Module Four: Engaging Partners

Drug checking is a complex intervention that requires support from all levels- from the people who will be accessing the services all the way through organizational leadership. The following are strategies to build support for drug checking with key partners.

1. Create Meaningful Engagement with People Who Use Drugs

The practice of harm reduction is defined by the input and leadership of people who use drugs (PWUD). Likewise, when developing novel programming, the voices of PWUD should always inform decision making. For concrete guidelines for what meaningful engagement should look like, we highly recommend the AIDS United definition of meaningful engagement. Investing and prioritizing the voices of people who use drugs shows that the program is genuinely committed to being a part of the community and cultivates a spirit of ownership and shared decision making. This breaks down the provider-versus-participant dichotomy and helps to hold providers accountable to the needs and goals of people who use drugs. ‍

“Harm reduction organizations thrive best when they are a part of, and form their own, communities. Making the people of the community a working part of an organization builds the program into the very fabric of the community.”
-Harm Reduction Hacks

Incorporating meaningful engagement is logistically beneficial as well. A drug checking program that seeks engagement and input from the community early in the design process will be better equipped to reduce barriers to service access, address concerns of the community, and ultimately, will roll out a more effective drug checking service.  Similarly, addressing the concerns, questions, and curiosities of administrators and leadership early on will ensure that the drug checking program isn’t unexpectedly halted or delayed. The following are recommendations for potential ways to secure support from partners, as well as guidelines for navigating conversations around legal considerations and law enforcement. A program may choose to conduct some or all of these options, depending on available time and resources. 

Strategies to Create Meaningful Engagement with People Who Use Drugs

• Conduct (paid) participant surveys to evaluate what service users want in a drug checking service. Assess preferences for where the location should be situated, hours it should be available, how results should be delivered, and how data should be communicated. Gauge concern around prosecution and law enforcement, interest in accessing the service, and potential barriers to accessing the service. Specifically evaluate perceived safety, utility, and comfort around drug checking for communities of color and trans and gender non-conforming (TGNC) communities who may be disproportionately impacted by criminalization, racism, and stigma. Incorporate findings into the implementation of the drug checking service.
• Review the drug checking service proposal and plan with local drug user unions or community advisory boards (CABs). Solicit feedback and create continuous avenues of communication between the drug checking service and local communities.
• Identify and engage key peers (see paragraph/pop out box below) who may be advocates of drug checking to interface with communities of PWUD and bring samples to get tested on their behalf. Service users who are interested in drug checking are invaluable to the expansion and roll out of a drug checking program. Involving them in the program design and early stages of training will help to build the reputation and acceptance of the drug checking service. 

A note about peers
The term 'peer', while often equated to ‘person who uses drugs’ or ‘person with lived experience’ has a number of problematic power dynamics and intrinsic assumptions that we wish to draw attention to. Despite progress made over the decades, organizations, institutes, and sometimes even harm reduction programs perpetuate the idea that people who use drugs and work in social services are different from ‘normal staff’ and require more supervision, more oversight, and their autonomy is restricted within the workplace. This relationship is often tinged with an unspoken intention of ‘we know what’s best for you’ or ‘we will tell you what is safe or unsafe for you’. This dynamic, while perhaps well-intentioned, reduces the autonomy of people who use drugs and contributes to stigma by marking them as ‘other’, or different from the rest of the staff.

The word peer also carries with it an assumption about someone’s educational background and abilities in the workplace. It is often assumed that people who are peers or have lived experience do not have a formal academic education or job training. Not only does this devalue the immense knowledge gained through lived experience in favor of institutional education, it is ignorant to the fact that people from all backgrounds, skills, and educations use drugs. Finally, referring to someone as a peer outs that person’s story and history without their consent, or the capacity to tell their story in the way they wish it to be told. This reduces autonomy and compresses a person’s expansive humanity and complex story into a one-dimensional identity. We understand that peer is a commonly understood terminology, but whenever possible we will use ‘person with lived experience’ (PWLE) or ‘person with experiential expertise’ in place of ‘peer’ in this workbook.

