Test Your Drugs, Not Your Limits

Episode 1: Test Your Drugs, Not Your Limits - The Role of Advanced Drug Checking in Harm Reduction

Featuring:
Allyson Pinkhover, MPH, CPhT, CHO
Brockton Neighborhood Health Center, Brockton, MA
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

Darlene Andrade Fonseca, BS
Brockton Neighborhood Health Center, Brockton, MA
Massachusetts College of Pharmacy and Health Sciences, Worcester, MA

Hosted by: Joe Wright, MD
Boston Health Care for the Homeless Program, Boston, MA

Episode one highlights how community-based advanced drug checking supports people who use drugs, harm reduction staff, and clinical providers. Hear from Darlene Andrade Fonseca and Allyson Pinkhover of Brockton Neighborhood Health Center about their work implementing drug checking with real-time FTIR technology, together with other tools. Alongside host Dr. Joe Wright of Boston Health Care for the Homeless Program, the trio discusses how advanced drug checking promotes autonomy for program participants and helps both harm reduction staff and clinical providers to better individualize the services they provide.

Find us online at amersa.org/amersa-podcast

Frontiers in Substance Use & Stigma & Substance Use are sponsored by Provider’s Clinical Support System – Medication for Opioid Use Disorder (PCSS-MOUD). Learn more about PCSS-MOUD at pcssnow.org.

Funding for this initiative was made possible by cooperative agreement no. 1H79TI086770 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Substance Use Across the Lifespan and Innovation in Action are sponsored by the Opioid Response Network (ORN). Learn more about ORN at opioidresponsenetwork.org.

Funding for this initiative was made possible (in part) by grant no. 1H79TI088037 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Transcript

kinna-thakarar--she-her-_4_05-24-2024_134040 0:13

I'm Keena Thakkar and welcome to the podcast series, Harm Reduction, Compassionate Care for People Who Use Drugs. Harm Reduction is a social justice movement started by and for people who use drugs, and it's a philosophy of care and practical set of strategies to optimize people's health, safety, and rights. We want to acknowledge and honor the long history of street medicine and healthcare developed by people with lived and living experience to keep one another alive and safe through community care. Whether you're a seasoned harm to the concept, we're glad you're here and hope you'll learn something new and are curious to explore seeing patient care through a harm reduction lens. This podcast series is brought to you by the Providers Clinical Support System, Medications for Opioid Use Disorder Project, and AMERSA. This week, we welcome Dr. Joe Wright in conversation with Alison Pinkover and Darlene Andrade Fonseca to discuss Test Your Drugs, Not Your Limits, the role of advanced drug checking in harm reduction. Our host, Joe Wright, is an addiction medicine and internal medicine physician and the Director of Addiction Treatment at Boston Healthcare for the Homeless Program. He spent the 1990s in San Francisco as a community organizer and community educator for HIV prevention. Then attended Harvard Medical School. in internal medicine, did additional training in HIV medicine, and then worked as an attending at Beth Israel Deaconess Medical Center in Boston. To Boston Healthcare for the Homeless Program in 2015 in order to better respond to the overdose crisis. There, Joe's primary focus has been increasing access to buprenorphine. Allison Pinkover is a public health practitioner focused in harm reduction and substance use and is the director of substance use services at Brockton Neighborhood Health Center. She is passionate about promoting the health and human rights of people who use drugs. Allison completed her MPH in community health and prevention at Drexel University and is a fourth year doctorate of public health student concentrating in health equity and social justice at the Johns Hopkins Public Health Center. Bloomberg School of Public Health. She currently serves as the chair of the Holbrook Board of Health. Darlene Andran Fonseca is a drug checking technician at Brockton Neighborhood Health Center. She is passionate about promoting the health and safety of people who use drugs by providing accurate information about their drug supply so they can make educated decisions. She completed her Bachelor of Science in Biology from Bridgewater State University and is a physician assistant student at Massachusetts College of Pharmacy and Health Sciences. Darlene hopes to work in family medicine and provide substance use care as a She is fluent in Cape Verdean Creole and Portuguese. The presenters reported nothing to disclose. Thanks for joining us, Joe, Allison, and Darlene.

