My Dope is Better Than Yours:
Analyzing the neglect of drug checking research for people struggling with structural vulnerabilities.
Christopher Blois
Coast Mountain College
Abstract
Drug checking is a harm reduction practice frequently provided at electronic music festivals. Knowing the chemical compound analysis of illicit substances can inform the consumer of risks involved with consumption. Drug checking is substantially observed and researched at electronic music festivals, but is minimally practiced at community level outside of music setting. There is a lack of knowledge regarding the effectiveness of drug checking outside of the festival setting and, therefore, the understanding of how drug checking can affect the lives of structurally vulnerable people who use drugs is unknown. Drug checking is best done through a consultation process which can also allow harm reduction promoters the opportunity to educate people who consume drugs. Drug checking research completed at a community level can make accessibility for harm reduction practices more equitable for all socioeconomic levels.
My Dope is Better Than Yours:
Analyzing the neglect of drug checking research for people struggling with structural vulnerabilities.
Introduction
As you walk around an electronic music festival, it is noticeable that festivalgoers are not in a normal state, but rather, have enlarged pupils and exhibit staggered walks. Illicit drug use at festivals is evident for anyone who attends these highly visited events. Valente et al. describe electronic music festivals as a dynamic environment which provides festivalgoers an opportunity to participate in dancing and illicit substance use (2019, p. 88). For this reason, promoters of harm reduction have provided drug checking services as a harm reduction strategy to mitigate the risks associated with the use of drugs. Drug checking services are also provided at a community level and street level. My personal experience includes working with AIDS Network Kootenay Outreach and Support Society (ANKORS) at Shambhala Music Festival as well as working with Positive Living North to provide fentanyl immunoassay test strip drug checking. Having worked with drug checking in an electronic music festival setting along with a community based setting, it is evident to me that substance users come from diverse backgrounds and socioeconomic backgrounds. . A noticeable discrepancy between the two settings is that substance use is accepted as a cultural norm at electronic music festivals but is stigmatized within the general community or street level. This stigma amongst drug use within the community is also exacerbated by the lack of research done for community based drug checking services.
There are many risks and impairments associated with substance use and these hazards increase with polysubstance use. Polysubstance use, using multiple substances at a time, can happen without a user’s knowing if a substance is adulterated. Illicit substances, due to their nature of not being regulated, can be adultured and contaminated with unknown substances (Day, 2018, p. 2; Gerace, 2019, p. 51). The risks associated with illicit drug use can include hyperthermia, seizures, high blood pressure causing organ failure, and sometimes death. The adulteration of substances increases these risks (Day, 2018, p. 2). Drug checking is a harm reduction practice which attempts to mitigate these risks. Harm reduction is defined by the International Harm Reduction Association (2018 as cited by Valente et al., 2019, p. 89) as “policies, programs and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unwilling to stop.” It is also necessary to mention that there is an opioid overdose crisis happening, and overdose deaths are one of the main causes of unnatural deaths in British Columbia, Canada (Mema et al., 2018, p. 241). In the United States, the Centre for Disease Control reported a staggering rise in opioid overdose deaths of 3,105 in 2013 to 20,145 in 2016 (Sherman et al., 2019, p. 2). The British Columbia Coroners Service (2019) identifies that 86% of the illicit toxic drug overdose deaths occur in residences rather than at public festival events, yet the research and study of drug checking services is predominantly performed at electronic music festivals while street level research is neglected.
