Commentary
Drug checking as a potential strategic overdose response in the fentanyl era

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Abstract

Adulteration of illicit drug supplies with synthetic opioids such as fentanyl has contributed to a dramatic rise in overdose morbidity and mortality in North America. One promising response to this crisis is the implementation of “drug checking” services. Drug checking encompasses a range of interventions used to assess the constituents of illicit drug samples, such as colour-spot testing, gas or liquid chromatography, and various methods of spectroscopy. Testing may be performed on-site at events or harm reduction service locales, performed independently by consumers, or sent to a centralized lab for analysis. This information may then serve to inform individual decision-making, enhance harm reduction efforts and strengthen public health surveillance and response strategies to prevent harms associated with illicit drug use. Historical examples of drug checking services that emerged with the 1990s synthetic “party drug” movement in Europe provide a theoretical and practical basis for the adaptation of these services for use in context of the current opioid overdose crisis. Potential harm reduction benefits of drug checking for synthetic opioid adulterants include individuals being more likely to use drugs more safely or to dispose of drugs found to contain harmful adulterants. Public health benefits of drug checking may also include negative feedback on the illicit drug supply with decreased availability or consumption of drugs from sources adulterated with synthetic opioids following public health warning campaigns. As part of the response to the current synthetic opioid epidemic in BC, pilot efforts are being undertaken in Vancouver to determine the feasibility and effectiveness of drug checking as an overdose response strategy. Models of drug checking service delivery and comparison of differing technologies, including unique challenges and potential solutions related to access to these services, legal obstacles, and sensitivity and specificity of testing technologies, are explored, alongside suggestions for future research and directions.

Introduction

Overdose deaths involving opioids have risen dramatically in North America in recent years (British Columbia Coroners Service, 2018, May, 2018, June; Rudd, Aleshire, Zibbell, & Matthew Gladden, 2016). The increasing presence of synthetic opioid adulterants, namely fentanyl and its analogues, in the illicit drug supply has been a major contributor to the unprecedented rise in mortality rates since 2010 (Seth, Scholl, Rudd, & Bacon, 2018). These are particularly risk-laden adulterants owing to their high potency (Poklis, 1995; Reynolds et al., 2004). Fentanyl adulteration has been documented in illicit heroin (Hempstead & Yildirim, 2014), but also in contraband pills (e.g. “fake” oxycodone or hydrocodone tablets) (Ellis, 2015, July 8; Sutter et al., 2017), as well as drugs sold as cocaine or methamphetamine (Woo, 2017, May 14). The potential that high-potency synthetic opioid-related overdoses may represent a “new normal” (Adhopia, 2017, June 20; McElroy, 2017, Sept 30; Mooney, 2017, Aug 11) underscores the need to develop responses that reduce overdose risk stemming from adulteration of the illicit drug supply.

Drug checking”, also known as “pill testing” or “adulterant screening,” is an integrated harm reduction and public health monitoring strategy that seeks to respond to shifting trends in illicit drug supplies (Brunt & Niesink, 2011; Giraudon & Bello, 2007; Martins et al., 2017; Spruit, 2001). Drug checking initiatives first emerged in the growing “party drug” scene of Europe in the 1990s, and an established body of literature now testifies to their effectiveness for public health surveillance (Brunt et al., 2017; Giraudon & Bello, 2007; Keijsers, Bossong, & Waarlo, 2008; Schroers, 2002). These initiatives seek to help people who use drugs (PWUD) avoid ingesting unknown and potentially dangerous adulterants and identify trends so the public may be alerted to emerging threats in illicit drug supplies (see Fig. 1).

More recently, drug checking has been identified as a potential strategy for prevention of overdose due to adulteration of drugs with illicit synthetic opioids (Tupper, 2017, August 11). Though it is presently an understudied and underutilized intervention in this context, drug checking holds significant promise as a response to the current opioid overdose crisis and the shifting illicit drug market in North America. A recent commentary in this journal from McGowan, Harris, Platt, Hope, and Rhodes (2018) has begun to explore the application of one type of drug checking for synthetic opioid adulteration: test strips. Here, we provide an overview of the history of drug checking services, the promising outcomes associated with their application, the challenges and opportunities of drug checking in the era of illicit synthetic opioids, and an update on emerging evidence.

Early drug checking efforts were driven by concerns regarding adulteration of illicit drugs that might alter expected purity or potency, or lead to adverse health outcomes (for example, para-methoxyamphetamine [PMA] contamination of MDMA [“ecstasy”], or levamisole contamination of cocaine) (Brunt & Niesink, 2011; Spruit, 2001). Beginning in the early 1990s—primarily in response to a shift in youth drug culture and a rise in popularity of “party drugs” such as MDMA, amphetamines (“speed”), and cocaine—government-supported initiatives in the Netherlands made voluntary testing of illicit drugs widely available through stationary testing facilities (Brunt & Niesink, 2011; Brunt et al., 2017).

