Drug Checking Research

This study aimed to evaluate the implementation of drug checking services with high-pressure mass spectrometry and FTIR spectroscopy devices at a syringe service program in Boston, Massachusetts. The researchers conducted site visits to observe the delivery of drug checking services and semi-structured interviews with staff and participants to discuss the successes and challenges of the program. Facilitators for implementation included the organization’s shared culture of harm reduction, which fostered shared implementation goals among staff, the organization's horizontal structure, strong identification with the organization among staff, and the organization's strong relationships with external funders. Barriers to implementation included the technological complexity of the advanced spectroscopy devices as well as unpredictable technical challenges and some inconsistent results, especially in outreach environments. Other significant barriers included ambiguous legal frameworks for drug checking services, regressive policing policies and activities, and program changes demanded by the COVID-19 pandemic. For harm reduction organizations to be successful in implementing and expanding drug checking services, these barriers need to be addressed, along with prohibitive costs and the need for technological support.

Boston, Massachusetts, USA

10.1186/s12954-022-00590-z

Rapid Response (BTNX) fentanyl test strips were tested against varying concentrations of four different pharmaceuticals (diphenhydramine [Benadryl], alprazolam [Xanax], gabapentin, and buprenorphine/naloxone) and three stimulants (cocaine, methamphetamine, and MDMA). False positive results indicating the presence of fentanyl were obtained from samples of methamphetamine, MDMA, and diphenhydramine in moderate concentrations. By eye, test strips with cocaine, alprazolam, gabapentin, and buprenorphine/naloxone were negative even at the highest concentration. Fentanyl test strips were also analyzed to determine how long a user should wait before reading the results. The researchers found that by approximately 15 seconds, the user should be able to determine if a test (negative result) band will appear by eye. This study concluded that since test strips are commercially available and successful at detecting fentanyl, they can be a valuable tool for harm reduction efforts. However, users should be aware that when drugs and adulterants are in high concentrations, test strips can give a false positive result. Samples for drug checking should be significantly diluted to avoid false positives from potential cutting agents and stimulants.

Fentanyl test strip (FTS); Opioid; Harm reduction; Drug testing; False positives; Fentanyl; Stimulant

Indianapolis, Indiana, USA

10.1186/s12954-021-00478-4

This study describes an association between illicit drug mortality (overdose) rates and fentanyl concentrations in drug checking samples in Vancouver, British Columbia. Using a statistical model, the authors show how fentanyl levels circulating in the unregulated drug supply rose and fell over time, similar to illicit drug mortality rates in the same setting. They propose that drug checking services may serve an important role in ongoing drug supply monitoring

Vancouver, British Columbia, Canada

10.1016/j.amepre.2023.08.016

Drug checking services were implemented at two supervised consumption sites in Vancouver, British Columbia using a FTIR spectrometer and fentanyl test strips. In the first six months of the pilot drug checking initiative (2017–2018), 1,714 samples were analyzed. Of 907 samples expected to be heroin, only 160 (17.6%) contained the expected substance, and 822 (90.6%) tested positive for fentanyl. Of 256 samples expected to be speed or crystal meth, 225 (87.9%) contained amphetamine or methamphetamine, and 15 (5.9%) tested positive for fentanyl. The FTIR also found unexpected and potentially dangerous substances and adulterants other than fentanyl. This pilot initiative has demonstrated the feasibility of drug checking for identifying individual drug samples containing unexpected or hazardous substances, including fentanyl. By identifying the range of adulterants and diluents and giving an estimate of their prevalence in different drug types, it has also provided information about the composition of the unregulated drug supply in an urban North American setting.

