Module Five: Building the Program

Once funding has been secured, the outlines of the program have been sketched out, and key partners have indicated their support, it is time to start putting the plan into action. There are many moving pieces that need to come together before a program is ready to be trained in how to use the FTIR and launch their drug checking program. This module will walk through hiring a technician, equipment purchases, what materials are needed, setting up secondary testing, and conclude with a brief description of possible staffing models.

1. Identify Technical Assistance and Expertise

First and foremost, programs will want to identify an experienced technician or consultant to work with to help set up the program and provide technician training. This should be done early in the process, before the conceptualization stage. Setting up a drug checking program that uses infrared spectroscopy is complicated. We are taking an advanced branch of chemistry (analytical chemistry), implementing in a point-of-care setting, and merging skill sets from direct service harm reduction provision, analytical chemistry, and knowledge about drugs and the drug supply. Beyond implementation logistics, the knowledge base needed to be a technician is massive and cannot be overstated. It is a requirement that drug checking technicians be well-trained, and the training should encompass harm reduction skills, a foundation in analytical chemistry, knowledge about the drug supply, critical thinking, data interpretation and communication, and messaging. Resources are available that can help support technicians in their education, but drug checking training cannot be done simply through didactic reading and learning. There is no replacement for direct, expert-led training and oversight. Programs should make sure funding has been dedicated for consultants and training, and should identify technician consultants or trainers they wish to work with early in the process. Remedy Alliance is one group that offers implementation support as well as technician trainings, email drugchecking@remedyallianceftp.org for more information.

2. Hire a Technician

One of the most important decisions a new drug checking service will make is deciding who the lead technician will be. In drug checking we have found that the technician plays an incredibly important role in the success of a drug checking program. They are the leaders, innovators, and drivers of this intervention, and the job position should be thought of as on par with a program coordinator or manager position. Many programs choose someone from within their pre-existing staff to take on the role of technician. Other programs hire someone new to the organization specifically to lead their drug checking program. Regardless of where the technician is found, it is recommended that the lead technician is a full-time position if possible. A person who already has a full-time program coordinator job should not be asked to assume the role of lead technician in addition to their already full plate of responsibilities. Having a full-time technician will help carve out the time needed to grow and expand the program, interpret and disseminate data, and oversee administrative tasks such as communicating with secondary verification labs, contract management, and ordering of drug checking supplies. See Example Job Description for ideas for how to structure a job description. If having a full-time technician is not feasible (which is true for many programs), make sure that the technician has protected time to do drug checking, and that their other responsibilities are reduced to make time for their new role. 

Identifying a good technician is crucial, but it can be difficult to find the right person for the job. We recommend looking for technicians who have lived or living expertise of drug use, who reflect and are a part of the community in which they will be working, and who have strong relationships with the community or who have the right skills and drive to build those relationships. This means if a program predominantly works in communities of color, their staffing and diversity of their team should reflect that. Customer service skills, an interest in drug chemistry, and excellent critical thinking and analysis skills are also key qualities to look for in a technician. See Who Makes a Good Technician for a more in depth discussion of this topic. A lead technician, or the person primarily responsible for operating the FTIR, should be the person in attendance at all drug checking-related trainings, and therefore should be hired prior to the training. It is not sufficient or realistic to have a program manager or coordinator attend a drug checking training and then pass the information along to the eventual technician. See Getting Started for more information about the drug checking training process.

Opportunities for Professional Development

One of the goals of this workbook is to highlight the importance of building capacity and expertise around drug checking within communities of color and people who use drugs. Academic institutions and governmental agencies can be good partners for this work, but the most effective drug checking programs also prioritize leadership roles for people of color, harm reductionists, people with lived expertise, and people who use drugs. Drug checking offers a unique opportunity to invest in the professional development of people who don’t have a traditional educational background and who have systematically been excluded from traditional professional paths. Drug checking is a skill set that is currently in high demand, and technicians will is an opportunity to develop technical skills as well as communication and customer service.  Investing in the hiring and training of people with non-traditional professional backgrounds builds this skill set, grows job experience, and offers the opportunity for advancement. 

