Exploring the intersections between Novel Psychoactive Substances (NPS) and other substance use in a police custody suite setting in the North East of England

Aims: Novel psychoactive substances (NPS), a range of plant-based/synthetic substances that mimic effects of other illicit substances (e.g. cannabis), are now illegal in the United Kingdom (May 201...


Introduction
Novel psychoactive substances (NPS) are a range of plantbased/synthetic substances that mimic the effects of other well-known illicit substances (e.g. cannabis and cocaine). NPS encompasses a diverse range of plant-based substances (e.g. salvia divinorum) and synthetically produced drugs derived from cannabinoids (e.g. spice), cathinones (e.g. mephedrone) and piperazines (e.g. BZP) (Winstock & Wilkins, 2011;Zawilska & Andrzejczak, 2015). Initially called 'legal highs' (in United Kingdom prior to May 2016), most of these substances fell outside of existing drug legislation, which could account for their notable rise in popularity. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) reported that there were nearly 560 NPS being monitored across Europe in 2015 (EMCDDA, 2016). Reported deaths involving NPS have increased year on year: in 2013, 60 deaths involved NPS in the United Kingdom (ONS, 2013), 2014 163 deaths and in 2015 204 deaths (Home Office 2016b). The number of deaths in or following police custody (2016/17) show 14 deaths occurring (8 report mental health problems; 11 linked to alcohol and/or drugs) (Grace, 2017, p. 9). It is not possible to ascertain if NPS featured within this substance use. Elsewhere, the Prison and Probation Ombudsman report new psychoactive substances as an 'epidemic' (HM Government, 2017, p. 9) with 79 prisoner deaths linked to NPS (2016) since 2013. NPS are now illegal in the United Kingdom to produce or supply, although not illegal for personal consumption except within a custodial setting (Psychoactive Substances Act (PSA), 2016).
The current status of NPS has some ambiguity from the perspective of community-based law enforcers, third sector organisations and users. The legislative change has received criticism from leading scientists, and 40 prominent scientific and policy figures have described it as 'unenforceable in practice' (Reuter & Pardo, 2017, p. 26). This is echoed in the EMCDDA (2016) report which states that the rapid change across European illicit drug markets has meant that public authorities enforcing drug control laws have struggled to keep up. In particular, this context makes it challenging for the criminal justice system in the United Kingdom to enforce punishments to deter and punish supply of NPS because, in criminal law, there must be certainty around what the substance is, that it also produces psychoactive effects upon consumption, while navigating specific legal exemptions (Baron, Elie, & Elie, 2011;Elie, Elie, & Baron, 2013;Easton, 2017;EMCDDA, 2016;Reuter & Pardo, 2017).
In the United Kingdom, the maximum penalty for production or supply of NPS is seven years imprisonment. While controlling the supply of NPS is challenging, negative behavioural consequences of NPS consumption mean that the users of these substances also frequently transgress the law, are arrested and detained in police custody suites (Winstock & Wilkins, 2011). Police staff (and other emergency responders) report a rapidly increasing workload due to NPS use. This is alongside a lack of confidence about identifying precisely what substance has been used and its likely effects, possible interactions with other substance use (PHE, 2016) and challenges regarding how to manage and provide appropriate care for detainees. While police staff have a duty of care towards detainees, there remain uncertainties about staff and detainee safety in the custody suite setting, compounded by other factors influencing behavioural disturbances such as diagnosed and undiagnosed (or unrecognised) mental disorders (McKinnon, Thomas, Noga, & Senior, 2016).
Detention in police custody can be for unlawful activity but also to provide a place of safety for individuals who are a risk to themselves or others (Birch et al., 2015;Borschmann, Gillard, Turner, Chambers, & O'brien, 2010;Boyd, Fast, & Small, 2016;McKinnon et al., 2016). Thus, detention can provide an opportunity to link in with services that could support the individual through a strategic care pathway around NPS (Bradley, 2009;Newbury-Birch et al., 2016). This is in line with the UK government's focus on the way that police custody should be responding to the wider health and social care needs of arrestees (HM Government, 2009, Her Majesty's Inspectorate of Constabulary (HMIC), 2015). Reuter and Pardo (2017) identify that part of the complexity of managing NPS use involves their consumption with or alongside other substances (polysubstance use). Specifically, this raises the possibility of harmful drug interactions and effects. There is also concern raised about the types, methods, potency and stability of NPS. However, it is also possible that NPS are being substituted by users for what are considered to be more harmful drugs (e.g. heroin) (Reuter & Pardo, 2017).
