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Drug checking: a potential solution to the opioid overdose epidemic? Bardwell, Geoff; Kerr, Thomas May 25, 2018

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COMMENTARY Open AccessDrug checking: a potential solution to theopioid overdose epidemic?Geoff Bardwell1,2 and Thomas Kerr1,2*AbstractBackground: North America is experiencing an overdose epidemic driven in part by the proliferation of illicitly-manufactured fentanyl and related analogues. In response, communities are scaling up novel overdose preventioninterventions. Included are drug checking technologies.Main body: Drug checking technologies aim to identify the contents of illicit drugs. These technologies varyconsiderably in terms of cost, accuracy, and usability, and while efforts are now underway to implement drugchecking programs for people who inject drugs, there remains a lack of rigorous evaluation of their impacts.Conclusion: Given the ongoing overdose crisis and the urgent need for effective responses, research on drugchecking should be prioritized. However, while such research should be supported, it should be completed beforethese technologies are widely implemented.Keywords: Drug checking technologies, Opioid epidemic, Drug use, Overdose preventionBackgroundThe opioid overdose epidemic remains the most press-ing public health challenge in North America. From2015 to 2016, overdose mortality rates in the UnitedStates increased by 21% to 19.8 deaths per 100,000individuals, and were as high as 52.0 deaths per 100,000in the state of West Virginia [1]. In various settings,including the Canadian province of British Columbia(BC), overdose rates have risen due to the proliferationof illicitly-manufactured fentanyl and related analogues.In 2017, an overdose rate of 29.6 deaths per 100,000 wasobserved in BC – a 42% increase from 2016 [2]. Giventhe magnitude of this crisis, public health officials havescaled up a variety of overdose response interventions,including supervised consumption sites (SCS) as well asnaloxone distribution. Despite such efforts, overdosemortality continues to rise throughout North America,which has prompted the search for novel overdose pre-vention interventions. Among these are drug-checkingtechnologies (DCT), which are designed to identify thecontents of illicit drugs, including the presence offentanyl and other contaminants. Although little isknown about the impact of DCTs in the context of thepresent opioid overdose epidemic, the excitement aboutDCTs have prompted some to claim that such technol-ogy has “the potential to save hundreds of lives” [3]. Inturn, DCTs are now being implemented in settingsthroughout North America in an effort to address per-sistently high rates of overdose death [3, 4].Drug checking technologiesDCTs range considerably in terms of cost, usability, timerequired, and data reporting specificities. Initial costsrange from $2 (USD) for basic and portable DCTs (e.g.,urine test strips) to upwards of $250,000 (USD) forlarger and more advanced models (e.g., mass spectrom-etry). Some DCTs are able to identify common drugsand unknown substances as well as quantify resultswhile others are more limited with regard to specificityand sensitivity, and types of drugs detected [5]. The timerequired per drug sample ranges from 2 min to hoursdepending on the DCT, and whether transport ofsamples is required. These run times for the DCTs donot include collection, preparation, or report generation[5, 6]. At this time, little is known regarding how suchdifferences in technology and process affect uptake andoutcomes of DCTs.* Correspondence: uhri-tk@cfenet.ubc.ca1British Columbia Centre on Substance Use, St. Paul’s Hospital, 608-1081Burrard Street, Vancouver, BC V6Z 1Y6, Canada2Department of Medicine, University of British Columbia, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Bardwell and Kerr Substance Abuse Treatment, Prevention, and Policy (2018) 13:20 https://doi.org/10.1186/s13011-018-0156-3Although a small number of studies on the implemen-tation of DCTs within drug user communities have beenundertaken, until recently these focused primarily ondrug use within dance or other nightlife settings [5] andthere is limited rigorous evaluation of their impacts [6].There are, however, a small number of studies of DCTsuse among people who use opioids, including peoplewho inject drugs (PWID). The results of feasibilitystudies examining expressed willingness to use DCTsamong PWID have varied, with willingness rangingacross settings from 33 to 90% [7–9]. Feasibility dataaside, preliminary findings from an actual fentanyldrug-checking program at a SCS in Vancouver, Canadaindicated that a positive fentanyl result was associatedwith higher odds of dose reduction [10]. However, aconcerning finding was that only 1% of SCS clients usedthis program when it was offered, although the extent towhich issues with program design or implementationaffected uptake is not known.DCTs have also been used in several countries forpublic safety and surveillance purposes [5]. Monitoringillicit drug markets on an ongoing basis could potentiallyoffer some benefit and allow health officials to issuewarnings regarding the toxicity of illicit drugs in localmarkets. However, past qualitative research on drugwarnings for PWID has raised questions about the ef-fectiveness of such warnings, as they do not appear toprompt changes