Programs should also spend some time thinking about a sustainability plan. How will you ensure that the program will continue if the lead technician leaves? Cross training and having staff interested in drug checking should shadow the lead technician will help to expand the programmatic knowledge of drug checking and make sure it survives past the current generation of technicians. A gradual apprenticeship and exposure to drug checking can make sure that staff are not struggling to meet their other job responsibilities while slowly increasing drug checking skills over time. 

Case Studies for Hiring a Technician

The following are examples of how harm reduction programs have found technicians from within the community. Hiring strategies for drug checking may look different than simply posting a job listing- be creative with how you’re spreading the word about the position. Use harm reduction networks and connect with drug activists through local drug user unions, Students for Sensible Drug Policy chapters, or DanceSafe chapters. Reach out to nightlife organizers. To find a technician who represents the community, you have to engage with and recruit from the community. 

1. A large and well-established harm reduction program wants to start an FTIR drug checking program. They have already been distributing test strips and using them to start discussions with community members around drug checking and giving people more information about the drug supply. Ale, a participant of the program, has already been accessing test strips through the harm reduction program and has a lot of experience with supplying and using drugs, and is passionate about keeping their friends and the people they sell to safe. After many conversations, Ale begins volunteering with the harm reduction program, and demonstrates an immense knowledge of drugs, the drug supply, and how people use drugs. They also show an incredible ability to connect and build relationships with people who use drugs because of their ability to understand and empathize with their experiences. The harm reduction program hires Ale to run the FTIR drug checking program. Because of their pre-existing connections and relationships with people who use drugs, they are immediately able to spread the word about drug checking amongst people who use drugs. Service users feel comfortable around them and the program grows rapidly during its first year. 

2. A predominantly volunteer-run harm reduction program is looking for a drug checking technician. Jaime, one of the full time staff members, is involved in the queer community in the city and often goes queer nightlife events. While there, they meet someone named Izzy and start talking about harm reduction, drugs, and drug checking. Through their discussion, Jamie learns that Izzy uses drugs themselves, has tested their drugs before using reagent testing, and values harm reduction principles. Jaime tells Izzy about the planned drug checking program and invites them to apply for the drug checking technician position. Izzy takes on the drug checking role and uses their immense experience and knowledge of drugs to hit the ground running. Service users respect and trust Izzy’s experience and knowledge, and feel comfortable having open conversations about their drug use and drug use experiences with Izzy. 

A Note about Hiring People with Lived Experience (Do it!)

People with lived experience of drug use often have extensive knowledge about the drug supply, as well as how people actually use drugs, and can be incredible drug checking technicians and advocates. Someone with lived expertise of drug use, (who also has the other needed skills and characteristics to be a good technician) are often able to have deeper and more meaningful conversations about drug use because they enter the conversation from a place of personal shared experience and understanding, rather than from a top-down prescriptive role. Language around drug use is very specific, and it’s very obvious when knowledge or comfort around drugs is fake. Technicians who don’t understand drug use may struggle to build trust and relationships with the community. In harm reduction more generally, people with lived expertise can expand harm reduction services into communities that may be more difficult to establish relationships with, and the same is true for drug checking. This is especially true for ensuring that drug checking is equitably accessed by communities of color. The drug war continues to be carried out in a way that explicitly targets, criminalizes, and marginalizes people of color. Black and brown people who use drugs have higher overdose rates, higher drug-related incarceration rates, and their needs are often not met or adequately addressed by harm reduction services¹. The whiteness of harm reduction service providers is a documented barrier to people of color accessing harm reduction services² and it’s critical that drug checking does not follow this same path. Accessing drug checking services inherently carries a higher risk for people of color and drug checking programs need to acknowledge and prepare for this. Programs should hire and look to the expertise of people of color to specifically design the drug checking service in a way that is equitable, builds trust, and centers the specific needs of communities of color.

