. Successful implementation of drug checking services requires knowledge of local needs and capacity and an in-depth understanding of the target population.

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.

Who supports drug-checking services in Australia? An analysis of 2019 National Drug Strategy Household Survey data

INTRODUCTION

Drug-checking services can minimise the potential harms from drug use and have received increased attention in recent policy debates in Australia. In this brief report, we aim to better understand the prevalence of support for drug-checking services among individuals of certain demographic groups, social status and social attitudes towards drug and alcohol policy.

METHODS

This report uses data from the 2019 National Drug Strategy Household Survey, a national population study of alcohol and other drug use conducted triennially in Australia. We examined support for drug-checking services descriptively, alongside associations between demographic, social and substance use variables and support of drug-checking using Generalised Linear Model analyses with a Poisson distribution and log link.

RESULTS

Overall, 56% of the sample supported policies related to drug-checking services. Support was highest among those aged 25-34 years (62%), most socioeconomically advantaged (66%), with an income over $104,000 (64%), with a bachelor's degree or higher (65%), living in major cities (58%), recent consumers of commonly tested drugs (88%) and other drugs (77%), and risky drinkers (64%). In the multivariable model, those who were younger, women and had the highest level of education were more likely to support the policy compared to those who were aged 55+ years, men and had lower levels of education.

DISCUSSION AND CONCLUSION

This report highlights that, while there were different degrees of support based on demographic characteristics, substance use status and social attitudes towards drug and alcohol policy, the overall majority of the sample supported the provision of drug-checking services.

"They sent it away for testing and it was all bunk": Exploring perspectives on drug checking among steroid consumers in Queensland, Australia

INTRODUCTION

Research supports the feasibility and acceptance of drug checking among nightlife and festival attendees. Interest in expanding drug checking to other groups of people who use drugs, including those who inject drugs, has grown. However, understanding the acceptability and feasibility of drug checking among specific cohorts, like anabolic-androgenic steroids (AAS) consumers, remains a research gap. This study explores AAS consumers' perspectives on drug checking and service preferences, aiding the preparation for drug checking delivery in Queensland, Australia.

METHODS

A purposive sampling technique was used to recruit 15 AAS consumers (9 males, 6 females; Mage = 36.80 years, SD = 6.12) from Australia. One-on-one semi-structured qualitative interviews were conducted with questions exploring participants' views on drug checking/testing and their preferences for AAS analysis. Thematic analysis was conducted with final themes established through iterative consensus.

RESULTS

Consumers expressed frustration with the prevailing stereotypes, social stigma, and the perception of criminality associated with the use of AAS. There was a strong dependence on personal connections and trusted suppliers, with coaches exerting significant influence. Participants expressed concerns about the widespread availability of counterfeit products and underground operations. The act of using unknown AAS was likened to a game of Russian roulette, underscoring the importance of obtaining accurate information and access to reliable drug checking services. Consumers expressed a preference for a web-based platform that enables individuals to access their own test results while contributing to a comprehensive database of brand-specific testing outcomes.

DISCUSSION

AAS consumers recognise the significance of monitoring their AAS use and seek a service that can not only assist them in making informed decisions regarding AAS usage but also potentially contribute to the knowledge of the wider AAS-consuming community. These findings underscore the importance of tailored education, drug checking services, and harm reduction measures to address the diverse needs of AAS consumers.

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.

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.

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.

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

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

Music festival drug checking: evaluation of an Australian pilot program

BACKGROUND

This paper explores the feasibility of delivering a music festival-based drug checking service in Australia, evaluating service design and stakeholder acceptability.

METHODS

Questionnaire and interview data were collected from adult service users and key stakeholders. A mixed methods approach was used to analyse the data on implementation, impact and acceptability.

RESULTS

The trial service tested 170 substances with more than 230 patrons (including individuals who attended in groups). Adult service users had an average age of 21 years. Voluntary participation in the evaluation resulted in 158 participants completing the pre-service questionnaire, most of whom also completed the post-service (147 participants). Eleven in-depth qualitative interviews were conducted with patrons in the weeks following the drug checking. Concordance between what the patron expected the drug to be and drug checking results occurred in 88 per cent (n = 139) of the sample. Evaluation results show that the experience of testing and the accompanying harm reduction brief interventions positively impacted on patrons' self-reported drug harm reduction knowledge, trust of health providers and stated drug use intentions. The service was received positively by service users.

CONCLUSION

This is the first independent evaluation of a pilot drug checking service in Australia. Consideration of operational feasibility and self-reported behavioural change suggests that the program was successful, although communication about the interpretation of drug checking results could be improved. Future studies should develop strategies for follow-up and consider the applicability of behavioural change theory.

Implementation and Uptake of the Massachusetts Drug Supply Data Stream: A Statewide Public Health-Public Safety Partnership Drug Checking Program

CONTEXT

The illicit drug supply is rapidly evolving. Equally important to gathering drug supply data for monitoring is timely sharing of information with people who use drugs, the providers who care for them, law enforcement partners, and public health stakeholders so that efforts to avoid harmful substances, take preventive actions, and better target interventions can occur.

PROGRAM

The Massachusetts Drug Supply Data Stream (MADDS) is the country's first statewide community drug checking program. Founded on public health-public safety partnerships, MADDS collects remnant drug packaging and paraphernalia with residue from people who use drugs and noncriminal samples from partnering police departments. MADDS tests samples using simultaneous immunoassay fentanyl test strips, Fourier-transform infrared spectrometry (FTIR), and off-site laboratory testing by gas chromatography-mass spectrometry (GC/MS). Results are accessible to community programs and municipalities, while trend analyses inform public health for cross-site alerts and informational bulletins.

IMPLEMENTATION

MADDS was launched statewide in 2020 and rapidly expanded to a multisite program. Program staff approached communities and met with municipal police and community partners to secure written agreements to host drug checking. Community partners designed sample collection consistent with their pandemic era workflows. Consultations with stakeholders gathered feedback on design and deliverables.

