Organized by Corporación Acción Técnica Social with the support of Colombia, Mexico, the Alliance for Collaborative Drug Checking, the Centro de Estudios de Derecho, Justicia y Sociedad, the Instituto RIA, the International Drug Policy Consortium

19th March 2024 -14:10

Chair – Zara Snapp, Instituto RIA: Today, we’ll be discussing the role of drug checking in addressing the fentanyl epidemic. This topic has garnered significant attention over the last two days, especially during the high-level segment. We’ll delve into practical, on-the-ground initiatives, exploring both publicly funded programs and those driven by civil society in New York, Colombia, and the Netherlands.

Yarelix Estrada – Alliance for Collaborative Drug Checking: In 2015, when I began working in harm reduction, approximately 50,000 individuals died from overdoses that year. Fast forward to last year, and we’ve seen this number rise to over 100,000. In New York alone, we’re facing an overdose every three hours, a situation that has only worsened over time. The drug checking service I provide is essential in this context. Drug checking allows individuals to understand the composition of their substances. In the US, not all substances are toxic, but opioids can be particularly dangerous due to the lack of information available about their contents. Our service educates people on what they’re testing.  Our program operates across five sites in New York City, each equipped with an FTIR machine. We also utilise test strips since the machines have their limitations. We collaborate with a laboratory to verify our findings at these sites. Funded by city and federal resources, our program is integrated into harm reduction sites where individuals can access needle syringe programs, counselling, and connections to other social services.  Our team comprises entirely black individuals and people of colour. We employ FTIR technology, which helps us identify compositions within a relative approximation, particularly useful for detecting fentanyl. For substances under a 5% concentration, we use test strips for benzodiazepines, xylazine (which is associated with wounds and abscesses), and fentanyl, as people have been experiencing blackouts in public spaces. Drug checking serves as a vital tool to mitigate these risks.  We’re working closely with our laboratory partners to validate our findings, especially concerning nitazenes, across our sites in Manhattan, the Bronx, and Brooklyn, and we’re hopeful about expanding our capacity. Although our program is relatively new, having started about two years ago, we’ve tested close to 2,000 samples. Remarkably, 95% of the opioids tested positive for fentanyl, with the concentration of fentanyl increasing – a trend that poses a heightened risk of overdose.  Interestingly, of the 2,000 samples, six that were not expected to contain fentanyl tested positive. Xylazine was found in 31.3% of opioid samples that also contained fentanyl. A key insight from our work is the impact of drug checking on users’ behaviours. Some individuals choose to alter their usage patterns, potentially reducing the amount they use or revisiting their dealers for different substances. In some cases, dealers engage with our services to ensure a safer supply for the community.  However, we recognize that our capacity to tackle the fentanyl crisis is limited. A paradigm shift towards a safe supply is imperative to address this issue effectively. The more data we gather on drug trends, the stronger the case we can make for a safe supply. It’s important to note that economic factors heavily influence drug use; those in poverty will continue to use substances out of necessity. In a system marked by inequity, drug checking offers a measure of bodily autonomy and a buffer against discrimination. Yet, without a move towards a safe supply, these efforts alone cannot effect revolutionary change.

Chair – Zara Snapp, Instituto RIA: Thank you for your insights. It’s crucial, as you’ve highlighted, for us not to fear drugs but rather to accord them the respect they deserve, understanding their place in society. There are many valuable takeaways from your presentation. Next, we’ll hear from our colleague from the Netherlands, who will share the advancements in their drug checking initiatives over the past year. We appreciate your presence here. It’s been some time since our last discussion on drug checking in 2017, and we’re eagerly anticipating the updates you have to share with us today.