When working with staff who have lived expertise of drug use, program management should clearly communicate the risks of providing drug checking services. This includes discussions around risk tolerance related to law enforcement involvement as well as their own personal substance use, whether that be managed use or sobriety. These discussions should be an exploration of the risk with clear communication around what is known and unknown, not management dictating what they perceive the risk to be. The program manager’s job is to provide as much information as they can, but ultimately the decision to participate in drug checking should be left up to the staff member. People with lived expertise who do drug checking should not be under increased surveillance, and there shouldn’t be extra security protocols or monitoring because someone has lived experience of drug use. In regards to the risk of law enforcement involvement, management will need to decide organizationally how they are going to protect staff, and this should be clearly communicated to all staff. 

‍Additional Resources for Hiring People with Lived and Living Expertise

• ‍Towards Trans-Inclusive and Trans-Centered Harm Reduction Services‍
• ‍Centering Sex Workers in Harm Reduction‍
• Harm Reduction Hacks: Why Hire People Who Use Drugs (and Other Peers)‍
• ‍Harm Reduction Hacks: Considerations for Hiring Peers

3. Purchase the Equipment

Once the program model, technologies, and specific instrument has been determined, programs should get a quote for the equipment and accompanying package (software, set up, accessories, etc). Compare quotes with other drug checking programs to make sure that the quote doesn’t include any unnecessary items or packages and, conversely, that everything required for point-of-care drug checking is included. Make sure to plan ahead when ordering the instrument; for many spectrometers there is a lag time of 8-12 weeks or longer from when the order is placed to when a program receives the equipment. The spectrometer must be present for the in-person training so plan accordingly!

Insuring the Equipment

Drug checking equipment is very expensive, usually starting at a minimum of about $40,000. Insuring the instrument is an important part of building a drug checking program, and reduces fears and anxieties about the instrument breaking or being damaged during service provision. When insuring a piece of drug checking equipment, consider the following:

1. The FTIR spectrometer should be considered 'general equipment'. Insurance companies don't need to know the specifics of what the instrument is being used for, and likely wouldn't know what to do with that information if it was provided. If you have pre-existing coverage for equipment, simply increase that amount to cover the spectrometer as well.
2. Don't let fear of damage or breakage impact the ways in which you provide services. Insure the spectrometer to a level where you feel comfortable doing whatever you may need to do with it (e.g., set up at a music festival without worrying about weather).
3. Be sure that the insurance coverage includes transportation and travel.
4. There are a number of companies that specialize in non-profit insurance such as the Nonprofits Insurance Alliance, these may be a better fit for many harm reduction programs.

4. Purchase Materials

Beyond the actual instrument used for drug checking, there are many other materials needed for a drug checking program. See Materials List for more information. Be proactive when ordering materials to minimize running out of crucial supplies that may cause gaps in service. It may be difficult to predict uptake and service utilization during the first year so be prepared to adjust expectations based on the need. The lead technician should continuously monitor the stock of supplies, expiration dates on supplies when applicable (e.g., immunoassay strips) and be responsible for ordering new supplies as needed. When thinking about ordering drug checking materials, it’s important to consider the purchasing process. Is the program able to order supplies directly or will the order have to go through a purchasing or procurement department? Are purchases limited to specific vendors? How much time does it take for orders to be submitted, approved, and received? 

Test Strips

Test strips, or immunoassay strips, are seemingly simple tools that end up being fairly complicated. Historically immunoassay strips were intended for use in urine testing and using them to test the drugs themselves was, and many cases still is, an off-label use (depending on the brand). Furthermore, there is no official oversight or quality control in place for manufacturers of these tests. Depending on the brand of the strip, the type of drug being tested, and the target drug being looked for, methods and protocols may differ. Much of what we know about certain test strip brands is knowledge generated by the drug checking community through extensive use of the strips and intentional communication. While the drug checking community has learned a lot about a few particular brands and types of strips, more and more new test strip companies are entering this unregulated market, with little-to-no point-of-care validation. With every new strip there is a new set of uncertainties and it has proven challenging to maintain the same level of community knowledge for every new strip that comes to market. 

