Illegal drug markets lack the quality control features of regulated product markets. Compounds of unknown quantity and potency can vary in composition and strength, increasing the risk of unexpected adverse events (1–5). Since 2009, more than 1000 structurally and pharmacologically diverse new psychoactive substances (NPS) have emerged, challenging traditional market surveillance, regulatory controls, health, and community responses (6, 7). NPS and other compounds are increasingly used as adulterants or substitutes to ‘bulk’ or ‘dilute’ products, and cross-contamination can occur during unregulated manufacturing processes (8). Experts agree that sudden increases in the availability of high strength and novel compounds are contributing to health and social harms worldwide (6, 9, 10). For example, unpredictable drug purity and NPS availability has been linked to consistently rising morbidity and mortality in the United Kingdom (11, 12), Northern America (13), Canada (8, 14), and Australia (9, 15).
In Australia, methylenedioxymethamphetamine (MDMA/ecstasy) related toxicity contributed to an unprecedented surge in hospitalizations and deaths in New South Wales in 2017-18 and Victoria witnessed four-fold spikes in MDMA- and NPS-related overdose deaths between 2018-20 (10, 16, 17). The risk of experiencing any drug-related harm increases when contaminants/adulterants are consumed unexpectedly (2–5). This was evidenced when a Victorian coronial inquest confirmed the leading cause of five deaths in 2016-17 was a particularly dangerous combination of 25C-NBOMe (a phenethylamine) and 4-FA (a cathinone) reportedly mistaken for MDMA or psilocybin (18). This unique combination also resulted in a cluster of distressed and unwell people presenting to hospital over a single weekend in Melbourne in 2017 (19). In 2020-21, the same unusual mix of compounds was detected again in two separate jurisdictions, resulting in government-issued warnings about potentially adulterated MDMA supplies (20, 21).
Drug market disruptions (e.g., adulterations/substitutes) were predicted during COVID-19 pandemic, where responses to the pandemic were expected to majorly impact traditional production and supply chains—particularly in Australia, where illegal markets rely heavily on importation (22, 23). Data from Canada reports record surges in accidental overdoses linked with unprecedented availability of NPS and cutting agents during the pandemic (8), but the impact of pandemic restrictions on Australian markets is less clear. Some sentinel groups have observed changes in price, availability, and perceived purity of some market supplies (24), but capacity for widescale and timely reporting of local market trends is limited. Many drug monitoring systems operate successfully in Australia, but no single dataset provides comprehensive market intelligence. Collation of aggregate data can be slow and insensitive to prompt detection and reporting of adverse outcomes, and the need for more timely and systematic data triangulation has been recognized (25).
In the absence of safer, regulated drug supplies, health, government, law enforcement, and community services are charged with the responsibility of reactively responding to a range of social and public health harms that traditional drug controls fail to prevent (26). Best-practice service provision for alcohol and other drug (AOD) problems is largely dependent upon workforce capacity for responding to new drug markets, patterns of drug-use, and changing community needs (27). Rapid monitoring of drug market intelligence can help to identify unexpected deviations in dynamically changing markets to proactively inform policy, policing, acute medical treatment, prevention, education, and harm reduction responses (4, 6, 8, 28). Coordinated systems such as the United Nations Office of Drug Control’s Early Warning Advisory on NPS (29) and others in Europe (1, 30), USA (31), Canada (28), and New Zealand (32) adopt features similar to public health surveillance and reporting of communicable diseases, with capacity for rapid and coordinated risk assessment and translation of emerging information into tactical responses (4, 6, 28). Systems that also publish timely risk communications (e.g., public alerts, warnings, or advisories) can also help mobilize individuals, communities, services, and governments into preventative or responsive action to reduce the burden that drugs place on health, government, and community services (1, 28, 33, 34).
A key feature of timely drug market surveillance is drug checking (6, 35–37). Drug checking services invite members of the public to anonymously submit samples for analysis and provide individualized feedback about results (35). They offer unique and novel insights about real-time market trends by differentiating between expectations about sample contents and confirmed analyses (37, 38). When significant threats are identified, information can be translated into targeted interventions and universal approaches can rapidly translate information into purposeful public health communications (e.g., warnings, alerts, or advisories) to promote risk-awareness and prompt individual or community action (39, 40). Drug checking may even help to stabilize local drug markets by reducing the purchase/sale of adulterated or contaminated supplies; and data can be fed into early warning systems (EWS) for systematic and cross-jurisdictional reporting and coordination of local, national, and international responses to perceived threat (41–43). More broadly, policy-sanctioned drug checking and associated risk communications may help to address some of the social and structural determinants of drug-related harm (i.e., stigma) by influencing community attitudes towards people who use drugs through ‘normalizing’ harm reduction approaches and modelling pragmatic, health- and wellbeing-focused responses to preventing drug-related harm before acute adverse events happen (42).