Daan van der Gouwe -Trimbos Instituut: Drug checking in the Netherlands boasts a history of 33 years, with full government funding. I’ll explain our approach to drug checking. We operate 33 outlets capable of analysis, staffed by trained health workers and fully commissioned by the Ministry of Health, receiving substantial funding. In 2022, we welcomed 18,000 visitors, analysing a total of 17,919 samples at DIMS, nearly two-thirds of which were MDMA. Typically, the user profile is a white, highly educated male who plans their drug use; we seldom see those with problematic use.  In 2022, we observed increased dangers associated with ecstasy use, although the availability of normally dosed, not excessively strong, ecstasy has risen. More than 75% of these were high to very high in dosage, a figure that has slightly decreased over the past few years, positively impacting health perspectives. Cocaine purity has been consistently rising, with fewer adulterants, offering more value for money. 3MMC has surged in popularity as a go-to choice after cocaine and MDMA, especially among nightlife enthusiasts. It was banned in 2021, leading to more adulteration in drugs marketed as 3MMC. Banning substances tends to decrease market purity.  We have various levels of red alerts for particularly dangerous substances. A full-blown red alert is issued sparingly, only when absolutely necessary. For example, red pressed Superman pills, which contained the more toxic PMA instead of MDMA, prompted us to issue warnings through mass media. This particular tablet caused significant harm internationally. Similarly, pink Tesla tablets, sold as 2CB but containing DOC, were removed from the market due to our drug checking efforts.  Regarding synthetic opioids, they are relatively rare in our samples. In 2022, we identified four instances of synthetic opioids, none with nitazene, but with tramadol and O-DSMT instead. The case involving protonitazene is believed to have been purchased online via the dark web, not locally, with no health incidents related to nitazene reported.  To adapt to these challenges, we’re expanding our services near drug consumption rooms and enabling health workers to gather and submit data on users. We’ve been monitoring the dark web for synthetic opioids and nitazenes, updating our health workers with this information. The SO-PREP project, funded by the EU for drug harm reduction in collaboration with C-EHRN, aims to monitor the local drug market in cities across Europe, including Wales, Scotland, and Ireland, as nitazenes enter the market, preparing us for ongoing threats.

Estefanía Villamizar: Échele Cabeza, Acción Técnica Social: There has been a global increase in coca bush cultivation and cocaine users. On the supply side, coca bush cultivation expanded to cover 315,000 hectares in 2021, paralleling an increase in overdose incidents in the U.S. The opioid crisis continues without signs of abatement. In response to prohibition policies, harm reduction interventions have gained prominence, with drug checking services being among the most popular strategies. These services have seen an increase in visibility, though the total number of services remains unspecified.  In 2013, ATS initiated a drug checking service within the EDM scene in Bogotá, Colombia, establishing a fixed site in 2015 and expanding operations continuously since 2019. This service extended to Medellín and Cali by 2022. Over ten years, they have analysed 32,300 samples. By 2023, more than 11,000 individuals have avoided potential negative experiences or intoxications from unexpected substances, thanks to this service which also offers specialised advice on the risks identified in the results. The service utilises colour reagents, lateral flow test strips, and thin-layer chromatography for analysis.  A notable substance emerging in the illegal market is “Tuci” or “pink cocaine,” typically a mixture of MDMA, ketamine, caffeine, and paracetamol. Other substances detected in “Tusi” during 2022 included oxycodone, phenacetin, various cathinones, and benzodiazepines. It’s emphasised that people who use drugs (PWUD) are at the core of drug checking services. Addressing the need for funding, changes in public health policies, and the removal of legal barriers, while focusing on interventions like needle exchanges, is crucial. Maintaining a focus on the needs and well-being of PWUD remains at the heart of effective drug checking services.

Chair – Zara Snapp, Instituto RIA: This past year, the National Drug Policy, overseen by the Ministry of Justice within the Colombian government, introduced their new National Drug Policy. At its core, this policy marks a shift in narrative towards embracing harm reduction and investigating public health centred alternatives. Today, we’ll have the opportunity to delve into how they are advancing harm reduction strategies.

Gloria Miranda – Ministerio de Justicia Colombia: Colombia has adopted its new drug policy, affirming the realisation that a world entirely free of drugs is an unattainable goal. Reflecting on the objectives set forth in 1961, aiming for a drug-free world has proven to be an unfulfilled dream. After more than 50 years of implementing this paradigm, we have not achieved the intended goals of reducing the demand and supply indexes. As a state, our approach is to mitigate the use and impact of drugs by prioritising human rights and public health at the core of our policies. This includes not criminalising users and placing a strong emphasis on harm reduction strategies, such as drug checking.  For us, drug checking services are essential in detecting dangerous substances and adulterations. Facilitating access to these services undoubtedly has the potential to save lives. Furthermore, we have developed an early warning system with the primary goal of disseminating information about emerging new psychoactive substances (NPS) in the country. Our early warning system operates as part of an international network, collaborating with institutions such as the Forensic Medicine Institute and coordinating with academic and civil society organisations. Consumers are our most important allies in this initiative. That’s why we have engaged with organisations that work closely with people who use drugs (PWUD). These organisations have been instrumental in making drug checking services accessible in music festivals and street contexts, presenting a significant opportunity as they provide real-time insights into drug trends.  To date, we have conducted tests on approximately 80,000 samples. This extensive testing reveals that the drug market in Colombia is in a constant state of flux, with variations observed in the concentration of MDMA, methamphetamine, MDA, DOC, and the identification of 59 NPS as of March 2024.  Colombia has historically been perceived as the “kitchen” in the war on drugs, and is now advising other countries and civil society that we are convinced drug checking and other harm reduction strategies can save lives, reduce harm, and monitor trends. We are committed to expanding and financially supporting this underfunded strategy, enhancing it technically, and, most importantly, strengthening our ties with civil society organisations, our principal allies. Now that Colombia is leading this coalition for drug reform, we want other nations to regard harm reduction strategies as essential components of drug policy. These strategies serve as evidence that adopting more humane policies is far superior to criminalising users. This represents the new direction Colombia is taking.