Cross Reactivity

All test strips, regardless of the brand, have a risk of cross-reactivity. Cross-reactivity is when the strip reacts with a substance that is not the target drug and gives a false positive result. For example, many fentanyl test strips will show a positive result when exposed to diphenhydramine, the active ingredient in Benadryl. Try crushing and testing a Benadryl pill to see for yourself! Manufacturers are not always forthcoming about the cross-reactivity of their product or don’t thoroughly test for it, and much of what we know about cross-reactivity and false positives has come from the experiential knowledge of the drug checking community. Known cross-reactive compounds also vary depending on the brand of the strip being used and the target drug being looked for. For example, WHPM xylazine strips have known cross-reactivity with ketamine and levamisole¹ while xylazine strips from BTNX were known to cross-react with lidocaine², although more recent formulations have reduced lidocaine cross-reactivity. Paying close attention to recommended dilutions can help to reduce the risk of false positives; the most commonly used dilution for fentanyl and xylazine test strips is 2mg/mL, or one 10mg microscoop in 5mL of water. When interpreting test strip results, it’s also important to have a solid understanding of the local drug supply, and the likelihood of the presence of cross-reactive compounds. For example, Chicago sees a high prevalence of diphenhydramine in their opioid supply, while diphenhydramine is relatively rare in Boston. Technicians in Boston can be fairly confident that a positive fentanyl strip on an opioid sample is due to fentanyl, while technicians in Chicago may have to rely on other tools such as an FTIR spectrometer or a GC/MS to determine if a positive result on an immunoassay strip is from fentanyl or from diphenhydramine.  

Evaluating Sources of Uncertainty

Cross reactivity is one source of uncertainty, but there are many different sources of uncertainty to be aware of when interpreting test strip results. Immunoassay strips are highly sensitive and a small amount of cross-contamination could cause a positive result. For example, if a cooker or a cotton is used more than once, the test strip will pick up on all of the things that equipment was used for. If someone stores multiple different types of drugs in their pocket, or if they reuse the same bag to store different drugs, that small amount of cross-contamination could be enough to trigger a positive reaction on a strip. Sometimes this cross-contamination occurs far up the supply-chain: if a seller bags up different types of drugs in the same space, cocaine that came into contact with trace amounts of fentanyl could test positive on a strip. Other variables that come into play when interpreting test strip results are the dilution ratios and sample heterogeneity (the concentration of a sample may not be uniform throughout). Technicians should ask participants if it’s possible that their sample came into contact with another drug (e.g., “Has this cooker only been used once?”), and should mix the sample as much as possible before testing. In general, if you get an unexpected test strip result, assess the sources of uncertainty. If something doesn’t make sense, make sure to send the sample for secondary verification testing to confirm. Remember that immunoassay strips of all kinds (HIV rapids, COVID-19 rapids, etc.) are a screening test, not a diagnostic or confirmatory test.

Test Strip Brands

When considering what brand of test strips to purchase, do some research with the drug checking community at large as well as other programs that may be in your area. Ask what test strips they’ve purchased, what factors influenced their decision, and their experience using those strips. You should also have a clear idea of what types of strips you want to include at the drug checking service. For example, some brands only sell fentanyl and xylazine test strips and won’t be able to supply benzodiazepine strips, nitazene strips, or LSD test strips. Buying in bulk will help to reduce price and depending on the quantity of test strips you purchase, some brands may have better bulk discounts than others so shop around to find the best option based on the program’s needs. Common immunoassay test strip distributors and manufacturers include BTNX, AssureTech, DanceSafe, WHMP, and Wise Batch, though other brands exist. If working with a new company, make sure their product has been validated within a point of care setting. Avoid brands that claim to check two or more drugs in one (for example, a test intended to identify both fentanyl and xylazine on the same strip) as they have not yet been validated and suffer from compounding issues of dilution ratios and cross-reactivity.