EVALUATION

The program tests sample donations on-site from community agencies and police departments, incorporates review by a medical toxicologist for health and safety concerns, crafts stakeholder-specific communications, and disseminates English, Spanish, and Portuguese language materials. For 2020, a total of 427 samples were tested, of which 47.1% were positive for fentanyl. By early 2021, MADDS detected shifts in cocaine purity, alerted communities of a new toxic fentanyl analogue and a synthetic cannabinoid contaminant, and confirmed the increase of xylazine (a veterinary sedative) in Massachusetts.

DISCUSSION

Community drug checking programs can be collaboratively designed with public health and public safety to generate critical health and safety information for people who use drugs and the communities where they live.

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.

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.

Microdosing psychedelics: Subjective benefits and challenges, substance testing behavior, and the relevance of intention

BACKGROUND

Microdosing psychedelics is the practice of taking small, sub-hallucinogenic doses of lysergic acid diethylamide or psilocybin-containing mushrooms. Despite its surging popularity, little is known about the specific intentions to start microdosing and the effects of this practice.

AIMS

First, we aimed to replicate previous findings regarding the subjective benefits and challenges reported for microdosing. Second, we assessed whether people who microdose test their substances before consumption. Third, we examined whether having an approach-intention to microdosing was predictive of more reported benefits.

METHODS

The Global Drug Survey runs the world's largest online drug survey. Participants who reported last year use of lysergic acid diethylamide or psilocybin in the Global Drug Survey 2019 were offered the opportunity to answer a sub-section on microdosing.

RESULTS

Data from 6753 people who reported microdosing at least once in the last 12 months were used for analyses. Our results suggest a partial replication of previously reported benefits and challenges among the present sample often reporting enhanced mood, creativity, focus and sociability. Counter to our prediction, the most common challenge participants associated with microdosing was 'None'. As predicted, most participants reported not testing their substances. Counter to our hypothesis, approach-intention - microdosing to approach a desired goal - predicted less rather than more benefits. We discuss alternate frameworks that may better capture the reasons people microdose.

CONCLUSION

Our results suggest the perceived benefits associated with microdosing greatly outweigh the challenges. Microdosing may have utility for a variety of uses while having minimal side effects. Double-blind, placebo-controlled experiments are required to substantiate these reports.

Drug use, harm-reduction practices and attitudes toward the utilisation of drug safety testing services in an Irish cohort of festival-goers

BACKGROUND

Festival drug-related deaths are a growing public health concern.

AIM

To examine drug use and related harm-reduction practices and attitudes towards utilisation of drug safety testing services.

METHODS

Data collection took place over the 2019 festival season (June-October). The questionnaire was self-reported. Data was gathered via the online survey, which was promoted through online and social media platforms and outlets. Social media communication methods were used to reach the targeted population more effectively.

RESULTS

A total of 1193 Irish festival attendees over the age of 18 completed an anonymous online survey. Alcohol, MDMA powder/crystals, ecstasy pills and cocaine were the highest reported drugs used by Irish festival attendees. The vast majority of participants reported polysubstance use (86.8%/n = 1036). Forty percent of participants (39.98%/n = 477) reported having had sex following the use of a drug at a festival; of these, 66% (n = 316) said that the sex was unprotected. Most participants (84.0%/n = 1003) engaged in some form of harm reduction when taking drugs at festivals. Overwhelmingly, participants reported a willingness to engage with drug-checking services. The vast majority (96.3%; n = 1149) and would use drug checking services more than three-quarters (75.1%/n = 897) reported that they would use an 'amnesty bin' for drugs if it were part of an alert system to notify if dangerous drugs are in circulation. A chi-square test of Independence was conducted to examine whether age and utilisation of drug safety testing service a festival were independent. Moreover, when all cases are taken together, the difference between testing modalities (onsite, offsite and amnesty bin) shows a significant difference p < 001 between those who would use onsite and offsite drug testing facilities.

CONCLUSION

The evidence from this survey indicates that those young people who use drugs at festivals would be prepared to utilise drug checking services and amnesty bins should help inform the public health response to this important area.

What About Drug Checking? Systematic Review and Netnographic Analysis of Social Media

Drug checking services have been operating worldwide as a harm reduction tool in places like festivals and night clubs. A systematic review and netnographic analysis were conducted to explore the public’s perception of drug checking. Although public perceptions of drug checking had not previously been evaluated in the literature, some positive and negative perceptions were captured. From twitter, a total of 1316 tweets were initially identified. Following the removal of irrelevant tweets, 235 relevant tweets were identified, of which about 95% (n = 223) tweets were in favour, and about 5% (n = 12) were not in favour of drug checking as a harm reduction intervention. Tweets perceived the service as part of effective law reform, public health intervention that serves in raising awareness and countering the role of the internet, initiative to reduce drug related harms and/ or potentially deaths, help in identifying Novel drug trends related to drugs, enabling a scientific basis to capture data, reducing harm from risky drugs or risky consumption, reducing the economic and social burden on society and preventing young people from having criminal records and punitive fines. Drug checking was perceived to support engagement with treatment services and support individuals in making more informed decisions. Tweets against drug checking focussed on the concerns over the quality of drug checking, particularly with false-positive results, which may lead to punitive outcomes, discrimination, and prejudice. The present study showed that twitter can be a useful platform to capture people’s perceptions of drug checking.

Risk perception and risk aversion among people who use New Psychoactive Substances

INTRODUCTION

New Psychoactive Substances (NPS) are often considered to be harmful and less safe alternatives to traditional recreational drugs. Yet we have little knowledge of the ways in which risk aversion affects NPS risk perception and how risk judgements differ across types of NPS. In the analysis that follows, we investigate whether the perceived severity of risk is amplified or attenuated by users' experiences, risk avoidance strategies and modes of knowledge on risk.

