'It's not going to be a one size fits all': a qualitative exploration of the potential utility of three drug checking service models in Scotland

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.

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

BACKGROUND

Adulterants, such as fentanyl and xylazine, among others, are present in a high percentage of the illicit drug supply, increasing the risk for overdose and other adverse health events among people who use drugs (PWUD). Point-of-care drug checking identifies components of a drug sample and delivers results consumers. To successfully meet the diverse needs of PWUD, more information is needed about the utility of drug checking, motivations for using services contextualized in broader comments on the drug supply, hypothesized actions to be taken after receiving drug checking results, and the ideal structure of a program.

METHODS

In December 2021, semi-structured interviews were conducted with 40 PWUD who were accessing harm reduction services in Philadelphia, PA. Participants were asked about opinions and preferences for a future drug checking program. Interviews were audio recorded, transcribed and coded using content analysis to identify themes.

RESULTS

Participants were primarily White (52.5%) and male (60%). Heroin/fentanyl was the most frequently reported drug used (72.5%, n = 29), followed by crack cocaine (60.0%, n = 24) and powder cocaine (47.5%, n = 19). Emerging themes from potential drug checking consumers included universal interest in using a drug checking program, intentions to change drug use actions based on drug checking results, deep concern about the unpredictability of the drug supply, engaging in multiple harm reduction practices, and concerns about privacy while accessing a service.

CONCLUSIONS

We offer recommendations for sites considering point-of-care drug checking regarding staffing, safety, logistics, and cultural competency. Programs should leverage pre-existing relationships with organizations serving PWUD and hire people with lived experiences of drug use. They should work with local or state government to issue protections to people accessing drug checking programs and ensure the service is anonymous and that data collection is minimized to keep the program low-threshold. Programs will ideally operate in multiple locations and span "atmosphere" (e.g., from clinical to a drop-in culture), offer in-depth education to participants about results, engage with a community advisory board, and not partner with law enforcement.

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

BACKGROUND

Drug checking services (DCS) provide harm reduction support and advice to individuals based on chemical analysis of submitted substances of concern. Whilst there are currently no DCS in Scotland, community-based services are being planned in three cities.

METHODS

In this paper, we report qualitative findings based on interviews with 43 participants, focused on perceptions of DCS and their implementation. Participants were relevant professionals, those with experience of drug use, and family members of those with experience of drug use. The Consolidated Framework for Implementation Research (CFIR) was used to inform data collection and analysis. We report findings under nine constructs/themes across the five CFIR domains.

RESULTS

Participants noted the importance of DCS being implemented in low-threshold, trusted services with a harm reduction ethos, and outlined a range of further service design considerations such as speed of testing, and information provided through the analysis process. In relation to the 'inner setting', a key finding related to the potential value of leveraging existing resources in order to expand both reach and effectiveness of drug trend communication. The approach of local and national police to DCS, and the attitudes of the public and local community, were described as important external factors which could influence the success (or otherwise) of implementation. Bringing together a range of stakeholders in dialogue and developing tailored communication strategies were seen as ways to build support for DCS. Overall, we found high levels of support and perceived need for DCS amongst all stakeholder groups.

CONCLUSIONS

Our findings present initial implementation considerations for Scotland which could be further explored as DCS are operationalised. Further, our focus on implementation contexts is relevant to research on DCS more generally, given the minimal consideration of such issues in the literature.

"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.