Test Strip Instructions

An additional factor complicating the use of test strips is the lack of consistent instructions. Many companies do not provide instructions, and for those that do, they can be confusing or don’t provide specific dilution ratios. There is no one consistent set of instructions that has been settled upon for using test strips for drug checking! It is outside the scope of this workbook to provide specific instructions for using test strips, but the following are recommended resources to explore:

• BCCSU fentanyl test strip instructions
• BCCSU benzodiazepine test strip instructions
• NYC DOHMH fentanyl test strip instructions
• NYC DOHMH xylazine test strip instructions
• NYC DOHMH test strip instruction video
• Wisconsin xylazine test strip instructions

The field is constantly learning more about test strips and refining the instructions. If you want to be up to date with ongoing discussions around test strip instructions, join the Remedy Alliance drop-in hours and the ACDC group!

5. Establish Secondary Verification Testing Partnership

Secondary verification testing, also known as ‘complementary’ or ‘confirmatory testing’, is lab-based analysis that confirms or validates the findings of the FTIR spectrometer, and can identify trace compounds, compounds that were missed by point-of-care testing, and novel compounds not in the FTIR libraries. Labs providing secondary verification testing typically utilize one or a combination of the following: GC-MS, LC-MS, DART-MS, paper spray MS, QTOF, or qNMR. It is essential to any drug checking program to have access to secondary verification testing, especially at the beginning stages of setting up a drug checking program. Beyond compensating for some of the limitations of FTIR, secondary verification testing is a helpful component of the technician training process.

Using Lab Testing to Assess Technician Proficiency

Drug checking programs have developed different approaches to ensuring that their technicians have reached proficiency. Some have internal tests a technician must pass, others require a certain number of shadowing hours, and others use more informal assessments. Many programs in the United States use a technician’s concordance rate, or how closely their FTIR results match the lab results, to assess proficiency.  We like this particular method and generally recommend that a technician should have a concordance rate of 90%, with at least 100 samples, before being considered fully trained (although there is no uniform standard for this). We believe the concordance method allows a technician to train on their own local drug supply in real time, ensures a wide variety of the types of drugs, and is one of the best ways for a new technician to learn. This recommendation is ideal for programs that will be working with complex opioid samples, and programs that work predominantly with samples with only one or two components may reach proficiency before this point. Reaching 90% concordance with 100 samples is ideal for a brand new program with a new technician, but as programs expand and add new technicians or as job transitions happen, the new technician can be trained through a combination of an apprenticeship model and secondary verification results. Concordance rates and the role of secondary verification will be discussed more thoroughly in Module 6: Getting Started.

Finding a Secondary Verification Lab

The type of equipment needed for secondary verification analysis often lives within universities, forensic laboratories, hospitals, and state labs. However, there is unique knowledge and expertise needed to work with and analyze the complicated samples seen by drug checking programs. Just because a lab has the required equipment doesn’t necessarily mean that they also have the required experience or skills. For example, a lab accustomed to analyzing blood specimens or wastewater may not have expertise working with complex drug samples, and may not know how to provide helpful interpretation and dialogue with community-based drug checking programs when the results are returned. 

When searching for a partner lab, look for the following green flags:

1. The organization is invested in harm reduction values and the goals of the intervention.
2. The chemists have experience working with regulated and unregulated drug samples.
3. The organization is willing to engage with the larger drug checking community.
4. The organization is humble and sees their relationship with the harm reduction organization as a true partnership. They are open and willing to learn from community drug checking programs.
5. They have worked with other community-based drug checking programs.
6. (Bonus) The lab can provide quantification results.

Some great examples of secondary verification labs widely used in the harm reduction community are the University of North Carolina (UNC), DrugsData, the Center for Forensic Science Research and Education (CFSRE), and the National Institute for Standards and Technology (NIST). Harm reduction programs may initially send test samples to multiple different labs to compare the workflow process, costs, findings, and the format in which results are provided to find the lab that is the best fit for their needs.

