Invited Commentary: Drug Checking for Novel Insights Into the Unregulated Drug Supply

Abstract

Tobias et al. (Am J Epidemiol. XXXX;XXX(XX):XXXX–XXXX) present a novel analysis of time trends in fentanyl concentrations in the unregulated drug supply in British Columbia, Canada. The pre-existing knowledge about unregulated drugs had previously come from law enforcement seizures and post-mortem toxicology. As both of these data sources are subject to selection bias, large scale drug checking programs are poised to be a crucial component of the public health response to the unrelenting increase in overdose in North America. As programs expand, we offer two guiding principles. First, the primary purpose of these programs is to deliver timely results to people who use drugs to mitigate health risks. Second, innovation is needed to go beyond criminal justice paradigms in laboratory analysis for a more nuanced understanding of health concerns. We provide examples of the role adulterants play in our understanding of drug harms. We also describe the applications and limitations of common laboratory assays, with implications for epidemiologic surveillance. While the research and direct service teams in British Columbia have taken groundbreaking steps, there is still a need to establish best practices for communicating results to sample donors in an approachable yet non-alarmist tone.

History and Future of Harm Reduction in North Carolina: Pragmatism and Innovation

“…By 2017, NCSU was among the first organizations in the nation to systematically use disposable test strips to identify fentanyl as it started to appear in the drug supply [26]. When fentanyl analogues and other adulterants emerged in force during the COVID-19 pandemic, NCSU was the first community-led drug-checking program in the country to use a sophisticated analytical chemistry machine to identify a wider array of contaminants and tie them to specific clinical harms [27]. Working with these partners in Greensboro, in 2022 UNC launched a groundbreaking program for harm reduction programs and health departments to conduct drug checking by mail during overdose outbreaks [28].…”

Co-Designing High-Risk Drug Alerts for Health and Community Service Practitioners

“…In the absence of testing substances consumed (where possible) it is unclear whether the presence of unexpected compounds is due to contamination/adulteration or under-reported, intentional polysubstance use. Systems that provide close to realtime detection of sample composition can differentiate from people's expectations about the substance of concern, and are better-placed to provide evidence-based insights about potentially adulterated, contaminated, or substituted supplies (37,38). Systematic, cross-jurisdictional detection and reporting that coordinates multidisciplinary responses (e.g., xed and mobile drug checking services, screening medical presentations, peerled intelligence, research activities, and wastewater analyses in substance use 'hotspots') can help to ensure more proactive and timely detection, evaluation, and reporting of emerging threat (41)(42)(43).…”

“…A key feature of timely drug market surveillance is drug checking (6, [35][36][37]. Drug checking services invite members of the public to anonymously submit samples for analysis and provide individualized feedback about results (35).…”

“…Drug checking services invite members of the public to anonymously submit samples for analysis and provide individualized feedback about results (35). They offer unique and novel insights about real-time market trends by differentiating between expectations about sample contents and con rmed analyses (37,38). When signi cant threats are identi ed, information can be translated into targeted interventions and universal approaches can rapidly translate information into purposeful public health communications (e.g., warnings, alerts, or advisories) to promote riskawareness and prompt individual or community action (39,40).…”

Current Attitudes Toward Drug Checking Services and a Comparison of Expected with Actual Drugs Present in Street Drug Samples Collected from Opioid Users

“…An emergent use of DCS is to monitor street drug markets, which by virtue of being unregulated and decentralized, produce drugs that vary widely in terms of the concentrations of fentanyl, other drugs such as benzodiazepines commonly used to potentiate the effects of street drugs sold as opiates, and cutting agents that are not always benign with respect to their health effects [17,18]. The unpredictable variability of the illegal drug market has itself become an overdose risk factor [19,20,21].…”