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Evaluation of a fentanyl drug checking service for clients of a supervised injection facility, Vancouver,… Karamouzian, Mohammad; Dohoo, Carolyn; Forsting, Sara; McNeil, Ryan; Kerr, Thomas; Lysyshyn, Mark Sep 10, 2018

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RESEARCH Open AccessEvaluation of a fentanyl drug checkingservice for clients of a supervised injectionfacility, Vancouver, CanadaMohammad Karamouzian1,2,3, Carolyn Dohoo4, Sara Forsting5, Ryan McNeil1,6, Thomas Kerr1,6and Mark Lysyshyn2,5*AbstractBackground: British Columbia, Canada, is experiencing a public health emergency related to opioid overdosesdriven by consumption of street drugs contaminated with illicitly manufactured fentanyl. This cross-sectional studyevaluates a drug checking intervention for the clients of a supervised injection facility (SIF) in Vancouver.Methods: Insite is a facility offering supervised injection services in Vancouver’s Downtown East Side, a communitywith high levels of injection drug use and associated harms, including overdose deaths. During July 7, 2016, to June21, 2017, Insite clients were offered an opportunity to check their drugs for fentanyl using a test strip designed totest urine for fentanyl. Results of the drug check were recorded along with information including the substancechecked, whether the client intended to dispose of the drug or reduce the dose and whether they experienced anoverdose. Logistic regression models were constructed to assess the associations between drug checking resultsand dose reduction or drug disposal. Crude odds ratios (OR) and 95% confidence intervals (CI) were reported.Results: About 1% of the visits to Insite during the study resulted in a drug check. Out of 1411 drug checks conductedby clients, 1121 (79.8%) were positive for fentanyl. Although most tests were conducted post-consumption, following apositive pre-consumption drug check, 36.3% (n = 142) of participants reported planning to reduce their drug dosewhile only 11.4% (n = 50) planned to dispose of their drug. While the odds of intended dose reduction among thosewith a positive drug check was significantly higher than those with a negative result (OR = 9.36; 95% CI 4.25–20.65), noassociation was observed between drug check results and intended drug disposal (OR = 1.60; 95% CI 0.79–3.26).Among all participants, intended dose reduction was associated with significantly lower odds of overdose (OR = 0.41;95% CI 0.18–0.89).Conclusions: Although only a small proportion of visits resulted in a drug check, a high proportion (~ 80%) ofthe drugs checked were contaminated with fentanyl. Drug checking at harm reduction facilities such as SIFsmight be a feasible intervention that could contribute to preventing overdoses in the context of the currentoverdose emergency.Keywords: Drug checking, Substance use, Injection drug use, Supervised injection facility, Canada* Correspondence: mark.lysyshyn@vch.ca2School of Population and Public Health, University of British Columbia, 5804Fairview Avenue, Vancouver, BC V6T 1Z3, Canada5Vancouver Coastal Health Authority, Vancouver, BC V5Z 4C2, CanadaFull list of author information is available at the end of the article© 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.Karamouzian et al. Harm Reduction Journal  (2018) 15:46 https://doi.org/10.1186/s12954-018-0252-8BackgroundAmong the most alarming drug trends in NorthAmerica is the rapidly increasing impact of illicitdrugs adulterated with illicitly manufactured fentanyl[1, 2]. While fentanyl can be prescribed to treat pain,it has high toxicity relative to morphine or heroinand is considerably more likely to result in a fataloverdose, a high potency that has drastically changedthe substance use landscape in North America [1, 3–6]. In the USA, the Centers for Disease Control andPrevention reports that fentanyl was detected in56.3% of 5152 opioid-related overdose deaths across10 states in the second half of 2016 [7].Canada is facing a similar unprecedentedopioid-related overdose epidemic, where exposure toillicit fentanyl can come from a number of sources in-cluding counterfeit opioid tablets (e.g. fake oxys) [5],heroin contaminated with fentanyl [1, 5], fentanylpatches from either illicit or pharmaceutical sources [1],and stimulants such as cocaine contaminated with fen-tanyl [2, 8]. British Columbia (BC) is one of the settingsthat have witnessed a sharp increase in the rate ofopioid-related overdose deaths leading to a public healthemergency declaration in April 2016 [1, 2, 5]. The surgein the number of fentanyl-detected