MATERIAL AND METHODS

The data were derived from a Polish cross-sectional study on patterns of NPS use and associated risks. A convenience sample of 605 users of NPS (Mean age = 22; range 15-49 years) completed a questionnaire. A principal component analyses and ordinal regression models were used to reveal the latent variables indicating modes of knowledge on NPS risk and risk avoidance strategies, and to determine the associations between risk aversion and perceived personal risk of NPS use.

RESULTS

Several precautionary measures were employed by the majority of participants in the study. The perception of individual risk differed across NPS types. Principal component analysis yielded three components in both risk avoidance strategies ('avoiding mixes', 'precautionary measures', 'planning') and modes of knowledge on risk ('experience', 'technical knowledge', 'harm reduction'). However, ordinal regression models show that perceptions of risk are only partially affected by the modes of knowledge on NPS risk and by risk avoidance strategies.

DISCUSSION

The results indicate that risk perception largely depends on NPS type. The perception of risk is driven by both modes of knowledge and risk avoidance strategies. However, they have different impacts on how individuals judge risk across various types of NPS. The perspective of risk perception should inform policy-makers and prevention experts to focus their efforts on honest and substantive risk communication.

CONCLUSIONS

The present study shows that individuals tend to rely on various strategies of risk avoidance, which indicates the need to improve the substantive communication on NPS risks, with a particular focus on the types of NPS, which could help people using them make informed choices.

Could a drug-checking service increase intention to use ecstasy at a festival?

INTRODUCTION

Calls to provide sanctioned drug-checking (pill testing) at Australian music festivals have been met with resistance from most governments due to concerns that such services would increase use of ecstasy and other drugs. We investigated that concern and used the Theory of Planned Behaviour to examine the determinants of intention to use a drug-checking service.

METHODS

Data were collected over a 3-day period at a music festival in Western Australia. Participants (n = 247; 50% male; 52% aged 25-34 years) were presented with three hypothetical pill testing scenarios: no testing provided, onsite testing provided and fixed offsite testing provided.

RESULTS

Neither ecstasy users (n = 212) nor participants who had never used ecstasy (n = 35) reported an increased intention to use ecstasy in scenarios in which drug checking was provided. The combination of attitudes, subjective norms and perceived behavioural control predicted intention to use a fixed site drug-checking service, while only subjective norms predicted intention to use an onsite service.

DISCUSSION AND CONCLUSIONS

These data do not support the view that offering a drug-checking service at a festival will result in ecstasy use by people who have never used ecstasy or lead to increased use among people who use ecstasy.

Drug Checking and Its Potential Impact on Substance Use

OBJECTIVES

Drug checking as a tool for harm reduction is offered in certain cities throughout Europe, the USA, and Australia, but in general, it is internationally still scarcely available and controversially discussed. This study aimed at investigating the potential impact of a drug-checking offer on Berlin nightlife attendees' illicit drug use and at identifying the encouraging and discouraging factors for using or refraining from such an offer.

METHODS

Using an online questionnaire, we conducted a cross-sectional survey in a Berlin party scene. A total of 719 people participated in the survey that took part in 2019.

RESULTS

The vast majority of participants (92%) stated that they would use drug checking, if existent. If the test revealed the sample to contain a high amount of active ingredient, 91% indicated to take less of the substance than usual. Two-thirds (66%) would discharge the sample if it contained an unexpected/unwanted agent along with the intended substance. If the sample contained only unexpected/unwanted substances and not the intended substance at all, 93% stated to discharge the sample. Additional brief counseling was stated to be useful. Participants showed a comparatively high substance use.

CONCLUSIONS

Drug checking as a harm reduction tool was highly accepted in the scene, and the majority of participants stated to align their consumption behavior accordingly, in a reasonable manner. A concomitant consultation would be appreciated, which may be used to direct educational information about harms and risks to users.

Drug Checking as Strategy for Harm Reduction in Recreational Contests: Evaluation of Two Different Drug Analysis Methodologies

Introduction: Drug checking as a part of drug harm-reduction strategies represents an essential aspect of public health policies. It focuses on rapid identification of drugs that individuals intend to use during night events, in order to implement health-protective behaviors. Chemical drug analysis techniques vary considerably, from simple colorimetric reagents to advanced forensic methods such as gas chromatography/mass spectrometry (GC/MS). Materials and Methods: In 2019, drug-check services were offered at some night events in Umbria (Central Italy). One hundred and twenty attendees directly delivered unidentified substances to a harm-reduction worker, who collected a few milligrams of the substances on ceramic plates and added a drop of colorimetric reagent. Multiple reagents were used to increase the diagnostic capacity of a substance, which may react with a specific drug or a few drugs. Later, a fraction of the samples was analyzed by GC/MS. The concordance of the results obtained using these two methodologies and the intended behaviors of consumers after being informed of the test result was evaluated. Results: We analyzed 120 samples by colorimetric test: 32 MDMA, 25 ketamine, 10 amphetamine, 11 cocaine, 8 heroin, and 4 LSD samples. The results were inconclusive for 29 samples. The GS/MS analysis confirmed MDMA in 84%, ketamine in 78%, amphetamine in 91%, cocaine in 92%, heroin in 88%, and LSD in 100% of the samples. The results of samples with inconclusive results were as follows: 2, MDMA; 7, ketamine; 2, amphetamine; 2, cocaine; 2, heroin; 2, mephedrone; 6, mixes; 1, debris; and 5, adulterants as the main component. Twenty-one of 29 participants reported that they had no intention of consuming the unidentified substance. Discussion: The high percentage of individuals who claimed no intention of consuming the unidentified drugs indicates that drug checking is viable as a part of drug harm-reduction strategies. Overall, colorimetric reagents showed a good performance with regard to samples being unadulterated (LSD) or minimal in quantity, but failed to identify mixtures of substances and the adulterants present in them. Therefore, the use of more discriminatory on-site methods such as Raman or infrared spectrometry is strongly recommended.

The effect of public opinion and politics on attitudes towards pill testing: Results from the 2019 Australian Election Study

INTRODUCTION AND AIMS

Following several deaths due to drug overdoses at music festivals in Australia, pill testing (or drug checking) has been proposed as a means of reducing the risk to young people. However, pill testing is a politically controversial policy in Australia. This paper examines the political dimension to the debate, its relationship with other social issues and how it divides party supporters.

