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Official websites use. Share sensitive information only on official, secure websites. This article was submitted to Addictive Disorders, a section of the journal Frontiers in Psychiatry. The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Introduction: Drug checking as a part of drug harm-reduction strategies represents an essential aspect of public health policies. It focuses on rapid identification of drugs that individuals intend to use during night events, in order to implement health-protective behaviors. Materials and Methods: In , drug-check services were offered at some night events in Umbria Central Italy. One hundred and twenty attendees directly delivered unidentified substances to a harm-reduction worker, who collected a few milligrams of the substances on ceramic plates and added a drop of colorimetric reagent. Multiple reagents were used to increase the diagnostic capacity of a substance, which may react with a specific drug or a few drugs. The concordance of the results obtained using these two methodologies and the intended behaviors of consumers after being informed of the test result was evaluated. The results were inconclusive for 29 samples. The results of samples with inconclusive results were as follows: 2, MDMA; 7, ketamine; 2, amphetamine; 2, cocaine; 2, heroin; 2, mephedrone; 6, mixes; 1, debris; and 5, adulterants as the main component. Twenty-one of 29 participants reported that they had no intention of consuming the unidentified substance. Discussion: The high percentage of individuals who claimed no intention of consuming the unidentified drugs indicates that drug checking is viable as a part of drug harm-reduction strategies. Overall, colorimetric reagents showed a good performance with regard to samples being unadulterated LSD or minimal in quantity, but failed to identify mixtures of substances and the adulterants present in them. Therefore, the use of more discriminatory on-site methods such as Raman or infrared spectrometry is strongly recommended. Illicit drug use is common among attendees of clubs and night events such as bars, discos, parties, and music festivals ; these individuals are at a higher risk of using drugs than the general population 1 — 4. These drugs have nicknames that change over time. The use of these drugs tend to be highly prevalent among night event attendees 3 — 7. Club drugs are used to increase the performance and enjoyment of recreational events, reduce physical fatigue, increase the communication and relational skills of individuals, and increase or modify the perception of reality 8. These drugs act on the central nervous system involving different neuromodulating systems and have different pharmacologic properties, physiological and psychological effects, and potential consequences 6. Several studies have highlighted that the use of club drugs is associated with serious physical health problems e. Stimulant intoxication can manifest as mania or hypomania, and substance withdrawal often manifests as dysphoria and depression Cocaine and amphetamines may mimic bipolar spectrum disorders, causing symptoms such as euphoria, increased energy, and decreased appetite 11 , Psychotic symptoms can also be observed 11 , Individuals who regularly use GHB often present with mild-to-moderate symptoms, including anxiety, irritability, mood swings, aggression, insomnia, and hallucinations LSD-associated psychiatric disorders can include psychosis and persistent hallucinations Club drugs are consumed worldwide, especially in the nightlife scene. The corresponding percentages for methamphetamine were estimated to be 1, 0. The strategies encompass interventions, programs, and policies that seek to reduce the health-related, social, and economic harms of drug use to individuals, communities, and societies 1. They are aimed at ensuring a pragmatic manner of dealing with drug use through a hierarchy of intervention goals that emphasizes on reducing the health-related harms of continued drug use, offering, for example, opioid substitution treatment and needle and syringe programs to prevent death due to overdose and reduce the spread of infectious diseases 1 , Since the s, harm-reduction services are occasionally available at various types of nightly musical events to inform users about the risks of drug use and ways of risk minimization This is to ensure that the users have the option to make a more informed choice about substance use 2 , Two broad categories of drug-check services are offered. The most common are color reagents, Fourier transform infrared spectroscopy, ultraviolet-visible spectroscopy, and Raman spectroscopy The most widely used on-site drug-checking method is the use of simple color reagent test kits Marquis reagent and others. Furthermore, color reagent tests are rapid and relatively inexpensive, and in most instances, high-level scientific knowledge is not required to perform these tests and interpret the findings The current gold standards in forensic drug analysis are chromatographic techniques such as high-performance liquid chromatography or gas chromatography GC coupled with mass spectrometry MS , wherein a sample is compared with a reference library of known substances including a wide range of adulterants 16 , 22 , These techniques are