There is a pressing need to understand the intersections between NPS and other substances and how they impact on police custody (Kaner, 2012;Newbury-Birch et al., 2016). Drawing on data from a qualitative study of police staff and NPS users, we explore the similarities and differences in treatment and management of NPS in custody, and how these substances are policed compared with other substances.

Methods
We used in-depth qualitative, semistructured interviews to explore the impact of NPS use on police staff and users within a custody suite setting. To reach NPS users, we used purposive and snowball sampling techniques. Participants were also recruited via publicity material from custody suites (police staff only), through social media and third sector organisations.
To be eligible to take part in this study, the participant had to be aged 18 or over, present as alert and orientated; able to speak English, and have some experience with NPS. Exclusion criteria included suffering from a serious mental health problem, injury, gross intoxication or unable to consent. Eligible participants gave written, informed consent to be enrolled into the study.
We conducted in-depth interviews with 15 police staff (11 male; 13 detention officers, 2 senior) and 25 self-identified NPS users 1 (9 female/16 male; 18-46 YRS; (self-identifying) 8 infrequent user; 13 current user; 4 ex user; all were Caucasian; 3 LGBT) during the 12-month study period. Interviews were structured via topic guides, but emergent (unforeseen) issues were explored further in subsequent interviews. Recruitment of interviewees continued until data saturation was judged to have occurred on the basis of the study objectives and in discussions with the external steering group. All interviews were audiorecorded and fully transcribed and narrative accounts were used to enable thematic analysis of key issues.

NPS users
NPS users were seen as a diverse group by police staff. Most officers reported that use was most prevalent in vulnerable people that they had encountered within custody. Particularly, those who were homeless, in supported accommodation, or had been in care as a child. However, it was also recognised that NPS could be used by anyone: One is your drunk and disorderly [ … ] those type of individuals could be absolutely anybody. It could be your professionals; it could be people that partake in crime in other types of criminal activity.
[ … ] Then, you've probably got that separate group of some other people who are struggling with, possibly, mental health issues, don't have the support network around them, the likes of your homeless people. People who are on the fringes of criminality. [Senior police staff 13,FEMALE] Almost all users felt stigmatised for using NPS (termed 'smeghead') and some purposely consumed NPS out of sight of the general public to avoid being shamed. I don't do it in the town centre and fall asleep in the town centre. I take it back to my bedroom. Because I know when you walk about and you see people, how many of the people in the town centre are looking at you saying "Look at the state of that. Look at the state of that. [NPS USER 4,MALE] Mental health was a significant issue among users, but it was unclear whether issues were a direct cause or consequence of initiation into NPS use.
My substance abuse problems continued throughout that and I experienced periods of, you know, like nervous breakdowns and getting in trouble, you know, with the police and getting arrested.
[NPS USER 6, MALE, 43 YRS] The use of NPS was also linked to exploitation. Some reported taking advantage of others in order to fund their usage: I was getting Carer's Allowance for my uncle. I was actually meant to be caring for my uncle and I wasn't. I was just … I wasn't doing anything, I just looked after myself and wasn't even doing that. I looked ill. [NPS USER 14,MALE,25 YRS] While users might not acknowledge the risks taken when using NPS some did express concern for others who were deemed to expose themselves to increased risk of harm.
The way I've seen them on the streets anything could happen to them and I mean anything. They could, the girls could get raped or anything like that. [NPS USER 18,FEMALE,37 YRS] Participants described the appeal of NPS being linked to the brightly coloured foil packaging. NPS were often specifically given names that were related to youth culture around computer gaming, adventure sports, superhero characters and iconic films.