Drug checking services have been happening internationally and for over a quarter of a century still remain to be controversial despite the research promoting its benefits. This barrier of controversy supports multiple research studies and articles regarding drug checking benefiting festivalgoers to be published (Day et al., 2018; Dilkes-Frayne, 2016; Gerace et al., 2019; Martins et al., 2017; Measham, 2019; Mema et al., 2018; Ridpath et al., 2014; Valente et al., 2019). The inception of drug checking started in 1992 in the Netherlands (British Columbia Centre on Substance Use, 2017, p. 9), and since has become a frequent occurrence on an international scale. In 2017, Barratt et al. (as cited in Measham, 2019, p. 103) identified 31 various community agencies providing drug checking services in 20 different countries. On the other hand, in countries such as Australia, government legislation prevents community agencies from providing drug checking services. In other areas the criminalization of illicit drugs creates barriers but doesn’t prevent drug checking services from happening (British Columbia Centre on Substance Use, 2017, p. 11). Even with the barrier of criminalization, research and studies around drug checking at music festivals continues to happen and data from the checking is published. The question this paper asks is why research and studies are also not being discussed and published regarding the effects of drug checking services on a community and street level?
To examine this question, one must look at the contrast of populations of people who use drugs (PWUD) at music festivals versus PWUD within a community setting including public streets and private residences. Bardwell et al. (2019) differentiates between those who use substances socially with a greater socioeconomic hierarchy level from marginalized populations that use substances at greater regularity (p. 126). Why are the benefits of drug checking services not examined extensively within structurally vulnerable populations? Few studies around drug checking and structurally vulnerable populations have been published, such as the study completed by Sherman et al. (2019) and Bardwell et al. (2019). Drug checking research for structurally vulnerable populations is limited and, to the best of my knowledge, includes no peer-to-peer research and no outreach based research. Could the stigma associated with structurally vulnerable PWUD limit the research published for this population?
This paper examines these questions by defining structurally vulnerable and discussing the behavioural contrast between PWUD who are structurally vulnerable to PWUD at music festivals. The paper will discuss the benefits of drug checking services which can change behaviour for PWUD and will also examine social barriers that prevent accessibility of drug checking services for structurally vulnerable populations. This discussion will then lead to identify opportunities for peer reviewed research around drug checking in communities.
This article argues that the lack of research on drug checking services in structurally vulnerable areas is a contribution to the overall stigma of drug use which further prevents structurally vulnerable populations from accessing harm reduction services. The article calls upon researchers and harm reduction promoters to further examine drug checking services in community settings to better serve structurally vulnerable populations.
Methods
Research was gathered by using Google Scholar and EBSCO to search for academic articles and publications on drug checking services. Keywords searched were “drug checking,” “electronic music festivals,” “pill testing,” “drug testing,” and “drug checking and harm reduction.” This research included qualitative interviews along with quantitative survey results. Further research was gathered from the found published articles reference lists.
Structurally vulnerable populations
Many groups and populations in society are vulnerable to stigma, poverty and oppression. Access to drug checking services for these populations is limited, and the research published for drug checking services with vulnerable populations is minimal. Bardwell et al. (2019) describe structural vulnerabilities as vulnerabilities experienced by groups of people who are discriminated and marginalized within society’s social hierarchy levels (p. 126). Examples of these social groups include “people who inject drugs, homeless individuals, impoverished populations, sexual minority populations, and Indigenous people” (Bardwell et al., 2019, p. 126). Further contribution towards the structural vulnerability is the stigmatization and criminalization of illicit substance use. Stigmatization is displayed in the academic field when reviewing the many published drug checking studies at music festivals compared to the fewer number of drug checking studies in outreach and community settings.
Notably less research and studies have been published around drug checking services in community settings. Therefore, the acceptance and willingness for structurally vulnerable PWUD to utilise drug checking services is not accurately determined. Bardwell et al. (2019) completed a qualitative study to combat this identified research gap. Within the article, the authors describe the amount of quantitative studies about drug checking technologies and people who inject drugs as “minimal” (Bardwell et al., 2019, p. 126). Parkes et al. (2019) discuss the importance of peer support in building relationships to connect homeless populations with harm reduction services. Peer-to-peer research is increasing as service providers understand the benefits of having supportive people educate their peers on harm reduction practices. There is an opportunity to study peer-to-peer drug checking services and how it can increase willingness and participation among structurally vulnerable populations.
