For emergency doctors with an interest in illicit toxicology, the arrival of the summer months in Australia signals, like some sort of grotesque seasonal cuckoo, the beginning of the music festival season. With it, the entirely predictable and unnecessary deaths of young Australians from illicit substance ingestion.
For the more strident in the community, this serves as proof of the inherent danger of the products involved, particularly in a more volatile-than-usual market, and an inevitable by-product of a sub-culture that insists on breaking the law. That is a hard position to justify from the perspective of a medical practitioner – our credo is ‘primum non nocere’ – “first do no harm”- the genesis statement of harm reduction. What if I told you that there was a way to effect change in those highest of high-risk environments, to not only alter the way in which young people consume drugs, but to also sample the market in a way that currently can’t be done?
Well, there is.
But hang on, I’m getting ahead of myself. Let me start by first telling you a story. Trust me- it’ll make more sense that way. It’s the story of how I got involved in the world of ‘pill testing’, and patient advocacy in drugs policy. A story that starts with the death of a young man under my care. A young man that I felt we’d failed.
I was working at a major hospital in Adelaide, South Australia, in the Antipodean Winter of 2001. A young man in his 20’s – let’s call him ‘A’ – was brought to our ED by ambulance, following an unknown drug overdose. From the start, while it superficially bore all of the hallmarks of a sympathomimetic toxidrome, he seemed a lot… well, ‘sicker’. We were in the midst of our first generation of methamphetamine epidemics, which were generally marked by poor quality product, angry young consumers, and the regrettable emergence of drum ‘n bass in Australia. But sick like this? We’d seen nothing like it so far.
With no exaggeration, we did everything that was known in medicine at the time to keep ‘A’ alive, and yet 3 days later, he died. Sure, we had some idea of how he died, as far as which organs had stopped functioning, and the order in which they stopped, but no real feel for what was behind it all. Several weeks later, post-mortem toxicology returned the verdict; it was a substance called para-methoxamphetamine, or PMA. It turned out that ‘A’ had enjoyed PMA in the past; it was an experience he pursued, and had been chatting about it on a well-known forum. I, frequently touted as a supposed ‘expert’, had never heard of it before then.
‘A’’s death stayed with me. It’s not at all uncommon for emergency docs to ruminate on their losses, especially those where a patient wasn’t really supposed to die. Over and over, I went through my increasingly shabby copy of his notes, looking for a hint about what we might have done differently. We learned everything there was to know about PMA. It was the only occasion I ever had to speak with Alexander Shulgin, who had synthesized it, and consumed it, and written about it in PIHKAL. He seemed incredulous that it would be a substance that would be pursued and wanted to know what it was about Australians that made them so reckless. We wrote up the case, and the associated series, and wrote it in such a way that other users could easily read the paper.
And, yet… It seemed that once PMA had been ingested, the damage was done. It became clear that, as with so many other situations in emergency medicine, it was far more important and useful to prevent young people overdosing, than merely accounting for the bodies as they passed though our care.
We needed to stop people taking PMA.
In my spare time, I started casting around for simple solutions- any solution- that might help young consumers avoid the same fate as ‘A’. It turned out there was something out there, something that was emerging from Europe.
When MDMA was first brought back to London and consumed in the cramped quarters of Shoom, purity was not an issue. But as the market expanded from the ‘early adopters’ and went mainstream, it became tainted. Consumers, recognising this, developed regimes designed to keep safe. For the most part, they involved simple reagent tests- throwbacks from the late Victorian era- colour changes straight out of the laboratories of the League of Extraordinary Gentleman. Tests with exotic names like ‘Mandelin’, ‘Marquis’, are still used as presumptive tests by law enforcement globally. Testing was largely conducted by consumers, for consumers, with the notable and ever-innovative exception of the Netherlands. There, their DIMS service has been offering this service since the mid-80s.
With the youthful enthusiasm of a young man unfettered by any political wisdom, we met with the promoters of a regular fixture on the South Australian social calendar, The Enchanted Forest ‘rave’, as they were called then. DJs Devious, Odyssey and particularly DJ MPK were young entrepreneurs in their 20’s, who understood the need for the initiative, and had the moxie to support it.
