Team:Northern BC/Human Practices
Human Practices
Project Direction
From our preliminary research, we learned that the opioid overdose crisis is a very complex problem. It became clear very early in our project that we needed to focus our efforts toward a well-defined group of drug users if we wanted to make a difference. Having heard many stories about accidental overdoses as a result of contaminated drug supplies, we decided to focus our efforts toward detecting opioid contamination of non-opioid drugs that are more typically used recreationally among young adults, such as cocaine and MDMA. Building a pre-consumption drug test to alert users of non-opioid drugs to potential opioid contamination is a harm reduction approach that will allow users to alter their drug usage behaviors when contamination is detected. This objective is in line with the Government of Canada’s response to the opioid overdose crisis, which is to adopt a harm reduction approach that emphasizes education and resources over law enforcement and criminalization1.
Before setting out to build our opioid sensor we needed to answer three major questions:
1. Is opioid contamination of non-opioid drug samples truly a problem?
2. Are drug users willing to test their drugs prior to consuming them, and would they alter their usage behavior if unexpected results were obtained?
3. Since drug testing methods already exist, is there good reason to build a new type of opioid sensor?
1. Opioid Contamination of Non-Opioid Drugs
When we first started our project we faced criticism from some of our academic colleagues as well as members of the general public who felt we were creating a problem to solve. They did not believe opioid contamination of non-opioid drugs was a real problem and believed instead the opioid overdose crisis was limited to over use of opioids among long-term opioid drug users. It was therefore imperative for us to explore this question to ensure we were addressing a problem of real significance. In order to do so, we connected with Mr. Brayden Scott, an Intensive Care Unit Nurse employed by a major trauma center in Canada who also volunteers as part of the Shambhala Music Festival Medical Team. The Shambhala Music Festival, held in the Kootenay region of British Columbia each summer, has offered a drug testing service for a number of years now. The organization that provides this service, ANKORS, releases a portion of the drug testing results for public viewing. Brayden directed our attention to the 2018 partial results to better understand what a highly sophisticated analytical instrument, the Bruker Alpha II FT-IR, is picking up in drug samples provided by festival-goers. Those results can be viewed here.
While we recognized the 104 samples ANKORS showed data for were likely hand-picked to highlight problem samples, we were shocked to see that most of the drugs listed in these partial testing results were not at all what the owner of the sample thought they had purchased. In some cases, the test result indicated the expected drug was present, but had been greatly diluted with flour, sugar, caffeine, or some other substance, while other samples were not the expected drug at all, and others were dangerous mixtures of incompatible substances with potential for very serious medical distress if consumed. Two samples could not be identified when compared to a chemical library of thousands of substances. In addition, three non-opioid drug samples, one Ketamine, one Cocaine, and one MDMA, contained the opioids Oxycodone, Noroxymorphone, and a spectrum consistent with fentanyl, respectively. Thus, with just this small sample size, we had confirmation that non-opioid drugs intended for recreational purposes may indeed be contaminated with opioids without the user’s knowledge. These findings strengthened our conviction to our harm reduction approach to the opioid overdose crisis.
2. Drug Users' Willingness to Test Their Drugs and to Alter Their Drug Use Behaviours
Before we began building our biosensor it was important to investigate whether drug users would be willing to use a pre-consumption drug test to detect opioid contamination of their drug supplies, and whether or not a positive result would lead to changes in drug use behaviors. It is important to note that fentanyl test strips already exist; however, the Government of Canada warns there is currently no reliable form of detecting the presence of opioids prior to drug consumption as a result of the high numbers of false positives, the inability to detect a variety of opioids, low test accuracy, and low sensitivity associated with these test strips2. Nonetheless, these test strips are being provided free of charge at supervised consumption and overdose prevention sites throughout the province of British Columbia as there is currently no better pre-consumption drug testing alternative3.
