Traces of Use: Uncovering Drug Use Insights From Paraphernalia Analysis

ABSTRACT

Introduction

The residue analysis of disposed paraphernalia from people who inject drugs is a novel way to discern drug taking behaviours. This study aimed to investigate the presence of conventional and novel psychoactive substances (NPS) in drug paraphernalia in South Australia.

Methods

Drug paraphernalia were collected in November and December 2024 from sharps disposal bins at three needle and syringe program locations. A total of 300 items of paraphernalia were taken from bins, including syringes, bags, drug storage vials/containers and filters. The items were rinsed with methanol, the solvent filtered and prepared for analysis using a Sciex 6500 + QTrap liquid chromatography tandem mass spectrometry (LC–MS/MS) and detections confirmed using authentic reference materials.

Results

A high proportion of paraphernalia contained methamphetamine (61%) and/or heroin (38%). A majority (57%) of the items analysed contained 2 or more drugs. In total, 14 different NPS were detected across 46 items of paraphernalia.

Discussion and Conclusions

The large number of paraphernalia items that had multiple drugs detected was likely an indication of polysubstance use. Residue analysis of drug paraphernalia is an objective approach to complement those currently used to ascertain drug trends, which strengthens harm reduction and public health responses to drug use. This study shows that drug residue analysis is feasible, non‐invasive and effective, providing a near‐real time approach to monitor the appearance of high potency NPS and other drugs being consumed, and determining trends in conventional substance use by people who inject drugs.

Key Point Summary

• The residue analysis of paraphernalia is an objective approach to monitor drug trends.

• The analysis reveals potential polydrug use or needle and syringe reuse

• A total of 14 different novel psychoactive substances were detected.

1. Introduction

Injecting drug use is commonly implicated in drug overdoses and death, and a high proportion of people who inject drugs (40%) will experience a non‐fatal overdose in their lifetime [1]. People who inject drugs also have additional risks associated with that form of administration, including the transmission of blood borne viruses such as hepatitis C and HIV as well as stigma and discrimination [2]. The appearance of highly potent novel psychoactive substances (NPS) in products used by people who inject drugs poses a particular risk to this population. Approaches used to ascertain drug trends are limited in their ability or suitability to provide analytically confirmed information on the types of drugs being injected. Current information sources include surveys that capture self‐reported data in specific and small populations [3]. Due to the unregulated production of illicit drugs, without analytical testing, people who report use may be unaware of what their product contains. Several Australian states are now providing free test strips for emerging opioids such as nitazenes to assist people using drugs to make informed decisions. The effectiveness of the strips remains a limitation [4, 5]. Therefore, self‐report data do not reveal all drug taking behaviour, including the unintentional consumption of NPS. Forensic and toxicology reports only raise awareness of polydrug and NPS use after an emergency admission following an adverse event, overdose or fatality [6, 7]. Wastewater analysis has been used to monitor drug trends and NPS, but this is performed at the population level [8]. Therefore, individual drug taking behaviours and route of administration remain unknown. Drug checking services are limited in Australia with one permanent and one trial fixed testing site, and ad‐hoc festival testing. Results from these services often indicate the primary drug is 3,4‐Methylenedioxymethamphetamine (MDMA), as expected by the client in the form of pills [9]. This suggests that people who inject drugs, mainly methamphetamine and heroin, are not the primary group that make use of these services. The Victorian government is funding a ‘pill testing trial’, with initial reports showing a proportion of people are unaware of the composition of their drug [10]. The current monitoring approaches cannot provide a complete picture of injecting drug use, including information about polydrug use and needle and syringe reuse. In South Australia, wastewater analysis and toxicology analysis are the only objective approaches available to monitor drug patterns but do not provide specific information about the sub‐population of people who inject drugs. Therefore, other monitoring techniques are required to understand the drug taking behaviour of people who inject drugs including information about potential polydrug use and the presence of NPS.

The residue analysis of paraphernalia can provide objective, analytically confirmed information about illicit drug ingredients. This approach can also provide an understanding of drug use behaviours, such as the main drug being injected, polydrug use or needle and syringe reuse and changes in trends when conducted over time. Importantly, the analysis provides specific information about the sub‐population of people who inject drugs, which is otherwise lost within population level objective monitoring approaches. The analysis of residues found in used syringes occurs across Europe, through the European Syringe Collection and Analysis Project Enterprise (ESCAPE) and the United States in localised studies [11, 12]. Syringe analysis in other countries has informed understanding of drug consumption patterns across large city‐level areas, revealing geographical differences in drug taking behaviours, as well as identifying emerging NPS drug threats such as the presence of xylazine in the illicit fentanyl supply [11, 12]. In Australia, paraphernalia analysis has largely been conducted in New South Wales and Victoria to date [13, 14, 15]. A trial study at Sydney's supervised injecting room found a good correlation between drug residues in discarded items and self‐reporting by clients [16]. However, several opioids were detected without the clients being aware of their presence. Drug use patterns vary considerably across the country as determined by wastewater analysis and surveys [3, 8, 17]. Therefore, objective information on substances used by people who inject drugs in other parts of the country and specific locations is limited. Our preliminary findings in a pilot study in South Australia focussed on the early reporting of nitazenes in discarded injecting paraphernalia [18]. The aim of this study was to obtain objective information on injecting drug use including trends in the use of conventional and novel psychoactive substances from the residue analysis of paraphernalia within Adelaide, South Australia.