3:03

All right. Thanks, Kina. I am Joe Wright and I'm talking today with two folks who are doing some really cool work in the Southern part of the Boston metro area. I know Allison because she's the person on our statewide calls. Who's always doing something cooler than me. There's always somebody, you know, you think you're going to be the coolest one on the call and then allison shows up. That's kind. Thank you. This is a great example. Also because I've gotten to know Allison just a little bit, we've decided that it's going to cost Immersa too much to cut out swearing. So we're, we're not going to swear. Yeah. We want the conference to be nice. Yeah. So Allison. Darlene, I'm really excited to hear about your work. Maybe you can each tell me a little bit about yourselves and how you came to be doing this work of drug checking. And then we'll talk a little bit about what is drug checking. Sure. This is actually, I think story that I tell a lot whenever we talk about drug checking. So both Darlene and I are in Brockton. We work for a large federally qualified health center. And we really started to look at the types of harm reduction services that we're able to offer. And the things that are going on in other places in Massachusetts. And one thing we come back to a lot is the cool things that go on in Boston. We always say the cool things have to go on in Brockton and, all the other cities that are, that are like Brockton and Massachusetts, because number one, that's health equity. And number two, our patients deserve that. So this was one of those things where we said, We need to have this and I can think back to a time maybe later on in the COVID pandemic when I sat down with a patient and he had just come out of the hospital he had used a bag that he thought was fentanyl and it turned out it was baking soda. And he didn't know that. He delayed going to the hospital for a while. And he ended up with stage three kidney disease from this bag. And I can remember sitting down with our chief medical officer and we were just like, we have to do better. This isn't okay. We need more information about what is out there. You know, this kid's 23 years old and, he's going to be living with this. And it just impacts too many of our patients. And so we really kind of went down the rabbit hole and said, well, we're going to start doing advanced drug checking and that's what we want to do. And so we started a little bit of that and then we were fortunate enough to get some funding from the Rise Massachusetts Foundation that allowed us to expand that work, which is when Darlene came to us. And started as our first full time drug checking technician and really expanded some of the work that we're doing. So Darlene, I don't know if you want to talk a little bit about what it's been like to get trained as a drug checking tech and, and what brought you to it, but it's definitely something I think that's unique to some of the work that we're doing at BNHC. Yes, it was really a unique experience. I never heard of anything like that before I came to the team. It was difficult at first because I didn't have any experience to begin with, but the whole team was supportive and I had other technicians who were always happy to help me with the whole process of drug checking. So I'm really grateful to have that opportunity to work as a drug checking technician. It really improved me as a person, as a professional, and I'm really thankful. Again, to have that opportunity. Darlene, what kind of education did you have before? And what kind of training did you have? Had you done any kind of lab work? Or who's the person we're trying to find for this job? So I have a bachelor's degree in biology. So I've done a couple of work in the lab, but again, never nothing like this that I have to use the FTIR or analyze the scans. So it was a new experience and it was great. Yeah. I got to learn a lot from it. And as you get more comfortable, you're better at identifying the substances. Like, for example, you see a peak, you're like, okay, this indicates a certain substance. So it was challenging at the beginning, but yeah, you learn as you practice. And I think, one of the biggest things, and certainly a big shout out that we have to give is to the team at Brandeis University, Tracy Green's team, because they have given us a tremendous amount of training and technical support for drug checking. Darlene, if you think differently, I would say for one person to get trained to use the FTIR. So that's the primary technology we're talking about for advanced drug checking today is FTIR. It probably would take like a full day of training and then maybe another four hours of training. And then a lot of it is just kind of learning as you go. If folks are interested in learning how to use an FTIR for drug checking, I think that's probably the amount of time they're looking at to learn it well enough that you start to feel comfortable using the FTIR in front of participants. All right. All right. Cool. Harm reductionist with your cool lingo. What is an FTIR? Yeah. Well, we're cool chemists, kind of. We like to tell people that we're like chemists. So an FTIR is Fourier Transform Infrared Spectroscopy. My brother is a chemist, and so I have to make sure that I get it correct. It's an instrument. It's not a machine. It's an instrument. And essentially it is a type of tool that can tell you what is in like remnants from a drug sample. It bombards a sample with infrared light and measures how it makes the molecules vibrate and then gives