Drug Checking for Contaminants / Drug Checking Services

"A public health intervention operating for more than 50 years, drug checking services (DCS) allow the public to submit drug samples from unregulated drug markets (i.e. illegal and legal drugs sold through criminal channels) for chemical analysis. DCS emerged across the United States in the late 1960s and early 1970s during the rise of a psychedelic counterculture that championed the use of psychoactive substances to expand consciousness [1, 2]. DCS were later expanded in European settings throughout the 1990s, beginning in the Netherlands, primarily in response to the popularity of dance events and associated use of 3,4-methylenedioxymethamphetamine (MDMA) and other drugs [3, 4]. More recently, DCS have been implemented in Australasia, the Americas and the United Kingdom, often with an emphasis on preventing harms from new psychoactive substances (NPS), including synthetic opioids. A global review of DCS conducted in 2017 identified 31 services operating across 20 countries [5]. Notably, the contamination of unregulated drug markets with fentanyl and the resulting opioid overdose crisis has motivated the recent expansion of DCS in Canada [6] and the United States [7].

"DCS provide people who use drugs (PWUD) with information on the chemical composition of their drug samples to facilitate more informed decision-making [8]. While some analysis methods can be operated by PWUD, DCS typically offer tailored harm reduction advice with the provision of analysis results to PWUD [9]. By aggregating data on the composition of drug samples, DCS provide insight into trends in the unregulated drug supply and inform policymaking and harm reduction activities at the population level [10]. DCS can inform public health alerts [11] when drugs of concern are detected, thus offering potential benefits to the broader community of PWUD and service providers [12]. DCS differ globally in terms of their legality and degree of government support, as well as where and how samples are collected and analysed. Models include mobile services at events, fixed services where samples can be dropped off or mailed and the distribution of analysis methods for personal use, all of which employ a variety of technologies with differing benefits and drawbacks [8, 13, 14]."

"Studies found that DCS [Drug Consumption Services] influenced intended behaviour and, although less researched, enacted behaviour. Among studies of PWUD [People Who Use Drugs] in party settings (referred to as ‘partygoers’ in studies), greater intention to not use the analysed substance was consistently reported if analysis results were unexpected [33, 35, 40, 42, 43, 45, 48, 52] or ‘questionable’/‘suspicious’ [49–51]. For example, a cross-sectional study from Australia (n = 83) in 2018 found partygoers were more likely to change their intention to use when analysis results were unexpected [odds ratio (OR) = 2.63, 95% confidence interval (CI) = 0.85–8.16] [35], as did two cross-sectional studies from Portugal (n = 310, n = 100) in 2016 and 2014 [40, 43]. Similarly, other intended behaviour changes—such as using less of a substance or seeking more information about it—were more common among partygoers when analysis results from DCS suggested that substances were ‘questionable’/‘suspicious’ [49, 51].

"The proportion of participants reporting analysis results from DCS influenced their drug use varied by population and setting. Among partygoers, 16% of participants in the Netherlands in 1996 [29], 50% in Austria in 1997–99 [37] and 87% in New Zealand (n = 47) in 2018–19 [33] reported that analysis results impacted their drug use. A cross-sectional study in 2017 from the United States among people who inject drugs (n = 125) found 43% changed their behaviour, and this was more likely when fentanyl was detected [adjusted OR (aOR) = 5.08, 95% CI = 2.12–12.17] [22]. Qualitative and longitudinal studies of young PWUD (n = 81) in the United States in 2017 supported this finding, and found that fentanyl detection was associated with positive changes in overdose risk behaviours (i.e. using less, using with others, doing a test shot) [31, 34]. Overall, and in alignment with findings on intended drug use behaviour in response to ‘questionable’/‘suspicious’ analysis results, self-reported behaviour was more likely to change when analysis results detected fentanyl. Beyond individual analysis results, a repeated cross-sectional study from Colombia (n = 1533) in 2013 and 2016 examined the influence of alerts from DCS and found that a majority of partygoers reported an impact on their behaviour [36].

"Only one study linked intended behaviours to observed health outcomes for PWUD accessing DCS. A Canadian cross-sectional study of DCS at a supervised injection site (n = 1411) in 2016–17 found that people who inject drugs were more likely to report the intention to use a smaller quantity than usual when fentanyl was detected by DCS (OR = 9.36, 95% CI = 4.25–20.65) [41]. In turn, those intending to use a smaller quantity were found to be less likely to overdose (OR = 0.41, 95% CI = 0.18–0.89) and be administered naloxone (OR = 0.38, 95% CI = 0.15–0.96).

"Disposal of the analysed substance was observed [24, 26, 27, 32, 35] or self-reported [22, 31, 34] as an outcome of DCS in eight studies. Like other behaviours, disposal was more frequent when analysis results from DCS were unexpected [24, 27, 32, 52]."

"Fentanyl test strips (FTS) emerged in this context as a drug checking tool to address the burgeoning fentanyl crisis. FTS was originally developed as a field immunoassay to screen for the presence of fentanyl in urine, but harm reduction organizations discovered that FTS can also detect fentanyl in illicit drug solutions. This realization has led many harm reduction organizations to distribute FTS to people who consume street opioids as an off-label approach to test street drugs for fentanyl (Peiper et al., 2019). Research published during this early period exposed a growing concern of unwitting fentanyl exposure among heroin consumers and a general willingness to use FTS. Studies showed a high percentage of PWID were interested in using FTS to test heroin (Allen et al., 2020; Krieger, Goedel, et al., 2018; Park et al., 2021; Sherman et al., 2019) and syringe services programs were making them increasingly available alongside naloxone in OD prevention kits (Beharie et al., 2023).

"Of particular significance were a handful of studies showing PWID modifying their drug use behavior upon receiving positive FTS results (Goodman-Meza et al., 2022; Krieger, Goedel, et al., 2018; Peiper et al., 2019). Notably, a community-based study in North Carolina found that PWID with positive FTS results had 5 times higher odds of practicing safer drug use compared to PWID with negative results (Peiper et al., 2019). Similar studies arrived at comparable effects and together confirmed that PWID were willing to use FTS and initiate risk reduction behaviors when consuming fentanyl (Park et al., 2020, 2021)."