2. Methods

Drug paraphernalia were collected across the same week, once in November and once in December 2024 from 240 L (63 GaL) sharps disposal bins at 3 Needle and Syringe Program locations in metropolitan Adelaide, South Australia. For each collection, 150 items were taken from bins, including syringes, bags, drug storage vials/containers, and filters. Each 240 L bin contained a variety of smaller sharps containers, paraphernalia, or packaging not related to injecting drug use (e.g., cannabis or blister packs), unused syringes, specifically labelled or marked syringes. From each smaller sharp container, 1 or 2 items were collected from each to achieve a representative sample from the entire bin contents. Items from the top of larger sharps containers were collected to capture more recent use. The preparation of paraphernalia was conducted as per the protocol developed for the European Syringe Collection and Analysis Project Enterprise from the European Union Drug Agency [11] with adaptation, as previously described [18]. Briefly, syringes were plunged five times with methanol to ensure the item was rinsed thoroughly. For bags, 1 mL of methanol was dispensed into the bag and mixed. A similar rinsing step was also performed for other items such as filter wheels or vials. The 1 mL aliquot from each item was then filtered using ultrafiltration cartridges (Amicon Ultra Centrifugal Filter 10 kDa MWCO, Adelab Scientific, Thebarton South Australia) to remove debris and large particulates from each sample. The samples were then analysed using liquid chromatography tandem mass spectrometry (LC–MS/MS). Certified reference material was purchased from Novachem (Heidelberg West, Victoria, Australia) or PM Separations (Capalaba, Queensland, Australia). Analytical grade methanol and formic acid were purchased from Chemsupply (Gillman, SA, Australia). A Sciex ExionLC coupled to a Sciex 6500 + QTrap (Ontario, Canada), fitted with a TurboSpray IonDrive source, was used for analysis. Details of the analytical method are included in the Supporting Information, and a list of included analytes is provided in Table S1.

3. Results

In total, 300 items of paraphernalia were analysed, including 218 syringes (73%), 58 plastic bags (19%) and 23 other items (8%) including filters, straws and other drug packaging. In total, there were 29 different drugs detected in paraphernalia across both collections. The most frequently detected was methamphetamine followed by heroin (Figure 1).

FIGURE 1.

Detection frequency of different drugs detected in paraphernalia. Other novel psychoactive substance (NPS) category included benzylpiperazine and desomorphine. Abbreviations: 6‐MAM, 6‐monoacetylmorphine; LSD, lysergic acid diethylamide; MDMA, 3,4‐methylenedioxymethamphetamine; NPS, novel psychoactive substance.

In total, 46 items of paraphernalia had NPS detections. There were 14 different NPS detected in this study, including ketamine, xylazine, delorazepam, metonitazene, isotonitazene, desomorphine, methcathinone, 5‐methyl etodesnitazene, bromazolam, N‐piperidinyl etonitazene, protonitazene, benzylpiperazine (BZP), etonitazene and N‐pyrrolidino isotonitazene. Some paraphernalia had more than one NPS detected. The specifics of the nitazene detections are described in Keller et al. [18].

The majority of the paraphernalia analysed in this study was positive for more than one drug (57%). The most frequently detected in combination with or without other drugs included methamphetamine and heroin (61 items, 20%) and methamphetamine and cocaine (51 items, 17%) (Figure 2). A large proportion of sample paraphernalia with the above dual combinations had additional drugs present. In total, there were 57 instances of one item of paraphernalia recording a unique mixture in the sample set of 2 or more drugs (19%). Of the 58 bags analysed in the study, 26 (44.8%) were positive for more than one drug. Additionally, of the 23 instances of methamphetamine and heroin co‐detected, 8 of these items were bags and the remaining were syringes.

FIGURE 2.

Frequency of combinations of drugs detected in paraphernalia. NB. Metabolites, production artefacts and related chemicals were classed as one drug. If found together, methamphetamine, amphetamine, pseudoephedrine and methcathinone were classed as one drug. The combinaiton of heroin, including 6‐MAM, morphine codeine and thebaine were considered one drug; similarly cocaine and benzoylecgonine. Colours indicate drug groups and include blue = stimulants, green = opioid or opioid like, orange = nitazenes, pink = other novel psychoactive substances. Abbreviations: BZP: benzylpiperazine, LSD: lysergic acid diethylamide, MDMA: 3,4‐methylenedioxymethamphetamine, NPS: novel psychoactive substance.

