GROOVIN THE MOO 2018
How did pill testing will work?
Once patrons entered the screened area, every patron was greeted by a peer-based harm reduction worker and asked to volunteer their phone, which was held in a safe for the duration of their time in the testing area to guard against photographs, and video and sound recordings. To our knowledge this was not breached inside the tent. But the issue of queuing outside the entrance due to space constraints inside the tent posed a significant potential risk of privacy being breached, although this did not appear to be a major consideration for patrons using the service. In addition, the weather became wet and very cold and patrons were left with no cover in the corridor when queuing. In feedback on service improvement fourteen patrons indicated that more space was required.
Prior to the testing patrons were assessed for eligibility and advised of the safety conditions of entry. The conditions are provided in Appendix 1 & Appendix 2. These were printed and laminated onto large sheets and hung outside in the entrance and then inside the induction area where eligibility assessment took place. A key condition that had been identified by police regarded possession of quantities of drugs that were legally ‘deemed’ to be of trafficable quantities. Patrons were advised that if they produced such amounts of drugs they would be refused service. Nobody was refused service for this reason however it is not known if on reading these conditions anyone in the queue outside left prior to assessment.
Although supply level testing did not occur during the pilot the law in this area is complex. If MDMA is taken as an example, then the level is around 10g and no-one exceeded this weight. For other substances the supply threshold can be much lower. For example, for fentanyl it is around 7.5mg. A situation could arise where the weighing and testing reveals a trafficable quantity. Although this did not happen at the pilot it could in future, detailed protocols for dealing with this situation need to be further developed in conjunction with law enforcement.
Another key condition identified by legal and insurance advisors was the need for a waiver form to be signed by all patrons. The wording of the form was drafted with input from a medical clinician and from a pro-bono lawyer who assisted in this task. A copy of the form is provided in Appendix 3. The form and its contents were explained, and all patrons had to sign it prior to entering the testing area. Signed forms were locked away immediately in a safety box and later transported to HRA offices for secure keeping. Legal advice indicates that the waivers need to be securely stored for seven years and then destroyed. Of those who entered the assessment area no-one refused to sign a waiver and leave at this point.
As part of assessing a patron for eligibility, a peer-based harm reduction worker asked a few questions and undertook a visual assessment to make sure the patron was not intoxicated and therefore unable to provide consent in any meaningful way. On two occasions patrons were refused entry due to intoxication (one based on the visual signs of intoxication, namely pupil dilation and bruxism, and the other based on their inability to correctly reference the date). On 11 occasions the harm reduction worker sought a second opinion as to whether the patron presenting had the capacity to sign a waiver (including if they appeared intoxicated from alcohol or said they were intoxicated with alcohol) and requested the on-site medical clinician to make a further assessment. In total 129 people were assessed (this included police/on-ground health staff who brought two orphan samples for testing) and the two people who were turned away.
The stage 1 induction area of the tent was not covered due to the limited space inside the actual tent being required for the chemical testing equipment and the brief intervention area. This was less than ideal with rain and increasing cold. During the 12-hour period 3.6 millilitres of rain fell and there were some localised thunderstorms. The temperature dropped to 2.9C. This again highlighted the need for more covered space and depending on the season and location, heating may need to be factored into local planning.
Accessing the lockable safe after the testing was completed also created some time delays, particularly when groups entered the stage 1 area for eligibility assessment. It became evident that on leaving many patrons had forgotten they had ‘stored’ their phones in the safe and had to be reminded to collect them. Designing the layout for future services will need to take this into account particularly if numbers accessing the service are significantly higher or the exit point is designed to be separate from the induction point. Consideration of whether phones need to be ‘confiscated’ on entry should be reviewed on a case by case basis.
A key issue going forward is how to deal with groups. There were in total 39 groups (excluding ineligible and orphan samples) with 98 people (see Diagram 2). Groups ranged from 2 to 5. There were 27 patrons (22 percent) who came on their own and a further 46 came in groups of 2 (36 percent). Thirty-nine were in groups of 3 (31 percent), eight in groups of 4 and five in groups of 5.
