DRUG CHECKING DEMONSTRATION: INNOVATIVE HARM REDUCTION SERVICES IN ACTION

Transcription

1 DRUG CHECKING DEMONSTRATION: INNOVATIVE HARM REDUCTION SERVICES IN ACTION Tara Marie Watson, Centre for Addiction and Mental Health Caleb Chepesiuk, University of Ottawa Kenneth Tupper, British Columbia Centre on Substance Use Karen McCrae, British Columbia Centre on Substance Use ISSUES OF SUBSTANCE 2017 Calgary, Alberta

2 OUTLINE Workshop Goals About Drug Checking Overview of Technologies Service Models Discussion and Questions 2

3 WORKSHOP GOALS Introduce drug checking services (rationale and evidence) Learn how to make the case for this evolving harm reduction intervention in your community! Learn some basics of setting up a drug checking service Through videos and hands-on demonstrations, see drug checking tools in action Discuss meaningful community engagement and context-appropriate strategies to maximize harm reduction potential 3

4 WHAT IS DRUG CHECKING? Introduced in the early 1990s as a strategy to reduce harms associated with use of novel psychoactive drugs at party settings across Europe and North America Anonymous drug analysis services that offer clients information and consultation regarding the contents and risks of the drugs they intend to use Can be conducted using a range of technologies, either at stationary labs or on site where drugs are consumed (e.g., music festivals, supervised injection services) 4

5 WHY IS DRUG CHECKING A RECOMMENDED HARM REDUCTION INTERVENTION? People who consume illicitly obtained drugs are not protected by government controls that ensure safe manufacture and distribution of products in legal markets Despite common stigma/misinformed views, people who use drugs care about their health and well-being! 5

6 WHY IS DRUG CHECKING A RECOMMENDED HARM REDUCTION INTERVENTION? Consumer protection not new: 1266 English statute, Assize of Bread and Ale o In Canada: 1875 Act to Prevent the Adulteration of Food, Drink and Drugs 1908 Opium Act 1920 Food and Drug Act 1996 Controlled Drugs and Substances Act

7 WHY IS DRUG CHECKING A RECOMMENDED HARM REDUCTION INTERVENTION? Drug checking is grounded in the consumer safety principle a central pillar of the contemporary approach to public health promotion Evidence from multiple jurisdictions show that drug checking enables consumers to make informed decisions and create accountability in illicit drug markets 7

8 EVIDENCE SUMMARY INDIVIDUAL-LEVEL BENEFITS To date, there are no clinical trials on drug checking Available evidence is mainly in the context of recreational non-dependent drug use A significant portion of non-dependent service users dispose of drugs testing positive for unusual substances 1-4 Preliminary evidence from Insite people who use opioids regularly are not likely to discard drugs testing positive to fentanyl, but may reduce dose to minimize risk of overdose Drug checking is shown to be the first point of access to any drug-use related service for most service users 5 8

9 EVIDENCE SUMMARY POPULATION-LEVEL BENEFITS Real-time consumer-centred surveillance tool Data gathered from drug checking services have helped characterize new trends in the illegal drug market and devise timely prevention and harm reduction interventions. 1,5-9 Regulatory tool People who use drugs tend to trust individually-obtained facts and disseminate information within their communities effectively 5-9 Informed consumers may gradually make it difficult for dealers to sell unknown or hazardous substances 1,5 9

10 OVERVIEW OF DRUG CHECKING TECHNOLOGIES Colorimetric reagents Immunoassay test strips FTIR spectrometer GC-MS HPLC-MS 10

11 DRUG CHECKING TECHNOLOGIES COLORIMETRIC REAGENT TESTS Set of liquids that react to certain compounds by changing colour The resulting colours are compared to the swatch provided by the reagent manufacturers Commonly used at festivals for rapid onsite testing of recreational drugs 11

12 DRUG CHECKING TECHNOLOGIES COLORIMETRIC REAGENT TESTS Pros: Low cost Fast (less than 6 minutes per sample) Ease of application with minimal training Useful as preliminary analysis in tandem with more robust technologies Cons: Interpretation can be highly subjective No quantitative analysis Multiple compounds can lead to in misleading results Only able to detect known compounds in the reference swatches provided with the test kit Little evidence for detecting fentanyl and other opioids 12

13 DRUG CHECKING TECHNOLOGIES IMMUNOASSAY TEST STRIPS Off-label use of urinalysis test strips Piloted at Insite in 2016 Evaluation: positive test = 10x more likely to reduce dose and 25% less likely to overdose 13

