Advocates maintain pill testing is firmly proven to reduce drug fatalities, but opponents are equally adamant they hold the moral high ground
As medical organisations now lend their voice to the growing public call to trial pill testing in Australia, police groups and state governments for the most part, continue to dig their heels in.
The recent spate of young people dying at music festivals are now bringing the debate to fever pitch.
Those in favour of pill testing – also known as drug checking, adulterant screening and safety testing – say that informing users about the contents of their drugs will save lives by flagging potentially toxic ingredients.
Those against it believe it will only make the problem of illicit substance taking worse, by giving users a false sense of security about their drug use.
Curiously, both say they have evidence on their side. The NSW premier Gladys Berejiklian has said her government would consider the strategy if they could ensure lives were saved, but that there was “no evidence provided to the government on that”.
On the other hand, the Royal Australian and New Zealand College of Psychiatrists says overseas examples firmly support its introduction.
“Pill testing is an example of an evidence-based, tried and tested method of harm reduction that could save lives and prevent the suffering of family, friends and communities,” it said in a statement late January.
Professional bodies for physicians, emergency doctors, nurses, the AMA and the RACGP president Dr Harry Nespolon have all weighed in with the psychiatrists in calling for trials of pill-testing here in Australia.
But it should not just be a case of which side do you back. Dr Rob Page, a Sydney GP who has worked at supervised injecting centres and other harm reduction services, says it is important for GPs to sidestep the politics on this issue and evaluate the research.
“Doctors are scientists and we should really know what the evidence is around something before we’re speaking to it.”
So what is the evidence?
Green lighting
One of the major arguments repeated by politicians and police is that allowing pill testing to occur at festivals or elsewhere will send the message that taking drugs is safe.
The Victorian health minister Martin Foley recently said that the state’s police advised them that pill testing would “give people a false, and potentially fatal, sense of security about illicit drugs”.
Similarly, the NSW deputy premier John Barilaro described pill testing as a “regime designed to give your loved ones and their friends the green light to take an illicit substance at a music festival”, in a recent article in the Sydney Morning Herald.
This is absolutely at odds with the reality of how pill testing actually works, advocates say.
Associate Professor David Caldicott, one of the doctors at the Canberra “Groovin’ the Moo” festival trial, says the “very foundation” of what they were doing was discouraging the consumption of drugs.
“The first thing we say to young people who come to us is ‘If you do not want to be harmed by the drugs you want checked, you should not consume any drugs today’,” says the senior lecturer and emergency consultant at the emergency department of Calvary Hospital.
Drug testing services around the world operate slightly differently, but at Groovin the Moo the team of doctors, chemists and other staff set up a tent so that festival goers could come in to see what might be in the drugs they plan to take.
As they walk in, Professor Caldicott says they are greeted by somebody who introduces the service and explains what it offers and the limitations of the equipment. At no point is a visitor ever told that the drugs are safe or that their drugs are good, he emphasises.
Instead, they run the analysis and provide specific information on what substances are in the pill or powder, and what that means from a medical standpoint.
At this festival, users would walk into a room and decide how much of their pill or powder they wanted to sacrifice for the test. They are told that the more they provide, the better an estimation of the whole batch’s purity the machine could provide. Users of the service typically provider a quarter or a half of a pill to be tested.
The analysed sample is placed onto a platform where an infrared spectrometer determined the fingerprint of the chemicals in the substance. This was then run against a database of 30,000 or more chemicals that is updated weekly courtesy of international databases. The answers from the analysis were usually ready within a minute.
At this particular trial, the test was conducted by a senior chemist from Australian National University, who also does analyses for prestigious organisations like the drug checking regulator WADA.
The sample was then discarded, effectively taking it out of circulation.
Rather than giving the client the “green light” to take drugs, the staff gave the drugs one of three categories: white, yellow and red.
White meant the sample has what the user expected in it, and yellow meant the sample had something other than what the user expected in it. So if a user thought they were getting MDMA and it had ketamine or perhaps a cheaper new substance, then it would get a yellow categorisation.
“This is one of the more hazardous ways you can consume drugs,” Professor Caldicott says. If somebody bought what they thought was MDMA and it was instead ketamine, ingesting it like MDMA could be dangerous.
