SCII.013.021.0031 ,"9 ,, CLAUDINE LYONS -CONS.UL TING- DRUG CHECKING MODELS: REVISED RAPID REVIEW July 2019 Prepared for NSW Ministry of Health SCII.013.021.0032 CLAUDINE LYONS COfiS\J L J" l ~i c- Table of Contents Project Purpose and Scope .......................................................................... 3 Definitions .............................................................................................. 3 Executive Summary ................................................................................... 4 Introduction to Drug Checking Service Models ................................................... 5 The rationale for, and concerns with, drug checking services ........................................ 5 Multiple services have emerged globally .................................................................... 5 There is debate in the literature about testing technologies .......................................... 6 Design features of drug checking services .................................................................. 6 Different models reach different populations ............................................................. 7 Services can improve by sharing information globally ................................................... 7 Drug Checking as a Harm Reduction Model. ...................................................... 9 Harm minimisation and harm reduction .................................................................... 9 Research suggests drug checking services prompt behaviour change ................................ 9 Drug checking services provide brief interventions although there is little information about how this is delivered .......................................................................................... 10 There is a need for more research on the optimal delivery model for brief interventions ... 11 Table 1 - 'Mode of Submission' Service Model Comparison ................................. 13 Onsite Drug Checking Models ...................................................................... 14 There is a need for more research comparing on site cohorts ........... ............................ 14 On site services can learn from each other ............................................................... 14 New approaches are being taken to test efficacy ....................................................... 15 A Victorian Parliamentary Committee recommended a 'halfway house' .......................... 15 Table 2 - Examples of On site Drug Checking Models .. .................. ...................... 17 Fixed Site Drug Checking Models ................................................................. 20 Drug Information and Monitoring System (DIMS), The Netherlands ................................. 20 Hybrid Drug Checking Service Models ........................................................... 22 Combined on site and fixed site checking model in Zurich, Switzerland .......................... 22 Drug checking service within a Supervised Injecting Centre, Canada .............................. 22 Do-It-Yourself (DIV) Drug Checking ............................................................... 24 Postal Drug Checking Services .................................................................... 25 EcstasyData, America .......................................................................................... 25 Welsh Emerging Drugs and Identification of Novel Substances Project (WEDINOS) ............. 25 Appendix 1 - Drug Checking Techniques and Technologies ................................. 27 Table 3 - Examples of Drug Testing Methods ................................................... 29 Appendix 2 - The Australian Context ............•..........•..............................•...•• 30 SCII.013.021.0033 ~ ,"II~i CLAUDINE LYONS -CONSULTINO-· Project Purpose and Scope The NSW Ministry of Health has commissioned a review of known models of drug checking. For the purpose of this rapid review these have been categorised by the mode of submission of the sample substance. These include but are not limited to: • Onsite drug checking; • Fixed site checking; • Do-It-Yourself drug test kits; and • Postal drug checking. While this rapid review will focus on these four models, they are not mutually exclusive. A 2017 global review found that out of 31 services identified, 10 ran onsite and fixed site services, one operating an onsite, fixed site and postal service and one ran a fixed site and postal service. 1 As far as possible this paper also canvasses these hybrid services as they have emerged from the literature available to the rapid review. This rapid review was conducted between 10 and 27 May 2019 and 2 July and 12 July 2019. Within the existing constraints of time and available evidence this paper includes a summary of service characteristics for different models. Given the significant variations in service designs while differences can be highlighted, there is a lack of evidence to support comparisons on the effectiveness of different services. This review does not make any conclusions about the advantages or disadvantages of drug checking itself. Definitions It is important to note that within the literature there is a lack of agreement about definitions and terminology. Services have been called drug checking, pill testing, adulterant screening and multi-agency safety testing, amongst other things. Measham has outlined that in the United Kingdom, stakeholders prefer the term 'safety testing' to 'checking' because the association of the word checking with a 'checklist' is problematic in a legislative context where encouraging or assisting a crime is also a crime. 2 A number of definitions also include specific aspects of a service model that may not be repeated elsewhere. For example, some definitions include participants submitting samples to others for analysis with the potential for counselling to occur. 3 This definition does not encompass do it yourself testing kits where there is little or no counselling opportunity. In this review the phrase 'drug checking' is used to refer to the chemical analysis of a sample illicit substance in the form in which it is meant to be consumed. That is, these kinds of tests are to occur before the drug has been consumed. This is why this review does not canvass hair, blood or urine-based testing methods (for example immunoassay) as they focus on the individual rather than the substance itself and are generally used to confirm an individual's drug use after the fact. Page 3 of 43 Drug checking models: a rapid review prepared for NSW Ministry of Health by Claudine Lyons Consulting I ABN 19 382 795 003 SCII.013.021.0034 CLAUDINE LYON S - C0 ~4 SU L T IN C Executive Summary Illegal drugs by their very nature operate in unregulated markets and there are no manufacturing guidelines. Harms from illegal drugs can arise from contamination and adulteration including poisoning or unintentional overdose. Drug checking services have emerged as one response to these harms. There are a number of different rationales for drug checking including: • Enabling consumers to be more informed about what substances they are taking and creating an opportunity for brief interventions aimed at behaviour change; 4 and, • Enabling law enforcement and health services to understand emerging trends and take action as required via public health warnings or regulatory activities. 5 Concerns relating to the implementation of drug checking services include : • Compromises in testing results; 6 • A focus on substances identified in a sample (such as contaminants) as opposed to risk behaviours (such as polydrug use); • Concerns that the evidence of effectiveness is complicated with many evaluations focused on attitudinal change rather than health outcomes with a lack of evidence showing the efficacy of onsite drug checking in reducing hospital admissions: 7 and, • Broader concerns about normalising attitudes towards, and decriminalising drugs. In recent times there has been an emergence of drug checking services across the world. A 2017 review of global services found 31 different checking services run by 29 separate organisations in 20 countries. 8 In the literature there is significant criticism regarding the capabilities and limitations of certain types of drug testing techniques. 9 Appendix 1 provides a brief outline of the strengths and weaknesses of the main scientific methods that have or are being used. Legal consequences for the user, service feasibility and acceptance (sometimes referred to as credibility) amongst intended participants are important and differ depending on the service model or jurisdiction. Different models may also reach different users as onsite testing is generally targeted to music festival and event attendees. It has been argued that service models are largely driven by the regulatory environments where they operate 10 and the legal ability and or willingness of venues to accept on site services. 11 These contextual differences between countries have resulted in some arguing that common testing protocols or service standards are impossible. 12 In addition, the distinct features of each jurisdiction and service model may limit the applicability of evaluation findings. For example, drug checking in Portugal was implemented alongside comprehensive legal and policy changes that saw personal possession of all drugs decriminalised; 13 a very different situation to many other countries. Nonetheless, there is constant sharing of information between