‘It’s just assumed it’s 100%’: The toxicology of pill testing

This weekend saw Australia’s second music festival pill testing trial conducted by Pill Testing Australia at the Groovin’ the Moo music festival in Canberra.
 
A total of 234 festival-goers took advantage of the services, with 171 substances tested, seven dangerous substances identified and seven people dumping potentially unsafe pills.
 
Organisers have declared trial a success.
 
‘The pilot was again overwhelmingly successful by any measure, but particularly by doing everything possible to keep our kids safe,’ Pill Testing Australia’s Gino Vumbaca said.
 
However, toxicologists Andrew Leibie and Dr John Lewis remain concerned. They fear any perception that onsite pill testing increases the safety of ingesting drugs is dangerously misleading.
 
‘The Hippocratic Oath is primum non nocere, “First, do no harm”, and I’m not sure pill testing complies with that,’ Dr Lewis told newsGP.
 
Mr Leibie agrees, emphasising that his concerns are analytical and medical, rather than social.
 
‘My intention is to try and ensure the debate is based around sound scientific principles, because even within the medical community there can be a lack of understanding of the analytical challenges [of drug testing],’ he told newsGP.
 
Dr Leibie is concerned at what he believes is limited focus on the reliability of testing methods.
 
‘A debate that should be put forward is, how inaccurate are we willing to have our onsite testing process?’ he said. ‘And that’s really for the clinicians and for the counsellors to say, “We can live with it as long as it’s greater than 90%”.
 
‘But, at the moment it’s just assumed it’s 100%, which it’s clearly not.
 
‘My view would be, at this stage, when the diagnostic is so uncertain it’s a real experiment – being conducted on drunk, intoxicated 20-year-olds at a music festival.’

Both toxicologists are concerned about the trial’s use of Fourier-transform infrared spectrometry, or FTIR, to analyse the pills.
 
‘You get a scraping of the pill and you put the grains onto a plate or a diamond and the infrared beam passes through it and produces a spectrum,’ Dr Lewis explained.
 
‘That spectrum is analysed mathematically and if it matches, let’s say ecstasy, it will give you a probability. It might be 80 or 90%.’

L–R: Andrew Leibie asks, how much inaccuracy are we willing to accept in onsite pill testing at music festivals?; Dr John Lewis is unconvinced pill testing is the right strategy in terms of harm reduction.
  
However, data from Europe – where FTIR has been used for the purposes of pill testing for several years – has highlighted some limitations.
 
‘FTIR is not very good at detecting poly-drug mixtures, so once you get more than two or three drugs in your sample – which is extremely common – you get too much noise and it can’t identify the drugs very well,’ Mr Leibie said.
 
‘The other thing is it doesn’t tell us anything about the dose, and that’s critical, certainly in the harm-minimisation aspect of some of these pills.
 
‘And the final point is, a lot of the newer drugs feature much more dangerous compounds, new psychoactive substances, or NPS. There is a real zoo of these things out there, literally hundreds that have only been recorded in the last few years.
 
‘The newer and the more exotic these compounds are, the less likely FTIR is to be able to detect them, because it relies on a library match – if it hasn’t been told what some of these new drugs look like, it just won’t see them.’
 
According to Dr Lewis, the fact FTIR analysis of a pill scraping cannot fully examine its contents represents another issue.
 
‘A pharmaceutical-grade pill is made so that every pill in that packet is to the same standard,’ he said.
 
‘Inside the pill you’ve got the active ingredient; you’ve got fillers, which are inert; you’ve got substances that make the drug dissolve at a certain rate; you’ve got glidants that make the drug slide out of the matrix so it goes into a solution, into the body, with a constant rate of dissipation into the bloodstream.
 
‘If you get a pill made in Bankstown or Guancheng, are they putting these release agents in or just packing it with fillers? Perhaps if you make one of these non-pharmaceutical grade tablets, by the time it gets into the gut, into the bloodstream, into the brain, you’re looking at about 20 minutes or so.
 
‘But what if this becomes a very slow release because of all the muck that’s been put into the pill? The person says, “I’ve bought a dud, it’s not working”, and they take another one. By that time, the first one’s dissolved, and so they’ve actually overdosed.’
 
But Dr David Caldicott, emergency medicine specialist and a key architect of the pill testing trial at Groovin’ the Moo, believes FTIR offers other advantages in a festival setting.
 
‘We run the pills through the FTIR, and it turns up in real time, in front of the consumer’s eyes, maybe containing something that will give them a good effect, in their eyes, but frequently, a list of contaminants and ingredients they’ve never heard of. And that’s deliberately disconcerting,’ he told newsGP.
 