The Dutch Drug Information and Monitoring System (DIMS) was the first coordinated system to track substance characteristics by conducting laboratory analyses of submitted compounds (Brunt & Niesink, 2011). Established in 1992, the DIMS network began to offer stationary testing services. Staff analyzed sample characteristics and conducted limited composition testing on the spot (Brunt & Niesink, 2011). Participants could also submit samples for detailed quantitative analysis via a centralized national laboratory (Brunt & Niesink, 2011). Information was collected on location of drug purchase, adverse effects, and knowledge of safer drug use practices from the participants, and results were cross-referenced nationally (Brunt & Niesink, 2011).

In the federally-supported Field Workers program in France, outreach workers collected drug samples from participants in a range of settings, including raves, clubs, and music festivals, but also in their homes, shelters, or on the street (Giraudon & Bello, 2007). Results from submitted samples contributed to a database for public health surveillance (Giraudon & Bello, 2007). However, these models lacked the crucial harm reduction function of providing information to individual PWUD, thus limiting their potential public health benefit. In parallel, grass-roots harm reduction initiatives in France such as Technoplus emerged to provide qualitative drug checking services on-site at events and at fixed-site locations (Barratt, Kowalski, Maier, & Ritter, 2018). Legal complications impacted the ability of these services to check drugs directly, and shifted to counseling participants on how to perform tests themselves. Since 2009, these services have been centrally coordinated under the XBT program of Médecins du Monde (Barratt et al., 2018).

Drug checking programs for “party scenes” have expanded from their early Dutch origins and are now present in numerous countries, including Austria, the United States, Switzerland (Bohannon, 2005, December 5; Brunt & Niesink, 2011; Kriener & Schmid, 2002), Spain, Portugal, Belgium (Brunt et al., 2017), France (Giraudon & Bello, 2007), the United Kingdom (Kenyon, Ramsey, Lee, Johnston, & Holt, 2005), Australia (Camilleri & Caldicott, 2005), and Canada (Sage & Michelow, 2016). For a comprehensive overview of current drug checking services operating around the world, see Barratt et al. (2018).

Most evidence on how drug checking influences use behaviour comes from participant self-report on future use intentions following receipt of a real-time test result. Evaluation of the Check It! initiative in Vienna, Austria, which provides on-site testing at raves and music festivals, found that two thirds of participants who received an unexpected test result reported that they would not use the tested drug and would warn their peers of a potential contaminated source (Kriener & Schmid, 2002). Data from a dance festival drug checking initiative in Portugal found that 74% of participants would not use the tested drug after receiving unanticipated results, citing concerns related to the “unknown” nature of the adulterants or potential harms of known adulterants (Martins et al., 2017). Results from UK’s first on-site drug checking service (Multi Agency Safety Testing [MAST]) found that one in five individuals opted to have their drugs destroyed on-site, immediately following a contaminated test result (Measham, 2017, May). Research from drug checking at dance festivals in Western Canada found that individuals were more likely to discard drugs on-site when unknown or harmful contaminants were detected, and were more likely to discard drugs if contaminants were either “unknown” (36%) or known to have high toxicity (31%; such as PMMA/PMA, NBOME and 2C‐T‐7) (Sage & Michelow, 2016; Sage, 2015).

Establishment of centralized databases such as those in the Netherlands and France provide strong evidence for the utility of drug checking services as public health surveillance tools. Findings of adulterated drugs can be communicated to the public through posters at events, press releases, and written, broadcast, and social media (Brunt & Niesink, 2011; Brunt et al., 2017; Keijsers et al., 2008; Spruit, 2001), as well as through peer networks of PWUD (Giné et al., 2017). In addition to local and national warnings, results of the Dutch drug checking experience led to the Early Warning System (EWS) of the EMCDDA. This system allows for cross-border information sharing and the generation of “red alerts” related to detection of adulterated drug supplies (Keijsers et al., 2008; Pirona et al., 2017; Spruit, 2001). Novel collaborations in Europe have recently sought to combine drug checking data from six countries (Spain, Switzerland, Belgium, Austria, Portugal, and the Netherlands) as part of the Trans European Drug Information (TEDI) project (Brunt et al., 2017). The TEDI Workgroup has identified drug checking as a cost-effective healthcare resource, with attributable reductions to both short- and long-term healthcare costs associated with illicit drug use (Trans European Drugs Information (TEDI) Workgroup (2011)).

