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]."

"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]"

"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]."

"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)."

"Harms of xylazine use in humans are not well documented, but evidence suggests that combined use of xylazine and an opioid such as fentanyl may increase the risk of overdose fatality.¹ Although naloxone, the opioid overdose reversal drug, is not effective against xylazine alone, unintentional fatal overdoses with xylazine detections also had heroin and/or fentanyl detections in Philadelphia, indicating timely administration of naloxone is critical for preventing deaths. Additional treatment for xylazine poisoning may involve supportive care using intubation, ventilation and administration of intravenous fluid.¹

"Of note, as fentanyl has largely replaced the heroin supply in Philadelphia, xylazine has been increasingly found in combination with fentanyl. Some evidence suggests that the combination of xylazine and fentanyl in humans may potentiate the desired effect of sedation and the adverse effects of respiratory depression, bradycardia and hypotension caused by fentanyl alone,¹ comparable to the synergistic effects of combining benzodiazepines with heroin and/or fentanyl.⁷ While benzodiazepines were detected in 97 (58%) of the 168 unintentional overdose deaths with heroin and/or fentanyl detections in Philadelphia in 2010, this decreased to 232 (28%) of the 858 unintentional overdose deaths with heroin and/or fentanyl detections in 2019. This decline may be the result of increasing demand for xylazine among people who use drugs in Philadelphia and/or changes in the illicit drug market as drug seizure data indicate that xylazine is increasing in polydrug samples. Indeed, focus groups with people who use drugs in Philadelphia have suggested that the addition of xylazine to fentanyl “makes you feel like you’re doing dope (heroin) in the old days (before it was replaced by fentanyl)” when the euphoric effects lasted longer."

"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%)."

"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."

"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."

"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."

"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."

"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)."

"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."

"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."