@ Mathematica

Progress Together

Drug Checking Programs in the
United States and Internationally:

Environmental Scan Summary

 

September 17, 2021

Jia Pu, Tosin Ajisope, and Joel Earlywine

Submitted to:

Office of the Assistant Secretary for Planning and Evaluation
U.S. Department of Health and Human Services

200 Independence Ave., SW

Washington, DC 20201

Government Task Lead: Jessica White and Teresa Manocchio
Contract Number: HHSP2332015000351/HHSP233370151T

Submitted by:

Mathematica

505 14th Street, Suite 800
Oakland, CA 94612-1475
Phone: (510) 830-3700
Fax: (510) 830-3701
Project Director: Jia Pu
This page has been left blank for double-sided copying.
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

Contents
I. INGPOMUCTION ...... i i nnn nnn rnin i nn nnn eee ne ee ee eee eee eee 1
A. The overdose crisis in the United States ...........cc ce ccecseeeseneeeeeee eee eeeeeneeeeeeecaeeeeeeeeneeeeeeeee 1
B. The concept of drug ChECKING.............:::cccccccccssssssssssnseeeceeeesessessneaeeeseeeeseesssssssenseeeeeneeees 1
C. Purpose of the environmental scan and methodolog)..............cccssssseesseceeceeeeessssssssseeeees 2
Il. Methods for the Environmental SCann............cc:ccccceccceeseeeeeeeeeeeeeeeeeaeeeseeeeeeeeeeesenaeeeeeeeeeeeneeeneaes 3
lll. Synthesis of Drug Checking Programs and Evaluations ...........:::cccceseeeeeeeeeeeneeeeseeeeeeeeeeeenees 4
A. Overview of drug checking programs in different Settings ...............:ccccescssssessseeeeeeeeeeeeees 4
1. Drug checking at music festivals .................c::::csscccceeecesssesseeseeeceeeeeeessssssseseeeeeeeeeess 4

2. Point-of-care drug checking services at sites offering other harm reduction

SUPALEGICS 0.0.0... ceecceeeccsesesseesseesseeseeceneeceeecueccneeeesceeeseesceeeseeeseeeaeeeeaesaseeeseaaasaassaassnaesneas 5

3. Outreach to drug users outside the point-of-care testing SiteS ...............cccsceeeeees 5

B. Program outcomes and evidence Of SUCCESS ............:cccccccesssssssscsseeceeecessssssssseneeseeeeeeeeess 6

1. Attitude change and intended USE ............ee cece eset eee eeneeeeeeeeeeeeeeeeeeeeeeeeseeaeeeeeeseenees 6

2. Actual drug uSe behavior CHANGE ............cccccccccccceccecceceeeceeeeeseeeceeesseeeseeseeseeesanseaeenaes 6

3. Link to other health OUTCOMES... eee eeeeenee ee eeeeee ee eeeeea ease eeeeeaeeeeeeeeaeeeeeeecaaeeees 7

C. Stakeholders' perspective of drug checking SErviCes ..............:::ssssccecseeeceeeesssssssssseeeenees 7

1. Perspectives from people Who USC CIuUGS..............cccssssssssssesseeeceeecesssssessnseeeeeeeseeeseess 8

2. Perspectives from stakeholders who provide harm reduction Services ..........c000 8

3. Facilitators and barriers to use of drug checking ServiCes..............:cccccccccessssssssseeeees 8

IV. Opportunities and Future Research... esses seeeseecseeseeeseeeeeeeeseeeneeeneeeneeaneneenneennenneensy 10
REPEPENCES..... ae. ceeeceeeeeeeecteeeceeeeeeea eee eeaeee canes see aaeeeee gees canes sea aaee eee aeee cages se aaeeeecaeeesnaaeseecaseeseneeeennaees 12

Mathematica
This page has been left blank for double-sided copying.
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

|. Introduction

A. The overdose crisis in the United States

The United States faces a national overdose crisis that has had a devastating impact on public health and
Americans' social and economic well-being. In 2019, about 70,630 people died in the United States
because of drug overdoses, and these numbers have only accelerated during the COVID-19 pandemic
(Centers for Disease Control and Prevention 2020). The primary driver of the rapid increase in overdose
deaths is illicitly manufactured fentanyl, a synthetic opioid that is 50 to 100 times more potent than
morphine and has become more common in the illicit drug supply in the United States (Centers for
Disease Control and Prevention 2020). For example, an examination of the illicit drug market using crime
lab data from Ohio's Bureau of Criminal Investigation from 2009 to 2018 corroborates that the presence
of fentanyl and its analogs strongly correlates with increases in overdose deaths. (Rosenblum et al. 2020).

The overdose crisis, including the increased availability of fentanyl on the drug market, is a rapidly
evolving crisis influenced by many factors (Foglia et al. 2021; Rosenblum et al. 2020). Fentanyl, which
has been discovered mixed into supplies of stimulants such as cocaine, is frequently pressed into
counterfeit tablets and sold as prescription pharmaceuticals to consumers who might assume they are
purchasing legitimate prescription pharmaceuticals (Foglia et al. 2021). The unintentional use of fentanyl
has resulted in an increase in drug overdose deaths across the country (Foglia et al., 2021). The rise in
overdose deaths reinforces the importance of ensuring that those most at risk of overdose have access to
effective prevention and response measures, including harm reduction strategies. This shifting dynamic of
the overdose crisis, particularly the increasing risk of overdose because of fentanyl-contaminated drugs,
necessitates new approaches such as drug checking services that place a greater emphasis on harm
reduction.