Traumatic events also affect people living with structural vulnerability. Sherman et al. (2019) discuss how two thirds of people accessing drug checking services in their studies witnessed an overdose (p. 6). With the increase in overdose toxicity deaths in recent years, PWUD are experiencing an immense amount of traumatic grief in their lives. People who are structurally vulnerable are four times more likely to die prematurely and seven times more likely to fatally overdose (Parkes et al., 2019, p. 2). Festivalgoers, due to their socioeconomic status and ability to purchase expensive festival tickets, tend to have a higher level of socioeconomic hierarchy status. Festivalgoers have more opportunity to access health care and services than PWUD who are structurally vulnerable. Practices to prevent overdoses need to be equatable among all socioeconomic status and, for this to occur, drug checking needs to be accessible to those who are structurally vulnerable.
Benefits of Drug Checking
It is evident that drug checking services are valued and appreciated at music festivals. From my personal experience I have seen hundreds of festivalgoers wait hours in line to have their substances checked during the Shambhala Music Festival. This shows a commitment from PWUD to engage in harm reduction practices. Munn et al. (2016) studied the impact that drug checking had at Shambhala Music Festival and noted that 5099 festivalgoers visited the ANKORS harm reduction tent. (p. 4) This is a substantial amount of people receiving harm reduction education and drug checking analysis.
Service providers utilise participants avidity towards harm reduction by receiving consent to complete questionnaires for research purposes. These questionnaires attempt to identify whether drug checking changes behaviour among PWUD at festivals. This self reported survey data shows that drug checking can change behaviour for PWUD if the results of a drug check are different than expected. (Sherman et al., 2019, p. 9; Day et al., 2018, p. 3; Martins, 2017, p. 3) Further anecdotal evidence supporting drug checking suggests that drug checking services lowers the strain on local healthcare providers. For example, Measham (2019) identifies a 95% drop in drug-related hospital admissions after the implementation of drug checking services at one of England’s electronic music festivals (p. 106). Studying the impacts of combined harm reduction services, Munn et al. (2016) argue that medical services combined with drug checking services can decrease the demand of community’s local health services (p. 6). Within the electronic music festival setting, there is a sense of enthusiasm among drug checking research as drug checking services receive willing participation and provide evidence to reduce harm and mitigate risks.
This enthusiasm comes during a time of grief as North America copes with and attempts to manage an opioid overdose crisis. In British Columbia, deaths from illicit drug toxicity climbed from 183 in 2008 to 1541 deaths in 2018 (British Columbia Coroners Services, 2019). The United States has the highest mortality rate due to illicit drug toxicity, where the number of overdose deaths rose from 3,105 in 2013 to 20,145 in 2018 (Sherman et al., 2019, p. 2). The assimilated research concludes that the more drug checking services available results in less illicit drug toxicity deaths. It has been hypothesized that drug checking services can “help shift and stabilize the illegal drug market towards a less toxic inventory” (British Columbia Centre for Substance Use, 2017, p. 9). Perhaps researchers and harm reduction promoters are hoping that drug checking could be a solution to prevent overdose deaths in the western world.
Drug checking services can change drug consumption behaviour for PWUD if the drug checked is different than expected. Mema et al. (2018) make mention that having fentanyl immunoassay test strips aided in the prevention of opioid overdose deaths at the Shambhala Music Festival (p. 741). Day et al. (2018), acknowledges that drug checking services have the potential to encourage drug use (p. 2), but describe how drug checking influences substance consumption behaviours for PWUD (p. 3). Results quantifying behavioural change has a broad range of 4-76% according to Leece (2017, as cited by Measham, 2019, p. 104). Self-reported data limits our research and provides subjective anecdotal evidence towards drug checking benefits. This suggests that drug checking services are not the solution to the global opioid overdose crisis happening in the western world, but rather a tool to be used in conjunction with other harm reduction practices.