"This study examined the performance of BTNX XTS [Xylazine Test Strips] for testing drug residue. The detection of xylazine’s presence was lower than expected although increased if xylazine was the sample major psychoactive component. Our findings suggest further research and field testing are needed to develop rapid XTS and procedures for residue testing in point-of-care DCS.

"Few studies have evaluated the performance of XTS in the community. One small laboratory study on samples from Philadelphia found no false-negatives compared to confirmatory results (i.e., a sensitivity of 100 %). Notably, the Philadelphia study tested samples rather than residue using a 1 mg:1 mL dilution factor (Krotulski et al., 2023), compared to our procedure of dissolving an unquantified amount of residue in 5 mL of water. A second study using 100 residue samples from Maryland and Nevada assessed crossreactivity of 77 different compounds found only lidocaine produced false-positives (Sisco et al., 2023). Each study tested different XTS batch lots which may have contributed to result discrepancies; quality and accuracy of lateral flow strips can vary between lots (Hayden et al., 2014).

"This study's limitations include its small sample size, limited collection radius and timeframe, and non-random collection procedure. Tested samples primarily contained fentanyl or other opioids; further research should explore the performance of testing non-opioids. Additionally, no validated procedure existed for testing drug residue at the time of the study. While collecting larger amounts of drugs to test would likely increase generalizability and confidence in findings, non-laboratory DCS fall into a legal gray area due to the Controlled Substances Act and resultantly often rely on drug refuse residue. Finally, while quantification was outside the scope of this study, it would provide stronger evidence of whether XTS perform in accordance with their stated detection limit in a community setting and should be considered for future studies. Given these uncertainties, our findings, while initial, caution against reliance upon the XTS alone for xylazine detection in drug residue and, if used, should be accompanied by a thorough discussion of the test’s limitations when interpreting the results or coupled with laboratory testing."

"Drug safety testing (drug checking) is a public health service whereby service users receive test results for a substance of concern submitted for forensic analysis as part of a harm reduction consultation.^12-14 Testing of submitted samples may be conducted onsite in rapid realtime as part of an integrated testing service, or elsewhere by a partner laboratory. Whilst these services vary widely in terms of types of consultations, forensic analyses, staffing, funding, waiting times, whether community or event-based, static or mobile, permanent or temporary, and whether the testing service is integrated or split into individual components, their shared core aim is harm reduction and their shared core service characteristic is direct user engagement. The rationale for these services is that drug-related harm can arise from the consumption of illicit psychoactive substances of unknown content and strength. Therefore, if testing services share results and other relevant information directly with service users, and potentially also other interested parties such as wider drug using communities and support services, they can communicate the risks associated with consuming that substance and enhance users' ability to make educated and informed decisions to reduce or avert future harm, protect their health and reduce the burden on health services. For stakeholders and support services, testing provides an opportunity to monitor trends in illegal drug markets and associated harms, and for alerts to be issued that are timely and accurately targeted to the appropriate drug using communities by utilising information that links composition of individual samples with what they were sold as, a distinct added value of drug safety testing.^14,15 A global audit¹⁶ identified 31 such drug safety testing programmes operated by 29 organisations in 20 countries at that time, with the largest and longest standing being the Dutch Drugs Information Monitoring System,^17-19 and more services have started operating since that audit."

"Few stimulant-specific harm reduction responses are implemented globally. Though NSPs and drug consumption rooms (DCRs) can be accessed by people who use stimulants, existing harm reduction services might not always be adequate for their needs.^[34] For example, stimulant use is associated with more frequent injection than opioids, but limits in NSPs on the number of syringes that can be acquired at any one time represent a particular barrier for those injecting stimulants. Stimulants are also more likely to be smoked or inhaled than opioids, but not all DCRs permit inhalation on premises, and smoking equipment is rarely distributed. However, safer smoking kits for crack cocaine, cocaine paste and ATS are distributed in several territories, including Portugal^[5][35] and harm reduction programmes for people who use non-injectable cocaine derivatives are in place in several countries in Latin America. There have been promising pilot programmes in Asia focusing on people who use methamphetamine, including outreach programmes distributing safer smoking kits, plastic straws, harm reduction education, and access to testing and treatment for HIV, hepatitis C, TB and other sexually transmitted diseases (see page 75 in Asia Chapter 2.1).

"Drug checking (services that enable people to voluntarily get the contents of their drugs analysed) is an important harm reduction intervention for people who use stimulants. These services are implemented in at least nine countries in Western Europe³, are available in the United States, Australia and New Zealand, and are increasingly available in Latin America⁴. Eight countries in Eurasia⁵ have some form of drug checking services through distribution of reagent test kits at music festivals and nightlife settings. Other methods of drug checking include the use of mobile testing equipment to determine the contents of what is sold using tiny samples of the product, allowing for identification of both drugs and contaminants. Though availability of drug checking is growing globally from a low baseline, implementation faces serious legal barriers in many countries as it involves handling controlled substances, and drug checking services often require formal exemption from drug laws in order to operate legally.

"No approved substitution therapy for ATS exists, although pharmacologically-assisted treatment with methylphenidate for ATS users was authorised by the government in Czechia during the COVID-19 pandemic, and in Canada, the British Columbia Centre on Substance Use released interim clinical guidance recommending the prescription of dexamphetamine and methylphenidate to people who use stimulants.^[36]"

"This study presents an independent, laboratory-based assessment of the potential of the first commercially available NTS for drug checking applications. The NTS displayed limited lot-to-lot variability, with an experimental limit of detection for isotonitazene of 2000 or 3000 ng/mL. Twenty-four of the 33 evaluated nitazene analogues cross-reacted with the NTS at concentrations at or below 9000 ng/mL. The test strips consistently detected the presence of a nitazene analogue in 6 authentic drug samples. Based on our cross-reactivity data, most of the currently circulating nitazene analogues, except for ‘desnitazenes’, are likely detectable with the BTNX NTS, while analogues with a lengthened linker between the aromatic groups may not be detectable. Altogether, taking into account limitations that hold true for test strip-based testing in general, and taking into account the cross-reactivity data presented here, the findings from this study indicate that the BTNX nitazene immunoassay test strips show potential to recognize the presence of nitazene analogues in drug preparations in real-life settings."