you a scan. And like Darlene said we'll put that scan up on the screen for you and give you a good idea of the top couple of things that are in that sample in terms of concentration. So it's a really good tool. It's not as accurate, but it's a really good field based tool, where I think GCMS is not really user friendly for, sitting down at the syringe services program and checking people's drugs. Well, so speaking of the syringe service program and checking people's drugs, how does this work for people that show up with drugs and is that legal? Like how sort of in a gray area are you to be hanging out with people and their drugs? This is one of our favorite questions. And it's the question that everybody asks all the time. And the answer really is that right now it varies state to state in Massachusetts. We're in a little bit of a gray area where the department of public health and certainly a lot of other state agencies have expressed that they are supportive of doing drug checking work and, we don't have the type of paraphernalia laws that other states have. And so it really falls into this gray area of. We know this is a public health service. We want people to provide it. the state is in support of that. But do we have actual legislation on the books that says we're protecting the harm reduction workforce? Not as great as states like Pennsylvania. So Pennsylvania actually just maybe about a year and a half ago passed comprehensive drug checking legislation. They were trying to get fentanyl test strips And at the last minute, some folks got together and really made the advocacy effort to say, we want all forms of drug checking legalized. And they did. So I think right now, it really varies state by state. There are certainly some states where this is not in the gray area where it's criminalized. There's a great policy brief out from the network for public health law that I think goes over state by state where it falls in. But it's an area for advocacy for sure where I would say for folks in Massachusetts and in other states where there seems to be a big interest in doing advanced drug checking that we have to spend the time and do some advocacy effort around drug checking. Okay, so kind of legal. Fine, fine, fine. But I'm running a health center. I'm trying to get some children's vaccines in the front door and you're coming to me and telling me you want me to do this. What do you need to get me on board? And What would somebody need to do in a health center or a hospital or a public health program to prepare their managers, administrators to feel okay about this? This question comes up a lot too, because there is a lot of interest in drug checking among like the boots on the ground staff. And I think once you try to get through some of administration, it can be more difficult. By nature, there are some organizations that are more risk averse than others. For the ones who tend to be a little more flexible in their thinking, the questions come up around legality and liability and things like that. One of the things that was really helpful for us was working with the Brandeis team on an MOU upfront. Between us, Brandeis, and the police department that essentially had some clauses in it that was like, we know the health center is doing this as a public health service. We recognize it's a public health service and we're okay with it, essentially. And so that helped. A lot with our own executive team, and I think it's helped in a lot of other communities in Massachusetts as well. So getting something in writing from law enforcement that is saying we acknowledge folks are doing this and we're okay with that going on. We know it's a public health service. This question also came up a lot when places started distributing fentanyl test strips. It was the same kind of thing. It was like, well, what if you give someone this test strip and there really was fentanyl in it and something happens? And I think a lot of that comes with informed consent. We do a lot of things that have an inherent risk to them and, providing education to patients that the information we're giving you is not set in stone. There is certainly better chemistry that is going to give you things that an FTIR might miss, but we're here to give you some education about what we're finding in the drug supply, what that could mean for your health, and the message is not, Hey, we check this one sample for you. This is safe to use. Go ahead and use it. That's not what's happening. And so I think it's important for people to understand that. And when leaders and administrators hear that they become a little more flexible on providing those types of services. I think the public health argument, that we wanted to talk about the mechanics because we're going to assume that people listening to an immersive podcaster are well aware of the rapidly changing contaminated drug supply, just a lot of different clinical trials of different synthetic substances going on around the country being conducted by people who aren't recording the results. So. The importance of this for somebody who's doing community health certainly hard to overstate. It's also interesting to me. So Massachusetts is a state that doesn't really have county governments. Every square inch of Massachusetts is a town or a city. If you can get your folks in your town on board it's actually a nicer thing to say, we are the Brockton health center and that is the Brockton police department. You don't have a lot of overlap. So I like that about your story. Certainly this is also