Module Three: Conceptualizing a Drug Checking Program

Designing and setting up a drug checking service is complex and involves many elements. There are also an infinite number of ways that a drug checking service can look and operate based on funding source, size of program, location, political climate, and many other variables. This workbook operates as a loose guide through these steps, but there is no one-size-fits-all recipe. What works for one program may not work for another. Being as deliberate and thorough as possible when building the outline of your program will make sure that the drug checking service fits the environment, meets the needs of the community, and centers people who use drugs. As harm reductionists, we know all too well that the best laid plans will inevitably go awry. When that happens, a clear map to fall back on can get things back on track. This Readiness Assessment and Pre-Implementation Work checklist are tools that can help you through this process.

Step 1: Identify the Community 

The first step in conceptualizing a drug checking service is identifying and defining the community the service is intended to reach. Many decisions that you will make, such as what type of technologies to use, what your staffing model will look like, and the training process will be influenced by what communities you want to serve. For example, the drugs being checked for attendees of a music festival will likely be different than the drugs being checked for participants in a syringe service program (SSP), so the training requirements for technicians may be different for those two contexts. The legal risks involved with drug checking also differ between communities; people of color, people who are unhoused, and other people who are regularly exposed to structural violence and oppression are more likely to experience criminalization and punishment for accessing drug checking services. Programs may require different accommodations to ensure the most structurally vulnerable and impacted communities feel comfortable accessing the service. As a final example, communities in rural areas may not be able to access drug checking in a central location and may be better served by a mobile drug checking model rather than drop-in models that are effective in urban communities. Having a clear idea of who your target population is, and what their unique considerations are will help shape your program in everything from what model you chose to who you hire as a technician.  Most importantly, a program’s staff should reflect the community that it serves. If Black neighborhoods or Spanish speaking communities are experiencing higher rates of overdose, the program should hire people from those communities, specifically in leadership and decision-making roles. 

Successful drug checking initiatives are born from an articulated need from the community. Starting a drug checking program should be a response to a specific ask from the community, rather than having a drug checking service placed in a site at the whim of a large institution or because drug checking is perceived as a flashy and cutting edge intervention.  If you do not have currently established connections within communities of people who use drugs, or with organizations that already have those connections, setting up a drug checking service may be premature. Refer to the Readiness Assessment tool for more information. The questions below will walk through the process of identifying the community and should be answered in collaboration with people who may use the service. 

Questions to answer in collaboration with people who may use the service:

How has the desire to know more about the drug supply been expressed by people who use drugs? What are attitudes towards fentanyl or xylazine test strips? Do people know what drug checking is or recognize the concept? ‍

‍Consider the current level of participant buy-in. What work (if any) needs to be done to increase community knowledge and buy-in for drug checking services prior to starting a program?‍

‍Describe the community of people who will be accessing the drug checking service? (Describe what housing status may look like, the environments in which people may be using drugs, unique health risks or considerations, which drugs people are using and how, and what their main goals for drug checking may be)

‍‍What are unique considerations about this community that may influence how drug checking services are delivered? (What is the risk to service users? Where will service users access the drug checking service? How long will service users wait to receive results? How comfortable or uncomfortable will they be with data collection? How will you get results back to service users? What is the role of service users and people with lived expertise in service provision and information dissemination?)

‍‍What are the likely outcomes of a drug check? What outcomes are realistic? (Throw drug away, use it differently, make decisions based on personal health)

‍‍What does the harm reduction counseling conversation look like? Is there an organization-wide understanding of personal choice and its role in drug checking and drug use?

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Step 2: Learn About the Local Drug Supply

Different drug supplies have specific characteristics and therefore unique considerations for a drug checking service. It’s important to know what types of drugs you’ll most often be working with so you can start building knowledge about the local drug supply. For example, the opioid supply differs widely across the United States.  Some regions see high levels of xylazine in the opioid supply, leading to xylazine specific health conditions that require specialized care. Some regions often have diphenhydramine as a common adulterant in their drug supply, which complicates the interpretation of fentanyl test strips due to diphenhydramine causing false positives on the strips. Still others may see high concentrations of fentanyl which increases the overdose risk, especially to people who use drugs who are new to the area and may not have the tolerance for a stronger supply. How drugs are sourced, cut or adulterated, packaged, sold, and used also vary region to region and even neighborhood to neighborhood. Finding out as much as you can about the drug supply in your region will help to inform drug checking practice as well as programmatic decisions such as the way results are communicated to service users and the level of training needed to provide quality drug checking services. This will also help technicians discern over time what substances are normal and what substances are abnormal within the local supply, which can prompt further investigation and critical thinking when analyzing a sample. 