Drug checking; Fentanyl; Opioid; Overdose; Harm reduction; Public health

Vancouver, British Columbia, Canada

10.1016/j.drugalcdep.2018.06.020

Eleven in-depth interviews were conducted with harm reduction service providers to explore barriers and facilitators of implementing drug checking programs, the potential for integration with other health promotion services, and best practices for sustaining these programs, considering local community and policy landscapes. Several key themes were generated from interview data: (1) the instability of drug markets amid an inconsistent and dangerous drug supply; (2) implementing drug checking services in dynamic environments in response to the rapidly changing needs of local communities; (3) training and ongoing capacity building needed to create sustainable programs; and (4) the potential for integrating drug checking programs into other services. There are opportunities for drug checking services to make a difference in drug poisoning deaths, as they have been instrumental in monitoring drug supplies and providing information to people who use drugs about the presence of the highly potent synthetic opioid fentanyl. However, several challenges remain to implement them effectively and sustain services over time.

Drug checking; Harm reduction; Community-based; Substance use; Fentanyl; North America

Several key informants were based in California, USA and others were recruited from elsewhere in the USA and Canada

10.3390/ijerph20115999

This was the first study to describe the outbreak of benzodiazepine-adulterated opioids in British Columbia. Drug samples (n=1,368) from harm reduction sites in Vancouver and Surrey, British Columbia were checked at point-of-care using fentanyl and benzodiazepine test strips as well as FTIR spectroscopy. A subset of these samples also underwent confirmatory testing with gas chromatography-mass spectrometry, liquid chromatography-mass spectrometry, or quantitative nuclear magnetic resonance spectroscopy. Of the 159 samples that underwent both point-of-care and confirmatory testing, 24 contained at least one novel psychoactive substance benzodiazepine. Of 114 confirmed samples that participants expected to contain opioids, 18 contained a novel benzodiazepine, with 16 containing both a novel benzodiazepine and fentanyl. False positive and negative rates were 15.5% and 37.5% for test strips, and 3.9% and 91.7% for FTIR, respectively. Novel benzodiazepine adulteration in an unregulated drug supply sample reveals new risks compounding ongoing harms associated with the synthetic opioid epidemic. Given substantial false positive and negative rates in this study for point-of-care detection methods, cautious use of combined point-of-care methods, routinely paired with confirmatory drug checking may aid in early detection and monitoring of unregulated drug markets and inform targeted harm reduction strategies.

Novel psychoactive substances; Benzodiazepine; Etizolam; Drug checking; Overdose

Vancouver and Surrey, British Columbia, Canada

10.1016/j.drugpo.2021.103169

This qualitative study explored how substance use stigma may impact community drug checking services. 26 semi-structured interviews were conducted with potential service users, such as people who use and/or sell substances, and others impacted by the illicit drug market, such as family members and friends who might benefit from services. People fear criminal repercussions, anticipate stigma when accessing services, and internalize stigma resulting in shame and avoidance of services. Overall, participants described the risk of criminalization and the anticipation of being poorly treated as the most significant barriers related to stigma and that deter service use. Strategies to mitigate stigma include: employing people with lived and living experience from diverse backgrounds and substance types at drug checking services, 2) locating services in openly public spaces that still preserve anonymity/maintain privacy, and 3) normalizing drug checking through health promotion campaigns, implementing drug checking within common spaces where people already go/feel safe, and promoting the positive benefits of drug checking more than the harms and risks of drug use. The authors propose that decriminalization could address the root causes of stigma.

Substance use stigma; Drug checking; Substance use; Harm reduction; Overdose; Fentanyl

Victoria, British Columbia, Canada

10.3390/ijerph192315978

Sixteen organizations from the US (n = 9), Canada (n = 5), and Mexico (n = 2) responded to The North American Drug Checking Survey, which aimed to characterize and monitor drug checking services operating in the region. Participating organizations reported testing a total of 49,786 drug samples between 2014 and 2022. Drug checking services were run by community-led organizations (44%), health departments (25%), universities (19%), or clinical/private laboratories (19%). While most organizations tested onsite using fentanyl test strips (88%) and FTIR spectroscopy (63%), many sent samples offsite for confirmatory testing (63%), most often with mass spectrometry. Common facilitators of operating a drug checking service included: interest of people who use drugs, interest of service providers, and receiving external technical assistance. Barriers included: lack of funding or staff, gaps in technical expertise as well as laws banning the possession and/or distribution of drug samples, drug paraphernalia, or drug checking equipment. Findings confirm that drug checking services are scaling up in North America. Given the evolving and localized nature of unregulated drug supplies, supporting the establishment and operations of drug checking services could enhance our understanding of local drug supplies to reduce drug-related harms over time.