B. The concept of drug checking

Drug checking services are well established in Europe and, to a lesser extent, in North America
(FORECAST 2018; Leece 2017). Drug checking services analyze drug samples and provide information
to people who use drugs about the chemical composition of the drugs they are taking. These services are
provided in various settings, including anonymously at safe consumption sites, at mobile services
provided on site at events, and through distribution of test strips for personal use (Barry, 2018;
FORECAST 2018). By helping people understand the contents of their drugs, drug checking services can
reduce morbidity and mortality associated with drug use, including illicit fentanyl. Fentanyl drug
checking lets people know whether fentanyl is present in a substance before they use it (Leece 2017;
Maghsoudi et al., 2021). A growing body of evidence has shown that drug checking services can alter
behavioral intention and, to a lesser extent, has demonstrated their impact on the behavior of people who
use drugs (Maghsoudi et al. 2021). Drug checking services, often coupled with tailored harm reduction
advice, can facilitate outreach to people who use drugs and help them access substance use disorder
treatment. When aggregated, data from drug checking services can provide important information about
local drug supplies to inform policymaking and public health surveillance (FORECAST 2018; Maghsoudi
et al., 2021). Drug checking services have been effective in detecting adulterants and novel psychoactive
compounds in the drug supply (Barry 2018; Leece 2017).

The level of technology and costs involved in drug testing methods vary. Simple, low-cost testing
methods include liquid reagent tests and thin layer chromatography kits. More advanced laboratory

Mathematica
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

techniques include gas chromatography/mass spectrometry, high-performance liquid chromatography,
and nuclear magnetic resonance techniques (Leece 2017; Strike and Watson 2019). This brief will
describe drug checking programs that use a variety of tests, with fentanyl test strips (FTS) being the
predominant testing methodology.

C. Purpose of the environmental scan and methodology

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) contracted with Mathematica
to conduct an environmental scan of drug checking programs to address the following policy questions:

e What is the landscape of drug checking as a harm reduction approach in the United States and
internationally?

e In particular, what is the landscape of drug checking for fentanyl?

e Have drug checking programs been evaluated for their impact on health outcomes, and, if so, what are
the findings?

e To what extent are existing drug checking programs coupled with other services, such as syringe
access programs, naloxone distribution, or counseling?

Through the environmental scan, ASPE seeks to better understand drug checking programs implemented
in the United States and other countries and inform potential opportunities for studying fentanyl drug
checking as a harm reduction strategy.

This report presents a review and synthesis of approaches and strategies adopted by drug checking
programs and existing evidence on their effectiveness in changing drug use attitudes, behavior, and health
outcomes. Our review includes studies of drug checking programs across a variety of settings in the
United States and internationally. We prioritize studies of drug checking programs that are specific to
fentanyl, are coupled with other harm reduction services, and include early evaluation of program
effectiveness. At the end of the document, we discuss the implications of the existing evidence for future
initiatives and further research on drug checking programs.

Mathematica
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

ll. Methods for the Environmental Scan

To identify promising drug checking programs, we reviewed recent studies of programs that aimed to
provide drug checking services, documenting key program features, the research methods by which they
were evaluated, and the main study findings. We also summarize our approach to identifying the studies
we reviewed and then explain the information we extracted from each study and how we did so.

We searched peer-reviewed manuscripts and gray literature to identify articles that discuss drug checking
programs in the United States and internationally. We limited the search to studies published in the past
10 years. We systematically searched five bibliographic databases: APA PsycINFO, CINAHL, Cochrane,
MEDLINE (Ovid), and Scopus. We searched for key words such as "drug checking programs" and
"fentanyl checking." Our search of the gray literature included websites of specialty societies and relevant
organizations. We also used Harvard's Think Tank Search to capture websites of institutions that generate
public policy research, analysis, and activity.

Two analysts and a researcher screened the search results for relevancy and selected a subset of 35
articles for in-depth review. The articles included reviews, articles on the implementation and
effectiveness of drug checking programs, and articles describing drug checking strategies. The selected
studies include drug checking programs implemented across a variety of settings and use a range of
research designs. We excluded articles not written in English from our review. We developed methods
together with ASPE that provided input on inclusion and exclusion criteria.

We imported the shortlisted articles into a Microsoft Excel spreadsheet for further review. The three
reviewers independently reviewed the full text of the selected articles, extracting data from them using a
template the team designed. Information extracted included year of publication, where the intervention
took place, the number of participants, the intervention type and description, the outcome measures, the
effectiveness of the intervention, and the implication of the program or study.

Mathematica
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

lll. Synthesis of Drug Checking Programs and Evaluations

In this section, we synthesize the information we extracted from the selected articles. First, we describe
the drug checking programs provided in different settings. We then present findings on program outcomes
and the effectiveness of drug checking services. Finally, we summarize the implications of the existing
evidence for future research.