Because of the space constraints a decision was made that all members of a group could enter if they were assessed as eligible and signed the waivers, even though they may not have a sample for testing. These people were ‘exposed’ to what occurred during the testing and analysis process however counselling was limited to only those people who provided a sample. Data collection was restricted to this sub-group of 83. Two issues that would provide useful information to inform future operations are a) the time delay between eligibility assessment and testing and b) how many people in the ‘groups’ had a sample tested. From the way the data were collected it was not possible to work out who provided samples and hence allow for matching of groups to the test results. What is evident is that in a number of groups, more than one patron had drugs for testing.
Given that the data from both the national household survey and the EDRS indicates that many young people are influenced in their drug taking by their family and friends, and that they often source drugs from friends, not engaging those people in the group who didn’t provide a sample in a brief harm reduction intervention is potentially a missed opportunity and needs to be carefully considered in the future. It is also reasonable to assume that some (if not all) of the ‘group members’ are likely to consume drugs even though they themselves are not presenting any drugs for testing. It should be possible to design a protocol that identifies this group and both counsels and collects data from them.
Prior to the testing the patron with the drugs was asked a short pre-test set of questions (see Appendix 4 for the HRA pre-test data collection sheet). A unique identifier was allocated to the patron at this point that was then used to link to their test results and their responses to the post-test collection sheet. This enabled the three pieces of data to be linked anonymously. In regard to the pre-test data collection, 84 patrons responded. However, this was because two patrons in the first group to enter the site were interviewed but only one of them presented drugs for testing.
An important innovation, not previously deployed to the knowledge of the STA-SAFE team, was a ‘catch-and-release’ system design to track any medical outcomes of those having their drugs tested. The patron who was handling the drugs was given a hospital identification (ID) wristband with the tested sample’s unique identifier number written on it. The wristbands were of soft vinyl dual-laminate material with tamper resistant clips in orange colours. Patrons were advised that they could discard the wristband or store it in their pocket or bag, however if they wore it and had an adverse reaction later on, the ID would inform the ambulance or hospital that they wanted their test results to be accessed to assist in treatment.
Overwhelmingly, patrons responded positively and many choose to keep them in their pockets. None of the wrist band were rejected; it is not known if they were later thrown away.
The ACT hospitals and ambulance staff were advised of the wristbands and did not report on any patrons with wristbands presenting at hospitals or requiring ambulance services during or immediately after the festival. ACT ambulance (ACTAS) were able to provide some basic data on presentations to this festival. In 2018 there were 85 presentations to the first aid provider and ACTAS. This does not include presentations to the additional support services provided by Red Frogs and Headspace. On these, 20 came directly to ACTAS and the majority were for intoxication. ACTAS reported the intoxication as a result of either alcohol or MDMA however this relies on their professional judgement and self-reports from patrons. Three patrons were transported to hospital and two were for intoxication and the third was not drug related; ACT health advised neither of the two intoxicated patrons had undertaken pill testing. ACT health were unable to provide information on these patrons once they entered the hospital environment. Data from ACTAS indicated there were 30 presentations to ACTAS in 2016 and 34 in 2017 as compared to 20 in 2018.
In the pill testing area, once the patron presented the drugs onto a sheet the chemist proceeded to scrape off a portion of the drug for testing purposes. Once submitted, no product, or part of product is ever returned to the submitter. At this point the chemist made a technical decision as to whether there was a sufficient amount to undertake meaningful tests. Once the test was complete the drugs were disposed of in a locked bin that contained bleach. At the end of the evening the bins were appropriately disposed of as chemical waste under the supervision of qualified chemists.
The original intention of STA-SAFE had been to hand the samples across to police for further testing, partly to validate the in-field tests with further laboratory testing, as well as to identify individual drug profiles, provenance and inform intelligence on illicit drug markets. However, for the purposes of the pilot, ACT Police advised that it was best for them not to be formally involved in the actual testing of the drugs. Nonetheless, as supply reduction is part of an overall harm minimisation approach, it should be considered in future services. Collecting samples across festivals and over time for more detailed analysis has the potential to improve intelligence holdings in a relatively cost-effective manner.
In total 85 ‘samples’ were provided but two were deemed to not be of sufficient amount for testing. Also two of the 85 samples were ‘orphan’ samples; one brought by law enforcement and one from on-ground health staff. They are included in the analysis of the test results but are not included when analysing patron responses. The effective usable number of test results was 83.
