Checking Guide for Overdose Prevention Services

Prepared by: Jessica Bridgeman, Regional Coordinator, Interior Health Chloe Sage, Prevention and Education, ANKORS Drug Checking Guide December 2018

Acknowledgments Much of the information found within this guide has come from Chloe Sage and ANKORS and their extensive work and experience in drug checking.

Purpose This guide provides the protocols and procedures necessary to offer drug checking options within the context of Overdose Prevention Services (OPS). Drug checking is intended to reduce harm(s) associated with substance use by offering individuals the option of checking their for the presence of fentanyl or other contaminants. The intention is to improve awareness amongst people who use drugs (PWUD) of the contents in the substances(s). Improved awareness of fentanyl exposure and its associated risks may encourage discussion and adoption of available harm reduction practices such as exploration of safety planning, dose reduction, Take Home Naloxone (THN), Supervised Consumption Services (SCS) and OPS.

Priority clients include those who use regularly or recreationally, particularly those who use alone and are not currently engaged in harm reduction services. In addition, by expanding drug checking to test for other drugs beyond fentanyl, the program’s reach may include users of illicit (i.e. , MDMA) and/or recreational users (i.e. party scene). Drug checking provides an opportunity to reorient harm reduction services to reach non-traditional clients who could also benefit from the service.

When clients present it is suggested that staff offer drug-checking to clients: “Do you want to check your drugs today?” The client can then choose the appropriate testing option, either drug checking or urine testing. Testing is done using a fentanyl test strip. Fentanyl strips are an enzyme immunoassay based test where a “sample can be introduced to a test strip that has been treated with a specific antibody with high affinity for the target compound, [in this case fentanyl]. If the target compound is present in the sample, its reaction with the antibody causes a change of colour which is recognized as a positive result”.1

Tests must never be given out to clients for personal use. All drug checking must be completed by a trained staff member . STAFF ARE NEVER TO TOUCH THE SUBSTANCES PROVIDED FOR CHECKING – THIS WILL ALWAYS BE DONE BY CLIENTS

Data Collection Data collection is a requirement for all sites participating in drug checking services. Each drug checking encounter must be recorded on the related Data Collection Form (Appendix A). Appendix B provides a Drug Checking Data FAQ for completing the forms. Please send all data forms to Interior Health at [email protected] Forms are to be submitted no later than Monday @ 0900 for the previous week.

Additional Resources For additional education on drug checking or overdose recognition and response and to ensure adequate level of knowledge on harm reduction education, please consider reviewing the following resources for more information:

Drug Checking as Harm Reduction Intervention: Evidence Review Drug Checking at Music Festivals: A How-To Guide Fentanyl Overdose Reduction Checking Analysis Study ANKORS Drug Testing Resources Training Manual: Overdose Prevention, Recognition & Response Guide to Harm Reduction

1 BC Centre on Substance Use (2017). Drug Checking as a Harm Reduction Intervention. Evidence Review Report. Retrieved from, http://www.bccsu.ca/wp- content/uploads/2017/12/Drug-Checking-Evidence-Review-Report.pdf 2 Drug Checking Guide December 2018

Drug Checking - Fentanyl Test Strips

In this testing scenario, the strips are used to test a substance directly and prior to consumption; rather than through a urine sample.

PRIOR TO DRUG CHECKING, PLEASE CONVEY THE FOLLOWING INFORMATION TO THE PERSON: • A negative test does not rule out that the drug contains fentanyl. Fentanyl can be irregularly distributed in the substance (i.e. pill) and although the portion tested may not have fentanyl, the remaining substance may still contain fentanyl.

• The test is not 100% accurate. • A negative result does not guarantee that your next dose will be free of fentanyl, even if the drugs come from the same “batch” or the same dealer. • The test strip can detect fentanyl and some analogues, not all. It cannot differentiate between fentanyl and fentanyl analogues. • Do you have any questions?

PROCEDURE: 1. Take out a Rapid Response-Fentanyl Test Strip™. 2. Fill a paper cup with 30 mL (1 ounce) of tap water. 3. Have the client add a small drug sample (the size of a grain of table salt) into the paper cup holding the tap water. a. If testing urine, have client provide a sample in the cup. b. Clients testing urine must have used within the last 3 days. 4. Remove the test strip from the pouch (open by the notches on the package). 5. Holding the strip from the solid blue end, dip the white end of the strip into the water/urine up to the blue line (above the wavy blue lines), wait for the red liquid line to become visible and climb the strip. There is no effect to leaving the strip in too long, but removing it to early can lead to an incomplete test (to avoid contamination, do not touch strip end with hands). 6. Remove the test strip from the fluid and place on a non-absorbent surface (the strip package works well), watch time, and read results at 1-2 minutes. 7. Complete documentation of drug checking interaction on Data Collection Form while awaiting results. 8. Results: • One color band = Positive • Two color bands = Negative

*Note: this is the opposite of what you would expect as a negative on a urine pregnancy test.