At the time of writing, no permanent drug checking services or national EWS exists in Australia, despite coroners and other experts calling for governments to support and fund these services to prevent avoidable harm (10, 18). Two successful drug checking trials were held in 2018-19 (44); and some states have trialed or currently manage existing local EWS, but these function in varied stages of maturity and capacity for ongoing, systematic data sharing and timely reporting (16, 45, 46). In Victoria, the State Government issued its first public drug alert in 2020 about green pills containing N-ethylpentylone (a phenethylamine) with no MDMA/ecstasy present after a research project piloted a mobile testing laboratory at large-scale public events (47, 48). The Emerging Drugs Network of Australia (Victoria: EDNAV) was also established in 2020 to improve monitoring of emerging and illicit drug presentations in hospital emergency departments. Three more public alerts were issued in Victoria based on these inputs (18, 49). Other Governments have also issued public drug warnings arising from local systems (21, 45, 50). Efforts to establish national monitoring and reporting systems have commenced (51, 52). While theoretically feasible, coordination of data across Australia’s federated system is challenged by time-delays and inconsistent reporting across jurisdictions and requires sufficient resourcing and ongoing funding to operate effectively (25).
Evaluating the broader social and public health outcomes of EWS interventions requires coordination of multiple indicators at the micro-, meso-, and macro-levels (53, 54) which is often out-of-scope for under-resourced health and harm reduction services. A small body of research has qualitatively evaluated community drug alerts targeting people at risk of experiencing opioid overdose in North America (28, 33, 34, 55–57). In summary, alerts must be carefully formulated to provide clear and simple, evidence-based, action-oriented, prompt communications tailored specifically to target audience needs (55). Information or advice that is perceived to be dated, inaccurate, unrelatable, irrelevant, or impractical can undermine trust and engagement with alert systems (33, 56, 57). It is therefore recommended that alert systems carefully prioritize the values, interests, needs, and concerns of target audiences to maximize reach, engagement, and information-sharing (33, 34, 42, 55).
Word-of-mouth is a powerful tool for disseminating drug-related risk communications (33, 55). Health and community services may be ideal locations for opportunistic risk prevention conversations to take place between practitioners and clients/patients, but people who use drugs may not consider healthcare providers reliable sources of drug market information (33, 55). A key challenge for workers in these settings is access to timely and reliable information, specifically regarding novel and emerging trends (58–62). Health and community workers report feeling less confident responding to novel drug harms, particularly in acute medical and mental health settings where AOD may not be core-business (61–63). Alerts targeting these audiences may facilitate timely information exchange to improve capacity for responding more effectively to drug-related harms and could boost workers’ confidence discussing novel and potentially improve perceptions about the credibility of information they provide. They may also facilitate optimal planning, resource allocation, and provision of best-practice care (4, 45). So, while the literature rightfully centers people who use drugs in the design and evaluation of drug risk communications, there is almost no evidence for what tools and mechanisms might be useful for informing health and community workers about emerging trends to inform their work.
Successful translation of research and evidence into policy or practice is inherently complex. Health and community services often rely on researchers to identify factors for successful implementation and measure outcomes and impact, but without effective consultation and planning, researchers may be oblivious to important nuances and practicalities of the systems and individuals affected (64). Formative evaluations are useful tools for ensuring that factors for successful implementation of public health interventions are considered from the outset to inform ongoing process, outcome, and impact evaluation (64). Through participatory and consultative design, risk communication designers can ensure appropriate messaging, design, and dissemination for maximum reach, engagement, and impact (64, 65).
This pre-implementation study engaged health and community service workers in the co-design and testing of drug alert prototypes specifically for the translation of high-risk drug market information into practice. This was the first phase of a larger pilot study for eventual design, implementation, and evaluation of drug alerts arising from existing drug intelligence systems in Victoria, Australia. We present this paper as the first in a two-part series alongside Volpe et al. (66) and recommend considering both papers for a comprehensive outlook on our experiences designing and evaluating drug alert prototypes.