While patrons were waiting for the results they were directed to a brief Intervention with a peer-based AOD counsellor and asked eight questions (see Appendix 5). Twelve people at this point declined to answer the questions although three did provide open-ended feedback on the service. This effectively reduced the post test data to 75 patrons. The tent size meant that some groups were waiting for test results, some people were being counselled and others were answering questions all in the close confines of a three by six metre tent. None of this was ideal as ‘conversations’ could be overheard and could have had a range of unknown effects on patrons. A 6 x 6m space is the ideal minimum-sized space for conducting a front-of-house pill testing service.
When the chemical testing of the drugs was completed the results appeared on a screen attached to the testing equipment. Using the unique identifier number, the patron was identified and called to the table with the drug testing equipment. At this point a chemist and the medical clinician explained what the results were to the patron (and others if a group). Due to the constrained space, others, not party to this particular discussion, could overhear what was being said. Although there did not appear to be any concerns, and the vast majority of people expressed an understanding of the physical conditions and the delays, the unintended consequences of these factors cannot be measured.
For the purposes of classifying and reporting the result, The STA-SAFE team borrowed the same front-facing system used by ChEck IT! In Austria (European Monitoring Centre for Drugs and Drug Addiction, 2018). ChEck IT! is one of the world’s most highly regarded pill testing services, based in Vienna. Test results were assigned to one of three different colours. All ‘red’ results and some ‘yellow’ and ‘white’ results were displayed for all patrons, on similarly coloured pieces of paper, pinned to a notice board to alert patrons of what may be circulating around the festival.
It was obvious that patrons did look at the board as they waited and there were discussions around what was being ‘discovered’. One of the patrons responding to the open-ended questions suggested that a printout of the tests should be provided to take away and another patron suggested that photographs of the substances should be pinned to the board so that patrons could more easily identify different types. The experience on the night suggested that photographs would not be helpful, as the vast majority of samples looked the same; further, take away print outs may be used outside the testing facility as drug quality ‘endorsements’; and, as discussed later in the report, the results are complex and should not be disseminated without a chemist, clinician, and harm reduction worker to explain the substances being ‘identified’.
Patrons were advised of the amnesty bin in which they could discard their drugs should they choose to do so. It was a requirement of the police that the bins contain bleach so all the discarded drugs were immediately rendered inert. It was intended that the bin be placed in a discreet location with a person allocated to ‘observe’ and record the number discarded. There was simply no room in the tent to implement this model. There was also considerable nervousness about the perceived ‘risks’ around the bin so it was placed next to the chemist and medical clinician. However, this meant that discarding anything become a highly visible act.
As a result, only five patrons were observed discarding their drugs by STA-SAFE staff and this was early in the day. It should be noted that at the end of the event, numerous discards were seen in the vicinity of the medical precinct, but it is not certain whether this was a reflection on patron uncertainty regarding the amnesty bin. This part of the process needs to be carefully reviewed for any future service including whether immediately destroying the drugs is a sensible approach if further analysis of the drugs at a later stage might assist in signature profiling.
The final stage of the process involved the collection of all the various data collection materials which could then be compiled and analysed after the festival.
Due to the short time frame around approvals of the pilot and the potential risks of complicating the process with technology, the data collection was a manual process that later required data entry. Although this was manageable given the numbers, any future service design should consider whether the data collection could occur on a hand-held device. This would improve efficiency and confidentiality, although different protocols would be required to manage confidentiality and data security. However, engaging with patrons with a short interview/conversation may put some of them more at ease as well as sending a message that what they have to say is important. Open-ended comments often provide useful material to inform practice and the extent to which individuals are prepared to type in such data needs to be assessed.
Producing a datasheet of useable test results was time-consuming as the equipment produced an individual PDF file for each test. It would be more effective if the key data could be outputted to a spreadsheet for merging with the other data. However, the PDF files do contain important information in terms of the profile of the compounds that can be critical for interpreting results. In particular, the spectra can be retained and later matched to other spectra as they become available. This is important for building the spectra libraries globally to assist in drug identification and the development of early warning system capacity.