Ensuring accurate information about the local drug supply

• Hire someone with an existing knowledge base.
• Assess bias and level of misinformation within different sources of data (e.g., from law enforcement).
• Check public drug checking databases such as DrugsData and StreetSafe from the University of North Carolina.
• Look through the Center for Forensic Science, Research, and Education’s (CFSRE) Novel Psychoactive Substance Discovery page for information about drug trends in your area.
• Talk to people who use drugs about what they’re seeing, hearing, and experiencing. Compensate their time and expertise with stipends!
• Sign up for the National Drug Early Warning System (NDEWS) weekly briefing email list.
• Ask the local Office of the Chief Medical Examiner or friendly neighborhood coroner if they would be willing to share trends they see in toxicology reports.
• Ask nearby drug checking programs (if they exist) what they have been seeing in the supply.

Review available drug data for your area and answer the following questions:

What types of drugs are people in your community of interest most frequently using?‍

‍What form do local drugs typically come in? (E.g., is the local ‘dope’ sold in powder form or pressed into pills? Is the methamphetamine sold in powder or crystal form? Are people using tar heroin?)

‍‍How are people consuming their drugs? (E.g., injecting, snorting, eating, smoking, boofing)
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‍What expected or unexpected substances are present in your drug supply? What fillers are commonly found in your drug supply? (E.g., which opioids are used locally and what are they cut with? What is the cocaine usually cut with? What else is pressed into MDMA/ecstasy pills?)
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‍‍What gaps do you see in the data that’s currently available? What else do people who use drugs want to know? (The answer to this question should come from people who use drugs. Use key informants, focus groups, etc. and appropriately compensate for time and experience with stipends.) 

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Step 3: Decide What Point-of-Care Technology to Use

Programs must also decide what drug checking technology to use. In most of North America and in other parts of the world, a Fourier-transform infrared (FTIR) spectrometer is a common instrument used for point-of-care drug checking and is the technology that we focus on in this workbook. An FTIR spectrometer shines a beam of infrared light on a drug sample, which absorbs infrared light in a particular pattern, depending upon the components of the sample. Software paired with the spectrometer translates the unabsorbed infrared light into a readable spectrum, or a unique fingerprint of the sample determined by the components present in a sample and how much of each component is present. FTIR spectrometers produce qualitative data (what is in a sample, not necessarily how much of each compound), give results in a short period of time, can analyze complex mixtures of substances, require minimal sample preparation, and don't require specialized chemistry training to use¹. However, there are a few limitations inherent to this technology. The largest limitation to FTIR spectroscopy is a limit of detection (LOD) of approximately 5% which means that the instrument may not be able to detect substances that are less than 5% of the total sample. This is a significant limitation when analyzing drugs that may contain highly potent compounds such as fentanyl, xylazine, medetomidine, benzodiazepines, DOM (2,5-Dimethoxy-4-methylamphetamine), DOB (2,5-Dimethoxy-4-bromoamphetamine), or others. The Alpha II from Bruker is a common instrument amongst drug checking programs, but other companies make FTIR spectrometers that can also be used for drug checking.

Remedy Alliance has no particular brand loyalty or partnerships with instrument manufacturers. However, the Alpha II FTIR model from Bruker Technologies is the spectrometer that the drug checking community in the United States and Canada largely began with and there is a large wealth of community knowledge and expertise related to this particular instrument. There are significant advantages to choosing an instrument that other programs, technicians, and trainers are familiar with. The Alpha II has been widely validated for drug checking purposes and there is collective experience to tap into for training, troubleshooting, and optimizing the instrument for analyzing drug samples. That being said, the amount of community expertise alone doesn’t necessarily mean that a better instrument doesn’t already exist, or won’t be available in the future. One of Remedy Alliance’s goals is to increase the knowledge base around other instruments to give the harm reduction community more choices in technologies that have proven to be effective for point-of-care drug checking. We unequivocally support the expansion of the different types of equipment and companies and look forward to continued advancements within the field.

Beyond FTIR spectrometers, other technologies that have been used in point-of-care settings include Raman spectrometers, surface enhanced Raman (SERs) spectrometers, paper spray mass spectrometers, handheld mass spectrometers, and others. It is important to fully understand the strengths and limitations of each of these technologies, whether they’ve been tested and validated within a direct service setting, as well as the abilities of any accompanying software. For more information and guidance when interfacing with instrument manufacturers, see “Considerations for Drug Checking Technologies” and Onsite drug checking technology purchase and partnership considerations, an incredible resource from the Toronto's Drug Checking Service.

