Evaluating networked drug checking services in Toronto, Ontario: study protocol and rationale

Abstract

Background: The increasing incidence of fatal opioid overdose is a public health crisis in Canada. Given growing consensus that this crisis is related to the presence of highly potent opioid adulterants (e.g., fentanyl) in the unregulated drug supply, drug checking services (DCS) have emerged as part of a comprehensive approach to overdose prevention. In Canada's largest city, Toronto, a network of DCS launched in 2019 to prevent overdose and overdose-related risk behaviors. This network employs mass spectrometry technologies, with intake sites co-located with supervised consumption services (SCS) at three frontline harm reduction agencies. The protocol and rationale for assessing the impact of this multi-site DCS network in Toronto is described herein. The aims of this study are to (1) evaluate the impact of DCS access on changes in and factors influencing overdose and related risk behaviors, (2) investigate the perceived capacity of DCS to prevent overdose, and (3) identify composition (qualitative and quantitative) trends in Toronto's unregulated drug supply. Methods: We will use a parallel-mixed-methods design with complementary data sources (including data from chemical analysis of drug samples, quantitative intake and post-test surveys, SCS, coroners, paramedic services, and qualitative interviews), followed by a meta-inference process wherein results from analyses are synthesized. Results: Whereas most DCS globally target "recreational drug users," in Toronto, this networked DCS will primarily target marginalized people who use drugs accessing frontline services, many of whom use drugs regularly and by injection. This evolution in the application of DCS poses important questions that have not yet been explored, including optimal service delivery models and technologies, as well as unique barriers for this population. Increasing information on the unregulated drug supply may modify the risk environment for this population of people who use drugs. Conclusions: This study addresses evidence gaps on the emerging continuum of overdose prevention responses and will generate critical evidence on a novel approach to reducing the ongoing high incidence of drug-related morbidity and mortality in Canada and elsewhere.

The potential impacts of community drug checking within the overdose crisis: qualitative study exploring the perspective of prospective service users

“…These newer drug checking technologies are increasingly being included in public health responses to the current overdose epidemic, where fentanyl and other potent ingredients are linked to unprecedented numbers of overdose deaths [ 18 ]. The emerging responses are raising new questions [ 19 ]: Will people who inject alone, and face significant risk of overdose, access drug checking services [ 21 ]? What are the factors that influence people to access community drug checking, and how can emerging services be responsive to structural vulnerabilities [ 12 , 22 , 23 ]?…”

What is needed for implementing drug checking services in the context of the overdose crisis? A qualitative study to explore perspectives of potential service users

“…It is within this context of fentanyl-related overdoses that drug checking has been re-emerging as a potential harm reduction intervention in Canada [6][7][8] and globally [9][10][11]. A 2017 evidence review of drug checking technologies and research concluded that communitywide drug checking may be instrumental as part of public health responses in British Columbia, and potentially a life-saving harm reduction service [12].…”

The Ontario Integrated Supervised Injection Services Cohort Study of People Who Inject Drugs in Toronto, Canada (OiSIS-Toronto): Cohort Profile

“…As of December 2020, there were nine SCS operating in Toronto. In response to the worsening overdose crisis, a range of harm reduction innovations emerged beyond SCS, notably a street drug-checking program [ 18 ] and “safer opioid supply (SOS)” programs. SOS are harm reduction programs aiming to reduce overdose risk by prescribing pharmaceutical opioids in place of unregulated street opioids [ 19 ].…”