The changing landscape of pharmaceutical alternatives to the unregulated drug supply during COVID-19.

BACKGROUND: The dual COVID-19 and overdose emergencies amplified strain on healthcare systems tasked with responding to both. One downstream consequence of the pandemic in the USA and Canada was a surge in drug overdoses resulting from public health-restricted access to services and an increasingly toxic unregulated drug supply. This study aimed to describe changes implemented by programs prescribing pharmaceutical alternatives to the drug supply during the early stages of the COVID-19 pandemic. METHODS: An environmental scan used surveys and qualitative interviews with service providers across Canada to examine pharmaceutical alternative prescribing practices and programs before and during the pandemic. This study summarized the nature, frequency, and reasons for pandemic-driven service delivery changes using directed content analysis, counts, and thematic analysis. RESULTS: Eighty-two of the 103 participating sites reported 1193 unique changes in physical space (368), client protocols (347), program operations (342), ancillary services (127), and staffing (90). Four qualitative themes describing the reasons for these changes emerged, namely (1) decreasing risk of COVID-19 infection; (2) decreasing risk of overdose; (3) prioritizing acute care of COVID-19 patients; and (4) improving client access to treatment. CONCLUSIONS: While most changes were aimed at decreasing risk of COVID-19 infection, some were found to be at odds with the measures needed to combat the overdose crisis; others met dual objectives of decreased risk of both overdose and infection. Further research should examine which changes should be kept or reversed once COVID-19-related public health measures are lifted.

"COVID just kind of opened a can of whoop-ass": The rapid growth of safer supply prescribing during the pandemic documented through an environmental scan of addiction and harm reduction services in Canada.

OBJECTIVES: In the context of the ongoing overdose crisis, a stark increase in toxic drug deaths from the unregulated street supply accompanied the onset of the COVID-19 pandemic. Injectable opioid agonist treatment (iOAT - hydromorphone or medical-grade heroin), tablet-based iOAT (TiOAT), and safer supply prescribing are emerging interventions used to address this crisis in Canada. Given rapid clinical guidance and policy change to enable their local adoption, our objectives were to describe the state of these interventions before the pandemic, and to document and explain changes in implementation during the early pandemic response (March-May 2020). METHODS: Surveys and interviews with healthcare providers comprised this mixed methods national environmental scan of iOAT, TiOAT, and safer supply across Canada at two time points. Quantitative data were summarized using descriptive statistics; interview data were coded and analyzed thematically. RESULTS: 103 sites in 6 Canadian provinces included 19 iOAT, 3 TiOAT and 21 safer supply sites on March 1, 2020; 60 new safer supply sites by May 1 represented a 285% increase. Most common substances were opioids, available at all sites; most common settings were addiction treatment programs and primary care clinics, and onsite pharmacies models. 79% of safer supply services were unfunded. Diversity in service delivery models demonstrated broad adaptability. Qualitative data reinforced the COVID-19 pandemic as the driving force behind scale-up. DISCUSSION: Data confirmed the capacity for rapid scale-up of flexible, community-based safer supply prescribing during dual public health emergencies. Geographical, client demographic, and funding gaps highlight the need to target barriers to implementation, service delivery and sustainability.

The utility of visual appearance in predicting the composition of street opioids.

Background: With the emergence of unregulated fentanyl, people who use unregulated opioids are increasingly relying on appearance in an effort to ascertain the presence of fentanyl and level of drug potency. However, the utility of visual inspection to identify drug composition in the fentanyl era has not been assessed. Methods: We assessed client expectation, appearance, and composition of street drug samples being presented for drug checking. Results of a visual screening test were compared to fentanyl immunoassay strip testing. We calculated sensitivity, specificity and likelihood ratios (LR) to assess the accuracy of the common assumption that samples with a "pebbles" appearance contain fentanyl. Results: In total, of the 2502 unregulated opioid samples tested, 1820 (73.5%) appeared as "pebbles", of which 1729 (95.0%) tested positive for fentanyl for a sensitivity of 75.9% (95% Confidence Interval [CI]: 74.2-77.6) and specificity of 59.4% (95%CI: 57.5-61.3). Although, the odds of samples containing fentanyl was 4.60 (95%CI: 3.47-6.11) times higher among pebbles samples compared to non-pebble samples, the positive LR for pebbles to contain fentanyl was only 1.87 (CI: 1.59-2.19). The negative LR was more useful at 0.41 (95% CI: 0.36-0.46). Conclusions: A positive screening test for pebbles is not strongly enough associated to be used as a proxy for detecting fentanyl. While the absence of the appearance of pebbles does somewhat reduce the likelihood of fentanyl being present in a given sample, the high prevalence of fentanyl and fentanyl analogues in the drug supply and the risks of consumption are such that public health providers should routinely advise people who use unregulated opioids against solely relying on visual characteristics of drugs as a harm reduction strategy.

