Insights from Drug Checking Programs: Practicing Bootstrap Public Health Whilst Tailoring to Local Drug User Needs

Abstract

The year 2021 was the most deadly year for overdose deaths in the USA and Canada. The stress and social isolation stemming from the COVID-19 pandemic coupled with a flood of fentanyl into local drug markets created conditions in which people who use drugs were more susceptible to accidental overdose. Within territorial, state, and local policy communities, there have been longstanding efforts to reduce morbidity and mortality within this population; however, the current overdose crisis clearly indicates an urgent need for additional, easily accessible, and innovative services. Street-based drug testing programs allow individuals to learn the composition of their substances prior to use, averting unintended overdoses while also creating low threshold opportunities for individuals to connect to other harm reduction services, including substance use treatment programs. We sought to capture perspectives from service providers to document best practices around fielding community-based drug testing programs, including optimizing their position within a constellation of other harm reduction services to best serve local communities. We conducted 11 in-depth interviews from June to November 2022 via Zoom with harm reduction service providers to explore barriers and facilitators around the implementation of drug checking programs, the potential for integration with other health promotion services, and best practices for sustaining these programs, taking the local community and policy landscape into account. Interviews lasted 45–60 min and were recorded and transcribed. Thematic analysis was used to reduce the data, and transcripts were discussed by a team of trained analysts. Several key themes emerged from our interviews: (1) the instability of drug markets amid an inconsistent and dangerous drug supply; (2) implementing drug checking services in dynamic environments in response to the rapidly changing needs of local communities; (3) training and ongoing capacity building needed to create sustainable programs; and (4) the potential for integrating drug checking programs into other services. There are opportunities for this service to make a difference in overdose deaths as the contours of the drug market itself have changed over time, but a number of challenges remain to implement them effectively and sustain the service over time. Drug checking itself represents a paradox within the larger policy context, putting the sustainability of these programs at risk and challenging the potential to scale these programs as the overdose epidemic worsens.

Preventing Overdoses Involving Stimulants: The POINTS Study Protocol

“…Other unintentional pathways have been documented in the literature, including the cross-contamination of fentanyl and cocaine when products are cut and packaged on the same surfaces. 33,34 Further, in research conducted by our team and others, PWUD reported various theories about why PWDD may intentionally adulterate the drug supply with fentanyl. 19,22,[34][35][36] These theories include beliefs that fentanyl is entering the supply to get people "hooked" on a more addictive substance in order to make more money.…”

“…33,34 Further, in research conducted by our team and others, PWUD reported various theories about why PWDD may intentionally adulterate the drug supply with fentanyl. 19,22,[34][35][36] These theories include beliefs that fentanyl is entering the supply to get people "hooked" on a more addictive substance in order to make more money. 22,[34][35][36] Given that a dearth of research has examined how and why fentanyl enters the stimulant supply speci cally, surveying and interviewing people who use stimulants is needed to explore whether similar theories are endorsed in relation to the contamination of the stimulant supply.…”

“…19,22,[34][35][36] These theories include beliefs that fentanyl is entering the supply to get people "hooked" on a more addictive substance in order to make more money. 22,[34][35][36] Given that a dearth of research has examined how and why fentanyl enters the stimulant supply speci cally, surveying and interviewing people who use stimulants is needed to explore whether similar theories are endorsed in relation to the contamination of the stimulant supply. Notably, however, people who use stimulants may have limited knowledge of the intentions and behaviors of PWDD, particularly those who are higher up in the drug distribution hierarchy (e.g., suppliers, manufacturers, tra ckers).…”

In Support of Community Drug Checking Programs: Position Statement of AMERSA, Inc. (Association for Multidisciplinary Education and Research in Substance use and Addiction)

“…31,32 The criminalization and federal prohibition of unregulated drug possession in the United States creates legal and logistical barriers that may preclude PWUD from utilizing drug checking services. 29 However, decriminalization of illicit drug possession is possible—as evidenced by Oregon’s Drug Addiction Treatment and Recovery Act (Measure 110) which passed in late 2020. 33,34…”

“…Moreover, drug checking programs may be more successful when created without law enforcement involvement as previous studies have found that such involvement could be a significant barrier to engagement. 23,24,29 This is especially relevant for Black PWUD as the history of violent policing and drug policy in the United States is entrenched in racist ideology, creating significant harm in communities of color. 37,38 Provided this historical context and the current political landscape, it is perhaps unsurprising that drug checking programs might be primarily utilized by White PWUD.…”