happening in Boston and some bigger cities as well. It's not that you gotta be in a small place. And darlene, tell me about what's a day like when you're doing this, who is showing up, where are you doing it? What's it like? Well so there's different experiences because some days I'm on the trailer and some days I'm doing in person drug checking. But what I think it's most rewarding is doing it in person with the participant because they can ask any questions if they have any questions at the moment. For example, at cope I used to do drug check in in person every Monday, one to 3 p. m. So the participants knew I would be there at that specific time every Monday. So it provides them a little bit of flexibility and they have a set schedule so they know when to go and to meet me there. So the participant goes in and they provide me a sample or maybe they went there to collect any hygiene products or any other products that they distribute at COPE. And I just inform them that with the work that we're doing, if they feel. Comfortable sharing any of the samples that they have, that all the information provided will be confidential. And some people actually feel like, they feel comfortable, and others don't. I try to encourage them, but again, we cannot force them to do anything. They don't feel comfortable, so I do my best encouraging them to share a sample. Once they share the sample, I test the sample right in front of them. I use the test strips, and I also use FTIR. And it's very interactive because the participant is right there, right in front of me, and I can show them the scan so they can better understand what's going on with their samples. And I always let them know about the limitations of each of the tests. If they have a phone number, which is one of the biggest issue is getting back to them with the results because most of the participants that we see don't have a phone or a set schedule. So if they have a phone number, I can write the phone down or I give them my business card so they can call me ask to ask about the results. So that's pretty much what I do on a day to day basis, but it varies from day to day and person to person. And Allison, as a sort of administrator, where did you think about putting these? And would you recommend that somebody put these sites? Yeah, that's actually a great question. And it's a question that we spent some time over the summer actually asking some of the participants of drug checking that we provided and then some harm reduction providers as well to really see what people thought about where advanced drug checking belonged. And people who are accessing services really felt that they needed to be walk in easily accessible, places like syringe services programs, harm reduction organizations places people feel comfortable just walking in for services. When we saw that too, we'll collect samples from within the clinic and test them at the clinic, but it's not really a great space to have people walk in. They feel uncomfortable. It's not really normal to have somebody come in and be like, Oh, did you bring your drugs into the clinic today? That's not a normal interaction for people, right? Really making sure it's the community facing places, people really liked the option of mobile. And I think there's a really cool opportunity to do more Mobile advanced drug checking. If that's something that can get funded at different places, a lot right now is it's easier to be a little stationary, but the FTIR is pretty portable. So if you had a decent setup with a little space, it could be something that's really great that is almost entirely mobile. So one of the things we want to do, it kind of medical education podcast is to think about. Going back from what does this look like? Where would you put it? What are the laws that govern it? Where are you? Where would you be doing this? We'll ask our audience to reflect now on what would you need to do to start this in your community? One of the important things is each community is a little bit different in how you would do that. So there's a lot of thought to be put in. It's not just the technology, but the context of the technology. So, Darlene, what's the experience of giving these results? What are people's reactions like? What's that like? Again, it differs from person to person. A lot of the participants, they know what they're getting, but a lot of them also don't know exactly what's on their samples. So a lot of the participants that I've seen they give me a sample thinking it's only cocaine, for example, but then I tested with the fentanyl test strips and it came back positive for fentanyl. So a lot of them were like, very surprised by the results. And they told me in the past many times that they're going to change your dealers. They're going to let the friends know what's in the sample. And some of them even told me that they're not going to use that sample But some of them already knew what was in the sample. They just go for confirmation and peace of mind. So it really depends on the participant. What's the weirdest stuff you've found? The weirdest I've found, I think, Because it was something that everybody was looking out for. And we tried the test strips and it wasn't really good, not really specific. But we've had some test results that came back positive. With the FTIR and the gas chromatography. So it was really interesting to see it actually being present in a sample because we've seen a lot of patients complaining about skin infections, but we never had like a positive result. It