Drug Checking: A Novel Evidence-Based Strategy for Preventing Overdose Traci Green, PhD, MSc, Deputy Director, Boston Medical Center Injury Prevention Center, Associate Professor of Emergency Medicine and Epidemiology, Warren Alpert School of Medicine, Brown University Susan Sherman, PhD, MPH, Professor, Johns Hopkins University Brandon Marshall, PhD, Associate Professor, Brown University EMBARGO - SLIDES FOR ZIBBELL, PEIPER, VINCENT ARE NOT INCLUDED Jon Zibbell, PhD, Senior Public Health Scientist, RTI International Nick Peiper, PhD, MPH, Behavioral Epidemiologist, RTI International Louise Vincent, MPH, Executive Director, Urban Survivors' Union Pre-Summit Workshop Moderator: Grant T. Baldwin, PhD, MPH, Director, Division of Unintentional Injury Prevention, National Center for Injury, CDC, and Member, National Rx Drug Abuse & Heroin Summit Advisory Board #Rx Summit www.NationalRxDrugAbuseSummit.org Disclosures  Traci Green, PhD, MSc; Susan Sherman, PhD, MPH; Brandon Marshall, PhD; Nick Peiper, PhD, MPH; Louise Vincent, MPH; and Grant T. Baldwin, PhD, MPH, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.  Jon Zibbell – Salary: RTI International #Rx Summit www.NationalRxDrugAbuseSummit.org Disclosures  All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.  The following planners/managers have the following to disclose: - Kelly J. Clark, MD, MBA, FASAM, DFAPA – Consulting fees: Braeburn, Indivior #Rx Summit www.NationalRxDrugAbuseSummit.org Learning Objectives  Describe the role of heroin, fentanyl and synthetic opioids in      the U.S. overdose epidemic. Summarize cutting-edge research findings on drug checking for public health applications. Recognize the need to generate discussion to create novel solutions to address the national opioid overdose crisis. Describe changes in street opioid markets and the risks posed by market unpredictability. Explain findings on behavioral outcomes associated with the use of fentanyl test strips and implications for overdose prevention. Describe strategies to incorporate fentanyl test strips into existing overdose education and naloxone programs and other harm reduction efforts (e.g., syringe service programs). #Rx Summit www.NationalRxDrugAbuseSummit.org The FORECAST Study: Initial Results Susan G. Sherman, PhD, MPH Ju Nyeong Park, MHS Traci C. Green, PhD, MSc Johns Hopkins Bloomberg School of Public Health Rhode Island Hospital Brown University Schools of Medicine and Public Health #Rx Summit www.NationalRxDrugAbuseSummit.org Opioid Overdose Source: The New York Times. “The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years.” Josh Katz. Sep 2 2017. #Rx Summit www.NationalRxDrugAbuseSummit.org Drug checking  Drug checking has been a public health intervention for decades.  European health departments  US music festivals and raves, by PWUD  Some SSPs in the US and Canada  There is no objective method for knowing if drug samples contain fentanyl (no product safety measures).  Drug checking involves testing a drug sample to check for its purity or for the presence of adulterants. #Rx Summit www.NationalRxDrugAbuseSummit.org Fentanyl Overdose Reduction Checking Analysis Study BOSTON 34.6 PROVIDENCE 35.3 BALTIMORE 83.5 #Rx Summit www.NationalRxDrugAbuseSummit.org Study Aims  April through December 2017 Phase I: To compare the limit of detection and accuracy of fentanyl testing strips, a hand-held machine, and a portable desktop machine in detecting fentanyl in 210 street drug samples. Phase II: Examine the interest in fentanyl checking among people who use drugs in Baltimore, Providence and Boston (N=335) Phase III: Explore key informant attitudes on drug checking and the programmatic considerations in implementing drug checking (N=32) #Rx