In a recent study, Krieger et al (2018) investigated the willingness of young adults to use currently available test strips and it was determined that 92% of study participants wanted to know if fentanyl was present in their drugs prior to consuming them, 70% said they were concerned their drugs contained fentanyl, and 95% indicated they planned to use the test strips that were given to them. In a follow-up study, Goldman et al (2019) showed that 77% of the study participants had actually used the test strips that were provided for them, and importantly, a positive test result had caused these participants to alter their drug use behavior. Altered behaviors included discarding the drug, using the drug in the presence of others to ensure help was available in case of an overdose, and making sure a Naloxone kit was present 5. Collectively, these findings demonstrate a willingness among young adults to test drugs before using for opioid contamination, and a willingness to alter drug use behaviors when a test indicates the presence of opioids. This suggests that if a reliable and sensitive testing option was available it could help to reduce the number of accidental overdoses, strengthening our position to move forward with the construction of our opioid biosensor.
3. Is There Good Reason to Build a New Opioid Sensor When Others Already Exist?
One last question we hoped to address before embarking on our wet lab work was to determine whether there was a true need for our opioid biosensor given the existence of other testing options. As stated above, while fentanyl test strips are available, Health Canada cautions against their use due to the high numbers of false positive results obtained, their inability to detect opioids, low test accuracy, and low sensitivity.2. Since our objective is to detect any opioid even at trace contamination levels in a non-opioid drug sample, we determined these test strips are inadequate for our intended purpose.
Next, we looked into the suitability of the Bruker Alpha II FT-IR instrument for personal drug testing purposes given its increased use at public events, such as the Shambhala Music Festival, and its use at supervised consumption and overdose prevention sites throughout the province of British Columbia. We reached out to Dr. Peter Krygsman, Regional Sales Manager - MIR and Raman Products at Bruker Ltd. to better understand what this instrument has to offer in the drug testing space. The initial cost of such an instrument ($44,000 - $48,000 CAD) and the level of training required to both use an instrument like this and to understand the spectral results obtained prohibits its use as a personal drug testing option. We learned that trained technicians can achieve a sensitivity of three percent to five percent using this instrument, however, the accuracy of detection is unknown and is currently under investigation by the British Columbia Centre on Substance Use (BCCSU) in collaboration with Health Canada. The Bruker Alpha II FT-IR has not been found to generate false positives for fentanyl although it can give false negatives because the detection limit is not particularly sensitive. It should be noted that the presence of caffeine in a drug sample can mask the presence of Fentanyl, which we find particularly alarming given that eleven of the 104 samples posted by ANKORS contained significant levels of caffeine. As a result of this preliminary research, we realized there is great need for a cost-effective, accurate, highly sensitive test for opioids, and we believe our opioid biosensor will provide just that.
Educational Resources
As we began building our opioid biosensor in the lab, a documentary was posted to YouTube titled: “It’s Here: The Opioid Crisis in Fort St. John”. This documentary highlighted the opioid crisis situation in Fort St. John with representatives from Northern Health, the First Nations Health Authority, the Salvation Army, the Fort St. John Woman’s Society, and School District 60 speaking on the issue. After seeing the emphasis these individuals placed on education and resources, we reached out to Mr. Stephen Petrucci, Superintendent of School District 60, to better understand how high school students in Northern British Columbia are being educated with respect to this crisis, and whether harm reduction approaches, such as pre-consumption drug testing, are part of this educational initiative. We were surprised to learn there is no official curriculum on opioid use for the general high school population and that only targeted students, that is, those who have been identified as being at risk for substance use, receive any sort of support, education, or counselling, despite individuals in this documentary recognizing Fort St. John has the second highest opioid overdose burden in Northern British Columbia. In response to this, we are currently working with School District 60 to develop an educational pamphlet that emphasizes the dangers associated with opioid contamination of drugs, pre-consumption drug testing resources that are currently available in and around Fort St. John, and a list of accessible resources for individuals who have been impacted by the opioid overdose crisis, either directly or indirectly.