"Drug checking, or the use of technology to provide insight into the contents of illicit drug products, is an evidence-based strategy for overdose prevention [10,11,12,13,14]. Drug checking services of various kinds have been operating across Europe and North America for several decades, with an estimated 31 services operational in 20 countries by 2017 [15]. In the United States, the use and distribution of fentanyl test strips is a relatively new but increasingly common drug checking strategy employed by SSPs and other programs, typically provided alongside harm reduction materials like sterile syringes and naloxone [16]. More complex technologies, like portable spectrometry devices, have been used for drug checking in several European countries since at least the 1990s [15] yet are only now emerging as an approach to drug checking in the United States [17,18,19]."

"The adulteration of illicit drugs is not a new phenomenon, with evidence of it occurring as early as the 1930s (Morgan, 1982). Ecstasy, in particular, has a long history of adulteration (Hayner, 2002; Morelato et al., 2014; Verweij, 1992) which has been exacerbated in recent years by the emergence of new psychoactive substances (NPS; ~900 identified to date, United Nations Office on Drugs and Crime, 2019). The composition of drugs sold as MDMA/Ecstasy/Molly in particular varies substantially over time and across countries (Brunt et al., 2017) – currently, adulterated ecstasy remains a concern in North America and Australia (primarily among nightclub and dance festival attendees; Australian Criminal Intelligence Commission, 2019; Mohr, Friscia, Yeakel & Logan, 2018; Palamar et al., 2017), while high dose/purity ecstasy is dominating the European market (European Monitoring Centre for Drugs and Drug Addiction, 2019). Drugs adulterated with fentanyl and its analogs are now of particular concern in the US as tens of thousands of people are now dying in the US per year from fentanyl exposure (Scholl, Seth, Kariisa, Wilson & Baldwin, 2018) and it is likely that many of these deaths result from unknown exposure (Ciccarone, Ondocsin & Mars, 2017). To mitigate the risks associated with consuming unregulated substances, drug-checking services have been operating for decades, whereby individuals submit drug samples to have the contents identified and analyzed for purity (Barratt, Kowalski, Maier & Ritter, 2018; Brunt, 2017; Renfroe, 1986). A global review of drug checking services operating in 2017 identified 31 services, three of which were operating in North America: DanceSafe, EcstasyData, and ANKORS (Barratt, Kowalski et al., 2018). These services reported using reagent tests kits, often in combination with other methodologies, including thin layer chromatography and gas chromatography mass spectrometry (Harper, Powell & Pijl, 2017).

"In addition to formal drug-checking services, the use of personal reagent test kits appears to be relatively common (i.e., ‘informal’ drug checking). A recent study estimated that over one-fifth (23%) of past-year ecstasy consumers in New York City had tested (or had someone test) their ecstasy using a drug testing kit in the past year (Palamar & Barratt, 2019). Similarly, a study of ecstasy consumers in Australia found that 22% reported personal use of testing kits (Johnston et al., 2006). However, while numerous studies have explored the prevalence, acceptability, and behavioral outcomes associated with both formal and informal drug checking (e.g., Barratt, Bruno, Ezard & Ritter, 2018; Day et al., 2018; Goldman et al., 2019; Measham, 2019), little attention has been devoted to understanding the role and broader experiences of ‘drug-checkers’ (i.e., people who test their own and/or other people’s substances). As such it remains unknown who is testing drugs, the motivations for doing so, and what barriers they may experience. This omission is particularly concerning given that many of these individuals are volunteers, operating in environments which are fraught with political and legal challenges (Barratt, Kowalski et al., 2018), and may be taking a considerable personal risk in providing such services."

"Illicit drug use at music festivals has been the subject of Australian public and media attention following the drug-related deaths of six young Australians across two festival seasons in 2019 and 2020 (Lee, 2019), and a further young Australian at a festival in February 2023 (Australian Associated Press, 2023). Internationally, studies show higher rates of drug use among music festival attendees compared to the general population (Day et al., 2018; Fox et al., 2018; Hughes et al., 2019; Hughes et al., 2017; Measham and Simmons, 2022). A substantial proportion of the health risks associated with illicit drug use relate to the lack of regulated drug supply caused by prohibition; for example, there is risk of variable purity, whereby the substance is stronger than anticipated (Day et al., 2018; Hughes et al., 2017), or risk of unexpected substances (e.g., fentanyl) being ingested at unknown doses or causing harm via interaction effects due to adulteration (Atherton et al., 2019; Karamouzian et al., 2018; Maghsoudi et al., 2022).

"Methods used to characterise drug use at music festivals include drug checking, in situ surveys and wastewater analysis. Drug checking services conduct chemical analyses of substances of concern submitted directly by the public and return the results to the service user through a tailored intervention that aims to reduce drug-related harms (Barratt and Measham, 2022). A secondary benefit of these services is their ability to generate unique and timely information about drug markets that can be disseminated rapidly via text message or social media alerts (Barratt and Ezard, 2016; Brien et al., 2023; Sample, 2015; Measham, 2019). Next, a handful of studies have used in situ patron surveys to investigate patterns of drug use at music festivals (e.g., (Day et al., 2018; Barratt et al., 2018; Southey et al., 2020)); while valuable, surveys are limited in their ability to accurately capture the full range of substances used due to sampling constraints and reliance on self-report (Lancaster et al., 2019; Zuccato et al., 2005; Tscharke et al., 2015; Gjerde et al., 2019). In contrast, other studies have analysed wastewater samples collected from festival-based sewage sources, essentially conducting an anonymised urine test on the whole festival (Bijlsma et al., 2020; Lai et al., 2013; Bade et al., 2020; Mackulak et al., 2019). While wastewater analysis cannot provide insight into individuals' experiences of substance use (e.g., amount used per person, motivations for use), it provides an objective, non-intrusive method of measuring substance use without raising major ethical issues (Gjerde et al., 2019; Lai et al., 2013; Mackulak et al., 2019; Mackulak et al., 2015), thus overcoming many of the limitations of survey data in these settings. A novel approach combines survey and wastewater data to compare substances that participants believe that they are using (via surveys) versus the drugs they are actually using (via wastewater analysis). We are aware of only one study internationally using this method among festival attendees; Brett and colleagues (2022) reported the detection of cathinones in wastewater at music festivals in New South Wales, Australia, yet no survey respondents reported intentional cathinone use, showing the value of this complementary approach (Brett et al., 2022). Using similar methodology to Brett et al. (Brett et al., 2022), and within the context of the imminent implementation of drug checking services in Queensland, this study aims to characterise the differences between drugs that participants self-report using or intending to use in surveys versus the drugs detected in wastewater at a Queensland-based music festival across two consecutive years (2021 and 2022)."