Psychoactive Substances Act 2016
While the PSA deterred a minority of participants, those who self-identified as still using (n ¼ 21) reported that they were accessing NPS illicitly through street dealers and at social events via friends and associates. Few reported using the Internet to access NPS. A number of these participants were already involved in criminal activity to fund their lifestyles prior to the PSA. Further, participants often found themselves in custody because of acquisitive, violent or Public Order offences, whilst also using NPS. I would steal things like aftershave and perfume and stuff. Instead of selling them and getting more money than what I could I was swapping them for the 3gm. If it was a really expensive perfume 6gm or 4gm. [NPS USER 16,FEMALE,18 YRS] There was some ambiguity among users about how long NPS would be illegal under the PSA.
So when is this blanket coming off? It's only a blanket ban for now, isn't it? It's not banned completely. [NPS USER 4,MALE] One participant commented that the PSA would not deter those who started using prior to the law change because usage was already established: Even though the government have tried to address it and make it illegal, a lot of people still started using it when it was classed as being legal. It's more -I think it's more accessible now [ … ] a lot of the premises are still sellingthat used to sell it are still selling it, but they've just made it-they've put it into the backroom or upstairs, hidden away [NPS USER 6,MALE] Everyday experiences of NPS and other substance use: similarities and differences Cannabinoid or cathinone varieties of NPS tended to be the most popular among users in this study, producing effects similar to depressants and amphetamine-type stimulants, respectively. NPS were variously compared by participants in their everyday experiences to a range of other illicit substances that they used like cannabis, cocaine, ecstasy and most notably, heroin. Interestingly, NPS were described as producing distinctly different effects compared to alcohol. It was emphasised by some participants that NPS should be controlled as a Class A substance under the Misuse of Drugs Act 1971 because of their perceived effects and social harmsthis mainly related to Spice and it's recurring comparison to heroin: At least with heroin, if you take that you couch out and you fall asleep, or with cocaine you're high, you can still move, you know what's going on. With that you were high, you couldn't move, but you knew what was going on and it was just not a buzz that I liked. [EX NPS USER,MALE 02,40 YRS] Experienced users attempting to transfer knowledge and practices from traditional illicit substances to unfamiliar NPS described experiencing negative effects: I thought for two years that you had to smoke it like weed to get a buzz, but no one actually realises you only need a couple of flakes to get that buzz. [NPS USER 7,MALE,20 YRS] For some, getting the combination of quantity, potency and method imbalanced (or indeed relying on pre-made joints] led to serious consequences to their health, with one participant stating: I got something called Red Dragon. It's a pre-rolled spliff type thing of legal high. It is so strong and so lethal that I took one drag from it and ended up in the back of an ambulance. [NPS USER 10,MALE,28 YRS] NPS was perceived to be better value-for-money due to greater potency than traditional illicit drugs: I was taking speed and everything and got to the point where they weren't doing anything for us and I thought I want something stronger. Legal highs were stronger. [EX NPS USER 14,MALE,25 YRS] Users reported concerning adverse effects resulting from the combination of NPS consumption with alcohol, as well as increased vulnerability: He'll drink [four cans] and get mad drunk and smoke legal high and you have to watch him "Joe, people will rob you. You'll fall asleep. Watch what you're doing!" I wouldn't like to see him end up in hospital. [NPS USER 4,MALE] Furthermore, one participant described his experience in hospital after consuming alcohol and NPS. He gave an insight into the uncertainty expressed by emergency staff regarding treatment.
I was in hospital once and that was because I was drinking on a legal high so I had to get my stomach pumped. It was the worst thing ever [ … ] they weren't going to do my stomach, they weren't going to pump it because of the legal highs, they said they didn't know which way to go about it. Then they just done it because I was in agony I couldn't cope, I was spewing and everything. I think I give myself alcohol poisoning as well. [EX NPS USER 14,MALE,25 YRS] Intersections of NPS with other substances in custody: staff perspectives The use of NPS with other substances by users impacted on their experience of custody. Further, detention officers faced a number of issues identifying whether a person had taken NPS, taken another drug and/or consumed alcohol. This impacted upon their ability to manage risk, safety and provide care to NPS users. Often these officers were reliant on the user declaring the substance they had taken, or the officer finding the substance when booking the detainee into custody. Detainees demonstrating erratic and harmful behaviours were often placed under level four 'close proximity' surveillance. This is used for detainees risk assessed as being at the 'highest risk of self-harm' under the Police and Criminal Evidence Act 1984 (PACE, see Criminal Justice Act, 2003) and allows for quick and immediate intervention in the event that there is a threat to life.
