Pill‐testing as a harm reduction strategy: time to have the conversation
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Perspectives
Pill- testing as a harm reduction strategy: time
to have the conversation
Despite harm reduction being a pillar of the Australian National Drug Strategy, cu
ent
governments are shying away from pill-testing as a viable strategy
The recent deaths of five young Australians at music festivals has once again placed pill- testing at the forefront of media discussion.
Rates of drug use are significantly higher among
certain subpopulations, with dance music nightclubs
and music festivals being examples of places with
elevated levels of drug use.1,2 Of 642 surveyed
attendees at an Australian music festival, 73.4%
eported drug taking compared with 28.2% of the
general young adult population, and for 3,4- methy
lenedioxymethamphetamine (MDMA; commonly
known as ecstasy) use, this was as high as 59.8%
compared with 7.0%.2 MDMA is increasingly
available in powder and crystal forms with street
names of molly, mandy and crystal, meaning some
users do not associate the drug with ecstasy.
Concerningly, the 2019 Global Drug Survey identified
Australia as the country with the highest number of
MDMA pills consumed on a single occasion (average,
2.0 pills v global average, 1.0 pills).3 Supporting this,
a survey of Australian music festival attendees found
that almost half (48%) of 777 respondents taking
ecstasy pills reported simultaneous consumption of
two ecstasy pills.4 Evidence of the dangers associated
with this behaviour can be seen in the global statistics,
with 2.3% of Australian users seeking medical
attention following MDMA use compared with a
global average of 1.0%.3
The toxicology of MDMA overdose involves
hyperthermia, seizures, hyponatraemia,
habdomyolysis and multi- organ failure causing
death.2 Hyperthermia is of particular concern in a
music festival setting; users often dance outdoors
for hours during the hot Australian summer,
with overheating, overcrowding and dehydration
complicating the toxic outcomes.5 Adulteration of
ecstasy is an additional risk factor, as drugs such as
methamphetamine or new psychoactive substances
are used to cut or replace MDMA to increase profits or
avoid legal implications.5 New psychoactive substances
are designed to mimic established illicit drugs but have
significantly different toxicity profiles to the drugs
they are mimicking.5
The three pillars of the Australian National Drug
Strategy are reductions in supply, demand and harm.6
Harm reduction interventions at festivals/nightclubs
include the availability of drinking water, chill- out
spots and first aid treatment.6 Despite harm reduction
eing a major focus, pill- testing, which fits clearly
within the scope of the harm reduction pillar, is not
cu
ently being considered by Australian governments.
Harm reduction policies involving illicit drugs are
understandably complex because of legal implications;
however, the Uniting Medically Supervised Injecting
Centre in Sydney7 is a real world example of how
public health workers and law enforcement can work
collaboratively to develop a positive relationship with
the explicit aim of harm reduction.
One of the major difficulties when considering
pill- testing programs is that there is no cu
ent gold
standard system in place, with major differences
etween techniques, accuracy, whether results are
qualitative or quantitative, and the method by which
esults are presented to users. For a summary of the 29
organisations across the globe offering drug-checking
services in 2017, see Ba
ett and colleagues.8
Pill- checking models can be classified
oadly into
two categories. The first provides results directly to
the patron who submitted the pill; in best practice
this involves a face- to- face interaction with a health
care provider, while the public is informed only of
especially dangerous pills. United Kingdom pill-
testing service provider, The Loop, employs this type
of model; it was also used in the Australian pill-
testing trials at Groovin the Moo in the Australian
Capital Te
itory in 2018 and 2019.9,10 The second
model involves public posting of results on notice
oards or the internet with a “good
ad” or “green
orange
ed” ranking applied to each pill. This model
is used by DanceSafe in the United States and the
Drugs Information and Monitoring System in the
Netherlands.8 We highly encourage that only the first
of these models be pursued in Australia, as the second
model is unable to provide a number of the harm
eduction benefits described below.
Pill- testing provides a clear benefit to information
warning systems and clinicians, providing ground
level data that systems based solely on drug seizures
or wastewater analysis do not reflect.11 While altering
lack market drug supplies is not a specific aim
of pill- testing, there is some evidence that drugs
identified as particularly dangerous cannot sell and
are removed from the market.11 Recreational drug
1 University of
Wollongong,
Wollongong, NSW.