A Case Study

Harm reduction program ‘Groundscore’ wants to start a drug checking program and is trying to decide what technology to use. They are approached by a company marketing a new device called the BX-304. This instrument is a high pressure mass spectrometer and the company claims that it can easily detect trace amounts of fentanyl and other drugs from only residue. They also highlight that it doesn’t need advanced training and is a ‘plug and play’ type of tool. Groundscore reaches out to their harm reduction and drug checking networks to see if anyone else has experience with this instrument and company. Harmless Shenanigans Society, a harm reduction program across the country, responds that they had previously tried this instrument and did not have a good experience with it. They share that the instrument wasn’t reliable, often broke down, and would regularly give false positives or false negatives. Harmless Shenanigans Society says that they use an FTIR instrument, and introduce Groundscore to a sales representative who is familiar with using FTIR for drug checking purposes and has worked with other harm reduction programs. This example demonstrates the importance of being in communication with the larger drug checking community and learning from the experiences of others before making the decision to purchase an exorbitantly expensive instrument. 

This case study highlights the importance of utilizing existing drug checking networks when considering a new technology. There is a wealth of information in the United States, and the experience of using a new technology in the field may be very different from what a company claims. Information from the field is invaluable when making those decisions. 

Step 4: Build the Model

Like other interventions and services in harm reduction practice, there is no one ‘right’ way for a drug checking service to look, but there are some key required components. First and foremost, drug checking should always be offered as one option from a larger menu of harm reduction services. The most effective models for drug checking incorporate or ‘package’ other harm reduction services alongside drug checking. Organizations that want to offer drug checking services should offer other harm reduction services such as needs-based syringe exchange, safer smoking equipment, naloxone distribution, immunoassay strip distribution, and HIV/HCV/STI testing, or partner with organizations that offer these and other key harm reduction interventions. Regardless of what specific model of drug checking a program implements, all drug checking services should develop strategies and protocols for how to incorporate wrap-around harm reduction services into the drug checking workflow. 

The other key component is having involvement and input from people who use drugs. A drug checking program should fit the community and its needs. Decisions about how the program is implemented such as the hours available, location, and modality of service provision should be decided with input from people who use drugs who may use the service. Many effective drug checking programs are staffed by people who have strong connections and relationships with the community, as well as lived expertise of drug use.  The person who fills the technician role should also be a reflection of the community and the community should inform the technician hiring process. This means hiring from communities of color, investing in people that may not have a traditional science background, and being creative when recruiting for drug checking positions.

A drug checking program should embody the harm reduction principle of ‘meeting people where they’re at’ by literally bringing drug checking services to where the highest need is, in a way that meets the requests of the community. The questions below will help guide how to deliver drug checking services in a way that best fits the needs of the community.

Questions to Inform the Drug Checking Model

How do you typically reach the population of people you work with? Do they come to a physical location to access other harm reduction services? Is the service mobile?‍

‍Are people concentrated in one area or are they spread out across a larger geographical region?‍

‍Assess your organization’s tolerance of risk. How risk-averse is the organizational culture?

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Depending on your answers to the questions in this module, you can begin to envision your drug checking service. Below are some examples of different types of models used in drug checking. This is not an exhaustive list and there is so much space for creativity and innovation in how drug checking programs are implemented. We invite you to use these models as a starting point and encourage you to expand beyond them in whatever ways best suit your program. 

Example 1: Drop-In Center Drug Checking Service

Drug checking at a drop-in center typically involves having a drug checking instrument permanently on-site. This is most often, but not always, embedded within an existing harm reduction program. Service users bring their substance directly to the program, the technician analyzes the sample on site, and then returns the results along with harm reduction counseling in the method most accessible to the participant or agreed upon by the program (face-to-face, phone call, text, email, etc.). This is an effective model that typically has a higher rate of uptake; program participants are already used to accessing a variety of services at drop-in centers and adding drug checking simply expands the number of available services. Within a drop-in center, drug checking should be set up within a private space. This allows for one-on-one counseling and discussion with participants, provides privacy which can help to build trust with the program, and allows the participant to watch and learn about the drug checking process. The space will need to have a locking door to secure the instrument when not in use, electrical access, and will need to be large enough for a small table and two chairs. Setting and keeping consistent hours for when drug checking is available at the drop-in center will build a sense of reliability between service users and the program.