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2. Build Support Within Organizational Leadership

The road to securing institutional support for a drug checking program can be long and frustrating, especially in regions that historically have not been supportive of harm reduction. Unfortunately, there is no quick and easy solution, but minds and hearts can be changed over time with consistent and persistent advocacy. Engaging key entities that have power and influence over the existence of a drug checking program can help build support even within more conservative environments. Some examples of these types of entities could be Executive Directors, Board of Directors, Medical Director, General Council, or program directors. The following are some strategies you can implement to help get the powers-that-be onboard with drug checking.

Strategize the framing

The way in which drug checking is contextualized and talked about can help to allay fears, concerns, and misconceptions that administrators or executive leadership may have. Rather than introducing drug checking as a novel or ‘experimental’ intervention, drug checking should be framed as an evidence-based add-on to already existing harm reduction services. Drug checking fits alongside safer smoking supplies, naloxone distribution, and syringe exchange as an additional tool in the in the harm reduction and overdose prevention toolkit already being offered by harm reduction programs. If your program distributes or uses fentanyl or xylazine test strips, guess what? You’re already doing drug checking! FTIR-based drug checking is just using a different technology that arms PWUD with a wider range of information to enable more informed decisions.

Research

A lot of the hesitation around drug checking stems from uncertainty. If people don’t understand how drug checking works and can’t envision how a drug checking service looks in the real world, it can feel complex, risky, and unmanageable. Researching drug checking programs and current effective models can help to outline and contextualize what a drug checking program looks like in practice. The best way to do this is to reach out to other organizations that have implemented drug checking services, especially if other programs already exist in your area. Organizations such as the British Columbia Centre on Substance Use (BCCSU) and the Drug Resource Education Project (DRED) have extensive and detailed manuals on how to set up and run a drug checking program (see Continuing Education). There are also published research articles exploring and evaluating drug checking programs, and universities such as the University of North Carolina (UNC) and Brandeis offer additional materials and information related to drug checking. Another avenue of research is to reach out to local groups who are already doing drug checking. Ask to shadow their operations and ask questions about their implementation process. Seeing a drug checking program in action can demystify it, and local programs are uniquely positioned to navigate local opposition, policies, or barriers. Highlighting research that supports drug checking, resources detailing the process, and observing how drug checking actually works can help make drug checking feel familiar and achievable.

Be proactive

Identify the decision makers who could potentially interrupt or veto a drug checking program. Reach out to them early, (before purchasing an instrument!) to see if they have questions or concerns. Find out what their hesitations are and strategize the best way to address them. For example, if a department director is concerned about having drug samples stored on-site, develop clear protocols for sample storage and disposal (see Example Storage and Disposal Protocols). If they are concerned about legal liabilities, highlight CDC and NIDA support for drug checking programs, and the fact that more and more states are changing their policies and laws to support drug checking¹.   

Real Talk- The Right Time to Start A Drug Checking Program May Not Be Now, and That’s OK!

While strategic framing, supportive research, and proactive advocacy can be helpful, when faced with a certain level of organizational resistance there is only so much convincing that you can do.  If you have to drag unwilling and unsupportive institutional leaders to the table, or if you have to compromise the purpose and intention of drug checking to persuade the powers that be, drug checking may not be a good fit for your organization at that time. Without genuine and enthusiastic organizational support and financial commitment, it is difficult to build a successful drug checking program. Drug checking operates in a legal gray area in many states, and many organizations are highly risk averse and are not comfortable working in that gray area. In these cases, the outcomes may not justify the immense amount of time, work, and money that goes into standing up an ethical and effective drug checking service. Before making the commitment to start a drug checking program, reflect on whether you have the resources and support required to successfully implement it. If there are significant hesitations or uncertainties, the community may be better served by putting those resources towards other interventions such as expanding naloxone distribution, safer smoking equipment, or other effective harm reduction interventions. Unlike many other things in harm reduction, drug checking is not an intervention that should be bootstrapped. Cutting corners or implementing a program halfheartedly can contribute to increased harm for people who use drugs and may make it more difficult to advocate for the continuation of the program. 