Chair – Zara Snapp, Instituto RIA: We’ll now open the floor to questions for the audience, and for the sake of preserving time, we’ll take the questions at the same time.

Question 1 – Safer Drug Policies Norway: In New York, there’s a noticeable population of individuals who use opioids. How have you managed to establish such a strong connection with them? We’re asking because, in Norway, reaching out to people who use opioids poses a significant challenge. Could you share any tips or strategies that have been effective for you?”

Question 2 – Audience: Following up on your earlier comment about shifting the narrative around drug use, could you elaborate on your strategies for communicating with the public? How do you decide what information to share with specific segments of the public versus others, and what motivates these distinctions?”

Question 3- Audience: Given the pervasive presence of fentanyl, not only at the US-Mexican border but beyond traditional supply chains, and considering potential impacts like the Taliban’s opium ban on heroin supply in Europe and the adulteration with fentanyl, how can we start to grasp the full scope of this issue?

Yarelix Estrada – Alliance for Collaborative Drug Checking: We stand out as the sole region in the country to have sanctioned Drug Consumption Spaces (DCS), and our harm reduction (HR) programs have been a cornerstone of the community for over two decades. These programs aren’t a novelty; they have woven themselves into the fabric of the community over the years. Being a member of this community and having friends among people who use drugs (PWUD) naturally fosters connections with these programs, enhancing their effectiveness. Programs lacking strong community ties often fail to attract consistent attendance. The key is existing community relationships, which facilitate ongoing engagement and trust. Prioritising funding for civil society groups that can foster these connections is crucial. When it comes to public communication, our approach has to be nuanced. Government alerts that incite fear without actionable advice can do more harm than good. Many PWUD already disregard government messages, and misdirected alerts can funnel more resources into enforcement rather than support. We aim for direct communication with PWUD, utilising targeted alerts through services they trust, like methadone clinics, to avoid exacerbating enforcement issues. The framing of these alerts is vital to maintain trust and effectiveness.

Daan van der Gouwe: Trimbos Instituut: Issuing a full-blown warning requires careful consideration to ensure it’s concise and trustworthy. The information shared should be directly helpful to the intended audience, particularly in risk communication. Concerning the impact of the Taliban’s heroin supply, we’ve yet to see significant effects in the Netherlands, but it’s only a matter of time before we do, possibly affecting us this year or next. The transition of users to synthetic opioids, such as nitazenes, is a considerable risk, as seen in the UK, Ireland, and Estonia with drugs like xylazine. It’s imperative that we prepare for such shifts to prevent unnecessary deaths, understanding that the drug landscape is ever-evolving.

Gloria Miranda – Ministerio de Justicia Colombia: Engaging effectively with PWUD means crafting messages that resonate with them, ideally through peer-to-peer communication. We emphasise that we’re not representing the government; we’re young people reaching out to our peers. The design and strategy behind our communication are crafted by individuals who understand what information would be appealing and informative from a user’s perspective. This peer-based approach ensures that the information we share is both relevant and engaging, fostering a community of informed and supported PWUD.

Chair – Zara Snapp, Instituto RIA: It’s crucial to recognize fentanyl’s place within the broader spectrum of substance use while staying alert to emerging trends. By focusing solely on one substance, we risk overlooking other dangerous behaviours and combinations, such as the use of “tusi” and its mixture with alcohol in various settings. Drug consumption is about enabling individuals to make informed choices, underscored by the creation of trust through peer engagement. Peer work is not just beneficial; it’s essential for saving lives by reducing intoxication risks and preventing adverse events. The power of collaboration and information sharing cannot be overstated. Alerts and vital information often spread faster among peer networks than through government channels. Civil society’s efforts to foster relationships, parallel to government actions as seen in Colombia, exemplify the importance of building a comprehensive and responsive harm reduction ecosystem.