highly discriminative and quantitative but are not rapid, unlike colorimetric tests; furthermore, they are associated with a high cost. Additionally, highly qualified personnel are required for their execution Despite a consolidated body of literature that shows the effectiveness of drug-checking initiatives for public health surveillance 24 — 27 , there are criticisms about the limitations of these initiatives and the potential false sense of security that might be related to the use of color reagent test kits. To address the latter issue, the use of more discriminatory testing methods that may provide more reliable results is recommended 20 , 24 , The drug-checking service based on forensic methodology allowed the determination of the main component of samples, as well as adulterants and contaminants, which are of particular concern because they might result in adverse health consequences Furthermore, we could evaluate the presence of new psychoactive substances NPS that may be circulating in recreational contests in central Italy. Drug-checking services were offered during five night events in Umbria in Individuals at these events were informed about the availability of on-site, anonymous no-cost drug-checking service via word-of-mouth or service promotion. They were then informed that the samples would be subjected to a colorimetric test on-site and a further laboratory test later. These procedures were performed after obtaining informed consent of the participants. The participants anonymously and spontaneously provided brief information about their age, expectation about the chemical nature of the sample, and their behavior in terms of drug use i. A few milligrams of the drug was analyzed on-site using colorimetric reagents. The operators conducting the test and interview had a specific training in harm reduction and maintaining the confidentiality of individuals. They worked under the supervision of the local health unit. A physician was present on-site. Both physician and operator were available to discuss the colorimetric test results and any potential health risks associated with substance use. In particular, the participants were informed of the limitations of colorimetric tests, including the inability to quantify purity, possible failure in detecting adulterants, and that the result did not guarantee the safety of the pill. As polyconsumption of substances is a rather common event, information was provided about the risks of combining alcohol with other drugs. The data collected lacked any identifiable information, and data associated with the risk of re-identification of participants were excluded. The ethics committee of the University of Perugia Institutional Review Board approved this study protocol no. According to General Data Protection Regulation GDPR , the storage security of the anonymously collected data demographic and analytical was ensured such that it prevented any unauthorized access via authentication and access control and use of passwords to access electronic files. Methanol, hydrochloric acid, and ammonia solution were of analytical quality and purchased from Merck Darmstadt, Germany. Certified reference standards of the target analytes as free bases or salts were supplied by Sigma Aldrich St. Warsaw, Poland. The on-site procedure was performed according to an internal protocol of harm-reduction service developed in collaboration with the local health unit. The participants directly delivered the drug sample for testing on-site to a harm-reduction worker. Preliminary screening was performed by scraping off a small amount of the substance 4—8 mg. Thereafter, a drop of Hofmann, Lieberman, Mandelin, Marquis, Merke, and Scott colorimetric reagents, respectively, was added. Each reagent produces a color change after a chemical reaction between an illicit substance and the reagent. This result was then matched to a color chart showing the expected color change of the reagent with various illicit substances MS acquisition for unknown substances was performed in the full-scan mode in the range of 41— amu. Unknown substances were identified by matching experimental full-scan spectra against the NIST spectral library, the most powerful database for screening unknown substances. The retention times and relative mass spectra of the analytes detected were then compared with those of certified standards analyzed under the same experimental conditions An example of a representative chromatogram of a sample containing a mixture of ketamine and heroin is shown in Figure 1. Of the attendees, The mean age of the attendees was Each participant requested us to analyze a substance of concern. Approximately half of the participants Although there were no limits on the number of substances to be analyzed, each participant requested a test for only one substance. Therefore, drug samples were analyzed using colorimetric tests. The results were obtained were conclusive and inconclusive for 91 Table 1 shows the comparison between participant expectations about the substance purchased and the results obtained using colorimetric tests. Based on the colorimetric tests, 33, 25, 10, 11, 8, and 4 samples were classified as positive for MDMA, ketamine, amphetamine, cocaine, heroin, and LSD, respectively. Comparison between colorimetric test results and client