Drug checking services are perceived as a novel harm reduction practice, the discussion around drug checking services includes discussion about illicit substance use and harm reduction which elevates the stigma associated with drug use. It could be argued that drug checking services aid the eradication of stigma by creating dialogue and discussion about illicit drug use behaviour.
Barriers for accessing drug checking services
There is a lack of availability to access drug checking services within structurally vulnerable populations, but other barriers are caused by social factors. Interviews completed by Bardwell et al. (2019) identify five factors affecting drug checking acceptance for structurally vulnerable PWUD. Those factors are: giving up a drug sample, time dedication, lack of accuracy, ambivalence towards overdosing, and the availability of drug checking services. If someone is struggling with poverty, they will be more apprehensive to give up a drug sample. If someone is in an anxious state they are less willing to wait in line to have substances chemically analysed. These factors can be interpreted as social barriers.
The barriers presented to structurally vulnerable populations for drug checking are not addressed by society at large. Providing drug checking services at music festivals provides easy accessibility for those who have the socioeconomic means to attend an expensive festival. Studies show that structurally vulnerable PWUD are willing to access drug checking as well. Sherman et al. (2019) surveyed drug checking participants in Baltimore, Boston, and Providence. In this study 84.6% of respondents identified that they were interested in drug checking services, and 68.9% identified they would change their drug use behaviour if the drug tested positive for fentanyl. (p. 5) Substance use behavioural change is not limited to the disposal of a substance but may also include finding a new supply or using less of a substance. Kennedy et al. (2018) surveyed willingness for PWUD to participate in drug checking services at supervised consumption sites. These results showed that 78% of people who inject drugs are willing to participate with drug checking services. PWUD want to have their drugs checked but there continues to be barriers preventing drug checking accessibility. Providing drug checking services at supervised consumption sites divides PWUD into various socioeconomic hierarchy levels, which leads to social stratification. Peer based support, as described by Parkes et al. (2019), could increase accessibility, but this has yet to be researched.
Vulnerabilities contribute to the reluctance to access harm reduction, specifically due to poverty constraints. People are less likely to provide samples for drug checking because they have to “hustle” for their drugs (Bardwell et al., 2019, p. 127). Bardwell et al. (2019) describe, through their study, that drug checking is more of a curiosity factor than reducing risks (p. 128). People want to know if they are getting scammed by purchasing adulterated drugs from their dealers. This can be interpreted as quality control, which is a major factor for PWUD at festivals as well (Day et al., 2019). The difference is that PWUD at festivals are more likely to dispose of their substances because they can afford to do so. Motivations for people in community settings to participate in drug checking might be similar and there may be differences in behavioural change, but this is not clear due to the lack of research.
One-on-One Consultation
The benefit of drug checking services is more than the identification of chemical contents in a substance, but also the one-on-one discussion between a harm reduction worker and a substance user. Drug checking provides an opportune space and time to educate and consult with PWUD on harm reduction practices (Dilkes-Frayne, 2016; Mema et al., 2018; Valente et al. 2019). Harm reduction is about building relationships and educating PWUD on best practices to reduce harm, which allows service providers to “meet people where they’re at” (Parkes et al., 2019, p. 3). Parkes et al. argue that peer support is a key component to harm reduction education and support. Harm reduction education includes instructing people about using clean equipment to prevent communicable diseases, prevention of sexually transmitted infections, training on Naloxone kits to prevent overdose deaths, and providing an understanding of the risks entailed with illicit substance use. In a community setting, drug checking services provide space to link PWUD with resources such as social services and substance disorder treatments (Sherman et al., 2019, p. 2). This information and one-on-one counseling could be essential to reducing the structural vulnerabilities associated with PWUD in community settings. Linkages among service providers, along with counseling resources, could be studied to determine best practices in drug use but can only be studied with the proper resources allocated towards them.
Illicit substance use has many risk factors, one factor being developing a dependency on substances. Substance use dependency can contribute to a vulnerable structure of life for many PWUD. If drug checking services can provide an opportunity for service providers to link PWUD to social services, then drug checking services can be seen to reduce vulnerabilities in the lives of PWUD. To further explore this, researchers need to closely examine the behaviours, motives, and attitudes of PWUD who have structural vulnerabilities.
