Drug Checking for Contaminants / Drug Checking Services

1. 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]."

Maghsoudi N, Tanguay J, Scarfone K, Rammohan I, Ziegler C, Werb D, et al. Drug checking services for people who use drugs: a systematic review. Addiction. 2021;1–13. doi.org/10.1111/add.15734

2. Drug Checking Services: Effects on Drug Use

"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]."

Maghsoudi N, Tanguay J, Scarfone K, Rammohan I, Ziegler C, Werb D, et al. Drug checking services for people who use drugs: a systematic review. Addiction. 2021;1–13. doi.org/10.1111/add.15734

3. Drug Safety Testing as a Public Health Service

"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."

Measham F. (2020). City checking: Piloting the UK's first community-based drug safety testing (drug checking) service in 2 city centres. British journal of clinical pharmacology, 86(3), 420–428. doi.org/10.1111/bcp.14231

4. Few Stimulant-Specific Harm Reduction Responses Implemented Globally

"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]"

Harm Reduction International (2020). Global State of Harm Reduction 2020. London: Harm Reduction International.

5. Methods of Drug Checking

"Two broad categories of drug-check services are offered. The most common are color reagents, Fourier transform infrared spectroscopy, ultraviolet-visible spectroscopy, and Raman spectroscopy (21). The most widely used on-site drug-checking method is the use of simple color reagent test kits (Marquis reagent and others). These tests are purely presumptive in nature although they can be fairly accurate in identifying a compound and/or mixture when a standardized procedure comprising a series of tests is used (16, 21). Furthermore, color reagent tests are rapid and relatively inexpensive, and in most instances, high-level scientific knowledge is not required to perform these tests and interpret the findings (16). The current gold standards in forensic drug analysis are chromatographic techniques such as high-performance liquid chromatography or gas chromatography (GC) coupled with mass spectrometry (MS), wherein a sample is compared with a reference library of known substances including a wide range of adulterants (16, 22, 23). These techniques are highly discriminative and quantitative but are not rapid, unlike colorimetric tests; furthermore, they are associated with a high cost. Additionally, highly qualified personnel are required for their execution (16)."

Fregonese M, Albino A, Covino C, Gili A, Bacci M, Nicoletti A and Gambelunghe C (2021) Drug Checking as Strategy for Harm Reduction in Recreational Contests: Evaluation of Two Different Drug Analysis Methodologies. Front. Psychiatry 12:596895. doi: 10.3389/fpsyt.2021.596895

6. Development of Drug Checking Services in Australia

"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."

Olsen A, Baillie G, Bruno R, McDonald D, Hammoud M, Peacock A (2022). CanTEST Health and Drug Checking Service Program Evaluation: Interim Report. Australian National University: Canberra, ACT.

7. What Are "Club Drugs"?

"Illicit drug use is common among attendees of clubs and night events (such as bars, discos, parties, and music festivals); these individuals are at a higher risk of using drugs than the general population (1–4). The most commonly used “club drugs” (also known as “party drugs” or “recreational drugs”) include entactogens such as methylenedioxymethamphetamine (MDMA, Ecstasy); sedatives such as flunitrazepam (Rohypnol) and gamma-hydroxybutyrate (GHB); stimulants such as amphetamine, cocaine, and methamphetamine; and hallucinogens such as ketamine and lysergic acid diethylamide (LSD) (1, 5, 6). These drugs have nicknames that change over time. The use of these drugs tend to be highly prevalent among night event attendees (3–7). Club drugs are used to increase the performance and enjoyment of recreational events, reduce physical fatigue, increase the communication and relational skills of individuals, and increase or modify the perception of reality (8). These drugs act on the central nervous system involving different neuromodulating systems and have different pharmacologic properties, physiological and psychological effects, and potential consequences (6). MDMA and stimulant drugs act mainly on dopaminergic, noradrenergic, and serotonergic neurons; flunitrazepam enhances the action of the neurotransmitter GABA; and hallucinogens such as ketamine and LSD act as an NMDA receptor antagonist and activator of serotonin 2A (5-HT2A) receptor, respectively (6, 9)."

