Drug safety testing, welfare & harm reduction in nightclubs, festivals & other leisure events

Professor Fiona Measham * Chair in Criminology, University of Liverpool, UK * Co-Founder & co-Director, The Loop UK & The Loop AU Overview: 1. What is the problem? ➢ Drug-related deaths, high purity & additional risks at festivals 2. What can we do? ➢ Drug safety testing / drug checking 3. What is the UK evidence on efficacy & wider impact? ➢ Disposals, DR medical incidents & DR hospital admissions (1) What is the problem? UK DRDs are highest on record & amongst highest in Europe (EMCDDA 2017)

“Policing practices undertaken in the name of the public good have demonstrably worsened public health outcomes” Csete et al, The Lancet , 387 (10026): 1427. 2018: 92

1999: Vietnam banned 2010-16: deaths safrole oil production 49mg➔165mg MDMA 2000: Large scale safrole oil in pills production in Cambodia from 6 festival deaths camphor tree 2011-16: 112➔371 2000/1: UK prevalence cocaine-related DRDs peaked Early 2000s introduction of high purity MDMA crystal 2nd Wave

1st Wave

2007 Cambodia banned safrole oil production 2007/9: Mass seizures of safrole oil in Cambodia leading to ➔ High & variable purity illegal global drought. Shift to Chinese chemical synthesis of piperonylmethylketone (PMK) instead of extracting PMK drugs are key driver for increased from safrole oil UK drug-related deaths “I’ve just dealt with too much death” Perfect storm (Jason Kew, Windsor police, 1/2018) • Prevalence of self reported drug use – highest in Europe • Purity – highest on record • NPS missold as street drugs: fentanyl analogues in opiates, cathinones in MDMA, cannabinoids in cannabis • Drug-related deaths – highest in Europe & highest since ONS records began (ONS, 2018) • Price – relatively low (E pills £5, ketamine £20/g, MDMA & cocaine £40/g) • Harm – £10.7bn estimated harm from illicit drug use in UK (PHE 2017) • Police – 20% cut to budgets by Home Office in 2010, disgruntlement with central govt, cuts linked to increased crime, reconsideration of enforcement priorities, leadership changing with new fast track graduate recruitment programmes • Policy regime – centralised prohibition, regional police operational independence, localised diversion initiatives growing across UK • Reframing festival drug policy from zero tolerance to 3Ps (Prevent, Pursue, Protect) based on UK counter terrorism policy “Atypical intoxication” – UK festival drug use • Theoretical perspectives on festivals: carnivalesque suspension of everyday social controls, a moral holiday (Matza), ‘Temporary Autonomous Zones’ (Hakim Bey), ‘time out’ from everyday life (for onsite agencies as well as customers) • Prevalence: National (UKFA, 2017) & international surveys (EFA, 2018; Hesse & Tutenges, 2012; Lim et al, 2010; Martinus et al, 2010) indicate festivals have higher prevalence of drug use than general population • Extended time period – 4+ days without constraints of work, home & family • Excessive – over ½ report taking drugs at festivals; over ½ take larger quantities than usual & ¼ take wider range of drugs. Over 9 in 10 also drank alcohol with their drugs (Turner & Measham, 2020) • Polydrug use – ½ of festival drug users taking 2+ illegal drugs in same session • Polysubstance use – over 9 in 10 polydrug users also drinking alcohol • Atypical – 1 in 12 only take drugs at festivals – increased risk • ➔ More drugs, longer sessions, all together • Window of opportunity for customers to access drugs & for drugs services to access drug users in an unique intense drug using space UKFA 2017 • ➔ Time to test & time to talk UK festivals are big business: £2,500m industry Small <25k customers Medium 25-75k Large >75k Glastonbury ¼ million (2) What can we do? How could ‘drug safety testing’ help reduce drug-related harm?

1. Providing information & intelligence to onsite and offsite PWUD, medical & emergency services, including monitoring trends in supply and use; 2. Identifying & removing from circulation high risk substances eg. missold drugs, variable purity, contaminants & adulterants; 3. Providing an opportunity for trained, experienced healthcare staff to deliver targeted health & safety advice, individualised harm reduction & referral to onward local drugs services, to harder to reach/ hidden populations not otherwise engaged with medical or drugs services; 4. Uniquely, drug safety testing can make the connection between what was actually obtained and what individuals thought they obtained, to measure the nature & extent of market missellling & target messages for maximum effect. What is ‘drug checking’?

• Direct public engagement • "Drug checking services invite (not postal or via 3rd parties) members of the public to anonymously submit psychoactive • Lab level forensic analysis (not drug samples for forensic analysis & just reagents) then provide individualised feedback of results & counselling as • Individual consultation (not appropriate" (Barratt et al, 2018:1) just test results) https://ndarc.med.unsw.edu.au/resource/bulletin-no-24-global-review-drug- checking-services-operating-2017 • + Aim: harm reduction • Pragmatic & non policy dependent health service • Introduced in UK in 2016 – at a festival History of ‘Drug Checking’

1. Mid 60s-70s: ‘street drug analysis’, California 2. Late 80s onwards: ‘drug checking’ in continental Europe 3. 2010s onwards: ‘safety testing’ in UK, Canada & Australasia