A. Overview of drug checking programs in different settings

Drug checking programs have been conducted in various settings throughout the United States and
internationally. Programs have been conducted at point-of-care sites-usually harm reduction service
sites, such as supervised injection facilities and syringe service programs-and through mobile services
offered at events such as music festivals. In either setting, people who use drugs can drop off samples for
testing and retrieve the results immediately, either at the site or online remotely. Recently, several drug
checking programs have been conducted outside the point of care, including those that distribute and train
people who use drugs on how to use drug checking test strips themselves (FORECAST 2018; Maghsoudi
et al., 2021).

 

Key observations

e Drug checking programs were conducted in various settings (such as music festivals, syringe
service programs, and safe injection sites), and outside point-of-care sites through use of test strips.

e Across all settings, studies aimed to assess drug checking as a harm reduction intervention by
evaluating behavioral responses to drug testing results, including drug disposal, drug dose
reduction, and adoption of other overdose risk reduction behaviors.

e Almost all programs combined drug checking with other harm reduction services, regardless of the
program setting.

 

 

 

1. Drug checking at music festivals

Music festivals and parties are an ideal place to conduct drug checking programs because of the high
prevalence of substance use at these events. Drug checking at music festivals was first implemented in
Europe and recently adopted by Canada and the United States (Palamar et al. 2021; Maghsoudi et al.
2021). For example, one drug checking program took place at the Shambhala music festival, the longest
running electronic musical dance festival in Canada, in partnership with the AIDS Network Outreach &
Support Society (Mema et al. 2018a). The BC Centre on Substance Use, in partnership with community-
based partners and local health authorities, implemented another program at three outdoor festivals and
Vancouver Pride (McCrae et al. 2019). Studies associated with these events examined types of
contaminated substances and assessed the results of the drug checking program, including whether or not
substances were discarded by clients after learning the results of the tests (McCrae et al. 2019; Mema et
al. 2018a). Programs offered at music festivals were provided under a temporary structure in a
centralized, highly visible location. The program made itself known to potential clients through service
promotion, and knowledge of the program spread among potential clients by word of mouth (Mema et al.
2018; McCrae et al., 2019a). These drug checking programs utilized different technologies to test
substances, including Raman spectroscopy, FTS, colorimetric reagents, gas chromatography mass
spectrometer, and Fourier Transform Infrared spectroscopy (McCrae et al. 2019; Mema et al. 2018a).
Program staff asked all clients about their expectations of the drug test results beforehand, and afterward,

Mathematica
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

they posted the results in real time on an electronic screen along with harm reduction tips (Mema et al.
2018a). Alternatively, they provided the results immediately, and a volunteer harm reduction worker
discussed the results and any health risks of using the substance with the clients (McCrae et al. 2019). To
track substance disposal after the test, staff provided an amnesty bin and observed and recorded whether
clients discarded their substances (Mema et al. 2018a). The presence of unusual or concerning substances
was posted outside the tent and reported to harm reduction groups and regional health authorities
(McCrae et al. 2019). Drug checking programs at music festivals are often coupled with other harm
reduction services. For example, a study of the drug checking program at the Shambhala music festival
specifically mentions that 200 guests received naloxone training and 100 naloxone kits were distributed
(Mema et al. 2018a).

2. Point-of-care drug checking services at sites offering other harm reduction strategies

Offering drug checking at other harm reduction service sites provides an opportunity to further engage
people at the point of care. These sites serve a vulnerable population that is a key target for drug checking
programs and harm reduction more broadly. Such settings offer a rare opportunity to engage clients and
deliver a combination of harm reduction services. In the United States, drug checking programs have been
conducted at syringe service programs (Park et al. 2021). In Canada, programs have been tested at safe
injection facilities along with other harm reduction services offered at these sites (Tupper et al. 2018;
Mema et al. 2018b; Karamouzian et al. 2018). The technologies used for drug checking in these studies
were primarily FTS. Some sites also used Fourier transform infrared spectrometer, while novel
psychoactive benzodiazepines were tested using a benzodiazepine test strip.

Drug checking services conducted at these point-of-care service sites provide important information about
behavioral responses to test results, such as drug dose reduction, drug disposal, and other harm reduction
practices, as well as overall drug test use and type of contaminated substances. For example, a program in
Canada expanded on existing harm reduction services at safe injection facilities and overdose prevention
sites and included a drug test for substances other than fentanyl, one of the very few studies to do so
(Laing et al. 2021). A study of the program described the number and type of novel psychoactive
benzodiazepines in a sample from a community drug checking program during the time of an outbreak of
novel psychoactive benzodiazepines. Another point-of-care drug checking program in Canada collected
information on overdoses to assess the relationship between drug checking and overdose (Karamouzian et
al. 2018). A noteworthy benefit of conducting programs at harm reduction sites is engaging hard-to-reach
and vulnerable populations, including people who inject drugs and people who use drugs in urban or rural
settings.

