Summary of the impact

This case study concerns research around public injecting and risks and has been led by Prof Coomber in partnership with Drug and Alcohol Action Teams (DAATs) in Plymouth, Barking and Dagenham, and Southend. The exploration and analysis of public injecting activity has impacted upon the policy and practice of all three DAATs. The research has led to the improved management of an environmental risk and hazard, impacted upon the planning of drug support services, and led to a change in strategy amongst drug agencies in the three locations.

Underpinning research

This case study concerns research around public injecting and has been led by Prof Ross Coomber (Principal Lecturer 2002-2005, Reader in Sociology 2005-2010, Professor 2010 - to date) in partnership with Drug and Alcohol Action Teams (DAAT) in Plymouth, Barking and Dagenham and Southend.

Public injecting of illicit drugs, if not managed, can put at risk some of the most vulnerable people in society, who are experiencing a wide range of social problems and dependency issues. Blood- borne viruses such as hepatitis and HIV, wound sepsis, and death by overdose continue to be a significant risk to injecting drug users. It can also constitute an environmental risk in terms of discarded needles and can increase the fear of crime in a locality. Very little research has previously taken place and policies can be disjointed and service specific.

The original research study arose out of concerns that had been raised by Plymouth City Council, Police, and the Plymouth Drug and Alcohol Action Team (DAAT) regarding drug related litter and fatalities in public settings. In 2006 Prof. Coomber was awarded an ESRC CASE studentship, explicitly designed to promote impact and engagement with local organisations. In partnership with the DAAT, the project considered the benefits of a new safer injecting service in Plymouth. To extend the research base, Plymouth DAAT also commissioned Coomber to undertake research on the extent/nature of public injecting in Plymouth. Coomber was PI on all projects and had overall responsibility while Stephen Parkin, (PhD Student 2006-2009, Research fellow 2010-2012), undertook the fieldwork and most of the report writing.

The research methods included ethnography and participant observation, environmental visual assessments, data on local public injecting sites, semi structured interviews with agencies, semi structured interviews with drug users and quantitative data analysis. The research produced a mapping of public injecting sites throughout the city and understanding of sites more associated with death and potential blood borne virus transmission, identification of risks and factors increasing risk of death and disease, an understanding of the impact of local policing and housing policies and practices on risky behaviour, recommendations on the appropriate placement of needle bins and the identification of target groups for Hepatitis A and B vaccination.

The research found almost 70 different public injecting sites within one square mile of Plymouth city centre. Most of the sites were not known as locations for injecting by outreach workers, drug services, or the general public. It also provided new evidence on the use of fluorescent blue lights in public toilets, which are used to deter injecting by making injecting into superficial veins difficult. The research found that the blue lights do not deter injectors and that they actually increased injecting related risks.

Coomber, in collaboration with Parkin, used this research to develop a rapid appraisal approach for researching local public injecting spaces. This led to the commissioning of two local Public Injecting Rapid Appraisals (PIRAS) for both Barking & Dagenham DAAT (2010) and Southend-on-Sea DAAT (2011). Although using the same methodology, the findings were rooted in the issues and context of each area.

References to the research

*Plymouth University PHD student

Details of the impact

On the basis of the findings of the research, the Plymouth DAAT developed new ways of approaching public injecting in the City. The changes have included deploying primary care services in hostels, reducing the size of the standard issues of syringe packs to reduce discards, introducing injecting bins in new sites and targeting outreach work to new locations. The DAAT publically stated the changes introduced as a result of the research to be: `... a really cost effective way of finding out about the problem in detail and using that detail to bring about effective changes to policy and practice'. The research and recommendations have enabled Plymouth DAAT to better target services and develop policies that are likely to mitigate rather than increase risks by reducing waste — both in terms of discarded equipment and services that are not needed or inappropriately sited — and develop partnerships and practices designed to reduce deaths associated with public injecting. They have also used the research to reach out to hidden and at risk populations. At a local level it has reduced the harm to public injectors as there is now a better understanding of the specific local issues that increase risks.