Summit www.NationalRxDrugAbuseSummit.org I street samples Phase I: Laboratory study BTNX fentanyl test strips Raman spectroscopy (TruNarc) FTIR (Bruker Alpha)  Baltimore Police Dept Forensic Crime Lab, RI State Public Health Lab Drug Chemistry Unit  Instrument manufacturers trained lab staff, strip training based on package insert and harm reduction organization’s input Limit of Detection • Fentanyl standard, prepared in solutions of ethanol (TruNarc) or water (BTNX test strips) • Sequentially tested 3 samples of known fentanyl concentration, decreasing the value of the concentration by serial dilution until not detected Fentanyl Detection in Street Samples • 210 powder and pill street drug samples, from Baltimore and Providence Police Dept cases • Half known fentanyl+, half known fentanyl- based on original GC/MS testing at lab • Lab staff blinded to results, systematically tested each sample per protocol #Rx Summit www.NationalRxDrugAbuseSummit.org Lab study results Technology Detection Limit Sensitivity Specificity RI Lab Baltimore RI Lab Lab Baltimore Lab BTNX Fentanyl Testing Strips (immunoassay) 0.13 micrograms/ml 96% 100% 90% 98% TruNarc (Raman Spectroscopy) 25 micrograms/ml 61% 39% 92% 92% Bruker Alpha (FTIR Spectroscopy) 3-4% weight, which is comparable to TruNarc 83% -- 90% -- Four samples containing fentanyl analogues tested: test strips detected 100% as fentanyl present; TruNarc and Bruker Alpha detected 3 of 4 as fentanyl present #Rx Summit www.NationalRxDrugAbuseSummit.org Instrument Considerations Fentanyl Testing Strips • Fast (3-5 mins) , minimal training, easy to use, cost • Only tests fentanyl, cannot distinguish among fentanyl/analogues/mixtures • Guard against confusion when reading results, with low fentanyl concentrations TruNarc • Fast (4 mins), some training, easy to use, durability • Challenging for street samples of low purity, mixtures. 2-step testing (SERS kit) essential • Ideally suited for high purity samples, such as in narcotics investigations Bruker Alpha • Fast (30-60 secs), easy to use, little training to scan, more training to interpret scans, substantial training to curate scans • Superb for street samples, identifying mixtures and drug components • Utility is a function of training and scan library • Potential to construct, curate local libraries #Rx Summit www.NationalRxDrugAbuseSummit.org Phase II Surveys with people who use drugs in Baltimore, Boston, and Providence #Rx Summit www.NationalRxDrugAbuseSummit.org Recruitment and sampling  Socio-behavioral survey of 335 people who use drugs Baltimore (N = 175): targeted sampling at street-based locations. Boston (N = 80) and Providence (N = 80): Referrals through Harm Reduction Services E.g. Needle Exchange. #Rx Summit www.NationalRxDrugAbuseSummit.org Participant characteristics (N=335) Baltimore Boston Providence (N=175) (N=80) (N=80) Total (N = 335) 55% 66% 60% 59% 45 (20 - 69) 42 (24 - 71) 43 (24 - 63) 43 (20 – 71) White 25% 68% 68% 45% Black 63% 18% 18% 42% Hispanic/Latino 1% 26% 19% 11% Currently homeless *** 60% 86% 67% 68% 59% 62% 64% 60% 33% 73% 51% 47% Male Median age (range) Education Diploma/GED/college Arrested in last year *** Significance (Chi2 p-values): * p < 0.05, ** p < 0.01, *** p < 0.001 #Rx Summit www.NationalRxDrugAbuseSummit.org Drug use (past 6 months) Baltimore Boston (N=175) (N=80) Providen ce (N=80) Total Heroin use 82% 86% 82% 83% Cocaine use 84% 88% 85% 85% Speedball use *** 36% 61% 27% 40% Prescribed opioid use 55% 65% 61% 59% Prescription opioid misuse 47% 40% 42% 44% Suspected fentanyl use *** 73% 88% 56% 73% Overdosed in past year *** 38% 68% 34% 44% Witnessed fatal overdose ** 41% 55% 30% 42% Significance (Chi2 p-values): * p < 0.05, ** p < 0.01, *** p < 