14 DRUG CHECKING TECHNOLOGIES IMMUNOASSAY TEST STRIPS Pros: Fast (about 1 minute) Cheap (about $1 each) Simple (minimal training) Cons: Unevaluated off-label use Only tests for fentanyl and (some) analogues Tells presence/absence only 14

15 DRUG CHECKING TECHNOLOGIES IMMUNOASSAY TEST STRIPS Positive for fentanyl (photo taken by presenters) Negative for fentanyl (photo taken by presenters) 15

16 DRUG CHECKING TECHNOLOGIES RAMAN AND FTIR SPECTROMETERS Laser directed at sample detects chemical fingerprint Raman monochromatic light FTIR infrared light Raman used by law enforcement FTIR successfully used for drug checking at festivals in the UK for the past 4 years; also being piloted in Denmark, Australia, Vancouver Mid-level cost (app.$50,000 CAD) 16

17 DRUG CHECKING TECHNOLOGIES FTIR SPECTROMETER Pros: Portable Fast (2-10 minutes, depending on complexity of sample) High accuracy No sample preparation required; minimal training Non-destructive testing Cons: Does not identify unknown compounds Not suitable for quantitative analysis 17

18 DRUG CHECKING TECHNOLOGIES ALPHA FTIR SPECTROMETER (BRUKER) (PHOTO TAKEN BY PRESENTERS) 18

19 DRUG CHECKING TECHNOLOGIES ALPHA FTIR SPECTROMETER (BRUKER) See video at 19

20 DRUG CHECKING TECHNOLOGIES GAS CHROMATOGRAPHY-MASS SPECTROMETRY (GC-MS) Gas chromatography (GC) separates chemical compounds in a gas-phase sample Mass-spectrometry (MS) identifies the separated analytes by measuring their unique mass to charge ratio Widely used in pharmaceutical industry and law enforcement (limited evidence in drug checking) 20

21 DRUG CHECKING TECHNOLOGIES GAS CHROMATOGRAPHY-MASS SPECTROMETRY (GC-MS) Pros High accuracy/specificity Quantitative analysis Some portable options Cons: Target compounds must be able to enter gas phase Complex sample preparation, relatively long runtime (~15 minutes) 21

22 DRUG CHECKING TECHNOLOGIES HIGH PERFORMANCE LIQUID CHROMATOGRAPHY (HPLC) Highly accurate separation-based technology capable of quantitative analysis Used in tandem with MS to characterize and quantify compounds Used for mobile and stationary drug checking in multiple jurisdictions (e.g., Switzerland and Austria) 22

23 DRUG CHECKING TECHNOLOGIES HIGH PERFORMANCE LIQUID CHROMATOGRAPHY (HPLC) Pros: Near perfect accuracy in chemical identification Highest sensitivity; requires very small amount of sample for testing Capable of quantitative analysis Able to detect new compounds Cons: Can only analyze one sample at a time Sample loading and analysis requires significant training May be cost prohibitive up to half a million $$ 23

24 ANY QUESTIONS AT THIS POINT? Any thoughts on the rationale behind drug checking services? Questions about the different technologies and demos we have shown? 24

25 OVERVIEW OF DRUG CHECKING SETTINGS Homes/residences (e.g. testing kits bought online) Outreach/peer-to-peer) Festivals/parties/clubs Supervised injection services Public health clinics/community health centres 25

26 SERVICE MODELS EUROPE Checkit!, Vienna; Streetwork, Zurich Mobile labs equipped with HPLC machines On-site drug checking and relevant counselling and information in a tent/kiosk set-up in festivals and nightlife events The Drug Information and Monitoring System (DIMS), Netherlands Network of participating labs offer real-time on-site results Additional drop-off stations offer preliminary consultation and send sample to participating labs All results are used to build national database Energy Control, Spain Central lab tests samples collected through mail-in service and nation-wide drop off stations Results are provided electronically within 1 week using code names 26

27 SERVICE MODELS CANADA Health Canada s Drug Analysis Service labs o o o o Tests samples of unknown (suspected illicit) substances using advanced analytic technologies Only accepts samples submitted by police for forensic purposes Some high-level information shared with public health officials No information given directly to people who use drugs 27

28 SERVICE MODELS CANADA Drug Checking Pilot, Vancouver Test strip testing available at Insite as of 2016; currently being expanded across the health authority As of October 31, 2017: FTIR testing available for 2-days per week at Powell Street Getaway and Insite in conjunction with fentanyl test strips Festival testing, Shambhala ANKORS has provided on-site colorimetric testing annually since 2003 In 2016, added Raman spectrometer and mobile thin layer chromatography kit testing In 2017, added mobile GC/MS Other pilots being proposed in Toronto, Ottawa, and Victoria 28