Opportunities
Drug checking happens internationally with multiple barriers including criminalization. Even with these barriers research is still published but directed towards the electronic music setting. Criminalization doesn’t prevent research from being published in music festivals. Therefore, the barrier preventing research from happening outside of music festivals is stigmatization, not criminalization.
Drug checking is best provided by means of one-on-one consultation, including counselling and harm reduction training. Peer provided and outreach based drug checking is not currently explored and researched thoroughly. Therefore, we do not fully understand the benefits that this consultation could provide at a community level. It also shows that there are limitations in the harm reduction training provided to structrually vulnerable PWUD. People living with structural vulnerabilities can have an ambivalence towards overdose risks (Bardwell et al., 2019, p. 128). Perhaps by providing drug checking services and offering one-on-one counselling, structurally vulnerable PWUD can find counselling and connections to other services which may combat their ambivalence towards overdosing.
Research and drug checking questionnaires can examine the motives for using substances. These motives have been identified for PWUD at festivals. The survey results done by Valente et al. (2019) specify that 70% of attendants from Portugal’s Boom festivals described their motive of substance use as one of having “fun” (p. 91). This qualitative data is limiting as it only describes motives for behaviours of those who partake in substance use in a social festival setting. Motives towards substance use behaviours are not researched and discussed among structrually vulnerable PWUD. Drug checking services have offered space to provide surveys among structurally vulnerable PWUD, and these surveys could identify their motivating behaviour.
Peer engagement can be a key factor in providing drug checking services and engaging structurally vulnerable PWUD in harm reduction. Peer engagement has shown to increase uptake for HIV testing and among people who inject drugs (Kravchenko, 2019, p. 123S). Parkes et al. (2019) describe peer engagement to be “ethically imperative” for reducing barriers and creating inclusion for structurally vulnerable PWUD (p. 4). To my knowledge, there have been no studies or research on drug checking and peer engagement. Parkes et al. (2019) mention that harm reduction is about building relationships and trust with clients to engage and educate PWUD on best practices (p. 3). Relationships can be established and maintained through drug checking services as it provides clients with valuable information which can regulate their drug supply. In essence, engaging peers in drug checking services can change illicit substance use behaviours to prevent overdose fatalities.
Conclusion
In analyzing the contrast in these populations, the amount of research around community level drug checking services available for structurally vulnerable populations is negligible when compared to the research done at larger music events. Drug checking provides the space to educate and consult with PWUD on harm reduction and link people to resources. This opportunity is neglected in the inaccessibility among structurally vulnerable populations. Drug checking is widely accepted by festivalgoers and has shown to change behaviour through quantifiable surveys. Acceptability and willingness is not consistent among structurally vulnerable PWUD due to sociological factors which inhibit accessibility.
Drug checking can be perceived by harm reduction promoters as a solution to the opioid overdose crisis, but without full research and accessibility, drug checking remains a novel harm reduction practice. It is unknown if drug checking services would be more widely utilised if facilitated by peers on a street level, further research is needed to understand this. By providing drug checking services to structurally vulnerable PWUD, harm reduction promoters, by creating relationships, would connect people with other social services to reduce their structural vulnerabilities. The inequitable amount of research done at music festivals around drug checking now must compel researchers to engage in drug checking on a street level that expands on how structurally vulnerable PWUD utilise the services.
Drug checking is not the solution to solving an overdose crisis. Solutions to illicit overdose deaths require extreme examination of the motives leading to why people use substances among all stratifications of social hierarchy levels. The research reviewed confirms that drug use occurs among all socio-ecomonmic levels. Harm reduction education should become accessible to all PWUD, to eliminate drug related stigma and deconstruct structural vulnerabilities amongst vulnerable populations.
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Christopher Blois 