Full title: Partnerships in Research – Reflections on Unlikely, Unusual and Productive Partnership By Prof Fiona Measham by Prof Fiona Measham, University of Liverpool. This was filmed as part of the Drugs Research Network Scotland Annual Conference. The lighting in the venue had broken and created poor conditions for filming.

 

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Introduction

Okay, so I was asked to talk today about, “Oh, is this safe?” looking at my health and safety, about unlikely, unusual, and productive partnerships in relation to research.

 

 

Context of Research

So, uh, I wanted to say a little bit about the context and, uh, what the particular concerns have been in relation to my research on these unlikely and unproductive partnerships. The way that we might think about evaluating interventions, and I’m particularly looking at this issue regarding the relationship between research impact, service delivery, and policy change. I guess my research is at the intersection of all of those, and I’m thinking about how best to conduct that research and evaluation at a micro level, and possibly sometimes at the macro level, but at the moment, it’s currently at my micro level.

 

 

Focus on Adolescent Drug Use

In terms of my research over the years, it has been particularly focused on adolescent recreational drug use. I have a colleague here, a co-author, Lisa Williams, with whom I was involved in the debate about normalization and issues around changing trends in drug use. Interestingly, I was co-editing a book on binge drinking 20 years ago, and then next month, I have a book that I co-edited which looks at the decline in young adult consumption around the world.

 

 

Key Issues of Interest

So, I’m particularly interested in changing trends, and I’d say key issues relate to issues around gender, class, ethnicity, intersectionality, and issues around transgressive leisure, uh, in relation to things like festivals, licensed venues, nightclubs, bars, and so on. I guess, like some of the previous speakers have said, I’m particularly interested in policy-oriented research, pragmatic research, and harm reduction. The bottom line for all of this is that probably all of the speakers today hope and want to make a difference. We’re at the coalface in various ways, and for me, I would definitely describe my own research as action research.

 

 

Involvement in Policy

I’ve also been involved in policy; I was a government drug advisor for 10 years on the Advisory Council on the Misuse of Drugs. I was also one of the founding members of David Nutt’s Drug Science Committee. I’ve sat on Liberal Democrat, Conservative, and Labour expert panels, and I set up an NGO with a colleague of mine in 2013 to deliver drug safety testing, as we call it, or drug checking in the UK. I also set up an Australian sister organization last year, and we now have about 500 volunteers in the UK, known as The Loop, and we have about 150 or so in Australia. The idea is that we are conducting research and evaluation, but we’re also delivering a drug checking service in what is still a politically, legally, and financially challenging area.

 

wearetheloop.org/research-activities

 

Partnerships in Drug Checking Services

What I wanted to talk about today is about this public-private third-sector multi-agency partnership that has resulted from that. I also do prison teaching, and I guess one of the themes, one of the questions for me, is about how we can progress reform in what are potentially ambivalent or even hostile stakeholder environments, where we might have resistance to any innovation that we might want to introduce.

 

 

Obstacles to Policy Change

For me, as an academic, I have a keen appreciation of the fact that top-down policy change faces many obstacles. What we find when we’re in the policy domain is that academic research often has less impact than things like personal anecdotes or the case study of one that somebody might bring into the room. This relates to what Alex Stephens called in his ethnography of the Cabinet Office, “the killer chart.” This idea that a civil servant might show one graph or one chart, which supposedly nails a particular line of argument in terms of the direction of policy.

 

 

The Current Drug Crisis

For me, in terms of the killer chart, it’s this one, and I guess this particular point has been motivated over the last few years. As we are all aware today, we have the highest recorded drug-related death rate on record and among the highest in Europe. We all want to do something differently in relation to this. For me, as a criminologist, part of this has been the role of policing. Public health and the criminal justice system are absolutely too entwined, and in relation to this, we have a bit of a catch-22, I think, in that when do we have enough evidence to be able to introduce policy change?

 

 

The Challenge of Evidence

Sitting on the Advisory Council on the Misuse of Drugs and observing the discussion around foil, one of the things that was frustrating for me was that the debate was centered on what is the evidence that this will reduce harm—and conversely, what is the evidence that it won’t increase harm. There was an idea that it could potentially drive people to use crack cocaine because they were going to be given free foil, and a demand for that, whereas the evidence to prove that that isn’t the case is lacking. Seeing these convoluted debates play out in the policy domain reveals the frustration surrounding the question: At what point do we have enough evidence to actually introduce some sort of intervention? Conversely, never asking the question, where is the evidence that the determinant value of criminal justice reduces drug-related harm?