The problem comes if they start harming themselves; if they tie things around their neck, or bang their heads on the wall, or even fall over by accident, then we have to enter the cell and stop ituntie whatever's round their neck, or stop them banging their headthat's when it becomes a problem, because it puts officers and staff at risk. It's also resource intensive; we might have to handcuff them, we might have to leave an officer with them on close proximity supervision, and it's just very resource intensive.
[Senior police staff 2, MALE] This senior officer described the NPS users he and his staff interacted with in custody as mainly long-term users, presenting with ongoing polysubstance and dependency issues: They're generally not people that we haven't seen before. There's very few, in my experience, [detainees new to custody]. Because of legal highs, I would think it tends to be those who are more prone to offend while on drink or drugs anyway. [Senior police staff 2, MALE] Some detainees were described as 'addicted' to NPS; however, a number of custody staff were dubious about its addictive potential: We've got a couple of lads that come through who are addicted to legal highs, or that they tell us they're addicted to legal highs. Whether you can be addicted to whatever is in these, I don't know. I guess you probably could if you're taking them as frequently as that. [DETENTION OFFICER 01,MALE] Detention officers described different typographies of NPS consumption, these include those who only used NPS, to those who combined NPS with alcohol or other drugs: … they're just generally using everything … everything they can get their hands on. Well, any street drug. [DETENTION OFFICER 07,MALE] Staff noted a divide between traditional drug users and NPS users; patterns of alcohol/polysubstance use also varied: There is a slight divide where you've got your alcoholics who won't touch drugs, but then you've got the drug users who don't drink because it reverses what they're getting from drugs. There's definitely people who do dabble in both who come in. I've had conversations with people … and they'll say, "Oh no, I wouldn't touch legal highs, I've just done heroin"' [DETENTION OFFICER 12,MALE] Detention officers reported that NPS use formed only part of a spectrum of different substances frequently used by custody detainees. Ultimately, however, the custody officers spoke of not knowing for sure what the users had taken and in what combinations. Often the detainees themselves would express ambiguity about the contents of their NPS. This lack of certainty about the content, quantity and potency of NPS were mirrored in the unpredictability of detainees' behaviour which became very challenging to manage within a custody environment. Although unpredictability was also a factor with traditional substances to an extent, what was distinctive about NPS users was that staff had not witnessed such erratic behaviour previously. Staff had a limited knowledge base of managing the physical and mental effects NPS.
Sometimes you just don't know what they've taken. They can be fine one minute, then they're kicking off the next, then they're crying, and then they're trying to fight the world, and then they start self-harming, and then they go back crying, and then they're fine again. You just don't know what they're going to do next. [DETENTION OFFICER 11,MALE] It was believed by some officers that it was the cocktail of substances: NPS with either other illicit drugs, prescription, medication and alcohol that was problematic. For others, the key issue was NPS itself because the substances lacked standardisation and changed within and between batches: I think the problem is not just the drugs themselves and the effects they're having but what they've been mixed with.