Fregonese M, Albino A, Covino C, Gili A, Bacci M, Nicoletti A and Gambelunghe C (2021) Drug Checking as Strategy for Harm Reduction in Recreational Contests: Evaluation of Two Different Drug Analysis Methodologies. Front. Psychiatry 12:596895. doi: 10.3389/fpsyt.2021.596895

8. CanTEST Drug Checking Service

"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."

Olsen A, Baillie G, Bruno R, McDonald D, Hammoud M, Peacock A (2022). CanTEST Health and Drug Checking Service Program Evaluation: Interim Report. Australian National University: Canberra, ACT.

9. Drug Checking and Harm Reduction

"Several international projects [Nightlife Empowerment & Well-being Implementation Project; Drug Checking Service: Good Practice Standards; Trans European Drugs Information (TEDI) Workgroup; Factsheet on Drug Checking in Europe, 2011; European Monitoring Center for Drugs and Drug Addiction; and An Inventory of On-site Pill-Testing Interventions in the EU: Fact Files, 2001] have implemented several harm-reduction strategies to prevent recreational drug use among young people (16). The strategies encompass interventions, programs, and policies that seek to reduce the health-related, social, and economic harms of drug use to individuals, communities, and societies (1). They are aimed at ensuring a pragmatic manner of dealing with drug use through a hierarchy of intervention goals that emphasizes on reducing the health-related harms of continued drug use, offering, for example, opioid substitution treatment and needle and syringe programs to prevent death due to overdose and reduce the spread of infectious diseases (1, 17). Since the 1960s, harmreduction services are occasionally available at various types of nightly musical events to inform users about the risks of drug use and ways of risk minimization (18). Such services are called “street drug analysis,” “pill testing,” “drug checking,” “adulterant screening,” “drug testing,” and “multi-agency safety testing (19).” Their main purpose is to provide individual drug users free testing services to identify the drugs that they intend to use during an event and all possible information on substance purity. This is to ensure that the users have the option to make a more informed choice about substance use (2, 20). The main objectives of this type of harm-reduction strategies are to change consumer behavior at the time of consumption, that is, when a consumer is confronted with an unexpected test result, facilitate brief interventions and referrals to services, and/or inform clinical management (20)."

Fregonese M, Albino A, Covino C, Gili A, Bacci M, Nicoletti A and Gambelunghe C (2021) Drug Checking as Strategy for Harm Reduction in Recreational Contests: Evaluation of Two Different Drug Analysis Methodologies. Front. Psychiatry 12:596895. doi: 10.3389/fpsyt.2021.596895

10. Interim Report on CanTEST: Negative Consequences

" 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."

Olsen A, Baillie G, Bruno R, McDonald D, Hammoud M, Peacock A (2022). CanTEST Health and Drug Checking Service Program Evaluation: Interim Report. Australian National University: Canberra, ACT.

11. Interim Report on CanTEST: Positive Consequences

" A small number of parents of young people who use drugs accessed the service with the aim of reducing the risks of harm that their children face in using drugs.

" Twelve percent of the primary service users resided outside the ACT, but note that this would include Queanbeyan, a city contiguous with Canberra. This proportion is not high enough to imply the existence of a ‘honeypot’ effect. Instead, it demonstrates the need for this type of service in other parts of the nation.

" A new ketamine-like substance was identified in the service in September 2022. The service understands that it is the first time globally that a new substance has been identified in a drug checking service. Its significance was highlighted by the fact that the service received enquiries about the substance nationally and across the globe. The service provided GC-MS analytical data to national forensic laboratories, providing timely information on the identity of a new psychoactive substance in the Australian drug market.

" The service found an unexpectedly high level of demand from people from diverse sectors wishing to do ‘walk-throughs’ of the service in which they are provided an understanding of the service user journey and demonstrations of the drug checking equipment. Senior policy makers and politicians, health professionals, researchers, advocates and media as well as people from interstate contemplating establishing drug checking services have completed walk-throughs. In this sense, the service provided a valuable information and an educational role in innovative drug harm reduction policies and practice in Australia.