3. Outreach to drug users outside the point-of-care testing sites

Recently, drug checking programs in the United States have focused on reaching the population outside
points of care through the distribution of self-use drug tests. For example, FTS served as an outside-the-
point-of-care drug test intervention in two U.S. studies, one in Rhode Island focusing on young adults
(Krieger et al. 2018) and another in Baltimore City focusing on female sex workers (Park et al. 2020).
These programs collected important information to assess change in frequency of substance use, overdose
risk behaviors, and future use of FTS. Test strips were distributed to clients along with training on the use
of the test strips and other harm reduction services, such as distribution of naloxone kits.

Mathematica
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

B. Program outcomes and evidence of success

The most common outcome measures examined in studies of drug checking programs were attitudes and
behaviors related to the use of the analyzed substance. One study also examined the association between
drug checking services and overdose (Karamouzian et al. 2018).

 

Key observations

e The use of drug checking has been shown to positively influence intended and, to a lesser extent,
actual drug use behaviors, such as discarding current drug supply and changing overall drug use
behaviors, including keeping naloxone nearby and using with someone else.

e Changes in drug use behavior were most often seen among people who received a positive
fentanyl test and had previously been unaware their opioid was contaminated with fentanyl or
questionable substances.

e Few studies reported program impacts on health outcomes. A program in Canada implemented at a
safe injection facility found that a positive test result was associated with intended dose reduction,
which in turn led to lower odds of overdose.

 

 

 

1. Attitude change and intended use

Overall, drug checking services were consistently associated with positive attitude change and intention
not to use the tested substance, particularly if the drug tested positive for fentanyl or results were
inconsistent with expectation. For example, a drug checking program provided at a supervised injection
service site in Vancouver, Canada, found 36.3 percent of participants reported planning to reduce their
drug dose. Receiving a positive drug test was associated with an intent to reduce drug dose compared to
clients with a negative test result (Karamouzian et al., 2018). Similarly, an Australian study also found
that people who use drugs at festivals and events were more likely to reduce their intended use if they
were surprised by the testing results. Yet the positive impact on attitude and intended use might not
translate into actual drug use behavior. The presence of drug contamination might not be enough to
motivate someone to dispose of the substance even if their attitude changed for the better. Therefore,
educating patients on the importance of behavior change is critical for prompting them to actually initiate
behaviors that would lower health risks associated with substance use (Mema et al. 2018b).

2. Actual drug use behavior change

Overall, studies found a positive association between positive drug test results and disposal of the tested
substance, but the size of this effect varied across studies. For example, one study at a Canadian music
festival found that participants were more likely to dispose of substances after receiving positive testing
results (Mema et al. 2018a). Several other studies, however, reported that although some participants
disposed of the drug after confirmation of harmful drug contamination, most proceeded to use the
substance, including some participants who used and injected more slowly and in smaller doses. At a drug
checking program provided at a Canadian supervised injection facility, only 11 percent of participants
reported planning to dispose of the substance, and 36.3 percent reported planning to reduce their use
(Karamouzian et al. 2018). Similarly, a cross-sectional survey of people who inject drugs who used FTS
in San Francisco found that among participants who received positive results, 26.5 percent disposed of the
tested substance, 30.1 percent reduced their use, and 43.4 percent did not change their use of the drug (Oh
et al. 2020).

Mathematica
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

In alignment with the findings on drug disposal, drug checking services were also associated with changes
in overall drug use behaviors. A community-based program in Baltimore focusing on female sex workers
found post-test reductions in frequency of substance use and drug injection, use of benzodiazepines, and
solitary drug use (Park et al. 2020). Consistent with this finding, a drug checking program provided at a
safe syringe program site in the southeastern United States found that 63 percent of the FTS results were
positive, and those who received a positive test had five times higher odds of changing their drug use
behavior than those who did not receive a positive test result (Peiper et al. 2019). Another study collected
information from clients who received FTS from two large syringe services programs in Baltimore and
Delaware (Park et al. 2021). About 23 percent of participants in Baltimore who used FTS and 69 percent
of those in Delaware adopted risk reduction behaviors, including using less of the substance than
originally intended, using the substance more slowly, injecting a test shot, and asking someone to check
on them. Other positive behaviors demonstrated included interest in sharing information about and
distributing FTS to acquaintances who were at high risk of exposure (Goldman et al. 2019).

Although additional information on harm reduction practices was available and integrated into many
programs, few studies evaluated information-seeking behaviors among participants who sought to
implement new harm reduction practices and avoid substance use harms, including risk of overdose.
Because of the low frequency of drug disposal after positive test results in several studies, understanding
the information-seeking behaviors of those who use contaminated substances could help explain the
discordance between susceptibility to overdose and a lack of risk reduction behaviors and drug disposal.

3. Link to other health outcomes

Although understanding the effectiveness and impact of drug checking programs on health outcomes is
essential, few studies evaluated health outcomes such as overdose and mortality. We found one study
conducted at a safe injection facility in Canada that assessed overdose as an outcome of drug checking
(Karamouzian et al. 2018). When tests were conducted after consumption, clients whose substances tested
positive were almost five times more likely to have overdosed than those whose substances tested
negative. This association was not statistically significant when the test was conducted before
consumption, which suggests the adoption of harm reduction strategies might have reduced overdose risk.
In addition, positive test results were associated with intention to reduce the dose used, which in turn led
to lower odds of overdose.

