Diverse psychotropic substances detected in drug and drug administration equipment samples submitted to drug checking services in Toronto, Ontario, Canada, October 2019–April 2020

Background The overdose crisis has generated innovative harm reduction and drug market monitoring strategies. In Toronto, Ontario, Canada, a multi-site drug checking service (DCS) pilot project was launched in October 2019. The project provides people who use drugs with information on the chemical composition of their substances, thereby increasing their capacity to make more informed decisions about their drug use and avoid overdose. DCS also provides real-time market monitoring to identify trends in the unregulated drug supply. Methods Sample data were obtained through analyses of drug and used drug administration equipment samples submitted anonymously and free of charge to DCS in downtown Toronto from October 10, 2019, to April 9, 2020, representing the first six months of DCS implementation. Analyses were conducted in clinical laboratories using liquid chromatography- and/or gas chromatography-mass spectrometry (LC–MS, GC–MS) techniques. Results Overall, 555 samples were submitted, with 49% (271) of samples that were found to contain high-potency opioids, of which 87% (235) also contained stimulants. Benzodiazepine-type drugs were found in 21% (116) of all samples, and synthetic cannabinoids in 1% (7) of all samples. Negative effects (including overdose, adverse health events, and extreme sedation) were reported for 11% (59) of samples submitted for analysis. Conclusions Toronto’s DCS identified a range of high-potency opioids with stimulants, benzodiazepine-type drugs, and a synthetic cannabinoid, AMB-FUBINACA. This information can inform a range of evidence-informed overdose prevention efforts.

Measuring adulterants in street drugs: Implementation of drug residue testing using portable mass spectrometry in a Northeastern U.S. harm reduction program, 2019-2020

Background: Fatal opioid overdose deaths involving illicitly manufactured fentanyl continue to escalate in the U.S. Drug checking services, as a harm reduction intervention for people who use drugs, has gained support as an effective strategy to reduce fatal overdoses. We examined implementation of drug checking services using portable devices in a syringe services program in the Northeastern U.S. Methods: Trained staff collected trace drug specimens from used paraphernalia provided by participants who requested drug checking services. All the specimens were tested using a portable mass spectrometer and sub-samples were tested for the detection of fentanyl using fentanyl testing strips. We assessed characteristics of participants who used drug checking services, self-reported types of trace specimens of substances that participants reported providing for testing, the actual mass spectrometer test results of these specimens, and agreement of the mass spectrometer and fentanyl testing strips results in detection of fentanyl and fentanyl analogues. Results: Of 155 unique participants who provided demographic information, 59% identified as male and 74.1% as White, with a mean age of 37.7 years. Based on analysis of 396 specimens tested with the portable mass spectrometer, the most common single substance detected was fentanyl (37.7%), without a trace of heroin or other adulterants, followed by methamphetamine (18.2%), and cocaine (13.6%). Fentanyl and fentanyl analogues were detected in specimens provided by participants that were reported as heroin (60.8%), cocaine (11.1%), and methamphetamine (6.7%). We found modest agreement of testing results between the mass spectrometer and fentanyl testing strips. Conclusions: Use of drug checking services within syringe services programs is in its initial test stages. Knowledge about the contents of substances purchased, and conversations between syringe services program participants and staff, have the potential to facilitate informed decisions to decrease overdose risks through engagement in harm reduction strategies. Through analysis of newly implemented drug checking services, we noted participant characteristics and dissonance between participants’ reports of the trace drug specimens submitted for testing and the actual drugs and adulterants detected by mass spectrometer results, which has implications for overdose risk, highlighting opportunities for harm reduction responses.