overdose deaths in2017 among people who use drugs (PWUD) in BC isvery concerning; 999 fentanyl-detected overdose deathswere identified from January to October 2017 comparedto 654 in 2016, 151 in 2015, and 91 in 2014 [9].Exposure to illicitly manufactured fentanyl may beunintentional [10], and PWUD may be unaware of fen-tanyl presence in their drugs. For example, among 231patients undergoing opioid withdrawal management inMassachusetts, two thirds of those who reported neverbeing intentionally or unintentionally exposed to fen-tanyl, tested positive for fentanyl [11]. Furthermore, arecent survey of 242 clients of 17 harm reduction sitesin BC detected fentanyl in 29% of the participants, 73%of whom were not knowingly using fentanyl [10]. On theother hand, given the ongoing overdose epidemic, manyPWUD may suspect their drugs to be adulterated withfentanyl; however, they have no reliable way of knowingwhich drugs are adulterated before they use them.In response to the overdose crisis in BC, interven-tions are now being implemented and scaled up, in-cluding the piloting of fentanyl drug checking servicesat Insite (i.e. a supervised injection facility [SIF]which provides a hygienic environment where individ-uals can inject their drugs under the supervision ofqualified staff ) [12–14]. Drug checking is a harmreduction intervention that has been implemented ina variety of settings. It was introduced in Europe fol-lowing the establishment of the Drug Information andMonitoring System in the Netherlands in 1992 (i.e. anational system of stationary testing facilities acrossvarious regional institutes catered towards substanceuse prevention and care). Drug-checking offers testingof street drugs to assess their composition (includingpotential contaminants) and allows for more informeddecision-making by PWUD [15–17]. Drug-checkingservices can vary in a number of ways including testingmethod (e.g. colorimetric reagents, high-performanceliquid chromatography, gas chromatography, mass spec-trometry), type of results available (e.g. presence orabsence of a component, quantitative information aboutall compounds), setting (e.g. at home, mobile, remote site),and purpose (e.g. individual harm reduction, public healthaction, market monitoring) [18]. While drug checkingservices have been shown to be effective in reachingyoung people who use drugs for recreational purposes andpersuading them to change their behaviour positively [19],they have also been criticized for creating an unjustifiedfeeling of safety about illicit drugs while the absence of un-expected or potent components in a sample of illicit drugscannot guarantee its safety [18, 20].While drug checking services have been availableacross numerous European countries such as theNetherlands, France, Austria, Belgium, Portugal,Spain, and Switzerland for over two decades [16–18,21, 22], they are considered illegal and thus remainunderdeveloped in Canada even though illegal drugchecking services have been implemented at somemusic festivals [9, 23]. The goal of the drug checkingservice that has been operating at Insite since July2016 is to improve clients’ awareness of their expos-ure to fentanyl and improve our understanding of thedrug supply. Improved awareness of fentanyl exposuremay encourage client adoption of available harmreduction practices. Therefore, this study aims toevaluate the drug checking service using data col-lected at Insite. In particular, this study assesses thefentanyl drug checking positivity rate, the prevalenceof fentanyl contamination by substance type, as wellas the impact of fentanyl drug checking results onintention to reduce their dose or dispose of theirdrug, overdose, and the need for naloxone administra-tion. Given the clear and urgent need for novel inter-ventions to address the overdose epidemic andlimited body of evidence on the evaluation of drugchecking services, the findings of this study have po-tential to inform current overdose prevention andharm reduction efforts.MethodsSettingInsite is North America’s first government sanctioned SIFthat offers supervised injection services in Vancouver’sDowntown East Side, a neighbourhood with high levels ofKaramouzian et al. Harm Reduction Journal  (2018) 15:46 Page 2 of 8injection drug use and related harms, including overdosedeaths [12, 13]. Insite aims to reduce harms to PWUD’shealth while linking them to care and treatment [12, 13].Insite operates under an exemption to Canada’sControlled Drugs and Substances Act which allows clientsto possess and use drugs on site and which permits thedrug checking service to operate in a legal manner in thissetting [12, 13]. Since its establishment in 2003, there havebeen over 3.6 million visits to the facility, and over 6000overdoses have been treated, none of which has been fatal.Insite clients are mostly high-intensity injection drug userswho often come from an extremely marginalized back-ground (e.g. unstable housing) [24, 25].Data collectionInsite’s clients were notified of the availability of drugchecking service at Insite through posters set up at thefacility. Insite’s staff offered all clients the opportunityto check their drugs for the presence of fentanyl as theyentered the injection room by asking ‘Do you want tocheck your drugs for fentanyl?’ Consenting participantswere then instructed to dissolve a small drug sample(i.e. the size of a grain of salt) in water in a cooker andthen test it with a BTNX Rapid Response Fentanyl TestStrip prior to consumption. These strips—which arenot designed to test drugs at SIFs—utilize an enzymeimmunoassay test which uses an antibody’s bondingwith an antigen to signal the presence of fentanyl quali-tatively (i.e. presence vs. absence) and are inexpensive(1$ each), simple to use, and easy to read [26]. More-over, BTNX strips have a detection limit (i.e. the lowestconcentration that could be detected) of 0.13 μg/mland have been shown to be highly sensitive and specificwhen used in this way [26]. Fentanyl drug checks couldbe performed before or after drug consumption, de-pending on the clients’ preference. Post-consumptionchecks were done using drugs that had not been con-sumed or residue left in the cooker that was used toprepare the drugs (Fig. 1). Once the result of the testwas confirmed by Insite staff, they were recorded onthe reporting form as either ‘Positive’ or ‘Negative’ andwhether they tested pre- or post-consumption alongwith the following information: client-reported sub-stance (e.g. heroin or methamphetamine or cocaine);substance dose reduction intention (yes or no);substance disposal intention (yes or no); overdose fol-lowing consumption (yes or no); and naloxone adminis-tration among those who overdosed (yes or no).Overdose was determined on site by Insite nursingstaff, and naloxone was administered according toInsite clinical protocols. Given the anonymous natureof data collection, no demographic or identifying in-formation was collected and participants’ unique iden-tification codes (i.e. Insite ID) were not linked to thestudy data.Participants were notified of the result of the test. Ifthe test result was negative, participants were informedthat the test strip only tested for fentanyl and their nega-tive test result could not ensure that their drugs werenot adulterated with other substances which could bemore potent than fentanyl (e.g. W-18). Participants werealso asked if they planned to reduce their dose or dis-pose of their drugs. Finally, participants were offered anyor all of the following interventions had they not beenaccessing them already: information on reducing harmfrom injection (e.g. use a little, do not use alone); TakeHome Naloxone and training; information on availabilityof other SIF; and offer to connect with addiction treat-ment services (e.g. Detox/Daytox, addiction counselling,opioid substitution therapy).Data analysisIn this cross-sectional study, we used data from the fen-tanyl drug checking service at Insite collected from July7, 2016, to June 21, 2017. Eligible participants for theanalysis included any individual who had accessed thefentanyl drug checking programme at Insite during thestudy period. Frequencies and descriptive statistics werecomputed for all variables. Fentanyl drug checking posi-tivity percentage within Insite was calculated using thefollowing formula: (number of positive checks/totalnumber of checks) × 100.Unadjusted bivariable logistic regression models wereconstructed to investigate the associations between drugchecking results and intentions for dose reduction ordrug disposal. Logistic regression models were also usedto assess the associations between drug checking results(pre- or post-consumption) and dose reduction inten-tions with overdose events as well as naloxone adminis-tration. Crude odds ratios (OR), as well as 95%confidence intervals (CI), were reported. Stata version 14(Stata Corp.) was used throughout the analysis, and Pvalues less than 0.05 were considered statisticallysignificant.Fig. 1 A test strip used to check drug samples for the presence offentanyl at Insite. (Image provided by Vancouver Coastal Health)Karamouzian et al. Harm Reduction Journal  (2018) 15:46 Page 3 of 8Ethics approval and consent to participateThis study involved the