DESIGN AND METHODS

The data come from the 2019 Australian Election Study survey-a large (n = 2179), nationally weighted representative probability survey conducted immediately after the federal election. Bivariate and multivariate analyses are used to identify the social groups, attitudes and vote preferences most associated with public views about pill testing.

RESULTS

Almost two-thirds of the public support pill testing at music festivals. The young and those who do not attend church are most likely to express support. Supporters of other liberal social opinions, such as the legalisation of marijuana, are also strongly supportive of pill testing. Those who vote for one of the two main conservative parties are less likely to support pill testing.

DISCUSSION AND CONCLUSIONS

While a majority of the public support pill testing, beyond the Australian Capital Territory this has not translated into policy in other jurisdictions. The results show that there is a high level of political polarisation surrounding opinions among both voters and political elites. This issue must be addressed if the policy is to be advanced as part of an overall harm reduction approach to drug use.

Suitability of infrared spectroscopy for drug checking in harm reduction centres

Drug checking is a service for people who use drugs that includes product analysis and an individual interview including results feedback and harm reduction counselling. It uses different analytical methods but few studies demonstrate their value in current practice. The main objective of this work is to compare the analytical performance of IR spectroscopy to laboratory reference method in the context of drug checking in a harm reduction centre. The secondary objectives are to carry out a description of the people who use drugs requesting a product analysis, and to compare the assumed compositions of products purchased with their real compositions. During 2018, all requests for drug testing analysis were included for on-site analysis by IR spectrometry in a harm reduction center and verified by the reference method (UPLC-HRMS) at Bordeaux University Hospital Center. Socioeconomic and product data were also collected. One hundred and thirty-six samples were collected. The results obtained with IR and UPLC-HRMS were compared. IR spectrometry results did not match with reference method in 8 % (n=11) of cases, corresponding to blotters, cannabis and some psychoactive substances present in mixture or in small quantities. Among the products collected, only 5.1 % (n=7) did not correspond to the declared product, either alone or with adulterants. The IR spectrometer allows a simple and rapid detection of at least one molecule, most often the one of interest. However, it is limited to powder and tablet type matrices and is not suitable for blotters, cannabis, mixed or low content substances for which high resolution mass spectrometry remains the reference method.

The influence of viewing a headline about ecstasy/Molly adulteration on future intentions to use

Background

Ecstasy (3,4-methylenedioxymethamphetamine [MDMA]), commonly referred to as Molly in the US, is commonly adulterated with drugs potentially more dangerous than MDMA. Synthetic cathinones ("bath salts") are common adulterants, and use of these compounds tends to be stigmatized. We investigated whether presenting information on the extent of ecstasy being adulterated with "bath salts" affects intentions to use.

Methods

A total of 1,025 adults entering electronic dance music parties were surveyed in 2018. Using an experimental posttest-only design with random assignment, half were randomly assigned to view a published Vice headline about ecstasy/Molly commonly being adulterated with "bath salts."

Results

Overall, 30.5% of the sample reported past-year ecstasy use, and before viewing the headline, 16.4% agreed that ecstasy/Molly commonly contains "bath salts." While controlling for pre-test knowledge of "bath salt" adulteration, viewing the headline reduced the odds of intention to use ecstasy/Molly only among non-past-year ecstasy users (Odd ratio [OR] = 0.54; p = .048). Viewing the headline increased the odds (OR = 1.81, p = .030) of past-year ecstasy users' intention to test their ecstasy for adulterants.

Conclusions

Knowledge that ecstasy is commonly adulterated may help reduce the risk for future use among non-recent users and increase the willingness of users to test their ecstasy. This information can be used to target those at risk for ecstasy/Molly use.

Patterns of ecstasy use amongst live music event attendees and their opinions on pill testing: a cross sectional study

Background

Pill testing services could potentially be used to reduce drug-related harm. This study aims to identify patterns of ecstasy use among live music event attendees; explore the opinions and potential usage of illicit pill testing programs and examine factors associated with the likelihood of still taking a pill containing a potential harmful substance.

Methods

A cross-sectional survey was completed by 760 people attending a major Australian live music event in 2017.

Results

The most commonly used drug in the last 12 months was ecstasy (73.9%). About 5% of people who use drugs had sought medical attention due to consumption of ecstasy. People who use drugs agreed “a lot” that pill testing should be provided for free at live music events (82.2%) and that it should be combined with harm reduction advice (62.9%). Additionally, 32% of all participants agreed ‘a lot’ that they would be more likely to take illicit drugs at a music festival if pill-testing services were present. However, if people perceived that a harmful substance was detected in their drugs after using a pill testing service, 52.3% of people who have used illicit drugs reported that they would ‘not at all’ be likely to still consume the drug. They also reported that they would still take a pill if testing demonstrated the presence of unintended MDMA-type substances (70.3%), amphetamines (31.2%) or ketamine (27.8%). Multivariate analyses demonstrated that only increased frequency of ecstasy use was significantly associated with taking a pill despite pill testing services detecting a harmful substance. Gender, age, alcohol and previously seeking ecstasy-related medical attention were not associated in the multivariate analyses.

Conclusions

A high proportion of live music attendees consume alcohol and ecstasy. Both people who have and who have not used illicit drugs support the implementation of pill testing services. People reported they would change their consumption patterns according to the results given by pill testing services. The findings may be used to stimulate public debate, and assist drug and alcohol policy makers in the implementation of harm minimisation strategies such as combining pill testing services with harm reduction advice.