C. Stakeholders' perspective of drug checking services

Various studies have been conducted among people who use drugs to capture their perspectives about
drug checking services-particularly their interest and willingness to use drug checking-and factors
influencing use. These studies are a mix of quantitative and qualitative studies conducted in a variety of
settings among populations such as young adults, party goers, people with a history of incarceration,
people with HIV, drug sellers, and sex workers.

 

Key observation

e Studies have shown that drug users were generally willing to use FTS, indicating their acceptability
as a harm reduction intervention.

e Most drug users were concerned about fentanyl and other questionable substances in their drug
supply and were interested in more information.

 

 

 

Mathematica
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

 

e People who use drugs perceived criminalization, stigma, anonymity/data privacy, and accessibility
issues as barriers to using drug checking services.

e Stakeholders who provided harm reduction services supported the concept of drug checking
programs but highlighted concerns about their legality.

 

 

 

1. Perspectives from people who use drugs

Studies have shown an overall willingness among people who use drugs to use FTS (Betzler et al. 2021;
Krieger et al. 2019; Kennedy et al. 2018; McKnight and Jarlais 2018). One study found that more than 90
percent of participants indicated a willingness to use rapid test strips regardless of having ever overdosed,
implying that rapid fentanyl testing is an acceptable harm reduction intervention among young drug users
(Krieger et al. 2019). Another study that examined the perceptions of FTS among young adults found that
most of the participants found the strips easy to use and useful (Goldman et al. 2019).

FTS-based interventions have the potential to reduce overdose risk among high-risk populations. A study
that assessed FTS awareness among female sex workers in Baltimore who used opioids found that most
women who received FTS reported using them (84 percent) and almost all (96 percent) reported being
likely to use FTS in the future (Park et al. 2021). Another study that examined the acceptability of FTS
among people who use drugs who had a history of incarceration and were living with HIV demonstrated
that FTS was a desired harm reduction strategy as participants believed they were vulnerable to fentanyl
contamination (Reed et al. 2021). The perspectives of drug sellers have also been documented in the
literature. Research shows that drug sellers used the information from drug testing to reduce fentanyl
overdose risks; drug testing was one of several tools they used to modify the potency of the fentanyl they
sold to minimize risk and maintain client trust (Betsos et al. 2021).

2. Perspectives from stakeholders who provide harm reduction services

The notion of drug checking has also been largely accepted by stakeholders who provide harm reduction
services, with the goals of providing people who use drugs with critical risk reduction information and
tools and functioning as an entrance point for enhanced service provision. A study that evaluated the
perspectives of 32 stakeholders from organizations that work with people who use drugs demonstrated
that stakeholders overwhelmingly supported drug checking but expressed concerns about its legality
(Glick et al. 2019). Concerns include the possibility that the strips could be used to support accusations
that providers or drug users are in possession of drug paraphernalia and to support drug possession
charges against providers that operate testing machines (Glick et al. 2019).

3. Facilitators and barriers to use of drug checking services

People who use drugs who either seek or avoid fentanyl use have expressed concerns about the content of
the drugs that they use and have conveyed a desire for more information. Research shows that although
some people who use drugs express their desire to avoid fentanyl for fear of overdose, others who actively
seek out fentanyl bemoan their inability to properly detect fentanyl in heroin bags (McLean et al. 2019).
Most people who use drugs support drug testing for overdose prevention, with intent heightened by
having witnessed a fatal overdose and having recently been exposed to fentanyl (Oh et al. 2020; Sherman
et al. 2019). Other factors that predict higher FTS use include currently owning naloxone and receiving
overdose prevention training (Oh et al. 2020).

Mathematica
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

Sociodemographic factors have also been implicated in the use of drug checking services. The results
regarding racial differences are mixed. Although one of the studies we reviewed found that FTS use was
lower among Black or African American people who inject drugs than among White people who inject
drugs (Oh et al. 2020), another study suggested being non-White was associated with greater intent to use
drug checking (Sherman et al. 2019). Other factors that have been associated with greater willingness and
intent to use drug checking are young age, older age, homelessness, and being female (Kennedy et al.
2018; Sherman et al. 2019).

Despite recognizing the benefits of FTS use, people who use drugs in various studies reported barriers to
using drug checking services. These include significant barriers such as concerns about criminalization,
stigma, anonymity and data privacy, and trauma experienced by potential service users (Betzler et al.
2021; Wallace et al. 2020). Drug testing continues to exist in a legal gray area, prompting mistrust among
potential service users and barriers for those who implement these services (Wallace et al. 2020).
Therefore, respectful, confidential, and anonymous services are essential. Other limitations mentioned
include lack of access to drug testing locations or accompanying services; the unpredictability of
purchasing or using drugs, which limits the ability to plan for or access testing before use; and the
unwillingness to postpone drug use for testing (Reed et al. 2021).