"This research sought the perspectives of people involved in the unregulated drug market on how drug checking could be implemented as a market intervention within the current context of a highly unpredictable drug supply and unprecedented rates of overdose. Currently, drug checking is positioned as a public health intervention promoted to people who use drugs within supervised consumption sites while being averse to aiding people who sell or produce drugs. Drug checking does not need to be limited to an individual-level behavioral intervention targeted at the end user of a substance, but holds the potential to also function as a supply-side intervention within the drug market linked to overdose. However, careful consideration is needed to design and deliver appropriate drug checking services within the context of the criminalization of substances and the drug market. The demand for quality and product assurance within the illicit supply may operate as a potential driving force to facilitate drug checking and we identified several novel strategies to this end; however, there are also significant implementation challenges.

"We heard that criminalization was the most critical barrier to accessing drug checking services for those within the supply chain. While unsurprising, there are particular considerations and intervention design factors to be addressed to engage sellers and potentially function at a market level. Overall, the benefits of drug checking services need to ensure high-quality services that enable quality products, provided by knowledgeable peers and scientists, and establish trust and safety to outweigh the risks of arrest for accessing services. Promoting drug checking for marketing quality products may be more successful than relying on traditional health promotion messages. Safer settings within the context of criminalization are critical and yet not clearly defined and vary depending on the person and context. Trust was identified as central to successful implementation and may be enhanced through engaging peers and word of mouth."

"One of the consequences of drug prohibition is the lack of knowledge regarding the composition and purity of illicit substances (Miron, 2003; Taylor et al., 2016). This information gap poses significant risks to individuals who consume drugs, as they lack knowledge of the contents which can lead to physical harm (Darke & Farrell, 2014; Unick et al., 2014). In the context of harm reduction, drug checking has emerged as a strategy to address this issue. Drug checking programs aim to provide consumers with accurate and timely information about the content and potential harms associated with the substances they intend to consume (Maghsoudi et al., 2022). Drug checking was traditionally designed to provide harm reduction services and information about illicit substances in party scenes, however, the remit of drug checking has expanded significantly (see Barratt & Measham, 2022). Drug checking programs can be traced back to the late 1960s in the United States (Barratt et al., 2018). According to a recent systematic review, these programs have expanded globally and are now implemented in many countries including the United States, United Kingdom, Netherlands, Switzerland, Spain, Portugal, Belgium, France, Australia, and Canada (Colledge-Frisby et al., 2023).

"Drug checking initiatives seek to empower individuals to make informed decisions about their drug use (Weicker et al., 2020). These programs typically involve analysing drug samples using various methods, such as spectrometry or reagent testing, to identify the presence of specific substances and potential adulterants as well as dosage or strength (Barratt & Measham, 2022). The provision of drug testing results to consumers provides some information about the potential risks associated with their drug use (Barratt & Measham, 2022), although it is important to note that these results may not encompass all possible risks due to limitations in testing methodologies and the multifaceted nature of drug-related harms (Masterton et al., 2022). Risks associated with drug use can be influenced by various factors, including the environment and co-substance consumption, which may significantly impact the overall risk profile beyond the specific drug content or purity (Masterton et al., 2022). However, the implementation of drug checking programs has shown positive outcomes and increased safety among drug consumers in jurisdictions where it has been applied (Bardwell & Kerr, 2018; Measham, 2019). Feasibility studies indicate acceptance and willingness among consumer populations to engage with these services (Kennedy et al., 2018; Krieger et al., 2018; Palamar et al., 2019; Sherman et al., 2019). The positive reception among consumer populations to engage with these services align with the call for widely accessible harm reduction measures."

"RAD involves a four-step process. First, wearing gloves, SSP staff members wipe or swab used drug paraphernalia received from registered SSP participants. Each individual wipe or swab is then placed into a small paper envelope that is collected in a larger mailing envelope (2). Program staff members administered a deidentified questionnaire simultaneously with paraphernalia sample collection and linked the questionnaire and sample with a unique barcode number.§§ Second, samples are mailed to NIST in accordance with U.S. Postal Service regulations. Third, samples are extracted and analyzed using direct analysis in real time mass spectrometry (DART-MS), a rapid ambient ionization mass spectrometry screening technique capable of analyzing a sample in seconds and detecting more than 1,100 drugs, cutting agents, and related substances¶¶ (3). Fourth, within 48 hours, NIST reports substances identified in each sample to CHRS and SSPs.*** SSPs are then responsible for sharing individual results back to the participant who submitted the sample. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.†††

"During November 19, 2021–August 31, 2022, staff members from eight SSPs asked program participants for permission to collect a sample from their used paraphernalia for drug testing and to complete a questionnaire about the drugs they had intended to purchase. A total of 496 paraphernalia samples were collected. For 248 (50.0%) of these samples, the program participant completed the questionnaire. No overdoses occurred on-site during sampling. The five most common types of paraphernalia tested, accounting for 95.7% of samples, were plastic bags (54.8%), cookers (16.3%), capsules (11.7%), vials (6.9%), and pipes or straws (6.0%). Among the 496 samples, one or more opioids were detected in 367 (74.0%) and cocaine in 77 (15.5%); none of the screened drugs were detected in 26 (5.2%) samples. Among the 367 opioid-positive samples, 363 (98.9%) contained fentanyl, 23 (6.3%) fluorofentanyl, and six (1.6%) fentanyl carbamate. One sample contained fluorofentanyl only; all other fentanyl analogs (e.g., fluorofentanyl and fentanyl carbamate) were also detected with fentanyl. Nonfentanyl opioids were detected infrequently: heroin (1.9%), tramadol (1.6%), methadone (0.5%), and protonitazene (0.3%). Among samples positive for fentanyl or a fentanyl analog (364), 84.4% had at least one other stimulant, sedative, or benzodiazepine detected: 293 (80.5%) had xylazine, 23 (6.3%) cocaine, 10 (2.7%) synthetic cathinones, six (1.6%) benzodiazepines, and three (0.8%) amphetamines (Figure)."