Detecting fentanyl using point-of-care drug checking technologies: A validation study.

OBJECTIVES: Point-of-care drug checking services, wherein individuals can check the content and purity of their drugs, have emerged as a public health intervention to address the fentanyl crisis; however, there have been no rigorous evaluations of the technologies against reference standard laboratory techniques. METHODS: Two point-of-care technologies, fentanyl immunoassay strips and Fourier-Transform Infrared (FTIR) spectroscopy, were implemented at two supervised injection sites in Vancouver, Canada. We calculated sensitivity, specificity, and false negative rate for both testing methods as compared to a laboratory reference standard. RESULTS: Between October 2017 and 2018, 331 samples were sent for confirmatory testing. Immunoassay strips had a sensitivity of 87.5% and specificity of 95.2%, with a false negative rate of 12.5%. FTIR spectroscopy had a sensitivity of 72.1% and specificity of 99.0%, with a false negative rate of 27.9%. CONCLUSION: As expected, while FTIR spectroscopy can quantify concentrations on a wide array of compounds, it can only do so above the detection limit. Using FTIR spectroscopy and immunoassay strips in combination has the potential to offset the limitations of each technology when used alone.

The effect of injecting alone on the use of drug checking services among people who inject drugs.

OBJECTIVES: Drug checking services aim to provide people who use drugs with information on the content and purity of their substances as a harm reduction intervention. The objective of this study was to determine the relationship between injecting alone and use of drug checking services in Vancouver, Canada. METHODS: Data were derived from three prospective cohort studies of people who inject drugs (PWID). We conducted bivariable and multivariable logistic regression analysis to estimate the effect of injecting alone on use of drug checking services. RESULTS: Between May 2018 and December 2018, a total of 793 people who inject drugs were included in the study: 579 (73.0%) reported injecting alone and 177 (22.3%) reported use of drug checking services. In a multivariable model adjusted for various confounders (including various sociodemographic variables, drug use patterns, and whether participants had suffered physical attacks/violence), injecting alone was negatively associated with use of drug checking services (Adjusted Odds Ratio = 0.65; 95% Confidence Interval: 0.44-0.97). CONCLUSIONS: We observed a negative association between injecting drugs alone and use of drug checking services, which may be due in part to a number of exogenous factors that prevent people who inject alone from accessing drug checking services (e.g., stigma, location of services). As these individuals are at heightened risk of experiencing overdoses, there is a need to pursue other strategies to reach this group of people who use drugs.

Assessing the limit of detection of Fourier-transform infrared spectroscopy and immunoassay strips for fentanyl in a real-world setting.

INTRODUCTION AND AIMS: Drug checking is a harm reduction intervention increasingly used in the context of the opioid overdose epidemic. The aim of the study was to determine the limit of detection for fentanyl of two point-of-care drug checking technologies. DESIGN AND METHODS: Samples tested at point-of-care using Bruker Fourier transform infrared (FTIR) spectroscopy and BTNX fentanyl immunoassay strips were sent for confirmatory laboratory analysis using quantitative nuclear magnetic resonance (qNMR) spectroscopy. Concentrations by weight were determined and compared to results obtained with point-of-care methods. RESULTS: In total, 283 samples were sent for qNMR analysis; among these, 173 (61.1%) tested positive for fentanyl. As determined by qNMR, fentanyl concentration by weight ranged from 1% to 91%. Among these 173 samples, fentanyl was not detected in 30 (17.3%) samples by FTIR and in 4 (2.3%) samples by test strip. Samples containing fentanyl that went undetected by FTIR had concentrations ≤10%. The four samples containing fentanyl that went undetected by test strip had concentrations ≤5% (i.e. 1%, 3%, 4%, 5%). DISCUSSION AND CONCLUSIONS: Fentanyl immunoassay strips were able to consistently detect the presence of fentanyl in samples at lower concentrations than FTIR spectroscopy. Given that FTIR spectroscopy is able to quantify content, mixture and concentrations on an array of compounds beyond just fentanyl but requires concentrations generally greater than 10%, these findings provide evidence for use of FTIR spectroscopy and immunoassay strips in combination to compensate for the limitations of each technology alone.