Barratt, M., Kowalski, M., Maier, L., & Ritter, A. (2018), Global review of drug checking services operating in 2017, Drug Policy Modelling Program Bulletin No. 24. Sydney: NDARC, UNSW European ‘drug checking’ services http://www.emcdda.europa.eu/system/files/attachments/6339/EuropeanResponsesGuide2017_BackgroundPaper-Drug-checking-harm- reduction_0.pdf

1987 onwards: Safer House, Amsterdam 2016 onwards: The Loop, UK

Evolution of UK ‘drug safety testing’: 2010- Shadowed ‘Back of House’ 2013- ‘Halfway House’ onsite FEWS 2016- ‘Front of House’ at 2 festivals 2017 FOH @ 3 festivals 2018 FOH @ 7 festivals & 5 city centre events, BOH at 5 festivals Loop Lab analytical process

1

2 4 3

5 Fentanyl strips for opiates

6 Bespoke GCMS with DU chemistry dept & mass spec manufacturers (3) What is the UK evidence? 3 summers of UK festival testing

Total MAST MAFEWS MAST MAST MAST festivals Front of Halfway Total Total healthcare Total house house samples consultations service testing testing tested users

2016 3 2 1 350 300 1,000 2017 4 3 1 1,800 1,500 4,000 2018 13 8 5 3,000 2,000 5,000 UK Test Results • 50% MDMA, 20% cocaine, 20% ketamine, 10% other (bulking agents, contaminants & fillers) • MDMA ½ pills ½ crystal • MDMA content of pills very high & variable: mean 168mg MDMA • 1 in 5 substances missold • 2018: ~1 in 20 MDMA crystal samples n-ethylpentylone (very longlasting cathinone, very similar in appearance & smell) • Displacement in NPS missold as established street drugs: decline of methylone & rise of n-ethylpentylone missold as MDMA linked to Chinese legislative control of methylone • 2019: n-ethylpentylone banned • As with SCRAs, displacement to each new generation NPS with greater harm – the ‘perversity of prohibition’ Behavioural Outcomes ‘Drug checking’ = forensic test + healthcare consultation = • Individual context: medical & drugs histories, current drug, alcohol & medication use • “Safest way to take drugs is not to take them at all” ➢9 in 10 service users never previously spoke about drug or alcohol use to healthcare staff ➢2 in 5, after hearing information about the strength of their sample & appropriate dosage, intend taking a smaller quantity of that drug in future; ➢1 in 5 dispose of further substances in their possession, either self disposal or disposal to the Loop for onward safe police destruction; ➢1 in 20 ask for signposting to a local drug treatment service ➢Significantly more females, younger and new initiates use the service & dispose of drugs. Older, male & regular users have more reliable supply lines & (think they?) already know more about harm reduction. x2 Festival Results Reductions in onsite drug-related medical incidents • Alerts to users, to festival, to police & emergency services embedded in intelligence on local drug market • Early presentations, confidence to treat onsite • 2016 95% reduction in hospitalisations Secret Garden Party (Measham, 2019) • 2017 25% Boomtown (Independent report to Boomtown, 2017) • 2018 12% Love Saves the Day (Red Cross, 2018) • But: • Challenge to disaggregate data on drug-related medical incidents & hospital admissions • Care with alerts – evidence-based, linked to genuine risk of harm, beware alert fatigue, pressures from funders to be seen to be doing something Not just festivals… • Community-based – fixed site or mobile testing • Wider reach, more inclusive • Any drug using communities • More proactive, ahead of special occasions • Embedded in existing infrastructure (drugs services, MSIC, NSP, policing initiatives) • More potentially productive engagement *if* straight & sober • NL - £1m govt funded national testing centres • ➔ The Loop supported introduction of testing at DCRs (Vancouver, Copenhagen, Sydney) & introduced city centre drug safety testing at 5 events in 2018 & in partnership in 2019 for the 1st HO licensed testing pilot: drugs services, youth and community centre, church… The feedback loop

Service Users

On-site Academic emergency research services at daily SAGs

Global: share Multi Regional & data, alerts & national EWS eg. reference Agency NEIU, Greater standards with Manchester Drug overseas drug Safety Early Warning checking NGOs Testing System

Member of National: EMCDDA/ TEDI Media & social Sentinel drug media checking NGO subgroup Member of European NEW- TEDI network of drug checking NGOs Twitter #LoopAlert Risk Communications: @WeAreTheLoopUK The off-site feedback loop – the ripple effects of test results How could drug safety testing help reduce drug-related harm? 1. Accessing ‘hidden populations’ & onward referral >9/10 never spoken to healthcare professional before >1/20 requested signposting to local drugs service – potential route to recovery 2. Identifying & removing from circulation high risk substances 4/10 after hearing strength & dosage advice, intended to take a smaller amount 1/5 (corroborated) disposals to the Loop, usually when result not as expected 3. Providing information & intelligence to onsite and offsite PWUD, medical & emergency services, including monitoring drug trends Hospitalisations reduced 95% at 1st festival pilot in 2016 (Measham 2018) 4. Uniquely, drug safety testing can make the connection between what was actually obtained and what individuals thought they obtained, to target messages at appropriate users for maximum effect Targeted N-ethyl pentylone alerts believed to have led to early presentation & prompt hospitalisation of 2 men & *maybe* according to paramedics helped to save their lives Thanks to… • Loop volunteers • Loop partners & patrons • Police, public health & press • International testing community • Academic colleagues

#TimeToTest Questions? ☺