In the 85 samples tested at the festival, a whopping 50% weren’t what the user anticipated. Overseas research showed this revelation often led people to discard their drugs, and undermined their faith in the market more broadly, Professor Caldicott says.
In Canberra, the team found adulterants such as evaporated milk and paint had been used as cutting agents.
In a world where new psychoactive substances are burgeoning, it’s also quite possible that people could be getting a more experimental drug without realising it.
The database used by Professor Caldicott and his team included all of the 750 or so known novel psychoactive substances, and during their testing they found one sample that was known to be linked to overdose deaths overseas.
In addition, there was yet another which wasn’t recognised by the database at all.
These both got a red categorisation, the clearest warning of danger they could give.
A UK festival trialled onsite testing for the first time in 2016 and found that one in five samples were not actually what the person believed they had bought. And when drugs weren’t being cut with cheaper psychoactive substances, they sometimes had cutting agents such as chloroquine, benzocaine, caffeine, ephedrine and paracetamol.
When the festival goers discovered the drug wasn’t what they thought, two out of three decided to discard their drugs. Overall, one in five of the people visiting the pill-testing service disposed of their drugs, and one in six said they would take less or take it more slowly than they would have before.
“This pilot suggests that festival-goers engage productively with onsite drug safety testing services when given the opportunity, such services can access harder-to-reach and new user groups and can play a part in reducing drug-related harm by identifying and informing service users, emergency services and offsite drug using communities about substances of concern,” wrote author Professor Fiona Measham, a professor of criminology with Durham University, in her analysis.
Another potentially positive sign, was that even though that year had the highest number of drug-related deaths at UK festivals on record, this trial site had none. There was also a 95% reduction in drug-related hospital admissions that year compared to the previous year when no pill-testing occurred.
Several things could explain this drop: that the trial raised awareness of contaminants among patrons and medical staff, and that those visiting the service spread the harm reduction messages they had heard onto their friend group, Professor Measham said.
Having this information out there led users to seek medical help more quickly, and, more confidence among medical staff at the festival meant many drug-related health issues were able to be managed on-site rather than requiring hospital transfer.
So what about the idea that giving a drug a white categorisation implicitly confers a degree of approval for use from the medical profession?
Aussies already have a voracious appetite for illicit drugs, consuming more than most other countries. Half the population has used illicit drugs in their lifetime and one in four young Australians have used illicit drugs in the last 12 months, according to the 2016 National Drug Strategy Household Survey. This was most commonly cannabis, followed by ecstasy and cocaine, and then methamphetamines.
Most people don’t speak to their healthcare professional about their drug use, however.
“In an ideal world, [these discussions] would happen in a primary care setting, but we live in an imperfect world unfortunately,” Dr Page says.
But people feel more comfortable asking questions and discussing drug use in a clearly accessible service dedicated to it, like pill testing, where the doctors, nurses and social workers are all knowledgeable and comfortable speaking about it, he says.
Rather than giving someone the thumbs up about their ketamine powder or MDMA crystals, Dr Page says the chemical analysis commonly triggers a discussion of the specific risks of that substance and harm reduction strategies.
It is also explained to clients that the analysis is not foolproof, it is possible there might still be potentially dangerous and potent contaminants that the analysis can’t detect. He says staff might also tell a visitor about the combinations of drugs or substances that are more likely to cause harm, or to suggest taking a quarter of a tablet first and waiting an hour or so if they have a high potency MDMA pill, for example.
Dr Monica Barratt, the author of a recent review of drug checking services around the world, backed this up, saying that all the official pill testing services operating currently provided users with some sort of intervention session with staff, and almost all provided harm reduction information or counselling.
The social scientist at UNSW’s National Drug and Alcohol Research Centre looked at 31 different services in Netherlands, Switzerland, Austria, Belgium, Germany, Spain and France. The oldest, in the Netherlands, has been in operation for 25 years.
She says that in all that data, there were no signs that pill testing or drug checking had any negative effects such as increasing drug use among individuals or across the community.
“We know that many of these people don’t otherwise talk about their drug use with any health professional, so this is a real moment where you’ve got a captive audience which is quite hard to reach,” she says.
“I think that’s quite powerful.”