Xylazine detected in unregulated opioids and drug administration equipment in Toronto, Canada: clinical and social implications

Background The North American opioid overdose crisis is driven in large part by the presence of unknown psychoactive adulterants in the dynamic, unregulated drug supply. We herein report the first detection of the psychoactive veterinary compound xylazine in Toronto, the largest urban center in Canada, by the city’s drug checking service. Methods Toronto’s Drug Checking Service launched in October 2019. Between then and February 2021, 2263 samples were submitted for analysis. The service is offered voluntarily at harm reduction agencies that include supervised consumption services. Samples were analyzed using gas chromatography–mass spectrometry or liquid chromatography-high resolution mass spectrometry. Targeted and/or untargeted screens for psychoactive substances were undertaken. Results In September 2020, xylazine was first detected by Toronto’s Drug Checking Service. Among samples analyzed from September 2020 to February 2021 expected to contain fentanyl in isolation (610) or in combination with methamphetamine (16), xylazine was detected in 46 samples (7.2% and 12.5% of samples, respectively). Samples were predominantly drawn from used drug equipment. Three of the samples containing xylazine (6.5%) were associated with an overdose. Conclusion We present the first detection of xylazine in Toronto, North America’s fourth-largest metropolitan area. The increased risk of overdose associated with use of xylazine and its detection within our setting highlights the importance of drug checking services in supporting rapid responses to the emergence of potentially harmful adulterants. These data also highlight the clinical challenges presented by the dynamic nature of unregulated drug markets and the concomitant need to establish regulatory structures to reduce their contribution to overdose morbidity and mortality.

Different Phases of ATS Use Call for Different Interventions: a Large Qualitative Study in Europe

Background: Amphetamine Type Stimulants (ATS) are globally widely used. However, there is limited understanding of what influences different phases of ATS use, as well as whether this varies by type of ATS user (groups). The ATTUNE study investigated which factors shape individual ATS use patterns. In this article, we report on these phases into and out of ATS use, and propose a set of recommendations for prevention, harm reduction and treatment of the different phases of ATS use.Methods: Qualitative, semi-structured interviews (n= 237) were conducted in five different European countries with participants who had used ATS, varying from a few times in a lifetime to daily. Results: Most ATS users consumed amphetamine only (28%), followed by amphetamine and MDMA (17%). Yet, types of ATS used differed between the countries. We found that that ATS users have various motives for and dynamic patterns of ATS use with alternating phases of increase, continuation and decrease. Cessation was pursued in different ways and for diverse reasons, such as mental health problems and maturing out. Availability seemed not an issue, regardless of the type of user, phase or country.Conclusions: These findings demonstrate that tailor-made interventions are needed for the diverse user types and different phases or patterns of ATS use, to reduce possible harms of use. We recommended a set of interventions for the different ATS phases. These include drug checking services, peer-led information, self-management of ATS use, mental health support to help people cope with stressful life events and prevent uncontrolled use, and follow-up support after treatment.

Drug use, harm-reduction practices and attitudes toward the utilisation of drug safety testing services in an Irish cohort of festival-goers

Background Festival drug-related deaths are a growing public health concern. Aim To examine drug use and related harm-reduction practices and attitudes towards utilisation of drug safety testing services. Methods Data collection took place over the 2019 festival season (June–October). The questionnaire was self-reported. Data was gathered via the online survey, which was promoted through online and social media platforms and outlets. Social media communication methods were used to reach the targeted population more effectively. Results A total of 1193 Irish festival attendees over the age of 18 completed an anonymous online survey. Alcohol, MDMA powder/crystals, ecstasy pills and cocaine were the highest reported drugs used by Irish festival attendees. The vast majority of participants reported polysubstance use (86.8%/n = 1036). Forty percent of participants (39.98%/n = 477) reported having had sex following the use of a drug at a festival; of these, 66% (n = 316) said that the sex was unprotected. Most participants (84.0%/n = 1003) engaged in some form of harm reduction when taking drugs at festivals. Overwhelmingly, participants reported a willingness to engage with drug-checking services. The vast majority (96.3%; n = 1149) and would use drug checking services more than three-quarters (75.1%/n = 897) reported that they would use an ‘amnesty bin’ for drugs if it were part of an alert system to notify if dangerous drugs are in circulation. A chi-square test of Independence was conducted to examine whether age and utilisation of drug safety testing service a festival were independent. Moreover, when all cases are taken together, the difference between testing modalities (onsite, offsite and amnesty bin) shows a significant difference p < 001 between those who would use onsite and offsite drug testing facilities. Conclusion The evidence from this survey indicates that those young people who use drugs at festivals would be prepared to utilise drug checking services and amnesty bins should help inform the public health response to this important area.