" At least one interstate government health department requested the service data on an ongoing basis from ACTHD, presumably to inform their own policy work on drug checking.

" The evaluation team received requests from interstate colleagues for the sharing of the service and evaluation data collection tools. The interstate colleagues plan to use this information to support their own work in developing the evaluation of drug checking services when they become available in their own jurisdictions. This exchange of information creates the potential for a minimum dataset in the collection of data from drug checking services as they emerge across Australia.

" Establishment of the Australasian Drug Checking Information Group as a flow-on from the evaluation team’s presentation to, and network-building activity at, the 2022 Darwin APSAD conference. The group involves a consortium of individuals interested in best practices in drug checking across Australia and New Zealand."

Olsen A, Baillie G, Bruno R, McDonald D, Hammoud M, Peacock A (2022). CanTEST Health and Drug Checking Service Program Evaluation: Interim Report. Australian National University: Canberra, ACT.

12. Reasons for Using a Community Drug Checking Service: Supply Chain

"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."

Larnder, A., Burek, P., Wallace, B. et al. Third party drug checking: accessing harm reduction services on the behalf of others. Harm Reduct J 18, 99 (2021). doi.org/10.1186/s12954-021-00545-w

13. Reasons for Using a Community Drug Checking Service: Family and Friends

"Of those who specified who they were checking for, friends and family were mentioned most frequently (68%), pointing to the importance of drug checking as a relational practice. Due to stigma and criminalization, it is worth noting a possible positive bias to the response of checking for others, as people accessing the service may feel more comfortable admitting they are checking for a friend than themselves. Preliminary research has shown practices of care among friends to be seen in drug checking services [7], and we found this translated to the community setting as testing for friends represented 52% of the time people were checking for others. This demonstrates the care practices of third party checking and the social aspects of using substances, as is the possibility of having a designated person who checks substances for a group who may be using or buying together.

"The inclusion of family members in supporting people who use drugs has been identified as increasing the reach of harm reduction outcomes [10]. Our findings show the supporting role that family members can play through drug checking. In most instances (68%), family members were checking for others only, highlighting how this service can provide a way for families to better understand substances and substance use to support their family members who are using drugs. It provides evidence for drug checking services being an access point to engage with harm reduction, enabling further openness in discussing substances and substance use.

"As community drug checking expands, we see benefits in engaging with families while also considering the challenges of consent and inherent power imbalances in families, such as a parent checking a child’s drugs unknowingly."

Larnder, A., Burek, P., Wallace, B. et al. Third party drug checking: accessing harm reduction services on the behalf of others. Harm Reduct J 18, 99 (2021). doi.org/10.1186/s12954-021-00545-w

14. Reasons for Using a Community Drug Checking Service: Outreach and Service Workers

"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."

Larnder, A., Burek, P., Wallace, B. et al. Third party drug checking: accessing harm reduction services on the behalf of others. Harm Reduct J 18, 99 (2021). doi.org/10.1186/s12954-021-00545-w

15. Drug Checking

"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%)."

Klaire, S., Janssen, R. M., Olson, K., Bridgeman, J., Korol, E. E., Chu, T., Ghafari, C., Sabeti, S., Buxton, J. A., & Lysyshyn, M. (2022). Take-home drug checking as a novel harm reduction strategy in British Columbia, Canada. The International journal on drug policy, 106, 103741. doi.org/10.1016/j.drugpo.2022.103741

16. Drug Checking Study In Vancouver, BC

"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."

Klaire, S., Janssen, R. M., Olson, K., Bridgeman, J., Korol, E. E., Chu, T., Ghafari, C., Sabeti, S., Buxton, J. A., & Lysyshyn, M. (2022). Take-home drug checking as a novel harm reduction strategy in British Columbia, Canada. The International journal on drug policy, 106, 103741. doi.org/10.1016/j.drugpo.2022.103741

17. City Checking: Community-Based Drug Safety Testing

"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."

Measham F. (2020). City checking: Piloting the UK's first community-based drug safety testing (drug checking) service in 2 city centres. British journal of clinical pharmacology, 86(3), 420–428. doi.org/10.1111/bcp.14231