was fascinating to me to see like a positive result. Something we're not going to spend a lot of time on, but you've mentioned Tracy green and people can Google Tracy green. That's T R a C I G R E E N. And Brandeis university has a big project. It's sort of keeping track of these. So there's a little bit of an epidemiologic surveillance benefit of this. And that's the kind of work she's doing of where are people finding What and what's going where not obviously on a block by block dealer by dealer level, unfortunately, or fortunately, but more broadly by region. Another reflection point is, thinking about where you might use this in patient care or how you would talk to patients about this if you're a clinical person or participants or clients, if you're not a medical person, what would it be like for them to know what's the clinical benefit of that? And I have to say, I think for lots of us who do this work, we're very curious. I think, you know, I have a little bit of a, you should get your drugs checked because I want to know what's in them. Which, you know, is not actually the point of this exercise, but I think thinking about what our patients would want from that is really important. It's a great call out because I think We as providers get super excited about this stuff and forget that really, the intention is that this is there for the participants and our patients. And that's the priority at the end of the day. But I agree. And this is something we spent. Sometime within the rise funded project that we were working on and starting to investigate a little bit because, I have a suspicion that in the next several years, as you start to see some flexible funding opportunities come out that might support drug checking, like opioid settlement funds the overdose data to action grants also permit expenditures on drug checking. Then, more organizations are going to become very interested in this work. And I think it's important now to set some of the groundwork for what is ethical, what is appropriate for drug checking services. And so we spent a little bit of time asking participants about that. We spent some time asking providers about that. And I think that was certainly where there was a dichotomy where participants for the most part were like, I don't want this information in my medical record. Anywhere it can follow me. There's a risk with that and providers being like, I think it would be great and I can include it in my note. And so really just, digging into that and making sure we have best practices as more places start to do this. I do think there has been a space where Having de identified drug checking results has helped our own clinical providers and they've talked about this with us. I can think of times where, you know, the hottest example right now, I'm sure is I Lizzie and everybody wants to talk about Xylazine. We see wounds. We're not sure if people are getting Xylazine or not. What amount of the drug supply actually has xylosine in it, but we absolutely have seen people who are testing their stuff for the first time. They think it's probably fentanyl or some other type of opioid or heroin. And the xylosine test strips are not as great as fentanyl test strips, and that's one concern I think is important to highlight, is, if they're positive, they're pretty good. If they're negative, it's really kind of 50 50, and that's important for people to know. So seeing some of those positive results come in, seeing folks with wounds, We spent some time and ended up adding in a new toxicology panel that picks up on xylosine and some of the other novel psychoactive substances that folks are using to really start to get a bigger picture of what people are buying, what people are using and what ends up, in their system. And we've seen it work both ways where people find out before they use something that it has xylosine or levamisole or phenoseatin in it. And we have seen people after the fact who are like, Oh, I have these wounds. And we'll say, let's put it in labs and we can see if you were potentially exposed to xylosine or something else. And so it really does give the clinical providers a better opportunity to tailor the type of clinical care they're providing to their patient to do better education on risk reduction with their patients. And, have that conversation about how can you be safer? How can we treat you, with the same level of medical care that you would be getting if you are a person who doesn't use drugs, right? Like this is care that is tailored towards people who use drugs and they deserve that same level of care that somebody with diabetes or cardiovascular disease deserves. And in some ways this elevates the level of care they receive too. What do you feel like people would need to do to get this started if they wanted to do this for themselves? Well, I think the biggest thing up front is going to be funding for sure. And that question comes up a lot too. FTIRs are not the most expensive type of equipment that folks could buy. The type that a lot of people are using tend to run between 35 and 40, 000. So they're not inexpensive. They're not no, they're not, but they are not as expensive as some other options like GCMS or LCMS. So, it's not without of reach for folks to look at this with opioid settlement funds for sure looking at grant funders who are really looking to fund harm reduction work and I think, the other piece is certainly training and technical assistance. There are Several different organizations throughout the country that are doing technical