For more resources and information about building support for harm reduction interventions, check out the following:

• ‍It’s Our Backyard Too: Building Community-Centered Support for Harm Reduction
• ‍Harm Reduction Hacks: Hacks for SSP Community Relations-External Community
• Enhancing Harm Reduction Services in Health Departments: Fentanyl Test Strips and Other Drug Checking Equipment
• From Fentanyl Test Strips to Mass Spectrometry: A Case Study in Civilian Drug Checking

3. Determine Relationship with Law Enforcement

The decision of whether to disclose a drug checking service to law enforcement is ultimately up to each program. There is no right or wrong answer, but it’s a question programs will need to grapple with. Some programs may choose to not tell law enforcement what they’re doing so as not to attract attention to the program or open participants to increased surveillance. Other programs may have a good relationship with local law enforcement and see value in obtaining their support. For example, having a memorandum of understanding (MOU) with local law enforcement may offer staff and participants some protections when handling drugs for the purposes of drug checking (see Example Memorandum of Understanding). Additionally, programs that are part of a city or state health department may be required to inform other city or state departments, such as law enforcement, about the drug checking service as both entities are under the umbrella of the same governing body. Larger institutions that are unsure about engaging with and disclosing the drug checking program to law enforcement can ask their internal legal team for guidance. 

If a program decides to inform law enforcement of the drug checking service, there are a few critical points to keep in mind: 

• There should be a clear understanding that the drug checking service will not share data with law enforcement agencies beyond what is already shared publicly via reports to the community or public health agencies.
• If possible (and this may be a big “if” for many programs or localities), there should be an understanding that law enforcement agencies will not arrest or prosecute for possession of illegal substances within the context of drug checking. These protections should extend to both staff and participants of the service. 
• The drug checking program will not provide services to law enforcement agencies for the purposes of criminalization or prosecution.
• Law enforcement should, in writing, acknowledge their awareness of the drug checking program. This is simply to inform law enforcement, not to ask permission.

4. Obtain Legal Clearance and Support

One of the biggest barriers to implementing a drug checking service and often the most difficult to resolve is obtaining legal clearance and support for drug checking. In many states, drug checking, at best, falls within a legal gray area. Supporting a drug checking program requires a tolerance for risk, and organizations that are highly risk-averse will likely be unsuccessful in establishing a drug checking program. Small community-based harm reduction programs are often well-practiced at working within legal gray spaces, which is one of many reasons why Remedy Alliance strongly advocates for drug checking to live within these types of programs. As governments and city and state health departments start to explore the potential of drug checking, they often hit legal walls resulting in delays or termination of the project altogether. However, city and state governments that do manage to clear those legal hurdles often have the most protection regarding the legality of drug checking. Government programs may also have access to more resources, infrastructure and support than non-profit or grassroots programs. Ultimately all programs and funders will need to decide if they’re comfortable moving ahead with drug checking without explicit legal protections.  If not, the other option is to advocate for policy change and to wait until drug checking becomes explicitly legalized. More and more states are accomplishing this, but it may take years for those policies to be put into place.  It’s important to highlight that many drug checking programs that currently exist did not start with explicit legal permission. Drug policy experts and advocates have used pre-existing drug checking programs as a tool and initiation point to change laws around drug checking and controlled substances, but this requires an immense amount of teamwork and coordinated political advocacy. 

Tips for Securing Legal Support

• Frame advanced drug checking as an enhancement of the drug checking and overdose prevention efforts that already exist. If your organization is already using immunoassay strips, FTIR is an extension of those technologies.
• Review your organizational mission statement and align drug checking services with the organizational mission. This could be an alignment in the value of safety, overdose prevention, the health and wellbeing of people who use drugs, bodily autonomy, the pursuit of pleasure, or other values.
• Highlight federal support of drug checking.
  • SAMHSA funding can be used to purchase drug testing kits, including fentanyl test strips (https://www.samhsa.gov/find-help/harm-reduction)
  • NIDA features drug checking as a research topic of interest and is supporting research into improving point-of-care drug checking technologies (https://nida.nih.gov/research-topics/drug-checking)
  • CDC Overdose Data to Action (OD2A) funding explicitly allows for the purchase of drug checking equipment such as FTIRs and staff time to implement a drug checking program (https://www.cdc.gov/overdose-prevention/php/od2a/about.html)
• Consider implementing protocols to minimize legal risk; only accept the smallest amount of sample needed, don’t store samples on site, don’t have staff directly handling the samples, etc.

As drug checking expands across the United States, legal barriers may decrease over time. Highlighting that the federal government is funding drug checking through the OD2A funds from the CDC, as well as showing examples of other drug checking programs across the US, may ease concerns over the legal status of drug checking. The Harm Reduction Legal Project within the Network for Public Health Law also is an incredible resource for navigating legal concerns around drug checking. 