secondary use of anonymousdata collected as part of the drug checking service. Par-ticipants’ refusal to participate in the study did not influ-ence the services provided to them. The University ofBritish Columbia (UBC) and Providence Health Careethics committees reviewed and approved the studyprotocol (UBC-REB NUMBER: H16-02973).ResultsFrom July 7, 2016, to June 21, 2017, there was a total of134,176 visits to Insite with an average of 533 daily visits(range 387–780). Since implementing the fentanyl drugchecking programme, a total of 1411 (1%) visits led to adrug check conducted by Insite clients. This representsa daily average of 4.0 checks with a range of 0 to 27checks per day. Out of all drug checks performed duringthe study period, 1121 (79.8%) were positive for fentanyl.The majority of drug checks were performed onclient-reported heroin, 84.1% (n = 939) of which testedpositive for fentanyl. The majority of checks wereperformed post-consumption (58%; n = 789). Drugschecked post-consumption were significantly more likelyto be positive for fentanyl compared to those checkedpre-consumption (82.9%; n = 654 vs. 76.5%; n = 438; Pvalue 004).Among those with a positive drug checkpre-consumption, 36.3% (n = 142) reported planning toreduce their drug dose, and the odds of dose reductionintention among those who had a positive drug checkwere significantly higher than those with a negative re-sult (OR = 9.36; 95% CI 4.25–20.65). Conversely, amongthose with a positive drug check pre-consumption, only11.4% (n = 50) planned to dispose their drug. Althoughthe odds of drug disposal intention were higher whenthe drug check was positive, the association was not sta-tistically significant (OR = 1.60; 95% CI 0.79–3.26).Detailed association of drug checking and intentions fordose reduction or drug disposal are presented in Table 1.During the study period, Insite’s staff reported a totalof 120 overdoses in association with drug checks; mostof which (94%; n = 113) were reported among those whotested post-consumption. The odds of overdose amongthose who had a positive drug check were significantlyhigher than those with a negative drug check (OR = 5.97;95% CI 2.41–14.78). Of the total recorded overdoses,76.2% (n = 92) required naloxone administration and theodds of naloxone administration among those who hada positive drug check were significantly higher thanthose with a negative drug check (OR = 4.42; 95% CI1.77–11.02). Moreover, of those who planned to reducetheir dose, only 4.5% (n = 7) overdosed and 3.2% (n = 5)were administered naloxone. Among all participants,dose reduction intention was significantly associatedwith lower odds of overdose (OR = 0.41; 95% CI 0.18–0.89) and naloxone administration (OR = 0.38; 95% CI0.15–0.96). Detailed statistics on the association of drugcheck results and overdose as well as naloxone adminis-tration are presented in Table 2.DiscussionOur study revealed that only a small proportion ofdrugs used at Insite during the study period werechecked using the drug checking service. However, ahigh proportion (~ 80%) of the drugs checked wasfound to be contaminated with fentanyl. We also ob-served that PWUD who received a positive drugcheck pre-consumption were significantly more likelyto plan to reduce their drug dose upon injecting butnot more likely to plan to dispose of their drugs. Ourresults are comparable with Health Canada’s DrugAnalysis Service laboratory reports that suggests ahigh and increasing proportion of illicit drugs seizedby law enforcement agencies in BC were contami-nated with fentanyl during this period [27]. However,they are considerably higher than the positivity ratesin previous assessments in BC including studies thatused urine drug screening tests and found that one inthree PWUD across 17 harm reduction sites acrossBC [10] and one in six PWUD in Vancouver [28]tested positive for fentanyl. While our findings arespecific to drugs checked at Insite during the studyTable 1 Association of drug check results and intentions for dose reduction or drug disposal of Insite clients who used a fentanyldrug checking service in Vancouver, CanadaDrug check resulta Total Dose reductionYes; n (%)bDose reductionNo; n (%)Odds ratio(95% CI)P valuecPositive 391 142 (36.32) 249 (63.68) 9.36 (4.25–20.65) 0.0001Negative 122 7 (5.74) 115 (94.26) Ref.Drug check resulta Total Drug disposalYes; n (%)Drug disposalNo; n (%)Odds ratio(95% CI)P valuecPositive 436 50 (11.47) 386 (88.53) 1.60 (0.79–3.26) 0.186Negative 134 10 (7.46) 124 (92.54) Ref.aLimited to pre-consumption checks. bAll percentages are row percentage. cP values based on chi-square and Fisher’s