[ … ] we don't know what's in legal highs there's no standard … … you don't know what's going to be reacting [with] whatever else they could be taking. [DETENTION OFFICER 15,MALE] NPS and the unpredictability of user's behaviour when taking NPS was often compared with alcohol, which was seen by many staff as 'the worst' substance in terms of the behaviours exhibited, and management of them within a custody setting. Having knowledge of what kind of behaviours might be associated with different levels of intoxication assisted officers in managing these detainees. In contrast, the production techniques involved in NPS created large variation in dosage and potency, making it difficult to predict how a user would react in custody: Because [NPS are] made in clandestine laboratories, because there is no control measures in relation to what's going in and what's going out, what you get in one packet might not be the same [.] so therefore your tolerances are not the same. Also, if you were to take cocaine or heroin, the purity of that is relatively small: 5, 10%. When you take an NPS, you think, "Well, I can take a gram of cocaine." For exampletake a gram of NPS, because it's in an unadulterated form, it's a massive difference, and that's where we have the problems. [DETENTION OFFICER 03,MALE] While managing people who had consumed alcohol was a real concern to officers, especially when detainees exhibited problematic behaviour and heightened risks around alcohol withdrawal. These concerns were amplified further when trying to manage the potent and unpredictable mix of alcohol and NPS: Sometimes their behaviour can be very bad, almost like they don't know what to do sometimes, just very strange behaviour. Some go to sleep, but some don't [ … ]. I've seen people with some very strange/odd behaviours, especially with it mixed with alcohol. You don't know, is it the psychoactive substance or is the alcohol causing it? [DETENTION OFFICER 06,MALE] Care provision within the custody environment The custody environment is challenging. Officers have to handle some of the most volatile, vulnerable and demanding members of society while undertaking their duties. Unlike other police positions, the key role of detention staff is the welfare of detainees as they either enter into the criminal justice system or are released back into the community. As one of the officers described: We're the in-between, we're just caring for them whilst that is going on and we're facilitating that. We're not here to give them a hard time or to make it any worse. If they're cold, we should be giving blankets. If they're dehydrated, we should be giving water. [DETENTION OFFICER 05,MALE] Officers generally considered themselves to be well equipped through their basic training, knowledge and experience on the job to deal with a wide range of issues and behaviours as part of their role. They felt confident in dealing with people who presented under the influence of alcohol, heroin, cocaine and other substances. However, NPS presented a new challenge to these staff. Those attending custody having consumed NPS displayed unusual, intense behaviours compared with other substances. Some officers described how many users were in such a high state of intoxication that it was challenging to ascertain what had been consumed. Therefore, other processes, particularly the on-site custody nurse formed a crucial part of the risk assessment process. Having the nurse within a custody environment 24 h a day/7 days a week, was described by all detention officers as being crucial in monitoring and managing risk. Staff were not clinically trained and were faced with other pressures, for example, having to deal with, care for and manage other detainees presenting with complex needs. Detention officers were cautious about managing the potentially harmful effects of NPS consumption and would frequently refer detainees to hospital if there was any uncertainty about the behaviour they presented.
It's a lot more stress, because we aren't medically trained. We've got a Level 3 First Aid … We've got one custody nurse and she's great and she'll go round [but we are a 50 cell complex with other health issues] you've got such a massive strain and stress that [NPS] then on top -it's like the cherry on the cake [ … ] because they are so unknown: with heroin and cocaine and stuff you know what it is, you know how to treat it, you know what to look out for, you know the symptoms and you know the dangers of it. With this, you don't know, so we try to edge on the side of caution and send them to hospital or the nurse' [DETENTION OFFICER 12,MALE] Some expressed a sense of frustration, perceiving the skills, tools and experience they possessed were relatively useless in this situation. Dealing with problematic users could be time-consuming for the officers involved and costly. They felt helpless to provide support and were left providing standardised care following a strict protocol of cheques and monitoring based on risk assessment: We get the job based on our people skills and our negotiation skills, with fairly aggressive and volatile people. However, people skills go out of the window when they're on this, because their personhood has been affected. They're not people, in the classic sense of the word. They're a, kind of, jumble of animal instincts … It makes it impossible to know how to formulate an actual plan of action with them. You don't know whether you should be constantly monitoring them, or leaving them for a bit, thinking that they're going to be alright. It puts you on high alert, and you just, you can't help thinking you're not doing the best for that person, because their behaviour is so erratic. [DETENTION OFFICER 05,MALE] Managing NPS use and providing appropriate care was priority for these officers, but they expressed feeling ill-prepared and uninformed, as well as under resourced to adequately deal with the impact of NPS on custody.