"In a harm reduction setting, a FTS might be used to test the drug residue in a cooker or baggie for fentanyl before use of the drug. Our results show that the concentrations of diphenhydramine, methamphetamine, and MDMA commonly found in street drugs are at levels that could generate false positives on the FTS. Many cookers and small baggies hold about 0.75–1 mL of water. If we assume there is 5 mg of methamphetamine in the container that is diluted with 1 mL of water, the concentration of methamphetamine will be 5 mg/mL and would trigger a false positive on the FTS. If the residue were dissolved with 10 mL of water, the methamphetamine concentration would be 0.5 mg/mL and would render a true negative on the FTS. If the drug residue instead consisted of 95% methamphetamine and 5% fentanyl, the 10 mL dilution would ensure that the methamphetamine concentration would not interfere with the FTS while the true positive result would come from the fentanyl present in the sample. As practical guidance for harm reduction groups, a dilution with at least 50 mL of water will provide a good margin of error for accurate detection of fentanyl in cooker or powder residues while avoiding false positives from other drugs. Over dilution is not a likely problem; the FTS is sensitive enough that if there was just 0.5 mg of fentanyl residue in a cooker and it is dissolved in a 10-L bucket of water (50 µg/L or 50 ng/mL), the FTS will still detect the fentanyl present."

"The Massachusetts Drug Supply Data Stream (MADDS) is the country's first statewide community drug checking program. Founded on public health-public safety partnerships, MADDS collects remnant drug packaging and paraphernalia with residue from people who use drugs and noncriminal samples from partnering police departments. MADDS tests samples using simultaneous immunoassay fentanyl test strips, Fourier-transform infrared spectrometry (FTIR), and off-site laboratory testing by gas chromatography-mass spectrometry (GC/MS). Results are accessible to community programs and municipalities, while trend analyses inform public health for cross-site alerts and informational bulletins.

"Implementation:

"MADDS was launched statewide in 2020 and rapidly expanded to a multisite program. Program staff approached communities and met with municipal police and community partners to secure written agreements to host drug checking. Community partners designed sample collection consistent with their pandemic era workflows. Consultations with stakeholders gathered feedback on design and deliverables.

"Evaluation:

"The program tests sample donations on-site from community agencies and police departments, incorporates review by a medical toxicologist for health and safety concerns, crafts stakeholder-specific communications, and disseminates English, Spanish, and Portuguese language materials. For 2020, a total of 427 samples were tested, of which 47.1% were positive for fentanyl. By early 2021, MADDS detected shifts in cocaine purity, alerted communities of a new toxic fentanyl analogue and a synthetic cannabinoid contaminant, and confirmed the increase of xylazine (a veterinary sedative) in Massachusetts.

"Discussion:

"Community drug checking programs can be collaboratively designed with public health and public safety to generate critical health and safety information for people who use drugs and the communities where they live."

"Results from samples expected to be stimulants were divergent between testing groups. Crystal methamphetamine samples tested using take-home drug checking were reported as fentanyl positive more often than on-site samples (27.6% vs. 5.2%). The same pattern was seen for cocaine samples tested using take-home drug checking (17.2% vs. 1.1%). However, the study was underpowered to evaluate equivalence between these testing groups. A small portion of the test strips (3.8%) yielded an unclear or illegible response. It is unclear what the participants did in these cases, but the inclusion of multiple test strips would have allowed for repeat testing.

"Notably, when the results of take-home drug checking were stratified based on previous experience with fentanyl test strips, there was a trend towards a smaller difference between the results of take-home drug checking and on-site drug checking. For opioids, when only results from those who were using fentanyl test strips for the first time were included, there was a difference of 1.6% between take-home drug checking and on-site drug checking. This difference was reduced to 0.6% when only including samples from those who had self-reported prior experience with using fentanyl test strips. Similar results were seen for crystal methamphetamine (28.9% to 15.2%) and cocaine (28.3% to 7.8%)."

"In order to help prevent overdoses, lateral flow immunoassay test strips originally designed for monitoring traces of fentanyl and its analogs in urine are being explored as a drug checking technology in harm reduction contexts [17,18,19,20]. One commonly used fentanyl test strip or “FTS” (BTNX Inc., Markham, ON, Canada) is a lateral flow chromatographic immunoassay for the qualitative detection of fentanyl in urine at the cutoff concentration of 20 ng/mL. A positive result on this test strip gives one line, a negative result gives two lines, and an invalid test gives either no line or no control line [21]. The “off label” use of the FTS in a harm reduction context involves preparation of a solution of the drug to be checked. For example, the residue in a cooker or baggie may be dissolved in a little water and then tested with the FTS. BTNX Inc. provides information about specificity of their test strip response, but for fentanyl 20 ng/mL FTS, the only drugs tested were fentanyl (detected at 20 ng/mL in urine) and norfentanyl (detected at 375 ng/mL in urine). In addition, a suite of pharmaceuticals were found to be non-interfering at levels of 100 ug/mL in a urine matrix [21, 22]. We have found that common stimulants and cutting agents that are often present in illicit drugs can create false positives. The problem arises from the cross-reactivity of the antibody for these other substances [23]. Although the affinity of the antibody for these substances is much lower than for fentanyl, if they are present at sufficiently high concentrations, they can cause a false positive result [24, 25]. As we consider the 4th wave of the pandemic, it can be expected that drug users will need to test stimulants to see if they contain fentanyl."