 

 

Limitations in Drug Safety Research

In relation to drug safety testing or drug checking, where is the evidence that people consuming unknown substances will reduce drug-related harm? There isn’t a driver for that. So, I guess part of me setting up the NGO, The Loop, was an understanding that academic research can and does fall on deaf ears in relation to policymakers. It was set up as an action research project as an impact case study but also to pilot this initiative to really jump into this catch-22 loop of people saying, “You can’t set it up because we don’t have the evidence base in the UK.” Well, how do we get that if we don’t set it up in the UK?

 

 

Labeling and Hosting Challenges

A bit of double speak here, though, is because drug checking was seen as approval, condoning, and facilitating drug use. We had to call it something different, so we referred to it as drug safety testing or, actually, we used the term multi-agency safety testing. We prefigured this idea of the multi-agency partnership in the conceptualization of our delivery of drug checking. In relation to the role of stakeholders, we drew them in in terms of how we might talk about tilting policy away from the zero tolerance that Adam was talking about and towards doing things differently. We borrowed the language of counter-terrorism, and we reformulated that in terms of drug policy at festivals, talking about the three P’s.

 

 

Negotiating Drug Policies at Festivals

We managed to get stakeholder buy-in to these three P’s, so before 2016, all festivals had an official zero tolerance drug policy. We would have festivals say to us, “We would love to introduce drug checking, but we can’t because we have a zero tolerance drug policy.” So, we had to get around that. The first P is to prevent drugs from getting on site. The second P is to pursue drug dealers on site, accepting that’s something that the police and security services will want to do, particularly in relation to things like violence and weapons. But the third P is to protect the general public. Within that realm of the third P, we were then able to negotiate that we could have drug checking on site under the umbrella of that third P.

 

 

Action Research Approach

In some ways, it was a policy double speak, but, in some ways, it helped facilitate stakeholders to take a step forward, which some of them wanted to take. For me, this was an action research project, so it’s very much tying in research with service delivery and collecting data in relation to that—collecting data to evaluate the service and accepting that although it’s been going for 50 years around the world, it is still relatively embryonic in terms of its evidence base and definitely not enough yet to have swayed some of the key policymakers in the UK.

 

 

Micro, Meso, Macro Analysis

One of the things I’ve been interested in is using this micro, meso, macro analysis to conceptualize the social structures in relation to moving from practice to evidence. We can’t be moving from evidence to practice, and I’m building on some work by showing colleagues in relation to the evaluation of large, complex, and messy evaluations. Drug testing has been underway for a long time—nearly 50 years if you include California, where they had LSD acid rescue teams and were testing for heroin. In Europe, though, it really bedded in from the late 80s, with the whole rise of acid house and rave, and then we saw it spread from the Netherlands to Belgium, to Italy, to Spain, and to Portugal, finally arriving in the UK after some time lag. But this wasn’t out of the blue; this was actually an evolution that came about because we already had various partnerships in the background.

 

 

Historical Context and Evolution

I was shadowing Home Office scientists and shadowing a commercial lab, and they were all testing behind the scenes for evidential and intelligence purposes. I think that was important because they already had the lab on site, and this could already be seen by stakeholders as having the value of a lab on site. We then bumped that debate a little bit further along and said, “Hey, why don’t we do this not just for intelligence and evidence purposes, but for harm reduction purposes?” We can test things in medical incidents and medical emergencies, and that was the reason we introduced drug checking in 2013 in nightclubs and festivals.

 

 

Progressing Public Engagement

Once we achieved that, we could say, “Hey, why don’t we let the public bring their samples too?” We’ve got these labs on site; the only people who aren’t allowed to bring samples are the public. We let all the other agencies do so, and it felt, in a way, like a natural progression. It wasn’t just plucked out of thin air. We tested two festivals for the public in 2016, three in 2017, and seven in 2018. I’m sure lots of people have already seen the media coverage, so I won’t spend too long on what we actually do.