in drug use behaviour [11]. However, itmay be that the surveillance opportunities afforded byDCTs may extend beyond overdose warnings and in-clude informing outreach strategies, although therecurrently exists no data to support such applications. Afurther concern relates to the fact that many DCTs relyon a reference library for detection. Although a recentstudy found that a few select DCT technologies wereable to detect a small number of fentanyl analogues [12],given the ongoing emergence of new fentanyl analoguesand other contaminants it remains unclear whetherDCT systems will be able to keep up with such develop-ments. A failure to do so could result in an inability todetect a potentially fatal substance in a given sample. Allconsidered, the potential impact of DCTs within thecontext of the current overdose epidemic is difficult toassess given these limitations.ConclusionsGiven the lack of rigorous DCT evaluations involvingpeople who use opioids, further research on DCTsshould now be prioritized to determine the true impactsof different DCT models across settings. These evalua-tions should include an examination of the uptake ofDCTs by type of drug use (e.g., stimulant vs. opioids);impacts of wait times and differences in technologies onuse of DCTs; impacts of DCT results on drug disposal,dose reduction, and other drug use patterns; effects onuse of specific supply sources (e.g., dealers) and drugmarkets; cost/benefit analyses; and potential unintendedeffects (e.g., failure of detection resulting in overdose).Furthermore, evaluations should also consider differentdrug use settings (e.g., level of fentanyl saturation ofdrug markets), how the features of such settings impactuse and outcomes of DCT programs, and how differentDCT services (e.g., brief counseling) may serve to reachhidden PWID.To combat the overdose crisis that is affectingcommunities around the world, government and publichealth officials must continue exploring, implementing,and evaluating novel overdose response interventions.However, given the lack of rigorous evidence supportingthe real-world effectiveness of DCTs, only modest andselective implementation of DCTs accompanied byevaluation of outcomes should be considered at thistime. Implementation in the absence of rigorous evalu-ation could result in the wasting of precious resources,and more importantly, more lives lost to fatal overdose.AbbreviationsBC: British Columbia; DCT: drug checking technology; PWID: people whoinject drugsFundingGeoff Bardwell is supported by a Mitacs Elevate Postdoctoral Fellowship fromMitacs Canada. Thomas Kerr is supported by a Canadian Institutes for HealthResearch Foundation Grant (20R74326).Authors’ contributionsGB and TK conceptualized the commentary. GB conducted the literaturereview and wrote the first draft of the manuscript. Both authors contributedto the development and editing of the manuscript and approved the finalversion.Ethics approval and consent to participateNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Received: 23 March 2018 Accepted: 16 May 2018References1. Hedegaard H, Warner M, Minino AM. Drug overdose deaths in the UnitedStates, 1999-2016. NCHS data brief. 2017(294):1–8.2. British Columbia Coroners Service. Illicit drug overdose deaths in BC,January 1, 2007 - December 31, 2017. British Columbia: Government ofBritish Columbia; 2018.3. Government of British Columbia Ministry of Mental Health and Addictions:Province expands fentanyl testing and launches drug-checking pilot inVancouver. British Columbia: Government of British Columbia; 2017.4. Health Canada. New federal initiatives to address the opioid crisis. Ottawa:Government of Canada; 2017.5. Kerr T, Tupper K. Drug checking as a harm reduction intervention: evidencereview report. Vancouver, BC: British Columbia Centre on Substance Use; 2017.Bardwell and Kerr Substance Abuse Treatment, Prevention, and Policy  (2018) 13:20 Page 2 of 36. Harper L, Powell J, Pijl EM. An overview of forensic drug testing methodsand their suitability for harm reduction point-of-care services. HarmReduction J. 2017;14(1):52.7. Kennedy MC, Scheim A, Rachlis B, Mitra S, Bardwell G, Rourke S, Kerr T.Willingness to use drug checking within future supervised injection servicesamong people who inject drugs in a mid-sized Canadian city. Drug AlcoholDepend. 2018; 185: 248-252.8. Krieger MS, Yedinak JL, Buxton JA, Lysyshyn M, Bernstein E, Rich JD, GreenTC, Hadland SE, Marshall BDL. High willingness to use rapid fentanyl teststrips among young adults who use drugs. Harm Reduction J. 2018;15(1):7.9. Sande M, Šabić S. The importance of drug checking outside the context ofnightlife in Slovenia. Harm Reduction J. 2018;15(1):2.10. Lysyshyn M, Dohoo C, Forsting S, Kerr T, McNeil R. Evaluation of a fentanyldrug checking program for clients of a supervised injection site, Vancouver,Canada. Montréal: Harm Reduction International Conference; 2017.11. Kerr T, Small W, Hyshka E, Maher L, Shannon K. ‘It’s more about the heroin’:injection drug users’ response to an overdose warning campagin in aCanadian setting. Addiction. 2013;108(7):1270–6.12. John Hopkins Bloomberg School of Public Health. Forecast: fentanyloverdose reduction checking analysis study. February 6, 2018. Baltimore,MD: Bloomberg American Health Initiative.Bardwell and Kerr Substance Abuse Treatment, Prevention, and Policy  (2018) 13:20 Page 3 of 3

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