"Based on our findings, distributed fentanyl test strips would be reliable for the testing of samples identified as opioids and should be more widely distributed. There is growing evidence that fentanyl test strips may help prevent overdose when included with other evidence-based strategies (Peiper, 2019). Other informal techniques such as visual inspection of a substance have been applied by PWUD, but may not be effective in substances that contain traces of fentanyl (Peiper et al., 2019). Our study situated fentanyl test strips within sites that provide naloxone kits, drug use supplies such as syringes, supervised consumption of substances, and drug checking using both test strips and more sophisticated technologies. In contrast to the potential for behaviour change from drug checking results, analysis of several cohort studies within Vancouver during the period of increasing fentanyl contamination in late 2016 showed that a majority of PWUD did not change their drug use behaviours nor translate the knowledge of a changing drug supply to an increased risk of overdose (Brar et al., 2020; Moallef et al., 2019). These findings indicate the need for targeted education and harm reduction interventions for those at risk. Distribution of testing supplies provides an opportunity for further engagement. In BC, an expansion of this pilot program, including continuation at sites included in this evaluation, has occurred to distribute fentanyl test strips labelled with instructions for use. Notably, the described positive behaviour changes rely on an individual possessing knowledge around safer ways to use substances, including knowledge around using a small amount (“test dosing”) and using with others or not alone to avoid overdose and allow for naloxone administration. Furthermore, participants identified using at an OPS/SCS as a potential behaviour, which necessitates that these services exist. Our findings around behaviour change in response to a positive fentanyl result underscore the need for comprehensive harm reduction services and education."

"Globally, community drug checking programs (CDCPs) allow people to submit drug samples for chemical analysis. The results are shared with the donating individual or organization for their health and safety.³,⁴ Data about the samples help drug supply monitoring and constitute a valid, nonduplicative source of information.⁴,⁵ While this strategy is an established harm-reduction tool in Europe,⁴ it is a new endeavor in the United States. Permissions to use federal funds to distribute immunoassay fentanyl test strips (FTS) came in 2021, indicating support for expansion of drug checking to detect fentanyl and raise community awareness of this approach.⁶,⁷

"Determining whether drug samples contain IMF or analogues can help mitigate consumers' risk of overdose and promote safety interventions.⁸–¹³ One study found substantial changes in overdose safety and drug use behaviors following FTS utilization.¹⁴ Our 3-city FORECAST Study found that many people who use drugs (PWUD) do not prefer drugs containing IMF¹³ and 39% employ practices to reduce risk, given unknown drug purity and content,¹⁵ suggesting advantages to disseminating drug checking results and harm-reducing messages.¹⁶ Drug checking with FTS and a handful of comprehensive CDCPs have been implemented in the United States alongside activities such as syringe service programs (SSPs),¹⁷ but no CDCPs operate as both a harm-reduction service and a drug supply monitoring program in the United States, and none globally integrate public safety partnerships or test noncriminal drug samples from police. We describe the approach and initial uptake of a harm-reduction service and public health monitoring tool, the Massachusetts Drug Supply Data Stream (MADDS), a statewide CDCP built upon public health, harm reduction, and public safety partnerships."

"Perhaps our most significant finding is that all of this SSP’s success in implementing drug checking was achieved in spite of, rather than thanks to, the legal and policy environment in which it operates. The COVID-19 pandemic made drug checking practically impossible, but only after systematic police violence against participants and threats against staff had already curtailed provision of this harm reduction service. Indeed, it is likely that drug checking could have persisted during the pandemic absent the very real risk of police interference. This finding mirrors that of qualitative pre-implementation studies of drug checking services in Canada and the United States, which found the criminalization and stigmatization of substance use to be the most likely barriers to implementation [31, 32].

"There is clear, scholarly consensus that law enforcement and criminal justice responses to substance use exacerbate—and sometimes even generate—the individual-level harms of substance use [37,38,39,40,41,42]. This study demonstrates in striking terms how essential harm reduction organizations are equally vulnerable to the misguided, punitive responses so often directed at the people they serve. Policymakers have not sufficiently protected harm reduction efforts from state violence. Stricter, more reliable, more enforceable protections against the impacts of drug criminalization are desperately needed. De-criminalization of substance use remains an effective strategy for resolving these and other related concerns [43, 44].

"Another barrier was the ambiguous legal status of drug checking activities. Some states have enacted laws that unambiguously legalize the distribution of fentanyl test strips but fail to clarify the legal status of using advanced technologies like portable spectroscopy devices for the same purpose (examples include Illinois Public Act 101–0356 and North Carolina § 90–113.22). As of May, 2021, at least 10 U.S. states had legislation pending that would create a legal framework for some drug checking activities [45]. In light of the fact that the U.S. Department of Health and Human Services (HHS) explicitly endorsed community drug checking by permitting grantees to spend federal funds on fentanyl test strips [46], any absence of a legal framework for making use of those technologies, including in Massachusetts where this study took place, is particularly glaring. This study demonstrates the importance of providing a clear legal framework for community drug checking with any technology."

"This study also demonstrates that available technologies fail to fully meet the needs of drug checking programs. As legal avenues for drug checking services expand, additional resources at the local, state, and federal levels should be directed towards the improvement of portable spectrometry devices and other technologies that might be useful for drug checking. The organization included in this study, and the broader drug checking peer-network in which they participate, has already made enormous advancements in the use of these devices for community drug checking [47]. Dedicated and well-resourced efforts to leverage that expertise and advance existing technologies could quickly bring drug checking out of its proverbial “Bronze Age.”