Along with a group of harm minimisation advocates, Enlighten, we started onsite pill testing in South Australia in 2003. On the first outing, we had undercover (UC) officers with us to ‘seize’ the scrapings and bring them back to our laboratory, and compare our findings with the reagent testing. We originally had one of those officers as co-author on our paper ‘Underground Pill Testing, Down Under‘.
They eventually and reluctantly requested that their name be removed – at the proof stage! – on the insistence of the South Australia’s Chief Police Commissioner, who was alarmed at the extent of collaboration between medicine and law enforcement. While it was easy to find supporters in law enforcement at an operational level, we found that the higher up the chain of command we went in law enforcement, the more susceptible individuals were to direct political pressure.
Recognising this, we set up an open invitation for any members of our state parliament to come and see what we were up to first hand – and two did.
Both were converted to the cause, and facilitated educational sessions in parliament for those willing to attend. While we had no problem in achieving agreement from those already inclined to agree with us, one of our earliest lessons was that it was more important to gain audience with our opponents than it was to sing to the choir. We presented our findings to the Federal Parliamentary Group on Drug Law Reform, The Victorian Premier’s Commission on Drugs and numerous state agencies. Our reception was universally the same- frequently sympathetic, but politically, like so many other issues of drugs policy in Australia, it was considered a ‘third rail’ option. Australia was governed at the time by a particularly right wing neo-conservative government, who had resurrected the rhetoric of the War on Drugs as ‘Tough on Drugs’. There were consequences for openly defying ‘The Message’. Those who did were singled out.
The Federal member for Sturt in S.A. described me as “one of a long line of medical people who treat drugs as a health issue, rather than the self-harm and criminal offences that they are”. He went on to suggest that the idea of pill-testing, among others, represented “dangerous views, which if allowed to become mainstream, would undermine the Government’s policy of being tough on drugs.”
Our rebuttal gained some notoriety, but not many friends – we won a battle, but succeeded in driving the war underground. It seemed to be the right thing to do. The same minister never engaged with us publicly again, conducting instead a punitive campaign of intimidation against those who had collaborated with us. The harm reduction group, Enlighten, was asked for their financial records, and was effectively issued with a ‘cease and desist’. Then, Smith and Nephew, the major analytical company with whom we had obtained an agreement to field test a series of new ion scanners under development, suddenly withdrew their support. It wasn’t until several years later, at a conference on the other side of the world, that we heard that ‘pressure’ from official sources had been placed on them to withdraw support. When it appeared that several jurisdictions were beginning to seriously consider introducing pill testing, the same politician openly vowed to oppose it and block any progress. When it was put to the Ministerial Council On Drug Strategy in November 2004, it was predictably rejected, although the reasons for that rejection were never fully articulated. A subsequent Freedom of Information request for the details of the reasons behind the rejection was blocked on the grounds of ‘public interest’.
As well as the political opposition, we were also faced with the approbation of their indentured advisors. Opposition had been academically articulated in a single 2001 article by what now might be regarded as the formidable trio of Adam Winstock, John Ramsey and Kim Wolfe. Back then, Adam was the director of the Mixmag Drugs Survey (now the Global Drugs Survey) and John was involved with the emerging TICTAC (now a burgeoning commercial forensic colossus). It could be argued that an intervention that provided information direct to consumers, could been seen as competition to both of those entities, and that conflicts of interest existed. It was an article that was regularly offered up to us as proof of error, despite being out of date even by that time. Since then both Winstock and Ramsey have recanted on their stated positions, but this single paper has developed a life of it’s own.