Drug addiction; Drug checking; Drug overdose; Fentanyl test strips; Harm reduction; Substance use

Canada, USA, and Mexico

10.1016/j.drugpo.2023.104206

People who inject drugs participating in a longitudinal cohort study in San Diego, California and Tijuana, Mexico completed structured surveys, which included questions about drug checking services, socio-demographics, and substance use behaviours. One-third of 426 participants had heard of drug checking, and 57% of these had ever used them. Among participants who knew about drug checking services but had not used them, the most common reasons for not doing so were disinterest, feeling there was “no point” in checking drugs due to lack of alternatives, or that services were not easily accessible. Among the 82 participants who had ever used DCS, most (98%) reported using fentanyl test strips, but most participants did so less than once per month. Among all respondents, 44% expressed interest in free access to test strips. Of 196 participants, 84% indicated interest in advanced spectrometry drug checking to identify and quantify multiple substances and 87% expressed willingness to go to a syringe service program to use this service. Findings highlight low rates of drug checking awareness and utilization yet high interest in advanced spectrometry services versus test strips and the potential role of syringe service programs in improving access to drug checking services.

San Diego, California, USA and Tijuana, Mexico

10.1016/j.drugpo.2023.104086

In a cross-sectional survey conducted at harm reduction sites across British Columbia, participants were asked about their use of drug checking services and what prevented them from using available services. 144 of the 519 participants (27.7%) reported using drug checking services within six months. Participants highlighted barriers such as not knowing where to access services or not having services in their area. Among people who did not report recent fentanyl use, 49.6% stated they would not use their drugs if they tested positive for fentanyl. Certain harm reduction behaviours, such as using overdose prevention sites and having a naloxone kit were positively associated with drug checking. This study identified desire for drug checking services among participants, suggesting a need for expanded drug checking services. Behavioural change was reported among a high proportion of people who said they would not use their drugs if they tested positive for fentanyl or benzodiazepines, meaning that test strips alone can be useful in the context of a toxic drug supply.

Drug checking; Harm reduction; Fentanyl; Cross-sectional survey

British Columbia, Canada

10.1016/j.drugpo.2023.104290

This study assessed the consequence of drug heterogeneity by examining drug checking results of typical consumer-level fentanyl samples purchased in Victoria, British Columbia. Variability in the concentration of fentanyl through the samples (n = 21) was quantitatively assessed from testing with paper spray mass spectrometry. The results demonstrate varied distributions of fentanyl concentrations within a single drug batch (also known as the chocolate chip cookie effect). However, the presence of hot spots, defined as outliers, were relatively rare. These results confirm that drug heterogeneity will affect the precision of quantitative results. While rare, heterogeneity can be extreme in poorly mixed samples, especially samples that are heavily diluted due to their potency. On a practical level, these findings should help guide the communication on limitations of drug checking services, supporting the aim of trust and transparency between service providers 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 of services will always be limited.

Drug checking; Opioids; Quantification; Heterogeneity; Paper spray mass spectrometry

Victoria, British Columbia, Canada

10.1186/s12954-024-00980-5

Drug checking services were offered at four music festivals and events in British Columbia using combination FTIR spectroscopy and fentanyl test strips during the Summer of 2018. The study aimed to measure drug supply components and compare the expected substance (as reported by service users) to the results from drug checking. In total, 336 checks were completed, and most samples were expected by service users to be psychedelics (69.3%) or stimulants (19.6%). Of the 233 psychedelic samples, only 27 (11.6%) contained additional adulterants. Of the 66 stimulant samples, 24 (36.4%) contained additional adulterants. Unexpected adulterants such as levamisole and phenacetin were found, in addition to several novel psychoactive substances. More than a quarter of all samples checked contained additional substances unexpected by service users, some of which have serious potential health implications. Given the proportion of substances found to contain unexpected adulterants, these findings highlight the value of continued drug checking, monitoring of the unregulated drug supply at festivals, and dissemination of results to attendees.

