Point-of-care community drug checking technologies: an insider look at the scientific principles and practical considerations

Implementation of a community-based LC-UV drug checking service: promising preliminary findings on feasibility and validity

BACKGROUND

The increasing diversity of psychoactive substances on the unregulated drug market poses significant health, psychological, and social risks to people who use drugs (PWUD). To address these risks, various harm reduction (HR) policies have been implemented, including drug checking services (DCS). Many analytical methods are used for DCS. While qualitative methods (e.g., thin layer chromatography, spectroscopy) are easier to implement, they are not as accurate as quantitative methods (e.g., LC-UV, LC-MS). Some HR programmes have implemented high-performance liquid chromatography coupled with UV detection (LC-UV). This article presents the cross-validation of this quantitative method with a reference liquid chromatography coupled with high resolution mass spectrometry (LC-HRMS) method.

METHODS

Drug samples were provided by PWUD to a DCS called DrugLab in Marseille, France. The samples were weighed and prepared through dissolution in methanol, followed by ultrasonic bathing. Samples were analysed onsite using LC-UV analysis. They were then subsequently analysed with the reference LC-HRMS method. The LC-UV instrument in DrugLab was calibrated after being purchased; analysis of standard solutions was routinely performed once a month and after maintenance operations. For the LC-HRMS instrument, calibration and quality control procedures followed European Medicines Agency (EMA) guidelines. Statistical analyses were conducted including Spearman correlation tests using IBM® SPSS® Statistics version 20.

RESULTS

A total of 102 samples representing different product classes and cutting agents were cross-validated. Differences between both analyses methods for each molecule analysed were ≤ 20%, with significant correlations between both methods' results for most substances. Notably, LC-HRMS provided lower concentration values for cocaine and acetaminophen, whereas it provided higher values for other substances. Correlations were significant for cocaine, ketamine, MDMA, heroin, amphetamine, caffeine, acetaminophen, and levamisole.

CONCLUSIONS

This study demonstrates that the results provided by DrugLab were accurate and reliable, making LC-UV an adaptable, stable, and suitable analytical method for simple matrices like drugs in a DCS context. However, this cross validation does not guarantee accuracy over time. A proficiency test project in HR laboratories across France is currently under development in order to address potential drifts in LC-UV accuracy.

Evaluation of a Drug Checking Training Program for Frontline Harm Reduction Workers and Implications for Practice

CONTEXT

Drug checking, defined as the use of instruments (e.g. spectrometers), test strips, and other technologies to provide information on drug composition for harm reduction purposes, has emerged as a promising intervention to reduce harms of illicit drugs linked to overdose deaths. While demonstrating potential, these interventions remain limited in reach amid questions of how to reach the full population of people who use drugs and are at risk of overdose, including those outside urban areas. In response to these limitations, Substance, a drug checking project based in Victoria, Canada, developed a Distributed Model of Drug Checking and a concomitant training program.

PROGRAM

The Distributed Drug Checking Training program eliminates need for point-of-care spectrometry technicians, instead capacitating harm reduction workers to provide drug checking using software developed by the project, infrared spectrometers, and immunoassay test strips. The training includes 5 hours of group content that can be delivered virtually, and 2 hours of practice time per learner.

IMPLEMENTATION

Training and data collection took place between May 2022 and March 2024 with learners from 6 locations across Vancouver Island, Canada. We offered 13 training sessions, with evaluation data collected from 54 learners.

EVALUATION

The training was evaluated across Kirkpatrick's 4 levels of training evaluation. The training was highly acceptable to learners, attributable to intended changes in knowledge and skill related to drug checking, resulted in competence to deliver drug checking through the project's Distributed Model, and facilitated expansion of drug checking services to 6 geographically distant locations.

DISCUSSION

After completing the 7-hour training program, harm reduction workers were able to deliver drug checking without need for on-site drug checking technicians. The short duration of the training and its demonstrated success with the Distributed Model of Drug Checking make this a promising approach for expanding the reach of drug checking services.