Enlightened hedonism? Independent drug checking amongst a group of ecstasy users

BACKGROUND

Research indicates that a body of ecstasy users across the globe employ 'home' drug testing technologies to learn more about the content of their drugs - a process referred to throughout this article as independent drug checking (IDC). Whilst a small number of studies offer accounts of this process, they do so through a narrow lens of harm reduction, potentially overlooking wider socio-cultural factors which may affect this. In response, this article draws on Slavoj Žižek's political theory of the cultural injunction to enjoy, situating IDC in the wider political economy of neoliberal consumer capitalism to contextualise and interpret its use as integral to pleasure and leisure.

METHODS

This empirical study documents the thoughts and experiences of a group of UK ecstasy users who independently use a privately owned drug-testing kit. Drawing on qualitative data generated through 20 semi-structured interviews, the article considers two research questions; what role did drug checking play in the group's drug journeys and leisure activities?; and is drug checking thought to be purposeful?

FINDINGS

For this group of ecstasy users, issues of safety and self-responsibility interweaved with the pursuit of pleasure as they sought to enjoy their drug consumption, but in a way that navigated potential harms. IDC therefore served to maximise pleasure via its 'guarantee' of a prolonged, enjoyable, authentic consumer experience whilst simultaneously safeguarding wellbeing via its premise of more responsible and controlled consumption practices.

CONCLUSION

IDC allowed this group of drug consumers to partake in 'enlightened hedonism' - demonstrating their conformity to the imperatives of capitalism and its social norms. Despite recognising the limitations of IDC and disclosing potentially harmful outcomes, the group's engagement with capitalist markets provided a belief that investment in your consumer experience can both improve it and make it safer - premises that belie the empirical reality.

What is needed for implementing drug checking services in the context of the overdose crisis? A qualitative study to explore perspectives of potential service users

BACKGROUND

The current illicit drug overdose crisis within North America and other countries requires expanded and new responses to address unpredictable and potentially lethal substances, including fentanyl analogues, in the unregulated drug market. Community-wide drug checking is being increasingly explored as one such public health response. We explored how drug checking could be implemented as a potential harm reduction response to the overdose crisis, from the perspective of potential service users.

METHODS

The research was guided by the Consolidated Framework for Implementation Research (CFIR). We conducted a qualitative, pre-implementation study to inform development and implementation of drug checking services that are acceptable to people who use substances and meet their needs. University and community researchers conducted 27 in-depth interviews with potential service users at prospective drug checking sites. We inductively developed emerging themes to inform the implementation of drug checking services within the five domains of the CFIR, and identified the most relevant constructs.

RESULTS

Implementing community drug checking faces significant challenges within the current context of criminalization and stigmatization of substance use and people who use/sell drugs, and trauma experienced by potential service users. Participants identified significant risks in accessing drug checking, and that confidential and anonymous services are critical to address these. Engaging people with lived experience in the service can help establish trust. The relative advantage of drug checking needs to outweigh risks through provision of accurate results conveyed in a respectful, non-judgemental way. Drug checking should provide knowledge relevant to using and/or selling drugs and informing one's own harm reduction.

CONCLUSIONS

For service users, the extent to which the implementation of drug checking can respond to and mitigate the risks of being criminalized and stigmatized is critical to the acceptability and success of community drug checking. The culture and compatibility of the service, setting and staff with harm reduction principles and practices is essential.

City checking: Piloting the UK's first community-based drug safety testing (drug checking) service in 2 city centres

AIMS

To explore the feasibility of delivering community-based drug safety testing (drug checking), to trial service design characteristics and to compare with festival-based testing.

METHODS

In total, 171 substances of concern were submitted on 5 dates at 3 venues in 2 UK cities and tested using up to 6 analytical techniques. Test results and harm reduction advice were distributed directly to over 200 service users through 144 tailored healthcare consultations, to stakeholders, and through early warning systems, media and social media alerts.

RESULTS

The 171 samples were submitted and identified as MDMA (43.3%), cocaine (12.9%), ketamine (12.9%), various psychedelics submitted by students, and heroin and a synthetic cannabinoid submitted by rough sleeping communities, with 76% of samples' test results as expected. The 144 primary service users identified as 91.7% white, 68.1% male, with an average age of 26.7 years. Reported harm reduction intentions included alerting friends and acquaintances (37.5%), being more careful mixing that substance (35.4%), lowered dosage (27.8%), disposal of further substances (6.9%) and additionally 2.8% handed over further substances for verified destruction.

CONCLUSION

Community-based drug safety testing (drug checking) was piloted for the first time in the UK-within a drugs service, a community centre and a church-with consideration given to meso-level operational feasibility and micro-level behavioural outcomes. Service design characteristics such as venue, day of week, prior publicity, service provider, and direct and indirect dissemination of results all may impact on outcomes. Future studies should consider cost-benefit analyses of community and event-based testing and context-appropriate macro, meso and micro-level evaluations.

Harm reduction programs and policy in Australia: barriers and enablers to effective implementation

Abstract. Background: Harm reduction is an integral component of Australia’s overall national drug policy. Harm reduction policy and interventions can be applied to any legal or illegal drug to mitigate harm without necessarily reducing use, but harm reduction is traditionally conceptualised in relation to injecting drug use. Early and comprehensive adoption of many innovative harm reduction interventions has meant that Australia has had significant success in reducing a number of drug related harms, avoided disease epidemics experienced in other countries, and established programs and practices that are of international renown. However, these gains were not easily established, nor necessarily permanent. Aim: In this paper we explore the past and present harm reduction policy and practice contexts that normalised and facilitated harm reduction as a public health response, as well as those converse contexts currently creating opposition to additional or expanded interventions. Importantly, this paper discusses the intersection between various interventions, such as needle and syringe distribution and drug treatment programs. Finally, we detail some of the practical lessons that have been learned via the Australian experience, with the hope that these lessons will assist to inform and improve international harm reduction implementation.

An assessment of the limits of detection, sensitivity and specificity of three devices for public health-based drug checking of fentanyl in street-acquired samples

BACKGROUND

Fentanyl has caused rapid increases in US and Canadian overdose deaths, yet its presence in illicit drugs is often unknown to consumers. This study examined the validity in identifying the presence of fentanyl of three portable devices that could be used in providing drug checking services and drug supply surveillance: fentanyl test strips, a hand-held Raman Spectrometer, and a desktop Fourier-Transform Infrared Spectrometer.