 

 

Laboratory Procedures

Suffice it to say that we have a pretty large lab; we’ll have anything up to 35 chemists in the lab on site. The samples will go along the production line of testing. People will come and get a raffle ticket, we ask them to go away and come back about an hour later. We photograph, we weigh, we catalog the samples. We then use Fourier transform infrared spectroscopy—almost like a triage—to very quickly identify the main ingredients, and we will remove the dye and filler from the substance. We will then quantify the strength using ultraviolet spectroscopy or mass loss analysis.

 

 

Addressing Substance Strength and Purity

In relation to the strength of substances currently circulating in the UK, as you will all be familiar with, purity is a real issue and dosage is a real issue. We need to know the strength and not just the contents of what we’re dealing with. We do have fentanyl testing for opiates, but we have virtually no opioid samples submitted, and we’ve never had a positive test for that. We’re also trialing mass spectroscopy with Durham University’s chemistry department, so there are developments underway in terms of making the equipment better, stronger, and cheaper—more happy to be transported to festivals. Generally, chemistry equipment doesn’t like going to festivals.

 

 

Personal Insights and Evolution of Purpose

I should admit that in the early days of my research, I didn’t particularly like going to festivals either; it seemed to be a bit of a race to the bottom in terms of physical exhaustion and personal hygiene. However, I have grown to love them now. It’s also worth saying why we introduce testing at festivals. I think there are quite a few reasons; there are multiple advantages. To flag up a couple of points: firstly, festivals are big business—they’re huge business in the UK. Depending on how you define festivals, there are anywhere between 700 and 900. Between seven and ten million people go to festivals every year. Our average size festival has about 25,000 to 75,000 attendees.

 

 

The Business of Festivals and Risks

Glastonbury has a quarter of a million attendees, and all the tickets sold out in half an hour. I’ve never actually managed to get a ticket for Glastonbury, as it’s always sold out. These are big businesses with huge numbers of people in a tiny space, intent on having that kind of excess that Adam was portraying. However, there is also a considerable risk of drug experiences going wrong, of medical incidents, of hospital admissions, and also of drug-related deaths. Our festival drug-related death rate is increasing. I can’t show the figures for that because we don’t have them; festivals are very good at keeping a lid on what’s happening at their site. You will see announcements of drug-related deaths at festivals, which only become apparent that they were drug-related a year later in the coroners’ inquest. Nevertheless, the rate is increasing; we had five drug-related deaths at a bank holiday weekend, all due to high-strength pills.

 

 

The Complexity of Licensing and Perception

There are particular concerns about this licensed leisure arena, and so festivals are concerned that drug-related deaths could lead to them having a licensing review and potentially losing their license. Their whole commercial business could depend on this. Equally, they don’t want to be seen as having a drug-related problem, and therefore they’re in this ambivalent position. They want to do everything possible to reduce drug-related deaths, but they don’t necessarily want it to be known that this is happening on-site because they don’t want to be seen as having a drug-related problem, which in itself might lead to a licensing review.

 

 

Historical Data and Research Development

This complexity outlines the negotiations when working with the private sector. Coming into this ten years ago, we began doing annual festival surveys, so we’ve accumulated ten years of data that we’re writing up at the moment. For me, this research led directly on from my work in the previous couple of decades, which focused on licensed leisure in terms of alcohol and drug use in pubs, dance clubs, and normal high street nightclubs. I’ve been interested in monitoring trends and also in why people are taking drugs and what the consequences are.

 

 

The Loop as an Action Research Project

The Loop was developed as an action research project. We have a team of chemists, a team of healthcare staff who deliver the results, and we also have a research workstream. We have about 50 volunteers involved with this data collection, crossing all disciplines—particularly public health, chemistry, and criminology—and so forth. We are also particularly interested in how we can better evaluate this service, in what I refer to as an embryonic evidence base, but in relation to what’s happening at the festivals.

 

 

Intoxication Patterns at Festivals

These surveys portray a picture of atypical intoxication; generally, drug use is higher at festivals around Europe than it is in people’s everyday lives. People are away from the constraints of work, family, or home, and in the UK, that could be for four days or more. In our research, we’ve found that on average, half of people attending UK festivals take drugs, and half of those say they take larger quantities than they do when they usually take drugs. A quarter of those say they take a wider range of drugs, which means they’re taking more drugs, in larger quantities, and of a wider variety.

