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Strengthening Public Health Surveillance of Illicit Drug Supplies through the Power of Community Drug Checking Programs

By: Henry Larweh and Danielle Nestadt

According to the Centers for Disease Control and Prevention, between January 2019 and June 2022, there was a 276% increase in fentanyl related fatal overdoses where xylazine, a veterinary sedative also known as “tranq”, was detected. Studies of people with opioid use disorder who use heroin and fentanyl report a general dislike of xylazine and safety concerns. Unfortunately, many people unknowingly ingest xylazine. This is cause for concern since there is no known overdose reversal agent (xylazine is not an opioid and therefore does not respond to Naloxone). The Office of National Drug Control Policy has released a plan to coordinate intergovernmental efforts for this emerging crisis. (For more information on Xylazine, read this blog post)

Xylazine is just one example of the proliferation of harmful adulterants that contribute to the unpredictability of the illicit drug supply across the country. To address this, drug checking has become a powerful tool that can strengthen existing public health surveillance, or the systematic collection and interpretation of data, of illicit drug supplies. As comprehensive systems to detect changes in the illicit drug supply are increasingly needed, states and local governments should consider investing settlement dollars into community-level drug checking programs.

Surveillance and Drug Checking 

Surveillance is defined by the Centers for Disease Control and Prevention as “the ongoing, systematic collection, analysis, and interpretation of health-related data essential to planning, implementation, and evaluation of public health practice.” Illicit drug supply surveillance can provide information that may prove important to the allocation of resources for opioid remediation.

While the primary goal of drug checking is to empower individuals to make better-informed decisions about their drug use through knowledge of the substances they’re using, there is the potential for drug checking to improve and enhance public health surveillance efforts of illicit drug supplies in American communities. State agencies and community based organizations can use a bottom-up approach to surveil illicit drug supplies statewide. 

Considerations and Approaches 

Currently, the United States identifies and responds to changes to its illicit drug supply well after contaminants appear. In this sense, our response is reactive, rather than proactive. The existing gaps in data collection and drug supply surveillance across the nation limit the ability of states and communities to respond to emerging contaminants in real time. While surveillance of opioid-related overdoses exists broadly throughout the US, including a national non-fatal overdose surveillance database, the discovery of what was involved in an overdose usually happens after the overdose occurs. This is often due to the efforts of medical examiners and coroners who investigate the causes of overdose deaths. While this information has proved useful for understanding the ongoing crisis, it is limited in its ability to proactively keep individuals safe from an ever changing drug supply.

Drug checking is a strategy designed to prevent overdoses among people who use illicitly purchased drugs by informing them of what substances are present in their sample. There are different methods and technologies to test drugs that offer their own strengths and weaknesses. 

1. The most common of these are test strips that are a targeted form of testing drugs, informing the user of the presence of a singular substance, for example fentanyl or xylazine. Test strips are now commonly distributed in many areas to people who use drugs to test their drugs before use. While test strips are cost-effective, user-friendly, and highly sensitive, they are limited to the analysis of one substance, are unable to measure how much of the substance is present in a sample, and are subject to produce false positives.

An example of a person using a fentanyl test strip.

2. Fourier transformation infrared (FTIR) spectrometry can provide an accessible option for more advanced point-of-care drug checking, as FTIR instruments are relatively portable and can identify multiple compounds within a sample within minutes. Staff at syringe services or other harm reduction programs can operate and read the results after in-depth training. However, FTIR spectrometers may not be able to detect substances present below a certain concentration and may prove costly for many community-based organizations.

An example of a FTIR spectrometer.

3. Advanced forms of spectroscopy, such as gas chromatography/mass spectrometry (GCMS), can provide more precise and accurate assessments on samples. However, they are generally only available in laboratories operated by toxicologists, analytic chemists, and other experts, because of cost, size, and level of expertise required, and are not accessible for point-of-care service delivery.

An example of a GCMS machine that can be typically found in a lab.

Current Drug Checking Initiatives

Several states across the country have supported community drug checking efforts and implemented statewide surveillance systems that utilize harm reduction programs and partners. Below are examples of some of the current initiatives going on across the nation.

  1. In 2023, New York State announced the creation of four new drug checking programs to protect people from overdoses due to unintended consumption of substances such as fentanyl. The hope is that these programs will both reduce the risk of overdose among users and inform communities of “emerging adulterants in the local drug supply”.
  2. The Maryland Department of Health’s Rapid Analysis of Drugs (RAD) tests paraphernalia voluntarily returned to syringe services programs (SSPs) around the state in partnership with a laboratory at the National Institute on Standards and Technology (NIST). Since 2021, more than 1000 samples have been tested, with results returned to local syringe service programs (SSPs) for dissemination to their clients and the surrounding communities; RAD data have illuminated emerging statewide drug supply trends, including the proliferation of xylazine.  
  3. The Massachusetts Drug Supply Data Stream (MADDS) provides a smartphone based app known as StreetCheck to pool data collected by local drug checking programs to inform communities across the state about emerging contaminants in their local supply. MADDS partners with community harm reduction programs to test samples and collect data about the drugs people come across in Massachusetts, creating a voluntary and informed system that both promotes the health of individuals who use drugs and surveys the makeup of the illicit drug supply in the state.
  4. The UNC Street Drug Analysis Lab provides drug testing by mail for samples sent from organizations and programs across the United States. Organizations send their samples to the lab to confirm if they are mixed with suspected contaminants. The Lab bolsters harm reduction efforts to inform people who use drugs what they are ingesting, as well as provide NC communities with current data on substances in their drug supply.

Considerations and Recommendations

For many individuals who use drugs there is an understandable fear that utilizing drug checking may put them at risk of criminal justice involvement. As of the writing of this blog, test strips are illegal in several states like Texas and Iowa. In other communities, drug checking using spectrometers are reserved for police departments to check any drugs seized during a raid. States and jurisdictions should consider how to ethically collect data and information regarding illicit drug supplies while protecting the privacy of individuals and organizations that choose to participate in drug checking and surveillance efforts. Additionally, changing policies that may hinder drug checking and surveillance activities should be prioritized by states and communities considering these methods.

States should consider spending their dollars to create or fund point-of-care drug checking programs at existing harm reduction services, including the purchase of instruments such as FTIR spectrometers, training technicians on how to use them, or creating state-level or inter-municipality data sharing partnerships. Expenditures such as these have the potential to build up states’ and communities’ drug surveillance infrastructure in accordance with Core Strategies Eight and Nine of Exhibit E. Establishing and supporting point of care drug checking programs in communities can help prevent opioid-related overdoses and become the foundation for illicit supply surveillance systems across the United States.

Understanding where and how to use harm reduction strategies and the knowledge gained by drug checking can strengthen current and future efforts for opioid remediation. Drug checking may prove to be a life-saving and powerful tool for states to consider adopting with their settlement dollars.

About the Authors:

Henry Larweh, BA is a Master of Science in Public Health in Health Policy candidate at the Johns Hopkins Bloomberg School of Public Health. He is a member of the Bloomberg Overdose Prevention Initiative working with the Government Support team studying how states are planning to spend their opioid settlement dollars, as well as providing advice for how states can best use their settlement funds.

Danielle Friedman Nestadt, PhD, MPH, MSW is an Assistant Scientist in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health. Her work focuses on social and structural determinants of health among marginalized populations, particularly women who exchange sex and people who use drugs, and she is currently leading the development of a mobile overdose- and HIV-prevention intervention in Baltimore that includes point-of-care drug checking.