Mathematica
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

IV. Opportunities and Future Research

Our review has shown that organizations in the United States and internationally have implemented
innovative strategies and adopted drug checking services to address the overdose crisis. These
interventions are implemented in different settings and include creative use of other harm reduction
services. There is a clear indication that the efforts to provide drug checking services have been largely
effective in changing intended and actual drug use behaviors. Results of this environmental scan suggest
several implications for future drug checking initiatives and further research on drug checking programs.
First, most of the drug checking programs in our review provided information only about the presence or
absence of fentanyl. Users desire additional information, such as quantity of fentanyl, other toxic
contaminants, and cutting agents, that can help them make informed decisions to reduce risk of overdose
(FORECAST 2018). For example, some fentanyl analogues, such as carfentanil, have an even higher
potency than fentanyl and might go undetected with some test strips (McGowan et al. 2018). Second,
sensitivity and specificity of drug checking results often vary by testing technologies. FTS is the
predominant testing methodology adopted by drug checking programs included in this environmental
scan. One particular concern about the use of FTS is its potential excessive sensitivity. Repeated positive
test results with lack of ill-effects after consumption can lead to decreased trust and acceptability of drug
checking services (McGowan et al. 2018). Lastly, removing legal barriers to providing drug checking
services is also important. In the United States, many states still include FTS and other similar items to
test drugs in their drug paraphernalia laws, which might increase concerns about distributing these drug
checking items and become a barrier for people who use drugs to use drug checking services (Lieberman
2020). Although state paraphernalia laws remain unchanged, the latest guidance from the CDC and the
Substance Abuse and Mental Health Services Administration (SAMHSA) states that federal funds can
now be used to purchase FTS (Centers for Disease Control and Prevention 2021; Substance Abuse and
Mental Health Services Administration 2021). This guidance might be an important factor that influences
future discussions that helps to address stakeholder legality concerns.

Because of the limitations of the current programs, it is particularly important to couple drug checking
services with other harm reduction services. Drug checking can serve as an important strategy to reach
out to people at elevated risk for overdose, engage them with harm reduction counseling, and help them
obtain access to necessary health care for treatment of substance use disorder. In addition, it is important
to provide training for self-testing and help users better understand the limitations of the drug checking
technologies and harm reduction strategies to prevent overdose. For example, to mitigate the risk of false
negatives, easy access to naloxone and instructions on the use of naloxone to reverse opioid-related
overdoses should be provided in drug checking programs. Because some of the fentanyl analogues with
high potency might not be detected by the test strips, other key harm reduction recommendations should
be provided alongside test strips, including encouraging the presence of others with naloxone when using
drugs, being prepared to call 911, and using or injecting more slowly and in smaller doses (FORECAST
2018; McGowan et al. 2018).

Although drug checking programs have been shown to be associated with positive changes in intended
and actual drug use behavior, the implications for health outcomes are less clear. Importantly, few studies
have examined the impact of drug checking programs on overdose risk. Although one study shows that
drug checking programs might reduce overdose risk through reduction in drug doses, there is still a gap in
evidence showing a clear and meaningful relationship between drug checking and overdoses. Studies that
track important health outcomes, such as overdose morbidity and mortality, and for longer follow-up
periods would improve our understanding of the ultimate benefits of drug checking. Finally, future

Mathematica 10
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

studies should consider the special needs of vulnerable populations such as racial and ethnic minorities
and sex workers. The population of drug users at risk for overdose has diverse sociodemographic
characteristics, so implementing a one-size-fits-all program design for drug checking services is
challenging. Tailoring interventions is important to reach the target population most effectively.

Mathematica

11
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

References

Barry, C.L. "Fentanyl and the Evolving Opioid Epidemic: What Strategies Should Policy Makers
Consider?" Psychiatric Services, vol. 69, no. 1, 2018, pp. 100-103.

Betsos, A., J. Valleriani, J. Boyd, G. Bardwell, T. Kerr, and R. McNeil. "'I Couldn't Live with Killing
One of My Friends or Anybody': A Rapid Ethnographic Study of Drug Sellers' Use of Drug
Checking." International Journal of Drug Policy, vol. 87, 2021.

Betzler, F., J. Helbig, L. Viohl, F. Ernst, L. Roediger, 8. Gutwinski, A. Stréhle, and S. Kohler. "Drug
Checking and Its Potential Impact on Substance Use." European Addiction Research, vol. 1, no. 27,
2020, pp. 25-32. https://doi.org/10.1159/000507049.

Centers for Disease Control and Prevention. "Increase in Fatal Drug Overdoses Across the United States
Driven by Synthetic Opioids Before and During the COVID-19 Pandemic." 2020. Available at
https://emergency.cdc.gov/han/2020/han00438.asp. Accessed August 20, 2021.

Centers for Disease Control and Prevention. "Federal Grantees May Now Use Funds to Purchase
Fentanyl Test Strips." 2021. Available at https://www.cdc.gov/media/releases/202 1/p0407-Fentanyl]-
Test-Strips.html. Accessed August 30, 2021.

Foglia, R., A. Kline, and N.A. Cooperman. "New and Emerging Opioid Overdose Risk Factors." Current
Addiction Reports, vol. 8, no. 2, 2021, pp. 319-329.