Example 2: Mobile Drug Checking

Mobile drug checking models are useful for bringing the drug checking service directly to the service user and in contexts where providing drug checking at a brick-and-mortar site is not feasible. In this model, the drug checking instrument and supplies are brought onto a van or other vehicle. Staff drive to encampments or areas where people are using drugs and offer on-demand drug checking alongside other harm reduction services. Mobile drug checking is most useful for programs that cover a large geographic area, do not have a physical drop-in center, or work with populations that can’t travel to a physical location to access services. Using a mobile model allows programs to be flexible and respond to hot spots of adverse events such as overdoses, or to respond to requests from participants. Additionally, a mobile model may be appropriate for contexts in which there are concerns about having drug checking services co-located with other healthcare or harm reduction services. As with all other models, consistency of service provision is key. The mobile drug checking service should be consistently scheduled so participants know when and where it will be available.  A mobile model requires a vehicle large enough to perform drug checking with a technician and at least one participant, as well as space for drug checking instruments and supplies. A power source such as an external battery will also be needed, as most FTIR spectrometers still require an external power source (although some newer versions may have a built-in battery). Drug checking in a non-climate controlled environment comes with an additional set of challenges. You may need to consider additional power sources for heaters, air conditioners, or dehumidifiers, depending on the climate the program is operating within. Allow additional time for set-up and take down, up to an extra half-hour on either side of the shift. The FTIR will need to be re-calibrated at the start of each mobile shift, and loading equipment and supplies on and off of a van every day takes time. Some supplies such as immunoassay strips are temperature sensitive and shouldn’t be left on a vehicle overnight in hot or cold weather conditions. Mobile programs should also have other harm reduction services available alongside drug checking and should strategize about how to incorporate wrap-around services in a mobile setting.

Programs will also need to develop protocols for transporting samples. Some samples collected at a mobile site will likely still need to be packaged and sent to a laboratory for secondary verification testing. Transporting drug samples may carry a higher legal risk than doing drug checking at a brick and mortar site, so programs will have to determine their institutional risk tolerance for transporting drug samples and problem solve to find an appropriate solution.  

Example 3: Hybrid Model

Programs that have both a drop-in location as well as outreach services may wish to provide drug checking in both modalities. This allows them to meet the needs of the participants accessing the drop-in space, as well as the needs of participants who only interact with the program through outreach. A hybrid model combines drug checking at a consistent physical location with mobile services, increasing accessibility to different communities. In addition to the considerations described for both drop-in center drug checking and mobile drug checking, hybrid models require more scheduling coordination to make sure the drug checking instrument and supplies are in the right place at the right time. Some programs solve this by having two drug checking instruments: one that remains on site and the other that is dedicated to mobile drug checking. There will also need to be considerations for staffing of the drug checking service to avoid service interruption. 

Example 4: Drop-Off or Drop Box

Some programs have started implementing a drop-box model, in combination with the models above. Participants fill out a brief form with information about their sample, their experience with it (if applicable), and their contact information and place it inside an envelope along with a small sample of their substance. Envelopes are collected in a locked drop-box and the technician tests the collected samples on their next shift. Results are communicated to participants through whatever contact information the participants provided on the intake form (phone, text, email, etc.). Programs who wish to implement a drop-box system need to ensure that the drop box is securely locked and can’t be stolen or broken into. Special thought should be given to the location of the drop box and, whether it’s installed inside or outside, accessibility should be balanced with protecting participant anonymity. There may also be additional legal risks to consider with this model, especially in states where drug checking is still not explicitly legal.

Example 5: Pop-Up Drug Checking

Pop-up drug checking is drug checking that is set up as a one-off event. This could be at a festival or nightlife setting, at a community space or event that has requested drug checking, or at a house or other location where many people may be using drugs together. The set up and layout are somewhat similar to mobile drug checking - all of the supplies and instruments need to be transported and set up on site. If the pop-up drug checking is provided in an outdoor setting, having a canopy or tent is helpful to protect the instruments from any inclement weather or sun exposure, and to provide privacy for the service users. Make sure there is a consistent and easily accessible power source! For many outdoor events, locating a power source is difficult and not having power will quickly impair a drug checking service. For events that draw a large volume of participants, such as a festival, technologies that require less training such as reagent testing can be incorporated alongside FTIR spectrometers and immunoassay strips to manage volume. Be sure to plan breaks for technicians, as high-volume settings are an intense and fast-paced work environment and burned out technicians are more likely to make mistakes. 

Reflection Questions

Which of the models above (or what combination of the models above) do you think would be a good fit for your program? Why?‍

‍What legal concerns will you have to address, relative to the model you choose?‍

‍Thinking of the longevity of the program and program expansion, is there a model that might not be the right fit now, but may be added down the line?‍

‍Most importantly: Describe how you are going to integrate other harm reduction services into the drug checking service.

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