Discussion
The literature regarding NPS remains at an early stage of development. Our data show that emergency services (e.g. police) and third sector organisations are still adjusting to the changes brought about by the PSA 2016. The speed of change in the production and distribution of NPS often makes it difficult for police staff to prove what a particular substance is and whether it is psychoactive upon consumption (Baron et al., 2011;Elie et al., 2013;EMCDDA, 2016;Reuter & Pardo, 2017). Suppliers of NPS are not concerned about maintaining particular versions of NPS, as Evans-Brown and Sedefov (2017, p. 37) state, 'In reality, most new substances are disposable, as manufacturers have replacement substances ready for sale even before a substance is controlled; the recipes for many thousands more are in the scientific and patent literature ripe for the picking' (for toxicology guidance see Abdulrahim & Bowden-Jones, 2015). These challenges make it difficult to enforce punishment within criminal justice systems. The Home Office (2016a) report that only four out of 500 individuals arrested under the PSA 2016 received a custodial sentence.
Over 23 varieties of NPS, ranging from stimulants to cannabinoids, were named by participants in this study. Often they were perceived by police staff as being aimed at younger substance users; however, our data show that a wide age range were attracted to them. Part of the appeal of these substances was linked to low cost, the unique, brightly coloured packaging and brand namesan issue also recognised by the police staff.
NPS, both cathinones and cannabinoids, were having a striking effect on custody suites, adding pressure to already overstretched police staff. Within police custody, detention officers followed standardised risk assessment procedures, but the level of risk for NPS users was difficult to ascertain. Young people and polydrug users were identified as being most at risk to themselves and to other people. Although officers recognised the general vulnerability to exploitation among users, it was the nature of NPS and the potentially explosive and unpredictable behaviour that caused most concern. The custody nurse was considered to be a particularly valuable asset when managing risk around NPS. It enabled shared responsibility for the care provision of NPS users and provided clinically informed support. This helped to bolster the confidence of these officers. Despite the employment of custody nurses being force specificthere are clear advantages of including a nurse within a custody setting across different forces (Hurley et al., 2013).
The notable intersections between NPS and other substances (including alcohol and heroin) suggest potential commonalities about how NPS can be managed alongside other substances (Abdulrahim & Bowden-Jones, 2015;Kaner, 2012). However, police staff reported feeling inexpert about responding to the needs of NPS users compared to 'traditional' substance users, which was further complicated by polysubstance use. Detention officers relied on their own initiative and support from colleagues (including custody nurses) when dealing with more problematic NPS users. Further basic training around these intersections of substances, particularly with alcohol, could potentially reduce risks for officers and detainees and improve the detention officers' capacity and confidence to meet their obligation to detainees.
It is evident among participants that NPS are rarely used in isolation and were frequently mixed with alcohol and other substances. NPS were often taken as a cheaper alternative to the substance they were supposed to mimic, but it was unclear to many users what NPS were 'cut' with during their formulation, compounding the unpredictability of effects and consequences. It is unclear how interactions between NPS and other substances might impact on longer-term health, particularly among vulnerable individuals experiencing social disadvantages, stigma and comorbid physical and mental health problems. Ultimately, custody is a challenging and highly pressurised environment which, as our data show, magnifies the complexity of issues around NPS use and places additional strain on custody staff.
While the PSA 2016 has impacted on the supply and availability of NPS, thus restricting use among new users and experimental users, NPS is still available and used among vulnerable communities and was sometimes linked to situations of exploitation. Hence, police staff often found themselves dealing with safeguarding as well as complex substance use challenges.

Conclusions
The intersections and associated harms of NPS with other substances are not clearly understood by users in this study nor staff responsible for keeping them safe. Moreover, the research evidence base around polysubstance use of this nature remains under-developed.
NPS should be considered a high public health priority because of their perceived addictive potential: 'for many users the drug turns out to be addictive and long-term dependence has dangerous behavioural and health consequences' (Reuter & Pardo, 2017: p. 27). NPS are having a significant adverse effect on custody staff, adding pressure on already overstretched police services. Our study highlighted that this threat to public health and impact on custody is exacerbated when NPS are used in combination with other substances like alcohol or other illicit drugs, potentially producing harmful interactions as well as increasing risky and unpredictable behaviour.
Further research is needed to explore the impact of NPS on immediate safety concerns and longer term health consequences including addiction, costs to services, as well intervention development to reduce recidivism, improve health outcomes and relieve some of the workload impact NPS is having on the police. Many NPS users are highly vulnerable individuals with a number of physical, mental health and social problems. Thus, future research and practice needs to focus on issues of care and safety, rather than emphasising control and containment.