exact test as appropriateKaramouzian et al. Harm Reduction Journal  (2018) 15:46 Page 4 of 8period, they may inform efforts aimed at monitoringand reducing risks in the local drug supply in juris-dictions across North America that are experiencingincreased rates of overdose with illicit fentanyl [4, 6,29].Drug checking has mostly been implemented at musicfestivals and in other community settings [17, 22]. Whileprevious studies have analysed the residual content ofused syringes in syringe-exchange facilities [30], we be-lieve our study is the first of its kind to examine a legalgovernment-sanctioned drug checking service at a SIF,which is a unique setting for studying drug checking ser-vices as it allows for observing clients as they performdrug checking, monitoring adopted harm reductionpractices, and documenting relevant health outcomes(e.g. overdose). For instance, in our study, drug checkingresults encouraged clients to plan to reduce their dosebut most did not plan to dispose of their drugsaltogether. These findings are different from docu-mented drug disposal practices in music festivals. Forexample, in 2015 at Shambhala Music Festival—an eventin BC with a long history of offering drug checkingservices—13% of clients disposed of their drugs follow-ing an unexpected result compared to 2% followingexpected results [23]. At Insite, clients may not haveplanned to dispose of contaminated drugs because theyare more likely to be dependent on the drugs they areusing, lack funds to purchase replacement drugs, andhave no access to unadulterated street drugs. Further-more, while a recent study has found no evidence ofcompensatory drug use following naloxone trainingamong a group of heroin users [31], it is possible thatsome clients may have specifically sought out fentanylknowing they can be treated for an overdose at a SIF, anassumption that needs to be further explored in ourfuture studies at Insite.Not surprisingly, a positive drug check result wasassociated with significantly greater odds of the clientexperiencing an overdose and requiring naloxone ad-ministration. These findings are comparable with astudy in a SIF in Sydney, Australia, where fentanylinjections had 4.6 times the risk of resulting in over-dose compared to heroin or other prescription opi-oids combined [32]. Nonetheless, interpretationsaround our findings of the association of drug checkresults and odds of overdose should be made withcaution as contrary to our expectations; the majorityof drug checks in our study were performedTable 2 Association of drug check results and overdose as well as naloxone administration among clients of Insite who used afentanyl drug checking service in Vancouver, CanadaDrug check result Total OverdoseYes; n (%)aOverdoseNo; n (%)Odds ratio(95% CI)P valuebOverallPositive 1028 115 (11.19) 913 (88.81) 5.97 (2.41–14.78) 0.0001Negative 242 5 (2.07) 237 (97.93) Ref.Pre-consumptionPositive 357 7 (1.96) 350 (98.04) 4.60 (0.26–81.21)c 0.297Negative 107 0 (0.00) 107 (100.00) Ref.Post-consumptionPositive 649 108 (16.64) 541 (83.36) 4.95 (1.97–12.39) 0.0001Negative 129 5 (3.88) 124 (96.12) Ref.Drug check result Total Naloxone administeredYes; n (%)Naloxone administeredNo; n (%)Odds ratio(95% CI)P valuebOverallPositive 1026 87 (8.48) 939 (91.52) 4.42 (1.77–11.02) 0.001Negative 244 5 (2.05) 239 (97.95) Ref.Pre-consumptionPositive 355 3 (0.85) 352 (99.15) 1.83 (0.09–35.87)c 0.688Negative 109 0 (0.00) 92 (100.00) Ref.Post-consumptionPositive 649 84 (12.94) 565 (87.06) 3.68 (1.46–9.27) 0.003Negative 129 5 (3.88) 124 (96.12) Ref.aAll percentages are row percentage. bP values based on chi-square and Fisher’s exact test as appropriate. cAs zeros caused problems with computation of theodds ratio or its confidence interval 0.5 added to all cells [36]Karamouzian et al. Harm Reduction Journal  (2018) 15:46 Page 5 of 8post-consumption. While PWUD could choose tohave their drugs checked prior to or after consump-tion, details of the timeline and sequence of decisionmaking to participate in the intervention were notcaptured. In other words, the motivation to perform adrug check might have been the result of an overdoseif PWUD asked for a testing strip after consumption.Conversely, motivation to perform a drug check may havenot been the result of an overdose if PWUD requested atesting strip before consumption but decided to checktheir drug post-consumption. While performing a drugcheck after consumption does not provide the client withan opportunity to reduce their dose or dispose of theirdrugs before consuming, it might still provide them withvaluable information. For example, the