Drug checking; Harm reduction; Festivals; Public health

British Columbia, Canada

10.1016/j.drugalcdep.2019.107589

A harm reduction program in Chicago, Illinois began offering drug checking with three technologies in 2019: fentanyl test strips, FTIR spectroscopy, and high-pressure mass spectrometry. During the study period, 422 samples were analyzed; most were heroin/dope. The findings revealed discordant results from the technologies, with the high-pressure mass spectrometer identifying fentanyl in samples that produced negative fentanyl test strip results (potentially false positives). The program demonstrated the feasibility of using multiple technologies to assess the presence of fentanyl in submitted samples and provided insights into the local drug market.

Drug checking; Fentanyl; Opioid; Overdose; Harm reduction; Public health

Chicago, Illinois, USA

10.1016/j.drugalcdep.2021.108976

This study examined the efficacy 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 FTIR. The researchers used 210 street-acquired drug samples of varying concentrations from Baltimore, Maryland and Providence, Rhode Island to test the devices’ abilities to identify the presence of fentanyl. Of the three devices, the test strips had the lowest limit of detection and could correctly detect the presence of at least two additional fentanyl analogs alone or in the presence of another drug, in both powder and pill forms. The test strips had the highest sensitivity (i.e., lowest false negative rate) and had high specificity (i.e., low false positive rate). However, the test strips do not indicate any other information on quantity, purity, or presence of adulterants or filler. 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. Devices for fentanyl drug checking, which are available, valid, and easy-to-use, can provide important insights about the changing nature of the unregulated drug supply. Drug checking services and drug supply surveillance should be considered and researched as part of public health responses to the opioid overdose crisis.

Fentanyl; Drug checking; Overdose; Public health; Surveillance; Harm reduction

Baltimore, Maryland, and Providence, Rhode Island, USA

10.1016/j.drugpo.2020.102661

This study aimed to determine the limit of detection for fentanyl with two drug checking technologies: the Bruker FTIR and BTNX fentanyl test strips. Samples tested at point-of-care using one of these two drug checking technologies were also sent for confirmatory laboratory analysis. Of 173 fentanyl-positive samples, fentanyl was not detected in 30 samples by FTIR (false negative rate 17.3%) and not detected in 4 samples by test strips (false negative rate 2.3%). Samples containing fentanyl that went undetected by FTIR had concentrations less than or equal to 10%, while the four samples containing fentanyl that went undetected by test strips only had concentrations less than or equal to 5%. Therefore, fentanyl immunoassay strips were able to consistently detect the presence of fentanyl in samples at lower concentrations than FTIR spectroscopy. Given that FTIR spectroscopy can quantify content and concentrations of a range of substances beyond fentanyl and fentanyl analogues, these findings support the use of FTIR spectroscopy and immunoassay strips in combination to compensate for the limitations of each technology alone.

Drug checking; Opioids; Fentanyl; Harm reduction

Vancouver, British Columbia, Canada

10.1111/dar.13004

One-on-one semi-structured interviews with people who use stimulants and/or opioids in Vancouver’s Downtown Eastside were conducted. Most participants discussed having a high level of trust for their drug dealers based on length of relationships, drug supply consistencies, and communication. Therefore, participants did not identify drug checking as a priority. However, participants discussed a lower level of trust when buying drugs from an unfamiliar source. Participants agreed that drug checking technologies would provide knowledge to drug dealers about drug contents and that communicating test results to customers could be a harm reduction measure. Yet, participants questioned whether dealers would actually use drug checking due to criminalization, surveillance, and privacy concerns that dealers might experience as well as the lack of concern that some dealers have about their drug supply. Future drug checking programs should consider ways to engage drug dealers to test their supplies and develop communication strategies to more accurately inform people who use drugs of drug contents.

Drug dealers; Drug supply; Trust; Drug checking; Harm reduction; Overdose

Vancouver, British Columbia, Canada

10.1016/j.drugalcdep.2019.01.035