Drug checking services at music festivals and events in a Canadian setting.

OBJECTIVES: Drug checking is a harm reduction intervention that allows for identification of drug composition. The objective of the study was to assess drug market components and concordance between expected substance reported by clients and results from point-of-care drug checking at music festivals and events in British Columbia. METHODS: From July to September 2018, we provided drug checking services at four events using combination Fourier Transform Infrared (FTIR) spectroscopy and fentanyl immunoassay strips. We measured concordance between expected substance as reported by clients to the results from the FTIR/fentanyl immunoassay strip and tracked unexpected adulterants. RESULTS: In total, 336 checks were completed. Most samples were expected by clients to be psychedelics (69.3%) or stimulants (19.6%). Of the 233 psychedelic samples, 169 (72.5%) contained the expected, unadulterated substance, and 27 (11.6%) contained additional contaminants. Of 66 stimulant samples, 41 (62.1%) contained expected substance, while 24 (36.4%) contained additional contaminants. Unexpected adulterants such as fentanyl, levamisole, and phenacetin were also found, in addition to several novel psychoactive substances. DISCUSSION: We found a large proportion of substances that contained unexpected adulterants. Our findings highlight the value of continued drug checking and will be helpful in designing future harm reduction interventions in similar contexts.

Drug checking at an electronic dance music festival during the public health overdose emergency in British Columbia.

SETTING: Shambhala is a 5-day electronic dance music (EDM) festival held in rural British Columbia that annually hosts between 15,000 and 18,000 people on a 500-acre ranch. The AIDS Network Outreach & Support Society (ANKORS) has provided harm reduction services throughout the duration of the festival since 2003, including point-of-care drug checking, which allows real-time testing of illicit substances to assess their composition. Drug checking results are provided directly to clients and displayed in aggregate on a screen for all attendees to see. INTERVENTION: In 2017, ANKORS added fentanyl checking to their repertoire of drug checking technologies for festivalgoers. Volunteers used a brief survey to collect information on what clients expected the samples to contain. Volunteers carried out drug checks and subsequently logged test results. ANKORS provided an amnesty bin at the tent for clients who chose to discard their substances. OUTCOMES: Of the 2683 surveys, 2387 included data on both the client's belief and the actual test result. Clients were more likely to discard when the test result differed from their belief (5.16%) than when their belief was confirmed (0.69%). Discarding increased to 15.54% when the test could not clearly identify a substance and to 30.77% if the client did not have a prior belief of the substance. Of 1971 samples tested for fentanyl, 31 tested positive and 16.13% of clients discarded compared to 2.63% in the negative group. IMPLICATIONS: Drug checking services appeal to festivalgoers who, when faced with uncertainty, may discard their substances. This innovative harm reduction service allows for a personalized risk discussion, potentially reaching others via word-of-mouth and early warning systems.

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

BACKGROUND: Opioid overdose deaths in North America have been rising largely as a result of fentanyl adulteration in the illegal drug supply. Drug checking is an established harm reduction intervention in some European settings but has not been broadly implemented or evaluated in North America. We are evaluating a pilot program offering drug checking for people who use street drugs in Vancouver, British Columbia. METHODS: Drug checking services were implemented at two locations in Vancouver between November 2017 and April 2018 using a Fourier transform infrared (FTIR) spectrometer and fentanyl immunoassay strips. We report on the findings generated by this technological combination during the study period. RESULTS: During the study period, a total of 1714 samples were tested. Of 907 samples expected to be heroin, only 160 (17.6%) contained the expected substance, and 822 (90.6%) tested positive for fentanyl. Of 256 samples expected to be speed or crystal meth, 225 (87.9%) contained amphetamine or methamphetamine, and 15 (5.9%) tested positive for fentanyl. The FTIR also found unexpected and potentially dangerous substances and adulterants other than fentanyl. CONCLUSIONS: This pilot program has demonstrated the feasibility of drug checking for identifying individual drug samples containing unexpected or hazardous substances, including fentanyl. By identifying the range of adulterants and diluents and giving an estimate of their prevalence in different drug types, it has also provided information about the composition of the illicit drug supply in an urban North American setting.