Pricing

Pricing varies widely for secondary verification; the equipment used is highly expensive and there is an advanced level of analytical chemistry expertise needed to operate the technology and interpret the results. Secondary analysis can cost anywhere from $50-$175 per sample and may be higher if quantitative analysis is being performed (how much of a particular component is in a sample). Programs should budget for at least 200 samples during the first year of operation (100 samples during the training period plus an additional 100 for the remainder of the year), and then calculate the amount of secondary testing expected for year two. Following the initial training period, programs should expect to send a baseline of approximately 10% of their samples, but for programs with more complicated samples or a higher frequency of adverse events, this proportion could be higher. Programs may also want to budget for additional samples if they anticipate adding or training a new technician.

6. Recommended Staffing Models

How a program staffs a drug checking service depends on both the size of the program and the type of drug checking model being used (e.g., drug checking at a drop-in center vs. a mobile drug checking program). At a minimum there should be one lead technician who may also be a coordinator or manager. It is recommended that this be a full-time position, although this may not be possible for smaller programs, or for programs that are just starting out and don’t have funding for a full time position. If it is not possible to hire a full-time technician, be sure to reduce a staff’s current tasks and responsibilities as they shift to undertaking the drug checking technician role. It is extremely difficult for a program coordinator or other staff member to add drug checking on top of their normal responsibilities. Carving out dedicated staff time for drug checking allows the program to ensure a high level of quality service provision, and protected time to grow and expand the program. 

The lead technician (or coordinator or manager) will play multiple roles besides simply providing drug checking services. They are responsible for packaging and sending samples to secondary testing, communicating with the secondary analysis laboratory, managing inventory and supplies, and analyzing and interpreting drug checking data. As the program grows, or if additional funding becomes available, it may be helpful to add other positions to the drug checking team. Additional technicians help to increase the capacity of the service and offer a level of duplicity if a technician is ill or on vacation, or if they leave the position. A data analyst can help with data organization, interpretation and dissemination, and a program coordinator or can support administrative tasks such as grant management and day-to-day logistics of the service. If there are additional funds available, creating a consultant line in the budget for a toxicologist may be beneficial for interpreting clinical relevance of the findings of the service, and for answering questions received from participants.

While not every staff member on the team needs to (or should) become proficient in FTIR drug checking, it may be helpful to have staff trained in how to talk about the drug checking service, collect samples, complete the data collection form, perform test strips, and communicate about trends in the drug supply. This is especially true for programs that plan on collecting samples while on outreach to bring back to a drop-in site.  Having multiple staff trained in the intake process will expand the number of people able to access the service. 

Many harm reduction programs rely on volunteers for day-to-day operations. In the case of drug checking, it is not recommended to have a volunteer provide drug checking services. The amount of training required to train a technician is time consuming, expensive, and far above the responsibilities of a volunteer. Unless you are completely confident that a volunteer will be able to commit to the necessary training and will continue to be involved in the program for years to come, using a volunteer as a technician is not advisable. However, volunteers can absolutely be trained in less time-intensive and less costly parts of drug checking such as collecting samples and running immunoassay strips.

Drug Checking Apprenticeship

Knowledge transfer in harm reduction often happens through being in dialogue with community, and learning from others with more experience while working side-by-side. As we work to expand drug checking capacity, we can rely on these same strategies. Creating an apprentice model for drug checking where new and inexperienced technicians work alongside an experienced technician can help to increase capacity for drug checking within an organization. This also ensures that drug checking knowledge and skill sets have staying power within an organization beyond a single technician. While a new technician is apprenticing, it’s important that they stay plugged into the larger drug checking community to share in continued learning and education and to course correct as needed. This apprenticeship model is another great way to build expertise and experience with people who use drugs, especially as professional opportunities for people with lived expertise are often limited. Consider bringing community members into the learning process and offering the opportunity to learn a new skill that is currently in high demand. If you find someone with an interest and a knack for drug checking, consider hiring them to work drug checking shifts to build their experience. By expanding access to drug checking knowledge, harm reduction programs can facilitate professional mobility and can open up amazing career pathways for people who use drugs as well as ensure their own sustainability beyond the first generation of technicians.

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