drug checking re-sult may help explain why an overdose occurred and mayhelp the client decide how to use drugs still in their pos-session. A positive result post-consumption might also en-courage clients to return to the SIF to consume their nextdose. Supervised injection services have been shown toprevent death due to overdose across numerous settings[23]. This study shows that offering drug checking at a SIFmight extend their benefits by enabling clients to reducetheir risk of experiencing an overdose in the first place.Further research is needed to confirm such effects. It isunclear whether drug checking might have similar impactsin settings where supervised injection services are notavailable. It should also be noted that as only a small pro-portion of people accessing Insite utilized the drug check-ing service, the service might have attracted clients morelikely to engage in harm reduction strategies.Overall, few visits to Insite (1%) during the studyperiod resulted in a drug check. It is difficult to comparethis uptake to other settings where drug checking hasbeen implemented. For instance, in 2015 at ShambhalaMusic Festival, 3224 drug checks were performed duringthe 5-day festival which involved over 67,000 attendees[23]. The low uptake of the drug checking service canalso be compared with the findings of a small survey ona convenient sample of 180 PWUD in the mid-sized cityof London in Ontario, Canada, in 2016 where 43% ofthe participants reported that if provided with the ser-vice, they would frequently check their drugs at a SIF[33]. Moreover, in a study of 93 young PWUD in RhodeIsland, USA, over 90% of the participants showed a will-ingness to use take-home rapid fentanyl test strips [11].These differences which should be interpreted with aneye to the small sample size and social desirability biasof the survey results in London and Rhode Island high-light the need for further research on whether willing-ness to use drug checking services at harm reductionfacilities could predict future service uptake [11, 33].There also remains a need for complementary qualita-tive research to examine how the degree of suspectedcontamination of the street drug supply, othersocial-structural factors (e.g. drug law enforcement,poverty), or providing peer-led distribution of drugchecking services influence drug checking behaviours.It is possible that the limited uptake of this interven-tion might reflect clients’ reluctance to check theirdrugs when they suspect the majority of street drugsavailable to be adulterated [33]. Nonetheless, becauseup-to-date drug checking results from this study wereregularly communicated to clients via posters, it isalso possible that even clients that did not performdrug checks themselves might have benefited fromresults of the drug checking service.It is also worth noting that further research isneeded to understand the limitations of current drugchecking technologies including the fentanyl teststrips. Previous studies including a recent report byHealth Canada have raised concerns about the validityof these test strips in detecting novel analogues offentanyl in street drug samples and the small possibil-ity for false-negative test results [34], and advocatedfor employing alternative drug checking technologieswith better discriminative abilities (e.g. infrared spec-trometry methods) [17]. Moreover, these studies arguethat the qualitative detection of fentanyl in drug sam-ples might be of limited value to PWUD, particularlyin areas such as Vancouver where fentanyl is beingincreasingly found in the drug supply [27]. However,the findings of the recent Fentanyl Overdose Reduc-tion Checking Analysis Study (FORECAST) that com-pared the ability of three drug checking technologies(i.e. BTNX fentanyl testing strips, TruNarc machine,and Bruker Alpha machine) in detecting fentanyl instreet drug samples with a gold standard test (i.e. gaschromatograph/mass spectrometer) concluded thatthe fentanyl testing strips used in this study had thelowest detection limit and the highest specificity andsensitivity for fentanyl among the assessed technolo-gies [26]. Furthermore, fentanyl test strips are consid-erably cheaper and require minimal training forproper use compared to other testing approaches andtherefore seem to be a practical and feasible interven-tion with a significant potential for reducing harm inthe context of the current opioid crisis [26]. Nonethe-less, further research is warranted to develop andidentify portable and easy-to-use testing technologiescapable of detecting fentanyl and its analogues indrug samples in a variety of settings [26]. Moreover, futuredecisions regarding the provision of drug checking ser-vices should consider distributing information alongsidethe tests about the potential limitations of these technolo-gies and the importance of continuing to use other harmreduction practices and programmes even after using adrug checking service [34].Karamouzian et al. Harm Reduction Journal  (2018) 15:46 Page 6 of 8We would like to acknowledge the limitations of ourstudy. The test strips used were not designed to checkdrug samples in a SIF. However, the findings of theFORECAST study suggest that these test strips are rela-tively accurate in detecting fentanyl in street drugs sam-ples. Moreover, the anonymous nature of our datarestricted our analysis. It was impossible to interpret thefindings per individual clients; it is not clear how many in-dividual clients made use of the drug checking service orwhether clients who used the service continued using itregularly. Moreover, we may have collected data from cli-ents more likely to have fentanyl present in their drugs.Given the limited generalizability of our findings, future re-search should seek to combine drug checking data with cli-ent SIF utilization data to generate more detailed analysisspecific to this issue.ConclusionsThis study suggests that a high portion of illicit drugschecked at Insite might be adulterated with fentanyl.While responding to the overdose epidemic requires amultifaceted approach [29, 35], drug checking might bean additional harm reduction strategy that could con-tribute to preventing overdoses in the context of a streetdrug supply contaminated with illicit fentanyl. Thisstudy shows that it may be feasible and potentially usefulto offer drug checking in conjunction with supervisedconsumption services. However, further benefit may alsobe afforded by offering such services in community set-tings where supervised consumption services are notavailable. In addition, while this study used a relativelysimple and inexpensive drug checking technology, add-itional information may be gained with the use of moreadvanced drug checking technologies or through thecombination of such technologies. Governments andhealth authorities should work with community partnersto further implement and evaluate this potentiallyimportant harm reduction intervention.AbbreviationsBC: British Columbia; CI: Confidence intervals; FORECAST: Fentanyl OverdoseReduction Checking Analysis Study; OR: Odds ratios; PWUD: People who usedrugs; SIF: Supervised injection facilityAcknowledgementsWe would like to thank the study participants for their contribution to theresearch as well as the Insite’s staff for their administrative assistance andsupport during data collection.FundingThis study was funded by Vancouver Coastal Health. Mohammad Karamouzianis supported by Vanier Canada Graduate and Pierre Elliott Trudeau DoctoralScholarships.Availability of data and materialsThe datasets used and/or analysed during the current study are availablefrom the corresponding author on reasonable request.Authors’ contributionsML and TK conceived and designed the study. ML, CD, and SF supervisedthe data collection and facilitated access to the data. MK and CD performedthe data analysis. MK prepared the first draft of the manuscript. All coauthorsprovided critical input into the manuscript and the interpretations of thefindings. All authors read and approved the final version.Ethics approval and consent to participateThis study involved the secondary use of anonymous data collected as partof the drug checking service. Participants’ refusal to participate in the studydid not influence the services provided to them. The University of BritishColumbia (UBC) and Providence Health Care ethics committees reviewedand approved the study protocol (UBC-REB NUMBER: H16-02973).Consent for publicationNot 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.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 2School ofPopulation and Public Health, University of British Columbia, 5804 FairviewAvenue, Vancouver, BC V6T 1Z3, Canada. 3HIV/STI Surveillance ResearchCenter, and WHO Collaborating Center for HIV Surveillance, Institute forFutures Studies in Health, Kerman University of Medical Sciences, Kerman7616913555, Iran. 4Public Health Agency of Canada, Ottawa, ON K1A 0K9,Canada. 5Vancouver Coastal Health Authority, Vancouver, BC V5Z 4C2,Canada. 6Department of Medicine, University of British Columbia, St. Paul’sHospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.Received: 7 March 2018 Accepted: 27 August 2018References1. 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