‘Young people are very curious, they want to see what’s going on, and that’s the whole thing about drug policy. Young people need to be given some control of their decisions, and if you give them the information to make a decision that’s sensible, I would say 80% of the time they make a sensible decision.’
 
Dr Lewis and Mr Leibie are concerned that even if a pill is identified as being the drug its buyer expected – for example, ecstasy – this does not decrease its danger.
 
‘It seems the six people who died over the summer died from MDMA toxicity, partly because of the effect of MDMA in terms of cardiac effects and thermoregulation, body temperature and thirst response and things,’ Mr Leibie said.
 
‘A lot of the time the cause of death is actually heat injury, rather than drug toxicity.
 
‘So even if we had had pill testing, these people wanted to buy ecstasy. They did actually buy ecstasy and then they died, so I don’t see where a pill testing piece of equipment changes that paradigm.
 
‘FTIR can’t help them if they take the pills.’
 
Dr Lewis emphasises there is no safe dose, particularly for first-time users.
 
‘One in 2000 naïve users risk death the first time they use ecstasy,’ Dr Lewis said. ‘Forget the impurities, one in 2000 are going to risk death.’
 
Dr Caldicott agrees that there is no such thing as ‘safe’ use of illicit drugs, but that it is also unrealistic to believe that all illicit drug use can be stopped.
 
‘There’s no way that anybody in their right mind would say that we are going to make all people not use drugs,’ he said. ‘What we can do is we can make people behave in a way that makes it far less likely for them to get hurt.
 
‘That’s essentially the essence of harm reduction. We acknowledge the fact that kids will be kids and will use drugs – but it’s much easier to give people lessons in bad life choices if they’re still alive, and I think this is where medicine should come at this from.’


Dr David Caldicott emphasises that the purpose of onsite pill testing at music festivals is not to stamp out nor provide a ‘green light’ for drug use, but to minimise harm. (Image: Jeremy Piper)

When discussing Dr Caldicott’s further contention that the process is a valuable way to provide festival-goers with drug education they would not otherwise receive, Dr Lewis theorised this education could perhaps still be provided at music festivals without the pill testing aspect.
 
Mr Leibie, however, conceded this approach may have some value.
 
‘It’s really a loss-leader to get people to come into that tent to talk about the drugs, you’re luring them in with the promise of testing their pills,’ he said.
 
‘If it means you can talk to 60 or 80 people about safer ways to use their illegal drugs, fair enough. Although, again, that’s a social-policy question completely unrelated to my analytical field.’
 
Regardless, Mr Leibie remains uncomfortable with the risk posed by the FTIR testing method and suggests a possible alternative model already in use in Europe, where users send drugs to a central lab with high-end equipment for testing.
 
‘The instrumentation removes all of those analytical concerns,’ he said. ‘They can now test hundreds of different compounds in the drugs and exactly what the dose is, to a 99.9% confidence level,’ he said.
 
This type of testing takes longer than FTIR, which means drugs need to be sent a few days in advance. Results are posted anonymously on a website, identified by the sender by a tracking number.
 
Mr Leibie believes this kind of testing would also help to implement a more proactive approach, alerting healthcare professionals to new compounds and problems appearing in illicit drugs before they manifest at music festivals and other events.
 
Dr Caldicott has had experience working on this type of drug testing program, but prefers the onsite method because of its immediacy and the opportunity it offers to speak with people face-to-face.
 
‘The thing I like about the music festival environment is that you get to sit down with the consumer and talk to them, and this is very important from a preventive medicine perspective,’ he said.
 
Dr Caldicott also finds testing at a music festival provides an opportunity to confront the behaviour in its natural setting.
 
‘The problem with waiting to send [drugs] in to a lab is that the horse has rather bolted,’ he said. ‘You’re not preventing people, you’re just monitoring.
 
‘The whole point of testing it at music festivals is to detect and dissuade.’
 
Dr Lewis, for his part, is less certain about whether pill testing in any form is the right solution to the problem, and is waiting to see the results of the coroner’s reports on the music festival deaths over the summer.
 
‘I’m not sure pill testing is the way to go. How do you get people to be responsible for their own actions?’ he said.
 
‘I’ve heard people who are hard-core smokers say, “I’ve been smoking for 30 years, I haven’t got cancer, I’m all right”.
 
‘Well, it’s Russian roulette. And the people who take ecstasy are playing roulette.’

illicit drugs music festival pill testing