Red herring
Another argument against pill testing is that the information it gives doesn’t give enough relevant information.
The NSW premier put it this way on the Today Show: “What pill testing doesn’t do is take into account different people’s physical attributes.”
“What is safe for one person isn’t safe for another, what is a safe dose for one person isn’t a safe dose for another.”
This underscores another criticism of the Canberra trial, which was that it didn’t include information about the purity about the drugs.
Some of the recent deaths have been thought to be caused by high doses of MDMA.
If further pill testing trials were to happen in Australia, Professor Caldicott says he would like to see at least one more piece of equipment added in to enable purity testing.
Similarly, Dr Barratt says that ideally a patient service would be able to say, “The sorts of pills we’ve been seeing around this festival vary from no MDMA, to 20mg per pill, to 100mg, 150mg, 200mg and 300mg”, to give users a sense of scale of the difference of strength.
This was important because there was some evidence that Australians, in particular, were doing things like double dropping, taking two pills at once, while not knowing the strength of the pill.
“That’s a potentially catastrophic event if they’ve [taken] a 300mg pill,” she says.
The NSW premier has argued that an idiosyncratic reaction to MDMA means that anyone could have a harmful reaction, and for that reason any softening on the “Just say no” stance is putting lives at risk.
While advocates agree that there can be harm at any strength, purity can be a very helpful piece of information keeping people safe. Many testing proponents point to the recent approval of the US regulator to test 75mg MDMA in trials for PTSD, which undermines the idea that the substance is unsafe at any dose.
What is quite likely is that people are either taking too high a dose or not hydrating properly and risking hyperthermia, especially in this hot summer, or suffering hyponatremia from too much liquid, Dr Page says.
At the moment, it’s virtually impossible to know whether this is one of the causes behind the recent spate of festival hospitalisations, but it is vital knowledge that could be gleaned by the introduction of pill testing services.
The broader benefits
Having information about abnormal patterns in the drugs circulating would be useful, not just for people who use drugs, but also the general public, the police and anyone in health professions, Dr Barratt says.
Some international services send alerts to government, health organisations or event managers to alert groups to possible drug market changes and allow health services to reduce harm or respond more quickly to overdoses where possible.
A 2012 analysis of the two decades of Dutch testing and monitoring service (DIMS) clearly outlined how these services can save people’s lives.
In late 2014, the service found some pink “Superman” logo pills containing 173 mg p-methoxymethamphetamine (PMMA), a drug sometimes mis-sold as MDMA, and issued immediate red alerts on national television.
Nobody died from taking these pills.
“In the UK by comparison, without a national testing service or pre-emptive alerts from the authorities, four people died after taking similar pink Superman pills containing PMMA within a fortnight of the DIMS alert,” Professor Measham commented in her article.
“Overall there is no evidence that drug prevalence, initiation or mortality rates have increased in European countries with drug safety testing by comparison with those without.”
The slippery slope
But there’s another concern, and that is that pill testing is driven by advocates who “want to legalise drugs by stealth”, NSW’s police commissioner Mick Fuller told The Australian newspaper.
Australia’s national drug strategy has three pillars in minimising drug-related harms: reducing supply, reducing demand and reducing harm. The lion’s share of resourcing has traditionally gone to the law enforcement, but that approach isn’t a sacred cow for those looking for the best ways to minimise harms overall.
Professor Caldicott points to the evidence that pill testing can change the manner in which people consume their drugs, and that way is “the way that is less likely to have them end up in hospital”.
“It’s not addressing the nature of their eternal souls and the morality of drug use – that’s not my gig.”
“We can keep throwing good money after bad,” Dr Page says. “But people know that using things like heroin or methamphetamines are dangerous, people know that you can die if you take a pill, and yet people continue to do that.
“People know that you can get put in jail for personal possession of drugs, people know that if you have enough to constitute dealing you can get thrown away for a long time, yet people continue to do those things.
“Do we just continue to increase the penalties? How far do we take this before we acknowledge that a certain population will continue to use illicit drugs?
“This has been happening around the world for decades, if not centuries or millennia, and for those people who continue to use drugs we need to provide better means of engagement and harm reduction and information gathering.
“I don’t think it’s enough to just continue to be punitive, because it just doesn’t work well enough.”