Overview
The first step for our human practices team was to conduct extensive research on the opioid crisis and the effect that it is having on our community. This allowed us to better understand the opioid crisis as a whole, what resources are available to combat it, and what our team could do to improve and contribute to these resources. We were already aware of the extremity of the opioid crisis in our province of British Columbia, however, we needed to know a lot more in order to be able to put our knowledge toward the production of our biosensor.
What did we learn?
We learned very early on that British Columbia (B.C.) in particular is experiencing increasing rates of opioid related overdose deaths, with the highest number of deaths within Canada6. These rates are continuing to increase in B.C. while they are plateauing or even decreasing in other provinces7. B.C. reported 1 525 opioid related deaths in 2018, making up 34% of all opioid related deaths in Canada8. To put this into context, B.C. makes up roughly one eighth of the country’s population, yet a third of the opioid related deaths9, making it disproportionally affected by the opioid crisis.
Our Objectives
After doing our preliminary research, we knew we needed to decide on a few key goals to direct our human practices work. The main areas of concern we identified were the severity of the opioid crisis in BC, the overprescription of opioids, and the stigma around drug use. From these, we were able to form our objectives.
1. An assessment of the resources available to drug users and how they could be improved
2. The policies in BC pertaining to opioid prescription and tapering
3. Public education and understanding
Using these objectives we were able to divide our work into three main parts: interviews, a policy brief, and education. These were our focuses for the year and allowed us to decide which information was important to us without being overwhelmed by the mass amounts of information surrounding the opioid crisis. This also meant focusing our work in order to best help our community and effectively contribute to our project. These three objectives also helped to organize our workflow clearly into three parts.
Human Practices Workflow
References
2. Government of Canada. (2018) Health Canada reminds Canadians of the limitations of fentanyl test strips being used to check street drugs before consumption. Retrieved from: http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2018/67106a-eng.php
3. BC Government. (2019) Overdose Prevention. Retrieved from: https://www2.gov.bc.ca/gov/content/overdose/what-you-need-to-know/overdose-prevention
4. Krieger, M., Yedinak, J., Buxton, J., Lysyschn, M., Bernstein, E., Rich, J., Green, T., Hadland, S., Marshall, B. (2018) High willingness to use rapid fentanyl test strips among young adults who use drugs. Harm Reduction Journal, 15, 7. Retrieved from: https://doi.org/10.1186/ S12954-018-0213-2
5. Goldman, J., Waye, K., Periera, K., Krieger, J., Marshall, B. (2019). Perspectives on rapid fentanyl test strips as a harm reduction practice among young adults who use drugs: a qualitative study. Harm Reduction Journal, 16, 3. Retrieved from: https://doi.org/10.1186/ s12954-018-0276-0
6. Overview of national data on opioid related harm and deaths. 2018. Government of Canada. https://canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids/data-surveillance-research/harms-deaths.html (accessed on April 11, 2019).
7. Fentanyl-detected illicit drug toxicity deaths: January 1, 2012 to May 31, 2019. 2019. Ministry of Public Safety. https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/fentanyl-detected-overdose (accessed on August 18, 2019).
8. National report: Apparent opioid-related deaths in Canada. 2019. Government of Canada. https://health-infobase.canada.ca/datalab/national-surveillance-opioid-mortality.html (accessed on August 18, 2019).
9. Canada at a Glance 2018: Population. 2018. Statistics Canada. https://www150.statcan.gc.ca/n1/pub/12-581-x/2018000/pop-eng.htm (accessed on August 25, 2019).
10. Federal Actions on Opioids. 2019. Government of Canada https://www.canada.ca/content/dam/hc-sc/documents/services/substance-use/problematic-prescription-drug-use/opioids/responding-canada-opioid-crisis/federal-actions/federal-actions-overview.pdf (accessed on August 25, 2019).