A strategy for the detection of benzodiazepine drugs using low-resolution paper-spray mass spectrometry for harm reduction drug checking

The ability to detect newly emerging substances is of great importance in reducing harms for people who use drugs. New psychoactive substances including novel benzodiazepines in the illicit drug supply have been linked to high rates of overdose deaths while complicating drug checking as an overdose prevention strategy. Paper-spray mass spectrometry (PS-MS) has emerged as a novel strategy to rapidly detect trace components in street drug samples. While targeted, low-resolution PS-MS methods have proven effective, newly emerging substances are often missed. To address this, a method was applied to low-resolution full-scan PS-MS data to aid in the early detection and identification of novel benzodiazepines in the unregulated drug supply. Using the developed method, true positives rates of 0.89 and 0.75 were achieved for bromazolam and etizolam in street samples obtained in a community drug checking service. The applicability of the method was further demonstrated for a novel benzodiazepine, desalkylgidazepam, that has recently emerged in the illicit drug supply.

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

INTRODUCTION

The Sydney Medically Supervised Injecting Centre provides a safe, non-judgemental space where people can inject pre-obtained substances under the supervision of trained staff. This article describes an unusual incident occurring at the Medically Supervised Injecting Centre in January 2023.

CASE PRESENTATION

Two regular male clients attending the Medically Supervised Injecting Centre injected a substance they believed to be cocaine. Both clients experienced adverse reactions; one was transported to hospital, while the other became extremely distressed and agitated. Paraphernalia sent for testing returned a result of tiletamine (a dissociative used in veterinary medicine) and no cocaine, 30 h after the incident.

DISCUSSION AND CONCLUSIONS

Where substances are novel or unknown, adverse events are often unexpected and may be more difficult to prepare for. Substance-induced acute agitation can be alarming and hazardous for people consuming drugs and those around them and may pose challenges for staff. There is a substantial evidence base for the benefits of on-site drug analysis and drug checking in reducing harms related to drug use, and in enhancing drug market monitoring. This incident was successfully managed by Medically Supervised Injecting Centre and hospital staff, with no major consequence, however clinical management could have been improved using point of care drug testing.

Mixed host co-assembled systems for broad-scope analyte sensing

Here we report a systems chemistry oriented approach for developing information-rich mixed host chemosensors. We show that co-assembling macrocyclic hosts from different classes, DimerDye sulfonatocalix[4]arenes and cucurbit[n]urils, effectively increases the scope of analyte binding interactions and therefore, sensory outputs. This simple dynamic strategy exploits cross-reactive noncovalent host-host complexation interactions while integrating a reporter dye, thereby producing emergent photophysical responses when an analyte interacts with either host. We first demonstrate the advantages of mixed host co-assembled chemosensors through an increased detection range of hydrophobic, cationic, neutral, and anionic drugs. We then implement mixed host sensors in an array-based platform for the differentiation of illicit drugs, including cannabinoids, benzodiazepine analogs, opiates, anesthetics, amphetamine, and common adulterating substances. Finally, the potential of this approach is applied to profiling real-world multi-component illicit street drug samples, proving to be more effective than classical sensor arrays.

Trace Detection of Adulterants in Illicit Opioid Samples Using Surface-Enhanced Raman Scattering and Random Forest Classification

The detection of trace adulterants in opioid samples is an important aspect of drug checking, a harm reduction measure that is required as a result of the variability and unpredictability of the illicit drug supply. While many analytical methods are suitable for such analysis, community-based approaches require techniques that are amenable to point-of-care applications with minimal sample preparation and automated analysis. We demonstrate that surface-enhanced Raman spectroscopy (SERS), combined with a random forest classifier, is able to detect the presence of two common sedatives, bromazolam (0.32-36% w/w) and xylazine (0.15-15% w/w), found in street opioid samples collected as a part of a community drug checking service. The Raman predictions, benchmarked against mass spectrometry results, exhibited high specificity (88% for bromazolam, 96% for xylazine) and sensitivity (88% for bromazolam, 92% for xylazine) for the compounds of interest. We additionally provide evidence that this exceeds the performance of a more conventional approach using infrared spectral data acquired on the same samples. This demonstrates the feasibility of SERS for point-of-care analysis of challenging multicomponent samples containing trace adulterants.