METHODS

In Fall 2017, we first undertook an assessment of the limits of detection for fentanyl, then tested the three devices' sensitivity and specificity in distinguishing fentanyl in street-acquired drug samples. Utilizing test replicates of standard fentanyl reference material over a range of increasingly lower concentrations, we determined the lowest concentration reliably detected. To establish the sensitivity and specificity for fentanyl, 210 samples (106 fentanyl-positive, 104 fentanyl-negative) previously submitted by law enforcement entities to forensic laboratories in Baltimore, Maryland, and Providence, Rhode Island, were tested using the devices. All sample testing followed parallel and standardized protocols in the two labs.

RESULTS

The lowest limit of detection (0.100 mcg/mL), false negative (3.7%), and false positive rate (9.6%) was found for fentanyl test strips, which also correctly detected two fentanyl analogs (acetyl fentanyl and furanyl fentanyl) alone or in the presence of another drug, in both powder and pill forms. While less sensitive and specific for fentanyl, the other devices conveyed additional relevant information including the percentage of fentanyl and presence of cutting agents and other drugs.

CONCLUSION

Devices for fentanyl drug checking are available and valid. Drug checking services and drug supply surveillance should be considered and researched as part of public health responses to the opioid overdose crisis.

Adulterants and altruism: A qualitative investigation of "drug checkers" in North America

BACKGROUND

"Drug checking" has become a common harm reduction method used to test illicit substances, such as ecstasy, for purity and/or the presence of adulterants. Formal drug-checking services have been operating for decades, and the use of personal reagent test kits appears to be relatively common; however, little attention has been devoted to understanding the role and broader experiences of 'drug-checkers' (i.e., people who test their own and/or other people's substances). As such, it remains unknown who is engaging in this practice, their motivations for drug-checking, and what barriers they may experience. We addressed this research gap by interviewing people who check drugs about their experiences, with a goal of better understanding drug checking practices.

METHODS

We conducted in-depth interviews with 32 adults in North America who reported testing drugs. Coding was conducted in an inductive manner and thematic analysis was used to identify relevant themes.

RESULTS

Over half (56.2%) of our sample was affiliated with a drug checking organization. Among non-affiliated checkers (43.8%), the majority (57.1%) tested for friends, 21.4% tested only for themselves, and 21.4% were people who sold drugs and tested for their clients. Motivations were driven largely by altruism, described by checkers as wanting to protect their peers from exposure to adulterants. People interviewed who sold drugs were altruistic in the same manner. Barriers to checking-particularly at nightclubs and festivals-included perceived illegality of test kits and denied approval to test drugs at venues, although many checkers circumvented this barrier by checking drugs without such approval.

CONCLUSIONS

Drug checkers in North America seek to educate people who use drugs about the risk of exposure to unexpected substance types, but they face various barriers. Policy change could help ensure that these potentially life-saving services can be provided without fear of fines and/or criminal prosecution.

Multi-drug cocktails: Impurities in commonly used illicit drugs seized by police in Queensland, Australia

BACKGROUND

Impurities in commonly used illicit drugs raise concerns for unwitting consumers when pharmacologically active adulterants, especially new psychoactive substances (NPS), are used. This study examines impurities detected in illicit drugs seized in one Australian jurisdiction.

METHODS

Queensland Health Forensic and Scientific Services provided analytical data. Data described the chemical composition of 9346 samples of 11 illicit drugs seized by police during 2015-2016. Impurities present in primary drugs were summarized and tabulated. A systematic search for published evidence reporting similar analyses was conducted.

RESULTS

Methamphetamine was the primary drug in 6608 samples, followed by MDMA (1232 samples) and cocaine (516 samples). Purity of primary drugs ranged from ∼30% for cocaine, 2-CB and GHB to >90% for THC, methamphetamine, heroin and MDMA. Methamphetamine and MDMA contained the largest variety of impurities: 22 and 18 variants, respectively. Drug adulteration patterns were broadly similar to those found elsewhere, including NPS, but in some primary drugs impurities were found which had not been reported elsewhere. Psychostimulants were adulterated with each other. Levamisole was a common impurity in cocaine. Psychedelics were adulterated with methamphetamine and NPS. Opioids were quite pure, but some samples contained methamphetamine and synthetic opioids.

CONCLUSIONS

Impurities detected were mostly pharmacologically active adulterants probably added to enhance desired effects or for active bulking. Given the designer nature of these drug cocktails, the effects of the adulterated drugs on users from possible complex multi-drug interactions is unpredictable. Awareness-raising among users, research into complex multi-drug effects and ongoing monitoring is required.

Harm reduction measures employed by people using opioids with suspected fentanyl exposure in Boston, Baltimore, and Providence

BACKGROUND

Exposure to potent synthetic opioids such as illicitly manufactured fentanyl (IMF) has fueled the escalating overdose crisis in the USA, particularly in the east coast. Drug checking services, which allow people who use drugs (PWUD) to learn about the contents of their drugs, remain limited and even criminalized in many states. Further, there is a persistent belief that PWUD are not willing or able to change their behaviors despite being aware of their potential exposure to fentanyl through drug use.

METHODS

We conducted a multi-site cross-sectional study among PWUD to assess what behaviors, if any, were employed in the case of suspected fentanyl exposure, and the correlates of engaging in harm reduction behaviors (HRB). PWUD (N = 334) were recruited in Boston (n = 80), Providence (n = 79), and in Baltimore (n = 175). At the time of the survey, no legal drug checking services were available in these cities.