2 Illawa
a Health
and Medical Research
Institute, University
of Wollongong,
Wollongong, NSW.
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doi: XXXXXXXXXX/mja2.50385
Podcast with Jody
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podcasts
Jody Morgan1,2
Alison Jones1,2
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users, who typically do not consider themselves as
having a drug problem, are unlikely to be involved
in traditional counselling or treatment facilities, with
nine out of ten pill- testing service users in the UK
never having discussed their drug use with a health
care professional.12 Thus, pill- testing provides a useful
opportunity not only to identify the most dangerous
drugs but also to engage with a vulnerable group
to provide education and connect users to support
services.6,11,13
Despite the fact pill- testing has been performed in
Europe for over 20 years, there is a significant lack of
data on the success of these processes as randomised
controlled trials are unable to be performed; therefore,
self- evaluation is often all that is available.11 One
possible gauge of success is the number of people who
indicate they would not consume the drug following
pill- testing. In the UK, The Loop found that 19.5% of 230
samples at a 2016 festival had a variance from what they
were described as containing (that is, the confirmed
identity did not match what the pill was sold as) with
an in- facility discard rate of 21.3%. This increased
to 66.7% when considering only samples which
significantly varied from expectation.9 Additionally,
there was a 95% reduction in drug- related hospital
admissions compared with the same festival the
previous year.9 The second pill- testing trial in Australia,
held at Groovin the Moo in April 2019, was deemed a
success following the identification of seven samples
containing the potentially lethal new psychoactive
substance, n- ethylpentylone.10 All but one of these
samples were disposed of in the amnesty bins onsite.10
Additional circumstantial evidence that pill- testing
saves lives could be seen when the Netherlands and
Belgium produced a mass media warning against a
particular batch of pills found to contain 170 mg of
paramethoxymethamphetamine via a pill- testing
service on 19 December 2014. Following this warning,
no deaths occu
ed in either the Netherlands or
Belgium. In the UK, however, the same pills caused four
deaths between 24 December 2014 and 7 January XXXXXXXXXX
Common arguments against pill- testing include: the
testing technique is not accurate enough to identify
all components; the techniques available onsite cannot
provide a quantitative analysis required to prevent
overdose; complaints from policy makers about lack
of proven efficacy of harm reduction from pill- testing;
an overall feeling that pill- testing condones drug use;
and the fear that dealers will use pill- testing results
to promote their
and. All of these arguments can
e addressed by a well designed system that focuses
on incorporating accurate pill- testing as a single
component in a larger harm reduction strategy. The
inherent risk that drug dealers may use the testing
to give a check of approval to their drugs1 can be
minimised by requiring that all patrons receive a one-
on- one intervention with a health care provider and by
ensuring that pill- testing results are provided ve
ally
only, with no hard copy evidence that dealers could
use to support their claim. Additionally, the idea that
“bad” drugs may be on- sold to other users shows the
importance of providing amnesty bins for drug disposal
within the pill- testing facility which can be emptied in
an agreement with law enforcement personnel.
It is important to remember that in order to participate
in pill- testing, the individual must have already
purchased the drug, assumedly with the intent of
consumption. Therefore, any information regarding
dosage or adulterants provided to that patron is with
the explicit intent of harm reduction. In any best
practice system there will never be a circumstance
where health care providers tell patrons that their
drug is safe to take. In fact, as Dr David Caldicott,
who was involved in Australia’s pill- testing trials in
2018 and 2019, has explained, the exact opposite is
true, with all patrons informed at every step of the
process that no amount of illicit drug consumption is
safe.10 Additionally, while some pill- testing programs
are entirely reliant on chemical spot tests or similar,
which are unable to provide details of all components
in a mixture or the strength of active components,
there are better analytical techniques available. The
common argument that gas chromatography–mass
spectrometry — which is seen as the benchmark of
analytical techniques as it is able to identify complex
mixtures and provide dosage data in a relatively short
period of time — cannot be used at onsite testing
facilities is no longer true, with handheld devices now
available. An investigation should be performed to
determine the viability of this technique. Although
advanced techniques are available, there is a clear cost
a
ier associated with equipment set- up.
Last year the Greens political party announced a plan
for a pill- testing model in Australia which has been
costed by the independent Parliamentary Budget
Office.14 This model included 18 pill- testing services
across the country, fully staffed with world class
spectroscopic equipment at an estimated cost of $16