IF NEGATIVE: a. Indicate to the client that the dipstick only tests for fentanyl and some fentanyl analogues. Harm Reduction Tips

b. A negative result does not ensure that their drugs are not Dosing Strategies: Start small, take it easy; don’t use adulterated with other substances which can be more toxic than alone. Direct clients to OPS/SCS services where fentanyl. available. IF POSITIVE: Risks: Discuss with the client potential risks associated Seek feedback from the client – particularly if this was an a. with a particular substance. unexpected result. b. This is a good opportunity to provide some further education, Mixing: Take the opportunity to discuss mixing and harm reduction tips! substances and any related risk depending on the c. Dispose of contaminated drug(s) if requested by client different substances. d. Provide information on availability of other SCS/OPS. Overdose Preparedness: Ensure access to Naloxone and training on Overdose recognition.

IMPORTANT! Fentanyl Test Strips and Stimulants: If you are testing a and if a positive is indicated by a fentanyl test strip on a stimulant substance, the sample should be diluted by adding more water (another 30mL), and a second test should be run.

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Drug Checking Guide December 2018

Safety Information

Drug checking through the use of fentanyl test strips does not pose a safety risk to staff or participants. Please review the Fentanyl & First Responders FAQ on the Toward the Heart website for further information.

Personal Protective Equipment (PPE) There is no need for additional PPE while conducting drug checking. Staff may choose to utilize gloves during the drug checking encounter, however, staff are not to be touching the substances provided for drug checking.

Wearing a mask during drug checking is not required. There is no risk to staff regarding airborne particles or any other inhalation risk during the procedure. Wearing a mask unnecessarily can increase stigmatization and isolation for clients.

Please review the Fentanyl and First Responders FAQ for more information.

Cleaning Staff may utilize a cavi-wipe or related cleaner to tidy up after a drug checking encounter. Gloves should be worn if you are using cavi-wipes as they can be very hard on the skin.

4 Drug Testing Services - Data Collection Form

Agency Name: Completed by: Survey Date:

☐ Pre-use test ☐ Post-use test

Which substances were reported by the client? Check all that apply

☐ ☐Fentanyl Test Results

☐Opioids (not doctor prescribed) ☐Opioids (doctor prescribed) Fentanyl Test Strip Result:

☐Methadone ☐ ☐Positive ☐Negative ☐Indeterminate

☐Cocaine ☐Crack Fentanyl Urine Test Result:

☐GHB ☐Benzos (e.g. Valium, Ativan) ☐Positive ☐Negative ☐Indeterminate

☐Prescription stimulant ☐Other illicit stimulants Benzodiazepine Test Result

☐Psychedelics (i.e. MDA / MDMA / ecstasy / molly) ☐Positive ☐Negative ☐Indeterminate

☐Others (list): Click here to enter text.

If more than one substance was selected, please indicate the primary substance reported:

For benzodiazepine test strips only: Please collect the following information for benzo test strips which have a positive result

- take a picture whenever possible of the sample. This is used for sharing with others in the event of an alert

- what was the substance sold as ______

- physical description of substance (i.e blue fentanyl, hard, crystal like formation) ______- symptoms noted when used (i.e prolonged sedation) ______- any associated overdoses and/or hospitalizations after using the drug ______Please e-mail completed forms to: [email protected] Drug Testing Services - FAQ

Who should complete the form?

Site staff should complete any information relating the drugs believed to be being tested to ensure the information is collected as consistently as possible. The client or the site staff can complete information relating to the demographic characteristics of the client.

What is a prescription stimulant?

A prescription stimulant is a central nervous system stimulant and includes medications used to treat attention-deficit and hyperactivity disorder and some sleep disorders. Medication categories include and . Common drug names in this category would include: Ritalin, Dexadrine, Adderall, Vyvanse. Street names for these prescription drugs would include: rids, uppers, bennies, amps, speed and addies.

When should I select an “indeterminate” test result?

Only report a test result for the test that was conducted; for example, if only a urine test was conducted, do not put any information in the “Fentanyl Test Strip Result”.

For tests where there are some abnormalities with the result, such as no lines appear on the test, please try to use another test strip to obtain a result. If on the second try there is still an abnormality in the result, select “indeterminate”.

How do I record multiple substances?

The data collection form allows you to select more than one substance. Please select all selections that the client reports. If the substance is provided, please enter all substances that the client reports under “Other”.

Why do we have to complete the question “If more than one substance was selected, please indicate the primary substance reported:”?

The provincial reporting requirements are broad, and substances are being categorized into four categories – , stimulant, psychedelic and . In the case that the client reports multiple substances that cross categories, we still need to categorize the substance into one single category. In these cases, the primary substance reported will be the one that the tested substance is categorized as.

What do I do after the information is collected?

Please scan and e-mail the form to the Interior health harm reduction coordinators at as soon as is reasonable to [email protected]. The information will be entered into a database by IH staff; if the staff has any questions about the entries, they will contact you for further clarification.