On the basis of this research the NHS Plymouth Public Health Directorate signed a Memorandum of Agreement with Plymouth University to develop research, teaching and training and helped secure the post-doctoral employment of Stephen Parkin (Jan 2010 through to March 2012 when Parkin left Plymouth) in a newly developed and resourced Drug and Alcohol Research Unit under the Directorship of Coomber. DARU was built into the Memorandum as an explicit area to be supported in a collaborative way. The Memorandum commits both organisations to develop Public Health careers and education pathways, as well as broaden and deepen educational, research and enterprise. The Memorandum has led to a range of public health courses and research opportunities such as degree level modules run by Public Health.

Dissemination of the results from the first project (in Plymouth) resulted in greater awareness of public injecting practices and led to two new (Barking & Dagenham, and Southend-on-Sea) pieces of commissioned research to focus on those localities. Change of practice and attitude towards public injectors and public injecting by local DAATs and other stakeholders in each of the areas has since been implemented and evidenced.

In Southend-on-Sea the research has led to similar benefits around managing the environmental risk and the planning of services and strategy. The Southend DAAT Manager stated that:

`Instigated by the research and continued post-research was both better situational monitoring of public toilets by the contractor, and importantly, installation (via both retro-fitting and at time of build) of sharps disposals. Incidences of discards reported to DAAT have fallen subsequent to this process and there has been no further 'bad press' such as that immediately prior to us commissioning DARU.'

They also reported improved joint working with agencies in dealing with the issues and a more joined up approach to injecting including a joint policy on discards including the non-use of blue lighting unless problems persisted and then only with a full assessment. They stated that this would be `unrealisable without the research and the opportunity for dialogue it created'. They stated `by necessity the research brought some difficult subjects into sharp relief, together with the often conflicting responses to these. Joint approaches to such issues is more routine and relations are palpably improved.'

The research was presented at the National Conference on Injecting Drug Use (2010) which is a non-academic conference organised by Exchange Supplies - an established agency set up by drug workers to develop new products, produce publications and stage conferences. Attendees include Nurse specialists, needle exchange support workers and Addiction workers. The presentations have led to further knowledge and debate on the issue of public injecting.

By demonstrating that public injecting and the discarding of needles is not simply the result of thoughtless behaviour the research has enabled more reflexive policy development to take place that results in less harm for injecting drug users. The finding that fluorescent `blue-lights' used in public toilets does not deter injecting but make it more risky has been used by each of the DAATs to specifically change policy around how public injecting and needle distribution and exchange is approached in their areas. It has also led to wider debate around the use of blue light. We expect more studies to be commissioned and the impact to grow, both nationally and internationally.

Sources to corroborate the impact

Factual statement on impact available from Manager, Plymouth Drug and Alcohol Action Team.

Factual statement on impact available from Manager, Southend-on-Sea Drug and Alcohol Action Team Manager on the impact of the research on policy, planning of services and strategy.

Group Manager — Commissioning and Supporting People, London Borough of Barking and Dagenham, Barking and Dagenham DAAT, can confirm that the research carried out at Plymouth was taken up by the DAAT/Council and led to significantly improved methods of addressing the problem.

ESRC recognition of it as an `Impact case Study'
http://www.esrc.ac.uk/_images/Reducing_drug_risk_tcm8-3384.pdf

United Kingdom Drug Situation 2010, Department of Health. Annual Report to the European Monitoring Centre for Drugs and Drug Addiction:
http://www.nwph.net/ukfocalpoint/writedir/fcf022035%20FOCAL%20POINT%20REPORT%202010%20A4.pdf (References Coomber and Parkin 2010 (pg. 109) as only research on blue light and details that their research shows it is of little benefit to the public and may increase harm for injectors).

Debate around blue light usage — a selection of sources
http://www.concateno.com/newsletter/february11/#blue Concateno is the leading multinational drug testing company providing over 10 million drug, alcohol and healthcare tests each year for customers across 95 countries.

http://researchblogging.org/blog/home/id/939 Popular GP blog, debating evidence based research. This article has 1030 views.

http://www.smmgp.org.uk/html/smmgpupdates/2010/clin_2010_06.php Substance Misuse Management in General Practice — a network of GPs and primary care workers who aim to develop, support and encourage the role of general practitioners (GPs) and other primary care workers to work with problem drug users.