assistance for advanced drug checking at this point. And linking in with the ACDC, the Alliance for Collaborative Drug Checking is important as well. So outside of really making sure that you're able to get organizational support, finding funding is going to be probably the next biggest barrier for folks, but really, I think this is a service Once people start, the benefit to the participants is really kind of obvious. And so if you're able to find the ways to pull the funding together for it, it's really important. Tell me about some of those patients, what are they using it for? What's the clinical benefit that they're experiencing? Maybe both of you can think about people you've worked with. I mean I can think of one group of folks we were working with actually really early on when we started this. They were probably some of the first people who came to access drug checking and they somehow knew we did it, which was interesting because we hadn't met them before this. They had just heard we did it and we were like, oh great, okay, come on in. And they had some samples of what they thought was, Fentanyl or dope. And they said, it's making me feel really sleepy. It's kind of weird. And so we said, Oh, all right. So we ran the FTIR, we sent it out and it was positive for xylosine. And this was the first time really in Brockton, definitively, we had a sample that had xylosine and it was the first time that people were hearing about it. And so it kind of just set off this like wildfire of mouth to, you know, Mouth. Word of mouth. Like word. Thank you. Yes. Word of mouth. like woo, word of mouth. Among our participants where they were like, there's xylazine here. We don't really know what it is yet. And going forward, this group of people would actually come. They would buy from maybe three different dealers. They would label the sample with what they purchased it as, whether it was fentanyl or cocaine, and then had a little code for which dealer they bought it from, so when they got the results back, they knew exactly what they were getting from each of the dealers they were buying from, and then would change Who they would buy from based off of those results because they didn't want xylosine and it was just incredible To navigate their reality that way. It was really awesome darling I know you also have had some interesting results that you've given back to people and and different reactions that people have had Yes, I actually know The group of people that you're talking about because they actually went back again and again with three different samples Same story. They just want to know what it is before they use it. So I'm very familiar with that group of people. But I've also encountered many other circumstances like, for example, a participant, she went to COPE. She wanted me to test a sample because it made her feel very dizzy and tired. And with did the fentanyl test strips and it was negative. And we did the FTIR and I couldn't see anything that looked abnormal. So I sent the sample to the lab and the results were indicative of Leinil. I told the participant and I provided her a little bit of education about it, and then she told me that she would come back every Monday to check her samples. And she actually did for like three or four times that remember. So that's great that she came back to check her samples again until she felt comfortable using from that same dealer. We've also seen it be really validating for patients too. I can think of a couple of patients who actually received services in our office based addiction treatment program who are coming in, for buprenorphine and other medications for substance use. And at one point I can remember a patient who had spoken with his nurse and he was like, well, I bought this Adderall off the street and it made me feel kind of funny. And then he had a urine that was positive for methamphetamine. And he was like, there's no way that the pill I bought was meth. And so he had brought us like a half of a pill. We sent it out, we tested it with the FTIR and sure enough, it was methamphetamine. It really, I think validates the experiences people have and dispels some of the myths they have about what they're using too. Yeah. I had that same experience with urine toxicology Only we use a commercial lab. I don't know what you talked about expanding your panel. Was that with a commercial lab or an in house lab or how did you do that? Yes. With a commercial lab. All right. We got to get our act together, I think. I mean, prescribing buprenorphine with mortality reduction in mind, our diversion plan that is required by the DEA means that we check for the presence of buprenorphine. But I think a lot of the rest of what we're doing, it's partly about clinical conversations, and it's partly about it. That Adderall wasn't Adderall. And I think that played an important role that the urine toxicology when fentanyl was entering the supply. I don't think we started testing quite early enough, but we certainly started testing early enough to be able to start telling people. Yeah, the thing you thought was 1 thing is another thing. And I think there's a lot of street benzos that are in fact fentanyl. So people are buying those. And again, just validating that for people telling them, I feel like it's useful. But I also do feel like it's useful that I have that out of the clinical record. And when I'm ordering that and billing that as part of people's addiction treatment care that is absolutely part of their clinical record. I don't know if you have