 

 

Risks of Multi-Drug Use

Half of drug users are taking two or more drugs, so we’ve got to look at the synergies between different drugs. British people are also drinking on top of all of this, with over nine in ten also consuming alcohol as well as being poly-drug users. For those of you who are familiar with festivals, you’ll know that people act outside of their everyday experiences, so it’s quite common for people to report they had a lager for breakfast, which they would never do at home. The consumption patterns are absolutely out of their norm.

 

 

Accessing Atypical Users for Research

Interestingly for us, one in twelve festival-goers only takes drugs at festivals. We have a particular interest in that group and the additional risk for them as they are taking more drugs, having longer drug-taking sessions mixing all these different drugs together. From our perspective, it’s an opportunity; it’s an opportunity for them in terms of excess, but it’s also an opportunity for us to access that drug-using group within that particular drug-using space. So, we say it’s time for them—time to test but also time to talk as well—over the course of four or five days.

 

 

Building Partnerships with Stakeholders

In terms of the partnerships involved with this, the first unlikely one for us has been with the police. We probably didn’t expect this at the start, but the police have been the most supportive. For us, the introduction of drug checking has been at the forefront of everything we’ve done. We only go on-site at the invitation of the police and with a memorandum of understanding from them. It’s interesting to unpick this; to look at what’s happening in terms of English policing currently—driving harm reduction initiatives—we can see examples such as Durham’s checkpoint and Bristol’s drug education project.

 

 

Police Perspectives on Harm Reduction

I think some of this has come from the fact that we’ve seen more than a 20% cut in policing budgets, which has driven the police to reconsider how they use their resources. I have a quote here from Jason Q. from Thames Valley Police. When I asked him about his passionate support for police involvement in harm reduction, he said, “Policing is a privilege; it gives you a unique opportunity—a unique position in the community to drive social justice. Police-led local partnerships can make things happen. You can’t hang around just talking about it; I’ve just dealt with too much death. At the end of the day, it’s the police who will knock on the door of the parents when those children have died.”

 

 

Support from Unlikely Allies

We’ve also had unusual support from even a Hollywood actor, and we have had a lot of support from the press. In fact, even the right-wing press has been supportive of this. We’ve put a lot of time and effort into positive press coverage because we wanted to demonstrate the professionalism of our service—of the chemists and healthcare staff. It’s also helped us develop our relationships with other stakeholders in terms of positively addressing drug-related harm on-site, showing that we can work and collaborate with the police to try to keep people safe. That’s been something that we’ve put considerable time and effort into.

 

 

Unexpected Partnerships with Parents

The other unusual partnership has been with parents. When I started doing research, my boss said, “Never share a platform with a grieving parent.” That has been totally turned on its head now, with organizations like Anyone’s Child, which includes amazing, passionate, articulate bereaved parents who speak in this space now and are so well-informed. They can segue from the most tragic story to the most passionate political policy reform. Quite often, I say, “You know, we’re redundant now on these panels; they do such an amazing job.”

 

 

Collaboration with Grieving Parents

We work very closely with them now; I work closely with mothers who have lost daughters the same age as my daughter, and it’s a very close, very moving, and unexpected partnership that has become fantastically productive and has really changed the political debate around drug policy reform in the UK. The other surprising, unexpected, and unusual partnership has been with the church. We’re now involved in rolling this out from festivals to city centers, and we’ve been looking at different types of spaces.

 

 

Expanding Testing to City Centers

The idea is that if we have city center testing, it could be potentially more inclusive. It can have a wider reach, therefore creating a wider impact, and could potentially encourage any drug-using communities to use the service and be proactive. People could test ahead of a festival. We don’t need to wait for the festival to put out any alerts; we can do it ahead of time. You can then embed any particular concerns or referrals into existing infrastructure in health and social services and so on.

 

 

Community Engagement through Faith Organizations

Also, considering what I’ve just said about intoxication at festivals, you can be capturing people and having these healthcare interventions while they are hopefully more straight and sober than might be the case at a festival. What we have found, though, is that there has been reluctance to enter drug services for testing. We’ve tried our youth and community center drug service and found that the most popular venue for city center testing has been a church.

