Needle-exchange programs in cities can provide vital information about intravenous (IV) drug use, as well as more comprehensive opioid monitoring and real-time surveillance of emerging trends and novel psychoactive substances (NPS), according to the preliminary results of such a program in D.C.
In a presentation at the American Academy of Forensic Science (AAFS) virtual conference this week, Alexandra Evans, a chemist with the D.C. Department of Forensic Sciences, detailed how her lab is working with a needle-exchange program in the district to generate more data on the use of controlled dangerous substances (CDS).
Needle-exchange programs provide sterile injection equipment to people who inject drugs in exchange for their used syringes. The program helps reduce the risk of transmission of bloodborne viruses, like HIV. Washington, D.C., operates three difference harm reduction centers that include needle-exchange programs, as well as two mobile unites that offer exchanges on a daily basis.
Evan’s lab partnered with the program to collect syringes on a weekly basis from three of the sites. While the study is still ongoing, preliminary data from September to December 2020 shows positive results.
Before the partnership, the monitoring of drug trends was traditionally accomplished through two sources: 1) law enforcement seizures of suspected CDS, and 2) syringes associated with death investigations. Evans’ efforts add a third.
“Previously, there was a lack of real-time data, as seized CDS exhibits come from unknown stages in the supply-to-consumption process, and syringes in death investigations arrive after a death has already occurred,” Evans explained. “By supplementing the two data sources with another, we can bridge the gap.”
Over the span of 4 months, 578 syringes were analyzed using GC-MS—324 contained one or more CDS and 193 contained a non-controlled substance of interest. The scientists were unable to detect traces in 61 syringes, possibly due to them being cleaned after use, a fairly common practice among drug users.
The results overwhelming point to fentanyl as the most common opioid of use. Fentanyl was found in 61% of CDS syringes, and 34% of all syringes analyzed. But, the more concerning part of the results show fentanyl was not often detected by itself.
Eight syringes showed a combination of eutylone (bath salts) and fentanyl, while 13 others had a combination of xylazine—a veterinary sedative—and fentanyl. Another 6 contained etizolam, a benzodiazepine analog used for insomnia, with fentanyl.
“These substances illustrate the role of toxic adulterants in U.S. illicit opioid crisis,” Evans said. “These adulterants can cause unusual drug interactions, complications and medical conditions, all of which may increase the likelihood of an opioid-overdose and death.”
Caffeine, mannitol and diphenhydramine were also found to be common non-opioid adulterants.
The forensic chemists also identified dangerous non-fentanyl drug combinations. Forty syringes contained speedball—a mix of heroin and cocaine— while 3 others contained what is called a goofball, a mixture of heroin and methamphetamine. Evans said this is the first time the goofball combo has been observed in D.C.
This analysis is also the first confirmation of synthetic cathinones (bath salts) being used as an IV drug.
Comparison
With analysis complete, the scientists compared the results from the needle-exchange program to information yielded from syringes associated with death investigations. They found they were 30% more likely to find cocaine in a death investigation syringe, while needle-exchange syringes showed 10% more fentanyl and 30% more meth.
“This comparison tells us that analyzing drug residue from syringes obtained from needle-exchange programs is providing missing information about IV drug use. Had we only analyzed death investigation syringes, we would have missed the popular trend of meth injection, and the wider prevalence of fentanyl in populations not associated with death investigations.”
Compared with seized powder evidence, the scientists were 10% more likely to find fentanyl in a seized powder, 30% more likely to find heroin and 10% more likely to find cocaine. However, there were 30% more likely to find meth in a needle-exchange syringe.
“Seized powder exhibits do not encompass crystalline solids, which meth has been observed as. If we take into account crystalline solids, we find we are 20% more likely to find meth in a needle-exchange syringe. This comparison tells us we are observing the same drugs as in seized powders; however, we are now confirming their consumption by persons who inject drugs,” Evans said.
Overall, the lab-program partnership has shown it can provide comprehensive opioid monitoring and offer early insights into drug trends and any new NPSs that make their way into the illicit drug supply. The study is still ongoing, with two of the needle-exchange programs expanding to over a wider geospatial target once the pandemic allows. Additionally, Evans says her team is interested in investigating more sensitive analytical methods of detection to compensate of syringe rinsing and other limitations.