Table 1 Barriers and facilitators to the implementation of advanced drug checking services between March 2019 and December 2020

Characteristics of the intervention

The technology works right out of the box.

Use of the devices is adaptable to various locations and settings, with the right preparation.

Trialability is high. This intervention is easy to scale up or down rapidly.

The relative advantage of using advanced technology for drug checking (compared to fentanyl test strips or no drug checking at all) is apparent.

Drug checking is a new use case for this technology that presents many challenges. A large amount of time and energy is needed for troubleshooting.

The reliability and/or interpretability of spectrometry results is sometimes poor, which requires experience, additional training, and skill to overcome.

The technology is expensive and the cost of confirmatory testing is an ongoing and large expense.

Outer setting

Financial support was provided by a third party organizations for acquiring new technology.

Mutual aid came from a collective of harm reduction organizations providing drug checking with advanced technology.

Support came from community partners with professional expertise in spectroscopy devices and interpretation.

Meaningful customer support came from device manufacturers.

Current state policies do not adequately clarify the legality of activities that are part of the drug checking process.

Aggressive law enforcement activities put program staff and participants at risk of harm and make the provision of essential harm reduction services unsafe for all.

The COVID-19 pandemic and concomitant social distancing measures required resources be diverted and limited capacity to engage with participants in a safe and private manner.

Inner setting

A culture of harm reduction is shared.

An understanding of the goals and relative benefits of offering drug checking services is shared.

A largely horizontal organizational structure allows for flexibility and a (desirable) redundancy of skills.

The intervention is very compatible with the culture of the organization.

The organization is largely supported by grants that provide restricted funds. Drug checking consumes a meaningful quantity of disposable materials, from proprietary swabs and pads to aluminum foil and nitrile gloves. Keeping a steady supply of these resources may, at times, be challenging.

Characteristics of Individuals

Staff have a strong sense of self-efficacy.

Staff maintain strong personal identification with the SSP.

Interest among participants was very high, and the intervention clearly responded to an unmet need.

Some staff, especially those with lived experience of substance use, may have prior criminal records, which puts them at greater risk should law enforcement interfere with staff or services.

Process

Staff frequently reflected on service delivery and incorporated lessons learned into implementation strategies.

The SSP is flexible enough to use trial and error in determining appropriate procedures and logistics.

Engagement with participants provides staff with proof of concept that drug checking is an effective intervention.

Many challenges faced by the SSP could not have reasonably been anticipated prior to implementation.