FORECAST. "Fentanyl Overdose Reduction Checking Analysis Study." Baltimore, MD: Johns Hopkins
Bloomberg School of Public Health, 2018. Available at
https://www.naccho.org/uploads/downloadable-resources/MS-fentanyl-overdose-reduction-study-

toolkit24 pdf.

Glick, J.L., T. Christensen, J. Nyeong Park, M. McKenzie, T.C. Green, and 8.G. Sherman. "Stakeholder
Perspectives on Implementing Fentanyl Drug Checking: Results from a Multi-Site Study." Drug and
Alcohol Dependence, vol. 194, 2019, pp. 527-532.

Goldman, J.E., K.M. Waye, K.A. Periera, M.S. Krieger, J.L. Yedinak, and B.D.L. Marshall. "Perspectives
on Rapid Fentanyl Test Strips as a Harm Reduction Practice Among Young Adults Who Use Drugs:
A Qualitative Study." Harm Reduction Journal, vol. 16, no. 1, 2019.

Karamouzian, M., C. Dohoo, 8. Forsting, R. McNeil, T. Kerr, and M. Lysyshyn. "Evaluation of a
Fentanyl Drug Checking Service for Clients of a Supervised Injection Facility, Vancouver, Canada."
Harm Reduction Journal, vol. 15, 2018. Available at
https://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y &NEWS=N&PAGE=fulltext&D=psyc15&AN=
2018-45509-001.

Kennedy, M.C., A. Scheim, B. Rachlis, S. Mitra, G. Bardwell, S. Rourke, and T. Kerr. "Willingness to
Use Drug Checking Within FUTURE Supervised Injection Services Among People Who Inject Drugs
in a Mid-Sized Canadian City." Drug and Alcohol Dependence, vol. 185, no. 248, 2018.
https://doi.org/10.1016/j.drugaledep.2017.12.026.

Krieger, M.S., W.C. Goedel, J.A. Buxton, M. Lysyshyn, E. Bernstein, 8S.G. Sherman, J.D. Rich, S.E.
Hadland, T.C. Green, and B.D.L. Marshall. "Use of Rapid Fentanyl Test Strips Among Young Adults
Who Use Drugs." International Journal of Drug Policy, vol. 61, 2018, pp. 52-58.

Krieger, M.S., J.L. Yedinak, J.A. Buxton, M. Lysyshyn, E. Bernstein, J.D. Rich, T.C. Green, S.E.
Hadland, and B.D.L. Marshall. "High Willingness to Use Rapid Fentanyl Test Strips Among Young
Adults Who Use Drugs." Harm Reduction Journal, vol. 15, no. 1, 2018.

Mathematica 12
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

Laing, M.K., L. Ti, A. Marmel, 8. Tobias, A.M. Shapiro, R. Laing, M. Lysyshyn, and M.E. Socias. "An
Outbreak of Novel Psychoactive Substance Benzodiazepines in the Unregulated Drug Supply:
Preliminary Results from a Community Drug Checking Program Using Point-of-Care and
Confirmatory Methods." International Journal of Drug Policy, vol. 93, 2021, 103169.
https://doi.org/10.1016/j.drugpo.2021.103169.

Leece, P. "Evidence Brief: Evidence on Drug Checking Services as a Harm Reduction Intervention."
Ontario, Canada: Public Health Ontario, 2017. Available at https://www.publichealthontario.ca/-

/media/documents/E/2017/eb-drug-checking.pdf?la=en.

Lieberman, Amy. "Removing Legal Barriers to Drug Checking Can Help Reduce Drug-Related Harm."
April 8, 2020. Available at https://www-.networkforphl.org/news-insights/removing-legal-barriers-to-
drug-testing-can-help-reduce-drug-related-harm/. Accessed August 20, 2021.

Maghsoudi, N., J. Tanguay, K. Scarfone, I. Rammohan, C. Ziegler, D. Werb, and A. Scheim, "The
Implementation of Drug Checking Services for People Who Use Drugs: A Systematic Review."
Qeios, 2021. https://doi.org/10.32388/txe86u.

McCrae, K., S. Tobias, K. Tupper, J. Arredondo, B. Henry, S. Mema, E. Wood, and L. Ti. "Drug
Checking Services at Music Festivals and Events in a Canadian Setting." Drug & Alcohol
Dependence, vol. 205, 2019, 107589.

McGowan, C.R., M. Harris, L. Platt, V. Hope, and T. Rhodes. "Fentanyl Self-Testing Outside Supervised
Injection Settings to Prevent Opioid Overdose: Do We Know Enough to Promote It?" International
Journal of Drug Policy, vol. 58, 2018, pp. 31-36. https://doi.org/10.1016/j.drugpo.2018.04.017.

McKnight, C., and D.C. Des Jarlais. "Being 'Hooked Up' During a Sharp Increase in the Availability of
Illicitly Manufactured Fentanyl: Adaptations of Drug Using Practices Among People Who Use Drugs
(PWUD) in New York City." International Journal of Drug Policy, vol. 60, 2018, pp. 82-88.

McLean, K., S.M. Monnat, K. Rigg, G.E. Sterner, and A. Verdery. ""You Never Know What You're
Getting': Opioid Users' Perceptions of Fentanyl in Southwest Pennsylvania." Substance Use and
Misuse, vol. 54, no. 6, 2019, pp. 955-966.