 

 

Neutral Spaces for Testing

I think there’s something about it still being a neutral space, a sanctuary. There’s less fear that the police are hiding behind the curtain to come out and arrest people. It’s large enough that we can have a mobile lab in there, so it’s central enough that people can go and have a coffee if they have to wait for an hour for the test result or go shopping. We’ve also found it has been really good in terms of engaging opiate-using and rough sleeper communities.

 

 

Engagement with Vulnerable Populations

Some of these groups already have an existing relationship with the church, and we’ve been able to hook into that and piggyback off it. These are groups that might already come in and use cafes, toilet facilities, things like that. So we were testing in Durham city center, and we had opiate users and rough sleepers come in and use our service because of that relationship with the church. We need to think about venue, location, and stigma surrounding services.

 

 

Addressing Stigma in Drug Services

We had party drug users saying they wouldn’t go into existing drug services because they didn’t want to be seen by family, friends, or their employer walking past and seeing them use that testing service. So we have to consider those sorts of issues in designing what are the operational features for city center testing.

 

 

The Role of Multi-Agency Partnerships

In terms of the productive partnership, that would be the whole multi-agency partnership that we developed and designed to be a multi-agency partnership, working with the local police. Obviously, being a criminologist helped because I was already working with them, but also the fact that it was this slow, incremental change. We piggybacked off existing local partnerships; there were already people who were working together at festivals and in nightclubs, and we were able to collaborate with those existing productive partnerships.

 

 

Key Individuals in the Partnership

Particular individuals have made this possible. The photo in the middle shows some of the key individuals willing to support this. The festival promoter, the guy with the red tie, was the gold commander at the first festival that ever agreed to drug check in the UK. The person on the right-hand side, Freddie Fellows, owns the Secret Garden Party, which was the very first festival at which we delivered drug checking. He owns the land, and there are interesting issues around the dynamics of private property versus public property. It has been much easier to accelerate this on private land than on public land.

 

 

Advocacy for Evidence-Based Policy

These people were bright and willing to listen to the evidence, willing to hear about what’s happening in Europe, and to think about the potential for evidence-based policy within their commercial venue. We also decided to set the bar high, which I think helped in terms of the multi-agency partnerships. The aim has been to ensure these are professionals; we didn’t talk about our volunteers as peers, and we don’t ask for disclosure from our peers. We don’t ask what their motivation is.

 

 

Upskilling within Partnerships

I’m sure some would call themselves peers, and so we’re in a gray area, as Maddalena said, about the space between peer and professional as well. I think we also need to think about giving back. We do a lot of training on-site for the people involved in the agencies and partnerships, and that’s also true of the volunteers. There’s an idea of upskilling and professional development among the 35 chemists, with lots of opportunities for training each other but also in terms of training on-site.

 

 

Measuring Success at the Micro Level

So, how do we measure success? I’ll briefly say something about this at the micro and macro level. At the micro level, we’ve been looking at what the behavioral outcomes are in terms of individuals. We ask people about their medical history, their drug use history, their current drug use, medications, and we look at poly-drug synergies and so on. What we’ve found is that about nine in ten people who use our service have never spoken to a healthcare professional about their drug use before, so these are hidden populations, and they are largely hidden from drug services.

 

 

Impact of Drug Checking on Users

Two in five of the people who use our service—after they’ve heard about the strength of the substance and dosage—will moderate their dose afterwards. This ties back to Adam’s point about the importance of moderation, particularly with high-strength drugs. Currently, one in five actually throws away the substance—they don’t want to take it once they find out what’s in it. It’s not what they wanted, and we provide a disposal service for that. Additionally, one in twenty asks for onward referral to a drug service because they want to carry on these conversations about their health.

 

 

Demographic Insights from Service Users

Significantly, we find that the people who use the service and the people who dispose of substances—are more likely to be younger, newer initiates, and more likely to be female as well. There’s a question there that we’ve not yet answered: why is it that older men are less likely to use drug-checking services? It could be that they think they have more reliable sources in terms of their dealers and don’t think they need to use the service, or maybe they think they already know the harm reduction messages. But we’re definitely seeing age and gender issues here.