4. Discussion

This study has shown analytically confirmed drug detections in used paraphernalia collected in South Australia. Methamphetamine and heroin were the most frequently detected drugs in this study, which is consistent with self‐reported data on the most commonly injected drugs in Australia [3] and other studies of syringe analysis in Australia [13]. A large proportion of paraphernalia (57%) contained more than one drug, indicating potential polydrug use or needle and syringe reuse. The detection of multiple substances in other items such as bags could be indicative of polydrug use, which could be deliberate or inadvertent. Of the paraphernalia with more than one drug detected, the occurrence of opioids and stimulants was most common, with almost one‐fifth containing both heroin and methamphetamine. In a survey conducted in Australia in 2022, 29% of people who inject stimulants and/or opioids reported injecting both [19]. This group was more likely to experience psychological distress, stigma and discrimination and injected more frequently on average compared to people who injected stimulants only [19]. The pattern of stimulant and opioid consumption, either polydrug use at the same time or repeat use of a syringe is concerning due to the potential harm this combination can cause. In 2024, there were multiple alerts issued about opioids appearing in methamphetamine and cocaine samples in Australia where people who use drugs were unaware of co‐consumption or substitution [20, 21, 22].

Across both collections, 15% of paraphernalia recorded NPS detections. The only NPS that was detected on its own was methcathinone in 3 samples, indicating that the majority of NPS detections were found with other psychoactive substance/s. Of the NPS detections, the most frequent combination was isotonitazene and heroin. Although 4 of the 5 items with this combination were found in syringes, there was one bag also recording this mix, potentially indicating nitazene adulterated heroin products [18]. The most NPS detected in one item of paraphernalia was 4, with xylazine, metonitazene, protonitazene and bromazolam detected in conjunction with heroin. This combination has been reported in toxicological analysis in South Australia [23]. These findings highlight the potential for paraphernalia analysis to become a complementary source of information regarding the emergence of NPS in the illicit drug market.

The limitations of this study include the inability to distinguish between polydrug use or needle and syringe reuse. The latter appears to be common in Australia, with a national cross‐sectional survey of people who inject drugs finding that 35% self‐reported re‐use of their own needles in 2024, and smaller numbers reporting distributive (9%) or receptive (5%) needle sharing [3]. Blood residue in needles and syringes may also result in drugs being detected that were not administered at the time of that injecting episode. There is no way to visually determine an individual injecting episode when collecting paraphernalia. Therefore, a limitation of the sample collection is that one item does not represent one injecting episode, due to needle and syringe reuse or potentially collecting 2 items from the same injecting episode (e.g., a syringe and a bag). By limiting the collection of 1–2 items from smaller disposal units, the potential for paraphernalia to be counted multiple times is reduced. The paraphernalia that had no drugs detected could contain substances that were not included in the method, for example performance and image enhancing drugs. If sensitivity is sufficient, non‐target analysis using high resolution mass spectrometry could be used as a screening method to capture all drug residues. However, this may lead to the potential reporting of other contaminants such as trace amounts of drugs found in blood residues or those resulting from cross‐contamination of paraphernalia within the disposal bins. It is not possible to determine the age of the paraphernalia, and how long it has been in the disposal bins since use to time of collection. Degradation of substances within the paraphernalia could occur, resulting in negative detections for some samples.

The residue analysis of paraphernalia is an objective approach to determine injecting drug use patterns. The findings complement other monitoring approaches, such as self‐report information through surveys, wastewater analysis, toxicological analysis and drug checking services. The reported findings are useful for people who inject drugs and those delivering harm reduction messaging, where drug taking behaviour may be altered because of increased knowledge about the illicit drug supply. The analysis is also an important data source to inform public health responses, such as notification of the presence of emerging drug threats, or when monitoring is continuous, providing information on drug use trends and changes over time as a result of intervention and/or support. Future research studies and the application of the approach in other geographical locations and over time are warranted.

5. Conclusion

This study provided insights into injecting drug use in South Australia including the detection of high potency NPS. Multiple drugs were found in more than half of the samples indicating polydrug use or needle/syringe reuse. Opioids and stimulants were frequently found together, underscoring the need for harm reduction messaging about the contraindications when consuming multiple classes of drugs. This study provides analytical confirmation of substances injected and provides information that cannot be determined from existing data sources. Residue analysis of drug paraphernalia is an objective approach to complement existing methodologies used to ascertain drug trends, which strengthens harm reduction and public health responses to illicit drug use.

Author Contributions

Emma L. Keller: formal analysis; visualisation, conceptualisation; writing – original draft, review and editing; funding acquisition. Brock Peake: formal analysis; investigation; visualisation; writing – review and editing. Bradley S. Simpson: writing – review and editing. Marie Longo: writing – review and editing. Jason M. White: writing – review and editing. Cobus Gerber: supervision, resources, writing – review and editing.

Funding

This work was supported by the University of South Australia.

Ethics Statement

This project was deemed exempt from human ethics committee at the University of South Australia. The project was approved under a Low Risk Research Approval from Southern Adelaide Local Health Network Office for Research, SA Health, reference number: 175.24.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: dar70105‐sup‐0001‐Supinfo.docx.

Keller E. L., Peake B., Simpson B. S., Longo M., White J. M., and Gerber C., “Traces of Use: Uncovering Drug Use Insights From Paraphernalia Analysis,” Drug and Alcohol Review 45, no. 1 (2026): e70105, 10.1111/dar.70105.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.