29 SERVICES TO OFFER Information table (e.g. handout cards, posters, charts) Self-service harm reduction supplies (e.g., condoms, earplugs, safer drug use kits) A drug bible Internet-connected laptop, if available Disposal options Local list of substance use services Make it community appropriate & approachable 29

30 KEY GOOD PRACTICE STANDARDS Sustainability and funding Communication and stakeholder involvement, especially: Cooperation with law enforcement Involvement with communities of people who use drugs Relationships with health systems partners Communication with Health Canada Staff development Ethical health promotion and illness prevention Drug checking services, in short, should have a longerterm vision, involve community and numerous partners, enhance training capacity for staff, and always operate in accordance with ethical principles. 30

31 ACKNOWLEDGMENTS Tara Marie Watson is funded by a Canadian Institutes of Health Research Postdoctoral Fellowship BC Ministry of Health and Ministry of Mental Health and Addictions City of Vancouver Canadian Centre on Substance Use & Addictions 31

32 Q&A FOR DISCUSSION What do you think are the benefits and risks of providing service users with partial information about drugs they might consume? How can we (service providers, researchers, policymakers, peers ) address concerns about partial information? What are other barriers to establishing a drug checking service in your community? How can they be overcome? How would you address skeptics about drug checking as a harm reduction intervention? 32

33 REFERENCES 1. Brunt TM, Nagy C, Bucheli A, et al. Drug testing in Europe: monitoring results of the Trans European Drug Information (TEDI) project. Drug testing and analysis. 2017;9(2): Sage C, Michelow W. Drug Checking at Music Festivals: A How-To Guide. Nelson, BC Available at: 3. Benschop A, Rabes M, Korf DJ. Pill testing, ecstasy & prevention : a scientific evaluation in three European cities. Amsterdam: Rozenberg; Kriener H, Schmid R. Check your pills. Check your life. ChEck it!! High quality onsite testing of illicit substances. Information counselling and safer use measures at raves in Austria [Internet]. Vienna: CheckIT! Available at: r.htm. 5. Hungerbuehler I, Buecheli A, Schaub M. Drug Checking: A prevention measure for a heterogeneous group with high consumption frequency and polydrug use - evaluation of zurich's drug checking services. Harm reduction journal. 2011;8: Venture M, Noijen J, Bu cheli A, Isvy A, van Huyck C, Martins D, et al. Drug checking service: good practice standards. Nightlife Empowerment & Well-being Implementation Project (NEWIP); Available at: NEWIP_D_standards-final_ A4.pdf. 33

34 REFERENCES 7. Tupper K, Mackenzie B. Street drug testing Does Canada have a public health blind spot? Presentation at the Canadian Public Health Association Conference. Vancouver, BC. May 26, Tregoning W. Drug Checking Services: Brief. Unharm. May Available at: / /Drug_checking_brief_Will_Tregoning_for_Unharm_2016.pdf? Brunt TM, Niesink RJ. The Drug Information and Monitoring System (DIMS) in the Netherlands: implementation, results, and international comparison. Drug testing and analysis. 2011;3(9):

35 ADDITIONAL RESOURCE WEBSITES 1. Dancesafe.org 2. Ecstasydata.org 3. Checkyourdrugs.at 4. Ankorsvolunteer.com 5. Wearetheloop.org 6. Newip.safernightlife.org 7. Energycontrol.org 8. Tripsit.me 35

36 DRUG CHECKING TECHNOLOGY CHART Technology Detection of a variety of compounds Detection of fentanyl and other opioids Detection of multiple compounds at once Specificity Sensitivity Colorimetric Moderate Low Low Low Low reagent Immunoassay Low Moderate Low Low High GC-MS Very high Very high Very high Very high Very high HPLC-MS Highest Very high Very high Very high Highest FTIR High Moderate High High High Technology Quantitativ e Analysis Can identify unknown compounds Speed per sample Cost Suitable drug checking settings Colorimetric No No <6 min $ Stationary, Mobile reagent Immunoassay No No <2min $ Stationary, Mobile GC-MS Very high Yes 14.5 min $$$$ Stationary, Mobile HPLC-MS Highest Yes 7.5 min $$$$ Stationary FTIR Low No <2min $$ Stationary, Mobile 36