"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]."

"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]"

"There was significant advocacy work, including volunteer-run festival-based drug checking services by Pill Testing Australia, in the years leading up to the ACT [Australian Capital Territory] Government 2021 commitment to fund a fixed-site pilot. Upon the ACT Government announcement, a consortium of organisations (Pill Testing Australia, Directions Health Services and Canberra Alliance for Harm Minimisation and Advocacy) submitted a proposal for consideration. Negotiation with the Government included assessment of costs, what services could be provided, staffing and potential locations (see Figure 1 below). The result is a drug checking service in the City Community Health Centre at 1 Moore Street in the Canberra civic area. During the pilot status the service was to operate at specified regular times each week and to be staffed by a variety of professionals. Staff at each shift include one alcohol and other drug counsellor, one primary health nurse, one peer educator, two analytical chemists and a medical practitioner on-call. A senior chemical analyst and medical toxicologist are available on-call to provide feedback on analytical results of clinical concern (novel products for which there may not be community familiarity, potentially hazardous doses, and dangerous mixtures) as well as to assess whether ACT Health should be alerted on any drugs of concern. Directions Director of Service Delivery or CEO provides management oversight."

"The overall aim of the service is to provide discreet and private advice to people wishing to have drugs tested and as such, CanTEST is free and confidential (Figure 2). Drug checking is offered on a range of drug types, in the form of pills, capsules, powders, crystals and liquids. Some substances such as plant material, blotters or dilute solutions cannot be tested (Panel 1). Drug checking requires a very small scraping/sample of the pill or drug (as little as a few mg) for analysis. The drug checking process can take around 20 minutes if both FTIR and UPLC-PDA analysis is conducted, but can take longer depending on the substance and number of service users waiting. Once the drug checking is complete, the analysts discuss the results with the service user and an alcohol and other drug counsellor and/or peer educator in order to provide service users with information about the results and discuss the risks associated with consuming the substance/s detected, as well as any other concerns service users may have. Service users can also receive non-drug checking health services, such as discussing any health needs, with the service nurse (Figure 3).

"CanTEST nurses are able to provide advice and care across a broad range of health concerns ranging from alcohol and drug assessments and harm reduction through to wound care or sexual health screening. The peer educators and AOD counsellors specialise interpretation of analytical results and advice on drug interactions, strategies to reduce harm associated with drug use and overdose prevention as well as support services available (Panel 2 and 3). The analytical chemists test the substances and provide information about and testing procedure as well as quantitative and qualitative information about the contents and purity of drug samples. Chemists also collect samples for further detailed laboratory analysis off-site at the Australian National University Research School of Chemistry and the ACT Government Analytical Laboratory (ACTGAL).

"During the first three months of operation, the service provider coalition along with ACT Health designed the level and type of public release of results. CanTEST has a protocol for identifying high-risk substances and notifying ACT Health. Upon notification of a potentially high-risk substance, ACT Health convenes relevant key experts to assess the notifications and determine whether risk communications are required. As necessary, public drug alerts or alerts for the health or AOD sector and/or clinical first responders will be prepared. No drug alerts were issued by ACT Health in the first three months of service. Several community notices have been issued by CanTEST on social media to provide targeted information for the community and service clients on particular substances identified. These notices also encourage the community to bring substances in to CanTEST for checking. Alongside the development of risk communications, the CanTEST Drug Early Warning Protocol was developed in conjunction ACT Government, which helps to identify the emergence of drugs of concern and potential changes on the local/regional drug market."

" ACT [Australian Capital Territory] Health provided the funds to meet the budget provided by the service provider. However, a number of increased costs were unanticipated at the time of initial funding. While a certain level of in-kind contribution was expected at the commencement of the pilot, there was more work carried out to design and implement the service than expected. The three organisations providing the service, and the evaluation team, needed to make substantial in-kind contributions of time and expertise, over and above that provided for in original budgets. For example, service management rapidly realised that the promotion of the service was important, but that this was not adequately funded in original planning and budgeting for the service. Further, the service originally budgeted for one analytic chemist, however two were needed to meet the level of service demand. In-kind contribution were essential for sound governance, service design, and implementation. A range of the additional funds expended by Directions Health Services are intended to be covered by ACT Health.

" Finally, the equipment used is not owned by Directions Health Services or ACT Health. The FTIR is leased from Pill Testing Australia and the UPLC was donated by Waters Australia for the duration of the pilot. Costs of either purchasing the equipment or leasing longer term will be considered at the end of the pilot."

"Those accessing drug checking services for the purpose of selling or within the supply chain represented 12% of service users. There is likely under-reporting given the increased burden of criminalization on those who sell drugs, as this burden has been identified as a potential barrier to drug checking services for people who sell drugs [12]. Drug checking has been explored for its potential role in engaging people who sell drugs as a harm reduction practice with further reach to those vulnerable to unpredictability in the illicit supply [13–16]. Wallace et al. [9] highlight the potential of drug checking to act as a supply intervention and to potentiate market interventions by empowering consumers and providers with knowledge of the composition of their substances. Our findings confirm that indeed, drug checking services are used by people who sell drugs to provide some agency within the market and quality control for prospective consumers."

"Outreach and service workers checking for others represented 30% of these responses. Currently, regulatory frameworks bar the transportation of substances for the purpose of drug checking by social service and healthcare workers. Therefore, this finding highlights that these workers who are accessing drug checking services on behalf of their clients are likely doing so despite a regulatory environment that prohibits it.

"The outreach category also includes experiential workers and peer workers, as 12% of outreach workers reported checking not only for others, but themselves as well. Experiential and peer workers face disproportionate threats of criminalization and are further vulnerable to the impacts of enforcement [11]. Those providing outreach for drug checking are key in increasing the accessibility of a service to those who are less mobile within the city or those experiencing higher barriers to reach the service on their own behalf. As outreach workers represent a large portion of people accessing this service, regulation that enables social service workers to engage in drug checking services could further extend the reach of drug checking in addressing the harms of the current crisis."

"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."