So it won’t be at all surprising to you, dear reader, to hear that despite muted murmurings of support from behind closed doors, there wasn’t a great deal of support from the AOD sector in Australia at the time. We tried to generate a public consensus position, but were faced with averted gazes, and the red-faced, sheepish advice that the time ‘wasn’t right’. There were some notable exceptions. After vigorous banter lasting over 18 months, the then President of the Australian Medical Association Dr Mukesh Haikerwal oversaw the passing of resolution calling for trial in an Australian resolution- in November 2005. Professor Margaret Hamilton of the Penington Institute came out- she was senior enough to weather the storm. Dr Cameron Duff, one of the brightest minds in the AOD sector in Australia, spent several years in exile in British Columbia after supporting the initiative. This was an era when the then government released their laughably named ‘Winnable War on Drugs’, where those of us stood against The Message of prohibition were branded as ‘drug industry elites‘. To me, these were the real heroes of that era – scientists and doctors who put the science above the clear intimidation that was occurring. I couldn’t really blame those who didn’t see things in that way – but a little bit of my respect for them had died.
We knew a storm was coming. We had conducted a series of ad hoc analyses based out of the Royal Adelaide Hospital, and began to see increasingly unusual products and formulations, described elsewhere. We described the first occurrence of mephedrone in Australia through the same system and published the findings, but despite this weren’t even able to persuade the authorities that a hospital based testing system (Royal Adelaide Hospital Based Illicit Testing (RAHBIT) system had merit.
In 2009, I moved back to ‘old’ South Wales- just in time for the emergence of the novel psychotropic drugs. Unlike Australia, we found no trouble in gaining the ear of health and law enforcement, and developed WEDINOS- the Welsh Emergency Department Investigation of Novel Substances group- a Welsh RAHBIT, if you like. Funding was announced at the National Drugs Conference Wales in Cardiff on 19 April 2012.
We never seemed to have the problems in Wales that we have had, and still have, in Australia. We met frequently with law enforcement in the UK, and never once got the impression that they were overly interested in anything more than punters’ health in this space. We were always impressed with their ‘intelligence’- both in the information they had in their possession, in their capacity to process it, and preparedness with which they were prepared to use the science. It frankly doesn’t surprise me that Professor Measham has been able to find playmates in law-enforcement in Cambridgeshire.
Meanwhile back in Australia, we have good surveys (e.g. The National Household Survey, the Illicit Drugs Reporting System (IDRS) and the Ecstasy and Related Drugs Reporting System (EDRS)) which are fine if you are interested in what consumers think they’re taking; we have police and customs seizures, which tell us a bit about what is being sold, and more recently, wastewater analysis, which tells us about total quantities of known drugs being ingested. Here in the smallest jurisdiction in Australia- The Australian Capital Territory- we methodically analyse all unknown substances presenting with emergency patients. But there is no ‘advanced warning system’ in Australia that takes analysis to the point of consumption. ‘Drug checking’ provides us with a currency (the identity of a drug) with which to engage with a group of cynical, largely functional consumers, who can remain invisible to scrutiny, and who are almost certainly the group in which new and potentially dangerous products and trends are likely to emerge. Music festivals are to novel drugs what Sierra Leone is to Ebola- it makes no sense at all to not have dedicated professionals in the field and monitoring the situation.
These sorts of initiatives are now commonplace in dozens of countries throughout Europe, (e.g. Netherlands, Portugal, Spain, Switzerland etc), supported by the EMCDDA, and indeed, so well established that they have their own best-practice guidelines. In 2016, this practice is even more relevant and useful than it was 10 years ago. In every jurisdiction where it has been introduced, it has changed the way in which people consume their drugs. Far from the supposition of nay-sayers that consumers would pay no attention to results, the actual behaviour of consumers is far more nuanced.
What is different in 2016 is that the Australian market is now flooded with a heretofore unseen number of completely novel entities. A decade ago, we were concerned with impure or contaminated products. In the evolving global market, quite the opposite is now the case; drugs are manufactured to pharmacological purity, and released at a rate at which ponderous conventional monitoring systems just can’t cope. Such a nimble market demands an equally nimble response, and to date, our responses in Australia have been laughably lugubrious and inadequate. Drug-checking programmes are the only systems that have been able to keep up.
If it’s such a good idea, why hasn’t it already been adopted in Australia? Most programmes are conducted by motivated advocacy groups, who perhaps have not devoted their efforts and limited budgets into publishing their findings – in the words of Fiona Measham on the subject, “testers just like testing”. Fortunately, liberal environments such as the European Union have supported these endeavours, generating important data that can serve law enforcement and healthcare professionals alike.