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

BACKGROUND

Overdose deaths continue to reach new records in New York City and nationwide, largely driven by adulterants such as fentanyl and xylazine in the illicit drug supply. Unknowingly consuming adulterated substances dramatically increases risks of overdose and other health problems, especially when individuals consume multiple adulterants and are exposed to a combination of drugs they did not intend to take. Although test strips and more sophisticated devices enable people to check drugs for adulterants including fentanyl and xylazine prior to consumption and are often available free of charge, many people who use drugs decline to use them.

OBJECTIVE

We sought to better understand why people in the New York City area do or do not check drugs before use. We plan to use study findings to inform the development of technology-based interventions to encourage consistent drug checking.

METHODS

In summer 2023, team members who have experience working with people who use drugs conducted 22 semistructured qualitative interviews with a convenience sample of people who reported illicit drug use within the past 90 days. An interview guide examined participants' knowledge of and experience with adulterants including fentanyl, xylazine, and benzodiazepines; using drug testing strips; and whether they had ever received harm reduction services. All interviews were audio recorded, transcribed, and analyzed for emerging themes.

RESULTS

Most participants lacked knowledge of adulterants, and only a few reported regularly checking drugs. Reasons for not checking included lacking convenient access to test supplies, or a place to check samples out of the public's view, as well as time considerations. Some participants also reported a strong belief that they were not at risk from fentanyl, xylazine, or other adulterants because they exclusively used cocaine or crack, or that they were confident the people they bought drugs from would not sell them adulterated substances. Those who did report testing their drugs described positive interactions with harm reduction agency staff.

CONCLUSIONS

New forms of outreach are needed not only to increase people's knowledge of adulterated substances and awareness of the increasing risks they pose but also to encourage people who use drugs to regularly check their substances prior to use. This includes new intervention messages that highlight the importance of drug checking in the context of a rapidly changing and volatile drug supply. This messaging can potentially help normalize drug checking as an easily enacted behavior that benefits public health. To increase effectiveness, messages can be developed with, and outreach can be conducted by, trusted community members including people who use drugs and, potentially, people who sell drugs. Pairing this messaging with access to no-cost drug-checking supplies and equipment may help address the ongoing spiral of increased overdose deaths nationwide.

Pilot findings on the real-world performance of xylazine test strips for drug residue testing and the importance of secondary testing methods

Background

Xylazine is a sedative found increasingly in the illicit fentanyl supply that can cause hypotension, bradycardia, necrosis and death. This pilot examined the real-world performance of BTNX xylazine test strips (XTS) in drug residue samples.

Methods

This study was nested within a drug checking service in Rhode Island. We tested unmeasured drug residue dissolved in 5 mL of distilled water using XTS and Liquid Chromatography Quadrupole Time-of-Flight Mass Spectrometry (LC-QTOF-MS). Analyses compared XTS and LC-QTOF-MS results to calculate XTS detection of xylazine in residue.

Results

Among 41 residue samples, xylazine was detected in 11% by the XTS and 44 % by the laboratory. The LC-QTOF-MS detected xylazine in 18 samples: 4 major, 9 minor, 5 trace by volume relative to the whole sample. The XTS disagreed with the LC-QTOF-MS by indicating a negative result in 77.8 % (N=14) of the samples but never indicated a positive when the LC-QTOF-MS reported xylazine's absence. The XTS correctly detected xylazine 22 % of the time, however, this increased to 100 % of the time if xylazine was a major active component.

Conclusions

In this study, the BTNX XTS often disagreed with LC-QTOF-MS by indicating a negative result, likely due to the dilution levels used and sample composition. The XTS may not be accurate in detecting residual amounts of xylazine, especially if xylazine is not a dominant component of the tested sample. Given the novelty of BTNX's XTS products, we recommend XTS only be used in conjunction with other advanced drug checking modalities for residue testing.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

INTRODUCTION

Ecstasy (3,4-methylenedioxymethamphetamine [MDMA]) is a drug commonly used by people who attend electronic dance music (EDM) events at nightclubs and dance festivals. Drug checking has gained popularity in recent years to test for adulterants, but epidemiology studies are needed to estimate potential shifts in prevalence of drug checking to further inform harm reduction efforts.