"The cost of acquiring and using this technology is one that many harm reduction organizations cannot manage. The 26-billion-dollar global settlement from opioid litigation will soon be distributed to cities and counties across the United States, creating unprecedented opportunity to invest in high-demand, high-impact interventions like community drug checking. As states are developing their global settlement spending plans [48], numerous experts have urged state leaders to dedicate that funding toward the support of essential harm reduction services, including drug checking [49]. Further, as portable spectroscopy devices perform the same function as fentanyl test strips, but do so more expansively, there is a strong rationale to expand the use of federal funds to include both fentanyl test strips and other drug checking equipment. These instruments are often purchased for forensic reasons and maintained by law enforcement and forensic laboratories. Support for their purchase, use, and extension to public health and harm reduction realms would be a way for HHS to explicitly support community drug checking."

"Regardless of what led these individuals to become drug checkers, most appeared to be motivated by altruism and the desire to increase safety and minimize risks associated with others’ drug consumption. We describe their efforts in terms of altruism not only because they act in a selfless manner and donate their time and services, but also because unlike many other volunteers, drug checkers also risk arrest by handling illegal drugs, in order to promote the safety of others. Thus, they essentially place themselves under legal risk to help protect others.

"Many checkers mentioned the desire to educate the public about the importance of drug checking as there is a high prevalence of adulterated drugs in North American drug markets. Desire to educate was often two-fold—to directly educate those about to consume a specific drug (typically through the participants testing drugs in front of the individuals providing them), and to educate PWUD more broadly. Even participants who only tested for themselves often disseminated results, publicly, on social media, in order to inform harm reduction efforts for others. The work of drug checkers is driven primarily by the idea that drug checking allows PWUD to be more aware of the actual contents of the substance they intend to consume, so they believe checking reduces the risk of consuming an unknown substance which could produce untoward or unpleasant side effects."

"In June 2020, the presence of xylazine, a veterinary sedative, was first detected as an active cut in heroin/fentanyl MADDS samples but in very low or trace quantities from 2 sites. By fall 2020, the ratio of xylazine to other active drugs had increased, and by the end of the year, xylazine was identified in 6.3% of MADDS samples (13.4% of fentanyl, 22.2% of heroin) and detected at all sites. At the close of 2020, some samples were found to contain more xylazine than fentanyl (eg, https://DrugsData.org/9661).

"The stimulant supply also exhibited dynamic changes during 2020. In prior work,²¹ FTIR scans of cocaine street samples found few active cuts, the modal cut being levamisole, a deworming agent. However, the 2020 samples exhibited high ratios of phenacetin, an obsolete pain-relieving medication unavailable in the United States. The high ratio of phenacetin found in powder cocaine (eg, https://drugsdata.org/9491) and crack (rock) cocaine samples (eg, https://drugsdata.org/9314) across MADDS sites was of concern because it was unexpected and, if ingested, may have negative health effects for people regularly using cocaine. Phenacetin is a carcinogen and can be harmful to the kidneys,²⁸,²⁹ which is of concern for PWUD. In many drug markets, phenacetin is a common active cut of cocaine. Its presence in 17.1% of cocaine samples and in high ratio (eg, https://drugsdata.org/9588) suggests that cocaine supply chains in Massachusetts were disrupted by SARS-CoV-2. The prevalence of phenacetin might have been to “stretch” the available cocaine supply. Our review of the literature on xylazine and phenacetin prompted an informational bulletin on both substances in early 2021."

"These pilots suggest that community-based drug safety testing can provide, first, engagement with more diverse drug–using communities than event-based testing—in terms of demographics, drugs of choice and risk taking behaviours—and therefore potentially can be more inclusive and impactful across drug–using communities including with marginalised groups. Second, there is the potential benefit of issuing proactive alerts for substances of concern in local drug markets ahead of specific leisure events, as happened with a mis-sold ketamine analogue identified in this study. Third, community testing can benefit from accessing fixed site laboratory facilities (in this case, a university chemistry department) to complement the speed and convenience of mobile laboratories with potentially greater analytical capabilities and trialling of new technological developments.

"These benefits cannot be presumed, however. The community pilots highlighted that service design characteristics and operational variations such as venue, day of week, prior publicity and outreach activities all can influence outcomes. Moving to a neutral central building attracted larger numbers and a greater diversity of service users as well as building trust with new service user groups, with drugs outreach staff further enhancing engagement with more marginalised drug using communities."

"Although many checkers mentioned that they had not heard of anyone being prosecuted for possession of test kits, many were more directly affected by party promoter and venue owner reluctance to allow their services due to fear of fines or even prison sentences. Checkers affiliated with formal drug checking organizations in particular expressed concern over potential legal barriers associated with drug checking at festivals or other events. The main concern cited by many formal checkers is the “RAVE Act” (the “Reducing Americans’ Vulnerability to Ecstasy Act”). Although this bill in 2002 was never passed, it was reintroduced in US Congress the following year as the Illicit Drug Anti-Proliferation Act which made it illegal to knowingly lease, rent, or use a space for the purpose of distributing or using controlled substances. In response to this Act, party promoters and venue owners fear they would be prosecuted if their venue could be deemed a place where drug consumption was “allowed”. According to this Act, property owners or promoters could be fined up to $250,000 and face up to 20 years in prison if their parties were deemed places where illegal drug use was taking place.

"Checkers commonly cited this law (which they still refer to as the “RAVE Act”) as a major barrier to their harm reduction services as such organizations are often not given permission by party promoters or venue owners, because permitting them to operate on-site could be seen as encouraging or allowing drug use. There were also instances mentioned in which drug checking organizations acquire initial approval to set up a booth at a festival, and then the organization is denied access the day of the festival due to fear of legal liability."

"Xylazine is currently not a scheduled substance under the United States Controlled Substances Act, though some efforts are underway to change this (Drug Enforcement Administration, 2021; Murphy, n.d.). However, supply side efforts to control xylazine adulteration of fentanyl/heroin are unlikely to work and – similar to trends seen when trying to decrease the availability of alcohol, cannabis, and cocaine – will likely exacerbate adulteration (Cowan, 1986). Xylazine test strips, by contrast, are a demand-driven response to unwanted adulterants and may be able influence the composition of the drug supply if xylazine is linked to specific stamps (i.e., how fentanyl/heroin products are branded in Philadelphia) (Friedman et al., 2022). This new form of drug checking represents a potential tool to further empower PWUD to make informed choices about what and how they consume drugs.