Mema, S.C., C. Sage, Y. Xu, K.W. Tupper, D. Ziemianowicz, K. McCrae, M. Leigh, M.B. Munn, D.
Taylor, and T. Corneil. "Drug Checking at an Electronic Dance Music Festival During the Public
Health Overdose Emergency in British Columbia." Canadian Journal of Public Health, vol. 109, no.
5-6, 2018a, pp. 740-744.

Mema, S.C., C. Sage, S. Popoff, J. Bridgeman, D. Taylor, and T. Corneil. "Expanding Harm Reduction to
Include Fentanyl Urine Testing: Results from a Pilot in Rural British Columbia." Harm Reduction
Journal, vol. 15, no. 1, 2018b, p. 19.

Oh, H., K. Kim, D. Miller, D. Veloso, J. Lin, and W. McFarland. "Fentanyl Self-Testing in a Community-
Based Sample of People who Inject Drugs, San Francisco." International Journal of Drug Policy, vol.
82, 2020. https://doi.org/10.1016/j.drugpo.2020.102787.

Palamar, J.J, N.D Fitzgerald, K.M. Keyes, and L.B Cottler. "Drug Checking at Dance Festivals: A
Review with Recommendations to Increase Generalizability of Findings." Experimental and Clinical
Psychopharmacology, vol. 29, no. 3, 2021, pp. 229-235.

Park, J.N., S. Frankel, M. Morris, O. Dieni, L. Fahey-Morrison, M. Luta, D. Hunt, J. Long, and S.G.
Sherman. "Evaluation of Fentanyl Test Strip Distribution in Two Mid-Atlantic Syringe Services
Programs." International Journal of Drug Policy, vol. 94, 2021, 103196.
https://doi.org/10.1016/j.drugpo.2021.103196.

 

Mathematica 13
Drug Checking Programs in the United States and Internationally: Environmental Scan Summary

 

Park, J.N., C. Tomko, B.E. Silberzahn, K. Haney, B.D.L. Marshall, and 8S.G. Sherman. "A Fentanyl Test
Strip Intervention to Reduce Overdose Risk Among Female Sex Workers Who Use Drugs in
Baltimore: Results from a Pilot Study." Addictive Behaviors, vol. 110, 2020.

Peiper, N.C., S.D. Clarke, L.B. Vincent, D. Ciccarone, A.H. Kral, and J.E. Zibbell. "Fentanyl Test Strips
as an Opioid Overdose Prevention Strategy: Findings from a Syringe Services Program in the
Southeastern United States." International Journal of Drug Policy, vol. 63, 2019, pp. 122-128.

Reed, M.K., A.M. Roth, L.P. Tabb, A.K. Groves, and S.E. Lankenau. "'I Probably Got a Minute':
Perceptions of Fentanyl Test Strip Use Among People Who Use Stimulants." Jnternational Journal of
Drug Policy, vol. 92, 2021.

Rosenblum, D., J. Unick, and D. Ciccarone. "The Rapidly Changing US Illicit Drug Market and the
Potential for an Improved Early Warning System: Evidence from Ohio Drug Crime Labs." Drug and
Alcohol Dependence, vol. 208, 2020, 107779.

Sherman, 8.G., K.B. Morales, J.N. Park, M. McKenzie, B.D.L. Marshall, and T.C. Green. "Acceptability
of Implementing Community-Based Drug Checking Services for People Who Use Drugs in Three
United States Cities: Baltimore, Boston and Providence." International Journal of Drug Policy, vol.
68, 2019, pp. 46-53.

Strike, C., and T.M. Watson. "Losing the Uphill Battle? Emergent Harm Reduction Interventions and

Barriers During the Opioid Overdose Crisis in Canada." International Journal of Drug Policy, vol.
71, 2019, pp. 178-182.

Substance Abuse and Mental Health Services Administration. "Federal Grantees May Now Use Funds to
Purchase Fentanyl Test Strips." 2021. Available at https://www.samhsa.gov/newsroom/press-
announcements/202104070200. Accessed September 13, 2021.

Tupper, K.W., K. McCrae, I. Garber, M. Lysyshyn, and E. Wood. "Initial Results of a Drug Checking
Pilot Program to Detect Fentanyl Adulteration in a Canadian Setting." Drug and Alcohol
Dependence, vol. 190, 2018, pp. 242-245.

Wallace, B., F. Pagan, P. Phillips, H. Wagner, S. Calder, J. Aasen, B. Pauly, and D. Hore. "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." Harm Reduction Journal, vol.
1, no. 17, 2020. https://doi.org/10.1186/s12954-020-00373-4.

Mathematica

14
This page has been left blank for double-sided copying.
Mathematica

Princeton, NJ « Ann Arbor, MI « Cambridge, MA
Chicago, IL « Oakland, CA « Seattle, WA
Tucson, AZ « Woodlawn, MD « Washington, DC

EDI Global, a Mathematica Company
Bukoba, Tanzania «+ High Wycombe, United Kingdom

@

Mathematica

Progress Together

mathematica.org