Up until April of 2015, there still wasn’t a lot of appetite for discussion in about pill testing in Australia. And then Club Health in Lisbon happened. A cohort of Australian researchers who had attended returned with dilated pupils and the glad tidings of a ‘new’ intervention, this time called ‘drug checking’. Of course, there had been no transition in what had been occurring in Europe for the last 2 decades – it’s just been rebranded. It was argued that this was because the drugs that were being consumed were more variable than mere pills; it seemed more like a good way for junior researchers to re-invent something that had already been going on for a while. This corresponded to one of the worst starts to any festival season we had seen in a while, with 6 deaths around Australia. The media began to take an interest. Politicians were put under pressure. Instead of examining the evidence, they doubled down, threatening to arrest those involved in testing proposals. Testers dared them to. With the inchoate rage of intellectual pygmies facing academic annihilation, politicians threatened to have them arrested for manslaughter. The former Director of Public Prosecutions of NSW advised the Police Minister to go away and learn the law. Emails from the major research groups in Australia exhorted us to maintain the rage, while explaining why they couldn’t possibly get involved in the public debate lest it a) be perceived as ‘advocacy’ or b) skew their own chances of success in the field.
Seriously, you can’t make this stuff up…
Currently in Australia, it is difficult to find a health expert who doesn’t believe that at least a pilot of pill testing isn’t overdue. In addition to the support of the AMA from 10 years ago, a combined summit of every AOD expert worth their salt in Australia met in Canberra in early 2016, arriving at a series resolutions to guide future drugs policy in this country. As part of this, they concluded that “Drug checking presents as a potentially valuable option for reducing harm at public events and governments should enable trials to be implemented as a matter of priority.” Support can be considered as coming from three camps; those approaching it from a health perspective, those seeing it as a civil right, and those looking at it as an academic opportunity. While there is certainly some overlap between the camps, the ‘reducing harm’ narrative seem to be the one most palatable to the broader population.
And that’s where we stand. All of the science stands with us. There is no question in my mind that ‘advocacy’ is currently carrying the banner for the cause in Australia- academia is mostly waiting in the wings to see what can be picked from the field of battle. Arranged against us, like some Orc army destined for defeat, are the last vestiges of The Dark Era in Australian drugs policy, consisting of those too poorly educated to follow the global shifts in drugs policy, allied to those who have exploited the fear and persecution for their own personal gain. There will be a reckoning. Publicly advocating for the process, and addressing the charges placed against the process may cause us short term problems. But it creates the historical ledger against which both the scientists and politicians will be judged. And history will not be kind to those who have knowingly spoken against the science for their own political gain.
We will be conducting pill testing in Australia this season, because it’s the right thing to, and because I owe it to someone. The howls of our opponents are just a fringe benefit.
The next decade may end up evolving as an Age of Atonement, as far as international drugs policy is concerned. Questions – difficult questions – are likely to be asked of those who have historically pursued, against all of the evidence to the contrary, The Global War on Drugs. Some Australian politicians have shown a willingness to parlay, indicating a maturity and confidence in Australian political analysis of drugs policy not seen in this country for over a decade.
If our political counterparts wish to continue with a modicum of credibility on the issue of drug policy, support for ‘drug checking’ programs represents particularly low hanging fruit, from which all parties stand to gain. Consumers will have access to real-time information, provided by medical practitioners, which we know modifies, in a positive way, the manner in which they use drugs. Law enforcement and customs can obtain access to heretofore untapped, anonymised drug market data, with minimal effort or expenditure of political capital. Health professionals can function in a public health role, identifying hazards from a sequestered environment, and providing warnings prior to their emergence in a broader population. Perhaps most importantly, by creating a forum where everyone stands to gain something, where ongoing dialogue serves all parties involved, it provides a space where all protagonists can begin a conversation, with regards to global drugs policy, about how we get ourselves out of this fine mess we’ve found ourselves in.
Associate Professor David Caldicott is an Emergency Consultant at the Emergency Department of the Calvary Hospital in Canberra and a Clinical Senior Lecturer in the Faculty of Medicine at the Australian National University. Tweets @ACTINOSProject