RESULTS

The majority of PWUD (84%) expressed concern about fentanyl. Among those who suspected fentanyl exposure prior to using their drugs (n = 196), 39% reported employing HRB including using less of the drug (12%) or abstaining altogether (10%), using more slowly (5%), and doing a tester shot (5%). In adjusted logistic regression models, the odds (aOR) of practicing HRB after suspecting fentanyl exposure were increased among PWUD who were non-White (aOR 2.1; p = 0.004) and older (aOR 1.52 per decade of age; p < 0.001). Daily injection (aOR 0.50; p < 0.001), using drugs in public (aOR 0.58; p = 0.001), using drugs alone (aOR 0.68; p < 0.001), and experiencing multiple recent overdoses (aOR 0.55; p < 0.001) were associated with decreased odds of practicing HRB.

CONCLUSIONS

These data illustrate that PWUD employ a number of practices to reduce overdose risk in a context of unknown drug purity and content. Results may also guide efforts to identify early adopters of drug checking services and engage them in peer-outreach to target the most socially and structurally vulnerable PWUD, who are not reporting behavior change, with harm reduction messaging.

Risk intentions following pill test scenarios are predicted by MDMA use history and sensation seeking: A quantitative field study at an Australian music festival

INTRODUCTION AND AIMS

Most Australian Governments have resisted supporting formal pill testing (drug checking) at music festivals. With limited knowledge available regarding post-pill test substance use behaviour, we aimed to understand risk behaviour within three pill test scenarios by determining the individual factors which predict subsequent risky or risk reduction intentions.

DESIGN AND METHODS

Music festival attendees (N = 276) were presented with three hypothetical pill test scenarios and reported their risk intentions, MDMA use history and sensation seeking. The pill test scenarios described an inconclusive test (unknown substance), the detection of a high MDMA dose, or a harmful adulterant (PMA or PMMA).

RESULTS

Findings revealed that access to pill test results would facilitate reduced risk behaviour rather than maintained or increased risk behaviour for people who have never used MDMA. However, people who have used MDMA were not necessarily more likely to engage in risk reduction following a pill test. Furthermore, and using predictive analyses, harm-reducing behaviours are less likely when a person has a history of MDMA use and for those high in sensation seeking, particularly if a test result indicates a high MDMA dose.

DISCUSSION AND CONCLUSIONS

Pill testing alone may not prevent adverse outcomes in some festival attendees. While some individuals are more likely to reduce their risk than maintain or increase their risk, other features of a pill test scenario (e.g. referral to support services, drug education) are likely to be important facilitators of harm reduction intentions.

Synthetic cathinone adulteration of illegal drugs

RATIONALE

Current prevalence estimates of synthetic cathinone ("bath salt") use may be underestimates given that traditional metrics (e.g., surveys, urinalysis) often fail to capture the emergent issue of synthetic cathinone adulteration of more common illegal drugs, such as ecstasy (3,4-methylenedioxymethamphetamine).

OBJECTIVES

This review examines the evolution of synthetic cathinones and prevalence of use over the past decade in the United States. We also review methods of self-report and biological testing of these compounds as well as adverse outcomes associated with adulterated drug use.

RESULTS

Synthetic cathinone use emerged in the United States by 2009 with use associated with tens of thousands of poisonings. Reported poisonings and self-reported use have substantially decreased over the past five years. However, our review suggests that current estimates of use are underestimates due to underreporting stemming primarily from unknown or unintentional use of adulterated formulations of relatively popular illegal drugs, such as ecstasy.

CONCLUSIONS

While intentional synthetic cathinone use has decreased in recent years, evidence suggests that prevalence of use is underestimated. Testing of drugs and/or biological specimens can improve the accuracy of synthetic cathinone use estimates. Furthermore, we advocate that researchers and clinicians should become better aware that exposure to these potent compounds (e.g., as adulterants) often occurs unknowingly or unintentionally. To improve our understanding of synthetic cathinone adulteration, research utilizing a combinatorial approach (survey and biological testing) will help more accurately estimate the prevalence and impact of this public health issue.

On-site identification of psychoactive drugs by portable Raman spectroscopy during drug-checking service in electronic music events

INTRODUCTION AND AIMS

Hundreds of new psychoactive substances (NPS) have burst into the marketplace, making both the scientific community and people who use drugs lacking of adequate information about their diffusion and effects. In this scenario, drug-checking services have been recently proposed to assist harm reduction policies and provide a global description of the circulating drugs.

DESIGN AND METHODS

The results obtained by a portable Raman spectroscopy device on 472 alleged drugs within the first formal implementation of drug checking in Italy, are reported. The testing was made through a plastic bag held by the applicant and containing the alleged drug. The substance identification was executed by comparison with a spectral library.

RESULTS

Illicit substances were detected in 304 samples. Findings included MDMA (106 samples), ketamine (87 samples), cocaine (51 samples), amphetamine (47 samples), methamphetamine (two samples), heroin (two samples) and NPS (nine samples). Two samples were identified as precursors of psychoactive substances. Identification of a non-controlled substance occurred in 38 samples. Output of inconclusive result was recorded from 128 samples tested on-site, from which the applicant allowed us to collect a small portion in 68 cases, for a delayed laboratory analysis by GC-MS or LC-MS/MS.

DISCUSSION AND CONCLUSIONS

Drug checking by Raman spectroscopy proved effective to identify psychoactive drugs including NPS and track the drug distribution in various recreational settings. The field testing activity revealed the presence of several NPS in the nightlife scenario, often in replacement of traditional illicit drugs, thus posing a high overdose risk and a life-threatening situation.

Prevalence of reagent test-kit use and perceptions of purity among ecstasy users in an electronic dance music scene in New York City

INTRODUCTION AND AIMS

Ecstasy users in the electronic dance music scene are at high risk for using ecstasy adulterated with new psychoactive substances and/or methamphetamine. We examined self-reported testing of ecstasy among users in this scene.

DESIGN AND METHODS

We surveyed individuals (aged 18-40 years) entering electronic dance music parties in New York City in 2017. Past-year ecstasy users (n = 351) were asked if they had tested their ecstasy in the past year. We estimated prevalence and correlates of having tested one's ecstasy.