an answer to this, but it strikes me that you're kind of doing consumer safety work in an unregulated industry where the capitalists in question are a complicated group of people. Do you ever run into, Oh, I'm having an effect on the market, or is this just kind of consumer information along the side? I think that the work has allowed us to provide a lot more information like a public health alert kind of way that is publicly available for folks. We have certainly seen people who may be both using and selling drugs, get stuff checked because they are. Worried about what is in the supply as well. And it is such an odd, unregulated market where you have people who are involved in the drug trade who also don't know what they're selling and it's such a, yeah, it's such an odd situation to be in. Yeah, it's like being a retailer with cans of fish. You get the cans of fish and it could be fish. It'd be nice to know. You know? Yeah. I mean, that's a tough job. And I actually think consumer safety information certainly has a role for the seller as well. I actually think that's like a positive finding and thing to provide for people. Maybe people can reflect on how you might talk about these results with people clinically and how you think about this changing, chaotic drug supply. I think it is, it's challenging. I often say to my patients, it's my role to be the one who frets. And frets and worries. And I understand that you might not fret and worry in the way that I do. So when you're having these kind of contamination by unknown chemicals sort of thing. I do get my consumer safety hat on, but it starts to be like, just don't do drugs because you can't trust the supplier, which is, you know, not actually a useful thing for an addiction medicine person to be saying. So I would put it out to our listeners, how do you think about how you talk about this drug supply with people? How do you. Make sense of that with them. And how do you sort of sit together looking at that market and thinking about what it means for people. I think that the technical part of this, just learning these chemicals and what they do is certainly also challenging. We get these drug checking reports from our local harm reduction program, a hope, and they give us these lists of stuff they found that month. There's a fair amount of that where I'm like yeah, well, that, that looks like something, something you found in there. That sure is something. That was some feedback we heard from the providers that we had surveyed as a part of the project we were working on was really still a need about a lot of education on what some of the substances and chemicals are that are in the supply. I think my, my favorite one to explain, cause it's like one of those nerdy rabbit holes that I've gone down is around Levamisol because when I first started learning that Levamisol, which is an anti parasitic agent was in the drug supply, I was like, why on earth would anybody ever put that in the cocaine supply? Like that's. And so if you do a little bit of research the primary metabolite of levamisol is also a psychostimulant, right? And so it's in the cocaine to cut that and get more bang for your buck. If you're selling drugs and it has these unintended effects on folks around blood cell count and it's incredibly interesting and we don't do enough education with providers around that. If you ask most people who are probably doing like emergency medicine or community based health care, I don't know that a lot of folks would know those things. And so it's an untapped opportunity for education for sure. What is that site that the Brandeis people maintain with all the stuff they're finding? Yeah. So folks can go to streetcheck. org. All of the samples that are sent to the confirmatory lab, those results are publicly available. It's all de identified. So it's a nice little data hub as well, but they do have a really great tool that helps people understand what some of the different cutting agents or different contaminants are in the drug supply as well. Great. Well I know for a fact, because Alison and I have already proven this, that we could talk for another hour and a half about this. That is true. But I see the clock and hopefully people's commutes are over or their exercise sessions are done or whenever you were listening to us. And hopefully this has given you some things to think about, about both what's in the drug supply and how to find it.

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That was Allison Pinkover, Darlene Andrade Fonseca, and Dr. Joe Wright in conversation on harm reduction, compassionate care for people who use drugs. Thank you for listening. Be sure to tune in in two weeks when we welcome Dr. Marlene Martin, Dr. Kimberly Suh, and Amelia Goff to the series to discuss harm reduction in the hospital, meeting people where they are.

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Please take a moment to complete SAMHSA's post event evaluation survey on the IMRSA podcast page at www. immersa. org forward slash harm reduction podcast. We welcome any comments, questions, or other feedback for presenters. You can send those directly to IMRSA through the contact us form at IMRSA. org. To learn more about the provider's clinical support system, Medication for Opioid Use Disorder Project, and IMRSA, please visit our websites at PCSSMOUD. org and IMRSA. org. Funding for this initiative was made possible by Cooperative Agreement No. 1 H79 TI 086 770 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U. S. government.