"All participants who spontaneously discussed wanting xylazine test strips, or were asked if they would want them, indicated they would use them to test their fentanyl/heroin before drug consumption, if available. Xylazine test strips are not currently available and, to our knowledge, are not in development. Research is needed from broader monitoring and analysis of the drug supply to determine whether xylazine in fentanyl/heroin is pharmaceutical grade. Additionally, it is important to understand if a xylazine test strip would be capable of detecting any xylazine analogs.

"A xylazine test strip may have the potential to positively impact drug use in a similar manner to fentanyl test strips. Fentanyl test strips have been found to significantly alter drug use behavior and foster safer drug use practices with continued testing. Individuals using fentanyl test strips prior to drug use did so in order to prevent fentanyl overdose and the potential need for emergency interventions (Peiper et al., 2019). Additionally, there have been studies reporting fentanyl test strip use following drug use. Among these individuals, positive results for fentanyl were associated with use of reduced doses on subsequent drug consumption occasions (Karamouzian et al., 2018)."

"Both clinical and public interest has been growing in the therapeutic use of some novel substances, particularly psychedelic substances, but also dissociative drugs such as ketamine. A growing number of clinical studies are exploring the potential of a range of psychedelic substances to treat different mental health conditions. Generalising in this area is difficult, and much of the research remains in its infancy, but some research in this area appears promising. These developments have also received considerable media attention. An associated concern here is that this may encourage greater experimental use of these substances without medical support, potentially putting some vulnerable individuals at risk of suffering adverse consequences. At the same time, there are signs of unregulated programmes being operated in the European Union and elsewhere, in which the use of psychedelic substances is included as part of a wellness, therapeutic or spiritually oriented intervention.

"Together, these developments have placed a renewed emphasis on the need to obtain a better understanding of the availability of both non-controlled and less common substances, as well as their impact on public health, in Europe. In particular, there are concerns about chronic harms from some of these substances, such as ketamine, and risks associated with more intensive patterns of use in certain niche settings and contexts, including the use of GHB in the chemsex scene. The presence of combinations of new synthetic opioids and new benzodiazepines further complicates overdose prevention efforts, potentially raising the need for reviewing the delivery methods of overdose-fatality prevention measures such as naloxone. There is an urgent need to improve our monitoring of the use and harms associated with these substances and to develop forensic and toxicological information sources in this area. Drug checking services will also continue to be an important sentinel data source. This information is needed to support the development and evaluation of effective harm reduction and other interventions appropriate to the settings and contexts in which these drugs are being consumed and the risks they may pose."

"Creating a bridge between public health and drug policy in the context of AAS would be a significant step towards providing adequate healthcare to this, often overlooked, group of substance consumers (Dunn et al., 2023; Piatkowski et al., 2022, 2023a). The risk environments framework provides a theoretical foundation for doing so (Rhodes, 2002), emphasising the importance of enabling contexts and resources in advancing harm reduction (Duff, 2009, 2011). Substance use, including AAS, is influenced by various interacting factors within a social context. Hanley Santos and Coomber (2017) indicate that patterns of AAS use among consumers varied based on their motivations, prior knowledge, and experiences. Many users had limited knowledge about AAS before starting their use, relying on information from peers or suppliers, which was sometimes inaccurate or incomplete (Hanley Santos & Coomber, 2017). As Hanley Santos and Coomber (2017) suggest, when developing interventions targeting AAS use, it is crucial to consider the broader context (e.g., motivations and experiences). Therefore, we extend this study by investigating how individuals' social contexts and cultural interpretations of risk practices shape their engagement with and perceptions of drug checking services, aiming to enhance our understanding of the complexities surrounding risk behaviours and informing drug policy and practice in the context of drug checking. While there is some integration of AAS consumers in harm reduction, predominantly through needle service provision (Kimergard & McVeigh, 2014; Piatkowski, Hides et al., 2022), ensuring the delivery of sterile injecting equipment should be regarded as a minimal requirement (Bates et al., 2021), Scholars have suggested harm reduction frameworks should expand to encompass a comprehensive range of harm reduction interventions that address the needs of individuals using AAS throughout their entire usage cycle, including those who opt for temporary or permanent cessation of use (Bates et al., 2021; Bates & Vinther, 2021). Therefore, further establishing the position of AAS within harm reduction frameworks can facilitate an alliance between public health policy and AAS consumers."

"The Global Commission on Drug Policy recently advised governments to make harm reduction measures, including drug checking services, widely accessible (Bewley-Taylor & Tinasti, 2020; Buxton et al., 2020). Although there have been calls for drug checking in Australia for some time (Ritter, 2020), initially there were only two Australian trials of drug checking, both performed in a festival context (Byrne et al., 2018; Olsen et al., 2019). This comprised a fixed site trial service launched in Canberra in 2022, which has been extended and is expected to become a permanent service (Olsen et al., 2022). In February 2023, the government of Queensland (the second largest and third most populous state in Australia) announced support for the introduction of drug checking services (Australian Broadcasting Corporation, 2023). The recent recommendation to make drug checking services widely accessible aligns with the harm reduction approach, which recognises the social context and influences surrounding substance use (Bewley-Taylor & Tinasti, 2020; Buxton et al., 2020). The support for introducing drug checking services by the government of Queensland reflects a step towards implementing population-level interventions aimed at reducing drug-related harms and addressing health inequalities. While previous studies surrounding these services have focused on populations such as the nightlife/festival attendees, particularly ecstasy consumers, there is still a gap in research regarding the perspectives and experiences of those involved in the consumption of performance and image enhancing drugs (PIEDs) such as anabolic-androgenic steroids (AAS). Therefore, in the context of the Queensland government's commitment to supporting such services, this study specifically aimed to explore AAS consumers attitudes, perceptions, and needs regarding drug checking. Doing so aligns service provision with broader goal of enhancing health outcomes for this population given the high representation of AAS consumption in Queensland, accounted for by the overrepresentation of AAS-related arrests compared to other states and territories (Australian Criminal Intelligence Commission, 2021)."