 

 

Meso-Level Evaluation Challenges

The meso level is more difficult in terms of progressing evaluations. We can look at things like early presentations and an increase in confidence among medics to treat on-site, thereby reducing hospital admissions and the burden down the line to the NHS. We found that there was a 95% reduction in hospital admissions from the Secret Garden Party in the first year we introduced drug checking, and a 25% reduction in medical incidents at Boomtown in the first year we introduced it. The Red Cross conducted an independent survey at a Love Saves the Day festival and reported a 12% decrease in medical incidents.

 

 

Soft Data and Commercial Pressures

There are various forms of soft data emerging. We think that by providing these alerts, through this information for emergency services, we can spread information about what’s circulating. However, there are concerns—first of all, in terms of meso-level evaluation, it’s really challenging to get data related to alcohol and drug-related incidents, as they are often conflated. So, determining whether or not we’re making a difference is very difficult, even obtaining the data from the different agencies on site. They have better things to do, dealing with emergencies, than to collect data for us.

 

 

Corporate Interest in Public Safety

We’ve also found that festivals now want to issue alerts to be seen as actively addressing issues to cover their back. Thus, we’re not making these decisions in a vacuum about what we warn about; we respond to the pressures from these commercial situations.

 

 

Wider Impacts of Drug Checking

Finally, I would like to say something about the wider partnerships. We’re not only informing service users—individuals—about what’s in the substance, we’re also informing all emergency services on-site, whether that’s at a festival or in a city center. We also feed into local and regional drug services, into regional warning systems, and we broadcast alerts on our social media, which feeds into general media coverage. We are members of the European Drugs Drug Checking Network and a subgroup of that, and we’re starting to pool our data at the European level.

 

 

Global Collaboration in Drug Checking

This collaboration allows us to learn more about international trends, and globally, drug-checking services share reference standards. We are constantly discussing among each other the latest trends, the latest substances. If someone hasn’t identified a substance, then everyone else steps in to help. Thus, there’s a very strong and supportive global drug-checking community.

 

 

Academic Contributions and Alerts

Finally, that support is now feeding into academic papers. On-site, we have information about very localized, real-time alerts regarding local drug markets, but also off-site now, in terms of monitoring and evaluating the off-site feedback. Our alerts are now reaching over half a million people in the UK, allowing us to get the messages out. If something is a particular concern, we need to look at what the impact of such messages are. We have a PhD student examining risk communication and drug messaging.

 

 

Conclusion

To conclude, I started off by saying that in a way this was a bottom-up approach from grassroots community action. We have now steadily moved up. We’ve had support from public health and regional police, and probably the biggest national policy recognition thus far has come in a recent select committee report that endorsed on-site drug checking.

So, we have moved from the bottom up at a glacial pace, but finally, just to say, it’s not really about testing. It’s about informing and empowering individuals—treating individual drug users as agents of change—and also prioritizing their health and human rights over criminal justice, while recognizing the pharmacological pleasures they might enjoy. Additionally, I hope we can use this experience to help build bridges between stakeholders who don’t normally work together. There might be tensions between police, local authorities, public health, and commercial interests at festivals or licensed venues.

 

 

Prioritizing Harm Reduction

Getting everyone around the table to prioritize harm reduction has become a very positive experience. However, I think we need to break out of this catch-22 conundrum: When is there enough evidence to support the introduction of a new policy?

 

 

Evidence-Making Interventions

I really like the phrase by Tim Rhodes and Lancaster in Australia about an evidence-making intervention. I would characterize our approach as such. We cannot always wait for the perfect opportunity or a randomized control trial; we can have those evidence-making interventions. Additionally, we must consider that testing can operate in a wide variety of policy contexts. We do not have to think about this solely in relation to any one policy context.

 

 

The Way Forward

We will always need to ensure policy assurances, regardless of whether something is legal or illegal, whether it is regulated or unregulated. However, it creates pockets of tolerance—a tolerance zone of amnesty potentially—one could argue that this could lead to de facto decriminalization, and I think that it could be a stepping stone for progressive policy reform. While we wait for that, which could be quite a long way down the line, the final point for all of us is that, in the meantime, we have this record drug-related death rate, which motivates all of us here to address this issue.

 

Significance of Drug Checking

I believe that drug checking can be a significant part of that story.

 

Thank you.