expectations about the substance bought and submitted for testing. Thus, in most cases, the intention of individuals to use the substance was independent of the colorimetric test result Table 2. Answers to the questions posed to users about the consumption of the substance before submission of the sample for the colorimetric test and users' intention to use the tested substance after receiving the colorimetric test result. Furthermore, it was possible to identify nine samples with mixtures of substances, in which the substances were present in approximately equal quantities and had similar pharmacological activities. Thirteen samples contained multiple adulterants in approximately equal quantities. The analytical performance of the single reagents Hofmann, Lieberman, Mandelin, Marquis, Merke, and Scott reagents used on-site was also assessed Table 4. The two mephedrone samples could not be identified with the specific reagent, Lieberman reagent. The following adulterants were found in the cocaine samples: caffeine, levamisole, lidocaine, benzocaine, phenacetin, and acetaminophen. Paracetamol, diazepam, acetaminophen, and codeine were the adulterants in the heroin samples 32 — LSD samples were found to be unadulterated. A few ketamine samples were found to be adulterated; the finding was in accordance with that of a previous study Several countries worldwide have implemented drug checking with the aim to provide targeted preventive messages to recreational drug users. This approach, which is more individualized than mass media campaigns, provides an incentive for drug users to participate in a dialogue about harm prevention and reduction, because they get to know the test results and receive information about the drugs they are consuming. Although there are arguments in favor of drug checking, the strategy has also met with criticisms concerning the technical limitations of color reagent test kits and whether such interventions are better than no intervention at all because of the false sense of security that pill testing would engender. Furthermore, the evidence to date is equivocal 20 , 22 , Hence, in this study, we aimed to evaluate the analytical performance of colorimetric tests. During the study, drug-checking services involving the use of on-site colorimetric tests were offered at five night events in Umbria in The drug checking point was indicated by signs placed at the entrance and at various points in the place of the event, with attention toward highlighting that the service was free and would be provided anonymously. This information was also spread by word-of-mouth among users. There was a collaboration between drug test operators and the police. The police were always informed of the service at the events. The operators could request police intervention when needed. The police also recognized the importance of drug checking for health promotion and authorized the activity. However, it must be emphasized that the operators worked independently of the police, because the aim of harm reduction is not punitive. This low participation could be explained, in part, by the possible hesitance of the attendees in engaging in drug-checking services due to stigma and various fears, even if not motivated, such as confiscation of substances, removal from the event, and arrest 3. Other aspects could be related to limited effective information regarding the service, event organizers' resistance to advertising drug checking at event locations as they may not wish their events to be associated with drug dealing and consumption, and finally, inadequate visibility of the location of drug checking. For the drug samples tested using colorimetric tests, conclusive and inconclusive results were obtained for The positive findings mostly included MDMA 33 and ketamine 25 samples. After a period of low availability linked to a lack of precursor chemicals required for its manufacture, MDMA has experienced a revival in recent years It is a synthetic drug that possesses both stimulant and hallucinogenic properties; it is available in a tablet form often called ecstasy , and powder and crystalline forms of the drug are also available. New MDMA tablet designs, in various colors, shapes, and brand logos, are constantly being introduced into the market. The average content of MDMA in tablets has increased in recent years, and high amounts of MDMA in some batches have been linked to negative effects and death Ketamine was the second most commonly used drug in this study. Over the past two decades, recreational use of ketamine is increasing It is a short-acting dissociative anesthetic obtained in liquid or powder form and may be delivered orally, intranasally, intramuscularly, or intravenously Cocaine, heroin, and LSD appeared to be used less frequently. The use of NPS was only marginal among our participants, and two samples of mephedrone were found. The popularity of mephedrone increased from , as evidenced by the increased frequency and quantity of mephedrone seizures by police, surpassing the popularity of other NPS 38 , It is an amphetamine analog, considered as a prototypical synthetic cathinone structurally and pharmacological related to MDMA 38 , These samples were classified on-site as inconclusive by drug-checking operators because the reaction of the substance and the reagent