METHODS

Adults entering randomly selected EDM events in New York City were surveyed in 2017 and 2022. Those reporting past-year ecstasy use were asked if they tested their ecstasy in the past year using a drug testing kit and whether they found out or suspected their ecstasy contained other drugs. We compared estimates between 2017 and 2022.

RESULTS

In 2017, an estimated 23.1% had tested their ecstasy, and this estimate increased to 43.1% in 2022 (86.6% increase, p = 0.006). Among those who tested their ecstasy, in 2017, 31.2% always tested their drug, and this increased to 60.6% in 2022 (94.2% increase, p = 0.026). In 2017, 59.6% of those who tested their ecstasy reported finding out or suspecting their drug was adulterated, which decreased to 18.4% in 2022 (69.1% decrease, p < 0.001). Suspected methamphetamine adulteration in particular decreased, from 21.9% in 2017 to 3.6% in 2022 (83.6% decrease, p = 0.007).

DISCUSSION AND CONCLUSIONS

The use of drug testing kits has increased among EDM event attendees who use ecstasy and, at the same time, among those who had tested their ecstasy, suspected adulteration has decreased. Continued interest in understanding ecstasy contents among this population suggests the need for formal drug checking services.

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.

Adulteration and substitution of drugs purchased in Australia from cryptomarkets: An analysis of Test4Pay

INTRODUCTION

Prohibited drugs in unregulated markets may be adulterated, resulting in increased risks for people who use drugs. This study investigated levels of drug adulteration and substitution of drugs purchased in Australia from cryptomarkets.

METHODS

Data were collected from a darknet forum called Test4Pay from 1 September 2022 to 23 August 2023. Posts were included if they reported the results of drug samples submitted by post to the Vancouver-based Get Your Drugs Tested service, which uses Fourier-transform infrared spectroscopy with immunoassay strip tests (fentanyl and benzodiazepines).

RESULTS

Of 103 samples, 65% contained only the advertised substance, 14% contained the advertised substance in combination with other psychoactive and/or potentially harmful substances and for 21%, the advertised substance was absent. Substances sold as MDMA, methamphetamine or heroin were consistently found to contain only the advertised substance, while substances sold as 2C-B, alprazolam or ketamine were the most likely to be completely substituted. Only 4 samples sold as cocaine contained solely the advertised substance, with 13 containing cocaine with adulterants like lidocaine, creatine, levamisole and boric acid (n = 19). No fentanyl contamination was detected. Novel dissociatives and novel benzodiazepines were detected, as well as a nitazene compound.

DISCUSSION AND CONCLUSIONS

Drug markets under prohibition continue to contain numerous unexpected substances, some of which can elevate risk of harm. Cryptomarkets are not immune to this problem, despite review systems, which should, in theory, make vendors more accountable for the quality of their stock. These findings demonstrate a need for expansion of local drug checking services in Australia.

Enhancing drug checking services for supply monitoring: perspectives on implementation in syringe service programs in the USA

BACKGROUND

Shifts in the US drug supply, including the proliferation of synthetic opioids and emergence of xylazine, have contributed to the worsening toll of the overdose epidemic. Drug checking services offer a critical intervention to promote agency among people who use drugs (PWUD) to reduce overdose risk. Current drug checking methods can be enhanced to contribute to supply-level monitoring in the USA, overcoming the selection bias associated with existing supply monitoring efforts and informing public health interventions.

METHODS

As a group of analytical chemists, public health researchers, evaluators, and harm reductionists, we used a semi-structured guide to facilitate discussion of four different approaches for syringe service programs (SSPs) to offer drug checking services for supply-level monitoring. Using thematic analysis, we identified four key principles that SSPs should consider when implementing drug checking programs.

RESULTS

A number of analytical methods exist for drug checking to contribute to supply-level monitoring. While there is likely not a one-size-fits-all approach, SSPs should prioritize methods that can (1) provide immediate utility to PWUD, (2) integrate seamlessly into existing workflows, (3) balance individual- and population-level data needs, and (4) attend to legal concerns for implementation and dissemination.

CONCLUSIONS

Enhancing drug checking methods for supply-level monitoring has the potential to detect emerging threats in the drug supply and reduce the toll of the worsening overdose epidemic.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

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