0.001 #Rx Summit www.NationalRxDrugAbuseSummit.org The majority of PWUD are concerned about fentanyl and interested in drug checking  84% are concerned  89% reported fentanyl checking would make them feel more protected from overdose. Interest in fentanyl checking (N=335) 100 % interested about using drugs with fentanyl in it. 80 85% 86% 87% 86% 60 40 20 0 75% did not prefer fentanyl in their drugs #Rx Summit www.NationalRxDrugAbuseSummit.org Impact on Behaviors, Location of Services 70% reported that knowing their drugs contained fentanyl would lead them to modify their usage, including:       Avoiding drug purchase in the first place Using their drugs more slowly Doing a “tester” shot Using less than originally intended Throwing the drugs away instead of using them Telling others who purchase from the same person about fentanyl adulteration Desired location drug checking services 20% SSPs 17% Health Clinics 15% Drug treatment program 13% CBO 10% Safe consumption space 9% Homeless shelters #Rx Summit www.NationalRxDrugAbuseSummit.org Impact on Behaviors, Location of Services 70% reported that knowing their drugs contained fentanyl would lead them to modify their usage, including:       Desired location drug checking services 20% SSPs Avoiding drug purchase in “Convenience. If it's available inClinics my 17% Health the first place neighborhood. Using their drugs more Can do it when it's time 15% Drug treatment slowly to do it.” program Doing a “tester” shot Baltimore participant Using less than originally 13% CBO intended Throwing the drugs away instead of using them 10% Safe consumption space Telling others who purchase from the same person about fentanyl 9% Homeless shelters adulteration © 2014, Johns Hopkins University. All rights reserved. © 2014, Johns HopkinsUniversity. University. All All rights rights reserved. ©2015, Johns Hopkins reserved. “Anything I put in me I definitely want to know what's in it. I'm married and I don't want to leave my wife. They're dropping like flies off this stuff.” Baltimore participant “I wouldn't use as much if I knew.” Boston participant #Rx Summit www.NationalRxDrugAbuseSummit.org PWUD (N=335) are more likely to be interested in drug checking if… Older age*** Female gender* Race/Ethnicity (vs. Non-Hispanic White) Non-Hispanic Black** Hispanic ethnicity** Other / Multiracial* Witnessed a fatal overdose* Used a drug they thought had fentanyl, last 6 months*** aOR 95% CI 1.04 1.27 (1.02 - 1.06) (1.03 - 1.57) 1.80 2.30 1.46 (1.27 - 2.55) (1.44 - 3.68) (1.09 - 1.94) 1.74 (1.04 - 2.90) 2.11 (1.54 – 2.88) Controlling for homelesness, drug use type, rushed drug purchase * p < 0.05, ** p < 0.01, *** p < 0.001 Binomial regression with standard errors clustered by study city #Rx Summit www.NationalRxDrugAbuseSummit.org Explore attitudes and perceptions about fentanyl testing among harm reduction services providers #Rx Summit www.NationalRxDrugAbuseSummit.org Interviews with key informants Harm reduction organizations (n=11) Public health agencies (n = 10) Drug treatment providers (n = 2) General Healthcare Sector (n = 3) Peer/Family Groups (n = 7) #Rx Summit www.NationalRxDrugAbuseSummit.org Service providers support the concept of drug checking “Any education is education and just the fact that people who use drugs are able to use a strip by themselves or be trained and then use a strip by themselves is empowering and I think that’s really a lot of what we were trying to do. And it’s humanizing.” “…autonomy, even in your addiction, is hugely powerful. Feeling like you have a semblance of control over what happens is really important.” Executive Director, Harm Reduction Organization #Rx Summit www.NationalRxDrugAbuseSummit.org Key recommendatiens NATIONAL B