presented a color that is not among the color range in the reagent chart. In these cases, the operators strongly advised the participants against using these substances. Interestingly, a majority Assuming that behavioral intention is an immediate determinant of the actual behavior as suggested by the theories of reasoned action and planned behavior, these results are an indication of the effects drug-checking services can have on the behaviors of used 40 , The fact that the participants stated they will not use an unexpected substance is particularly relevant, it is extremely difficult for harm-reduction workers to provide objective and evidence-based information to the users without a drug-checking service to determine drug sample content Colorimetric reagents showed a good overall performance for samples that present a clear and easily interpretable chromatic variation, when adulterants were absent LSD or present in minimal quantity. Colorimetric reagents regularly fail to identify mixtures and the adulterants present in them. It is also important to underline the failure to identify two samples of NPS mephedrone , which should have been identified with Lieberman reagent. The limitations associated with identifying drugs using colorimetric reagents are well documented 21 , 30 , The factors contributing to inaccurate results include false-positive color reactions and variations in the response caused by differing drug concentrations or salt form. The colorimetric response produced is subjective and its interpretation can vary with the experience of the analyst, and the type or lack of lighting available when the test is performed The effectiveness of these reagents is further reduced by the increasing frequency of mixtures of substances within pills. The predominant color change masks or interferes with the color change induced by other substances, resulting in the failure to identify other substances In the market, where it is common to encounter combinations of substances within pills, and colorimetric tests could fail to identify all illicit substances present. Therefore, it is desirable that the drug-checking service is equipped with discriminatory methods on-site such as Fourier transform infrared spectroscopy, ultraviolet-visible spectroscopy, or Raman spectroscopy. However, this is often difficult, because harm-reduction agencies have financial limitations in terms of acquiring more expensive technologies. If the use of more discriminatory methods of drug testing is not feasible due to a lack of financial resources, the performance of colorimetric tests should be improved, using a simple smartphone application to identify colors with high precision and accompanying software that will enable to match the results in a searchable database This would help overcome the limitations of the human eye and its subjectivity Moreover, drug checking can be improved by increasing the number of spot-test reagents used, especially when uncertain results are obtained The drug-checking service examined was limited, in that a low percentage of participants availed the service. Therefore, in the future, this service must be implemented, for example, by advertisements on various media platforms. Furthermore, because of the small number of participants, the results obtained cannot be generalized to other settings nor provide a comprehensive overview of the drugs circulating in Central Italy. The present study has a double value, one essentially technical and the other social. The drug-checking service is a public health promotion activity, as it reduces harms through rapid identification of drugs and discrepancies between the expected and actual contents. It is important to provide a relevant and effective public health message that could orient drug users toward informed and health-protecting choices 20 , 40 and to establish contact with hard-to-reach populations 43 , The drug-checking service described herein achieves these goals, causing a significant change in the users' behavior when they are confronted with an unexpected result. However, a comparison of results obtained using colorimetric tests and forensic discriminative method highlights the failure of on-site testing in recognizing mixtures of substances and the adulterants contained in them. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. The studies involving human participants were reviewed and approved by Bioethics Review Board of University of Perugia. MF and AA carried out drug samples collection and on-site analysis. CC supervised the harm reduction project. AG analyzed the data. MB verified the analytical methods. All authors read and approved the final manuscript. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Front Psychiatry. Find articles by Martina Fregonese. Find articles by Andrea Albino. T Perugia, Ospedale S. Maria della Misericordia, Perugia, Italy. Find articles by Claudia Covino. Find articles by Alessio Gili. Find articles by Mauro Bacci. Find articles by Alessia Nicoletti. Find articles by Cristiana Gambelunghe. Received Nov 5; Accepted Jan 5; Collection date Open in a new tab. Client expectation No. Colorimetric results No. Click here for additional data file. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Proportion 0.

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