Drug checking may also offer some influence of quality control on the illicit market, with drug manufacturers and dealers less disposed to distribute highly dangerous substances when clients are able to check their drugs (Brunt et al., 2017). Survey reports of people who access drug checking suggest that inconsistent or contaminated drugs are cause for many to find a new dealer (Korf, Benschop, & Rabes, 2002; Martins et al., 2017). Furthermore, in countries where drug checking is well-established, tested samples more closely follow anticipated composition trends, as compared to countries not employing drug checking (Giné et al., 2017). While the DIMS system has not been directly linked to prevention of deaths due to “party drug” use, monitoring systems have shown decreases in detected batches of harmful drugs from local supplies following alerts (Butterfield, Barratt, Ezard, & Day, 2016). Early reviews of DIMS found that after each campaign, compounds people were warned against were no longer found in samples brought in for testing (Spruit, 2001).

Section snippets

Challenges and opportunities of drug checking for illicit synthetic opioids

Two-and-a-half decades of implementation and evaluation of drug checking for “party drugs” points to some potential for these services in the context of the current opioid overdose epidemic in North America. However, expansion of drug checking to synthetic opioid adulteration presents unique barriers and opportunities.

The ever-changing nature of illicit drug adulteration by highly-potent synthetic opioids presents significant challenges related to detection. With numerous analogues emerging

Future directions

Recently, the UN’s Global Commission on Drug Policy (GCDP) recommended that governments, “[m]ake proven harm reduction measures and treatment widely available,” including drug checking services amongst these measures (Global Commission on Drug Policy, 2017). Further, the Commission also calls for research into the role drug checking may play in addressing the specific risk factors for synthetic opioid overdoses. Such research can now be informed by a decades-old body of literature surrounding

Conclusions

Nearly 20 years ago, Winstock and colleagues stated that “[n]o vocal parties have called for testing for purity of heroin or cocaine on behalf of the consumer” (Winstock et al., 2001). Facing concerns at that time related to the increasing variability in the composition of ecstasy and other “party drugs”, health leaders responded by implementing and expanding drug checking services to reach people using drugs recreationally. More recently, the rapid rise in overdose deaths in North America

Declarations of interest

None.

Acknowledgements

The authors wish to thank Chiarine Hsu for her administrative assistance. We would also like to express our sincere thanks to the reviewers of our paper for their thoughtful suggestions. Dr. Nadia Fairbairn is supported by a Michael Smith Foundation for Health Research/St. Paul’s Foundation Scholar Award. Dr. Kenneth Tupper wishes to acknowledge Health Canada for a Substance Use and Addictions Program grant to the BC Centre on Substance Use to implement and evaluate a drug checking pilot in

References (59)

  • K.W. Tupper et al.

    Initial results of a drug checking pilot program to detect fentanyl adulteration in a Canadian setting

    Drug and Alcohol Dependence

    (2018)
  • V. Adhopia

    ‘Our new normal’: Hard-hit Ohio community fears opioid overdoses will be perpetual crisis

    (2017)
  • R. Barker-Williams

    Drug consumption rooms: A Welsh response

    (2017)
  • M.J. Barratt et al.

    Drug checking interventions can track the nature and size of the discrepancy between self-report and actual drugs consumed

    Addiction

    (2016)
  • M.J. Barratt et al.

    Global review of drug checking services operating in 2017. Drug policy modelling program bulletin

    (2018)
  • J. Bohannon

    Just check it! Toxicology comes to rave parties in Vienna

    (2005)
  • British Columbia Centre for Disease Control

    The opioid overdose emergency infographic

    (2017)
  • British Columbia Coroners Service

    (June). Illicit drug overdose deaths in BC January 1, 2008 – April 30, 2018

    (2018)
  • British Columbia Ministry of Mental Health and Addictions

    (March). Responding to B.C.’s illegal drug overdose epidemic: Progress update February/March 2018

    (2018)
  • T.M. Brunt et al.

    The drug information and monitoring system (DIMS) in the Netherlands: Implementation, results, and international comparison

    Drug Testing and Analysis

    (2011)
  • T.M. Brunt et al.

    Drug testing in Europe: Monitoring results of the Trans European drug information (TEDI) project

    Drug Testing and Analysis

    (2017)
  • J. Bryksa

    Sale of fentanyl test kits stopped over effectiveness concerns

    (2016)
  • F.P. Busardò et al.

    The never-ending public health issue of adulterants in abused drugs

    Journal of Analytical Toxicology

    (2016)
  • R.J. Butterfield et al.

    Drug checking to improve monitoring of new psychoactive substances in Australia

    Medical Journal of Australia

    (2016)
  • S. Caul

    Drug-related deaths "deep dive" into coroners’ records

    (2018)
  • T. Crawford

    Fentanyl test strips sell for $1.25 at Vancouver dollar store

    (2018)
  • DanceSafe

    Drug checking

    (2018)
  • Daniulaityte, R., Juhascik, M. P., Strayer, K. E., & al., e. (2017). Overdose deaths related to fentanyl and its...
  • E. Ellis

    No quick test for detecting fentanyl in street drugs

    (2015)
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