Additional Resources 

• ‍Legality of Drug Checking Equipment in the United States
• Harm Reduction Hacks: Upstream Advocacy

5. Build Support Within Program Staff

The success of any program depends on the health, wellbeing, and comfortability of the team and staff that supports the program. For drug checking this is especially true as the risks of drug checking, both legal and personal, may be different than those of other interventions. As harm reductionists our teams and colleagues come to this work from a wide variety of backgrounds. Many people working within harm reduction are in recovery from particular substances and may not feel comfortable being face-to-face with or handling drug samples. Many harm reduction programs have lost team members due to relapse and overdose, and we never want drug checking to put someone’s stability or recovery at risk. Program management should have open conversations with staff about the realities of providing drug checking services and work together with staff to address concerns. Conversations should be started early in the conceptualization process, (before any equipment is purchased), and should be ongoing. This can be a moving target as both people and programs change and move through different phases over time. Technicians should have ready access to clinical and administrative supervision to discuss challenges and voice any discomfort about their job responsibilities. Any decisions about changes to responsibilities should be led by the technician; if someone shares that they are struggling but they still want to continue the work, supervisors should find ways to help them feel safe AND continue the work. Drug checking should always be opt-in: no staff should ever be required to handle or collect drug samples if they choose not to. Conversely, staff should feel encouraged to utilize the drug checking service if they currently use drugs and program management should be open and welcoming to their use of the service. This should be coordinated with the technician in a way that doesn’t feel stigmatizing and protects the anonymity of staff if they wish to maintain that privacy. 

Programs should also have conversations about the legal risk of drug checking. Although many states have changed their laws to clearly legalize some forms of drug checking, in many states the legality of advanced forms of drug checking - and the possession of the trace amounts of drugs being checked - is ambiguous at best. It is therefore important that organizations that conduct drug checking know the law in their state, and clearly communicate known legal risks of drug checking to employees (including future employees and prospective technicians), volunteers, and participants so those individuals can make informed decisions about whether and to what extent they want to be involved. To our knowledge there have been no arrests or prosecutions related to advanced drug checking, but the possibility does theoretically exist in some states.

It is also important that organizations consider steps a program might take to mitigate potential legal risks. Having clearly written protocols, ensuring that the smallest amount of drug necessary is tested, that the technician does not personally handle the drug, and that all samples are returned or destroyed as soon as possible are a few ways to potentially reduce legal risk. Organizations can also consider proactively consulting with a local criminal defense attorney and even setting aside funds to pay for legal defense, bail, or bond. It’s also important to have an open discussion about how legal risk is not equal across all staff members. BIPOC, people with previous involvement in the criminal justice system, people who are on parole, and people who have Child Protective Service (CPS) involvement carry a different level of risk and likely higher legal penalties if something were to go wrong. It’s important to directly address these risks and be open about what the worst-case scenario may look like. Ultimately the choice of whether or not to participate in drug checking, and to what extent, should be left up to the staff member.  

Beyond staff safety, opening space for feedback, concerns, and ideas from staff will help to improve the drug checking program. Frontline harm reduction staff often have their finger on the pulse of the community and have wonderful insight into what would make a drug checking program successful. Additionally, many programs employ people with lived experience or people from the community who will have excellent feedback as to the feasibility of the implementation plan. Hiring directly from the community means that staff understand the history, culture, needs, nuances of that community. Leveraging the incredible knowledge of people with deep roots in the community will help to ensure that the drug checking service is trusted, realistic and reflective of the people accessing the service.

Risk Mitigation Strategies

• Don’t store drug checking samples on site, other than sending for secondary verification. If you must store on site, store the smallest amount possible and make sure the sample is clearly labeled.
• Have a Deterra bag or other method for neutralizing substances (See Protocols and Procedures for more information).
• Don’t leave drug samples sitting out unattended
• Use a lockbox or a safe to store samples when not actively working with them. Only designated staff should have access to the code.
• Consult with the organization's legal team (if available). Create an action plan in the event of staff arrest in conjunction with drug checking. 
• Reach out to a local bail fund and make a plan for if someone were to be arrested while either providing or accessing drug checking. If there isn’t a bail fund in your area, decide organizational commitment to providing bail funds. Decide if this applies to paid staff, volunteer staff, and/or participants.

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