RESULTS

23.1% reported having tested their ecstasy in the past year. Those with some college (adjusted prevalence ratio [aPR] = 0.49, P = 0.014) or a college degree (aPR = 0.41, P = 0.025) were less likely to test their ecstasy than those with a high school diploma or less. Using ecstasy pills (aPR = 1.89, P = 0.036) or crystals (aPR = 1.90, P = 0.006) ≥3 times in the past year was associated with increased likelihood of testing one's ecstasy, and purchasing from an unknown or untrustworthy dealer was associated with decreased likelihood (aPR = 0.63, P = 0.034) of testing one's ecstasy. Half (51.1%) of ecstasy users reported finding out or suspecting their ecstasy had contained a drug other than MDMA. Of these, 49.2% reported finding out their ecstasy contained methamphetamine or speed/amphetamine. Most ecstasy users reported that they would be less likely to use again upon learning their ecstasy contained 'bath salts' (54.8%) or methamphetamine (54.3%).

DISCUSSION AND CONCLUSIONS

Drug testing appears to help ecstasy users detect adulterants and results can help inform harm reduction efforts. Less frequent users in particular may require education about adulteration and drug-testing.

Early Identification of Locally Emerging Trends in Psychoactive Substance Use - Experience and Best Practice in Four European Localities

Background: Timely information about trends in psychoactive substance use could yield tailored interventions and reduce potential harms. However, conventional epidemiological tools might have limited capacity to detect trends emerging on a local level. Objectives: The aim of this study was to explore best practice in the identification of new drug trends at the local level. Methods: A total of 33 key informants from seven European municipalities/regions were interviewed to describe trends in substance use in their locality and to provide expert insights on how these were identified. Semi-structured interviews were analyzed with open coding method. Results: Four case studies that described local trends and responses were compiled: onset of problematic GHB use in the Dutch municipality of Breda (1); emerging retail shops selling new psychoactive substances (NPS) across the regions of Czech Republic (2) and in the Portuguese Agueda and Coimbra (3); and use of drugs with unknown content in the Italian region of Emilia Romagna, and its city Bologna (4). "Early identifiers" in the four case studies were organizations that work directly with people who use drugs (PWUD), emergency departments, and local police. Efficient methods of horizontal and vertical information sharing, sometimes facilitated by communication platforms, were in place, such that included early warning systems on local, national, and supra-local level. Local-level identification systems appeared as best suited to provide locally relevant information. Conclusions: Best practice in identifying emerging trends should involve all relevant "early identifiers", should consist of supra-local exchange platforms, integrate the qualities of local-level identification, and be facilitated by local-level coordinators.

Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States

BACKGROUND

In 2016, the number of overdose deaths involving illicitly-manufactured fentanyl (IMF) surpassed heroin and prescription opioid deaths in the United States for the first time, with IMF-involved overdose deaths increasing more than 500% across 10 states from 2013 to 2016. IMF is an extremely potent synthetic opioid that is regularly mixed with heroin and often sold to unwitting consumers. Community-based organizations have started to distribute fentanyl test strips (FTS) as a strategy to identify IMF in street purchased products. We investigated the association between FTS use and changes in drug use behavior and perceived overdose safety among a community-based sample of people who inject drugs (PWID) in the United States.

METHODS

Between September-October 2017, a total of 125 PWID completed an online survey about their most recent FTS use in Greensboro, North Carolina. Our first outcome of interest included whether PWID engaged in any of the following changes in drug use behavior after using FTS: used less than usual, administered tester shot, pushed syringe plunger slower than usual, and snorted instead of injected. Our second outcome of interest was whether PWID felt that FTS use made them feel better able to protect themselves from overdose. We conducted bivariate and multivariate analyses to determine the association between FTS use and these two outcomes.

RESULTS

Overall, 63% of the sample reported a positive FTS test result and 81% reported using FTS prior to consuming their drugs. For the outcomes, 43% reported a change in drug use behavior and 77% indicated increased perceived overdose safety by using FTS. In multivariable models adjusting for demographic and FTS correlates, PWID with a positive FTS test result had five times the odds of reporting changes in drug use behavior compared to those with a negative result. PWID who used the FTS after drug consumption were 70% less likely to report behavioral changes at subsequent drug consumption compared to those who used it before consumption. PWID who were not existing clients of the syringe services program had four times higher odds than existing clients to report increased overdose safety from using FTS.

CONCLUSIONS

We found that using FTS and receiving a positive test result was associated with changes in drug use behavior and perceptions of overdose safety. FTS may represent an effective addition to current overdose prevention efforts when included with other evidence-based strategies to prevent opioid overdose and related harm.

Planned and Unplanned Drug Use during a Night out at an Electronic Dance Music Party

BACKGROUND

Electronic dance music (EDM) parties at nightclubs and festivals are high-risk scenes for drug use. Although intention to use drugs (such as ecstasy) has been shown to be the most proximal determinant of use, little is known regarding the extent to which drug use is unplanned in this high-risk scene.

METHODS

We surveyed 954 adults entering EDM parties in New York City in 2017 and asked about planned drug use that night. A quarter (n = 236) completed the optional online follow-up survey which asked about drug use during their outing. We examined prevalence and correlates of planned and unplanned use.

RESULTS

A fifth (21.0%) of attendees reported planning to use a specific drug the night of the party and over a third (35.4%) reported using a drug later that night. A quarter (26.6%) used in an unplanned manner. Unplanned marijuana use was most common (10.7%), followed by unplanned use of ecstasy (7.3%), cocaine (4.7%), amphetamine (1.4%), LSD (1.3%), and MDA (1.1%). Unplanned initiation of ecstasy and PMA also occurred. Unplanned drug use was more likely to occur among those recruited outside of nightclubs compared to festivals. Non-heterosexual participants and those with a college degree or higher were also more likely to engage in unplanned marijuana use compared to heterosexual and less educated participants, respectively.

CONCLUSIONS

Unplanned drug use is common at EDM parties. Results can inform prevention and harm reduction in these scenes as unplanned use may exacerbate potential adverse outcomes related to drug use and often extreme party environments.