Drug checking in Australia: How pharmacists can be involved

Case scenario

Craig, a 26-year-old male, enters your pharmacy and asks to speak to the pharmacist. He enquires about the use of ecstasy and explains that he will be attending a music festival on the weekend with friends. It is the middle of summer, and you know it’s going to be very hot on the weekend. Craig asks you for advice on the risks associated with ecstasy use and methods for reducing these risks.

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Introduction

Drug checking, also known as pill testing, is a process involving the chemical analysis of an illicit substance such as a pill or powder, followed by tailored feedback and counselling. The main aim of the service is to reduce drug-related harms, hospital admissions and deaths. Drug checking services have become well established overseas, with services set up in a number of countries including the Netherlands, Spain, the United States, Canada, the United Kingdom and New Zealand.^1,2 These provide a mix of postal, fixed-site and on-site services, allowing people to anonymously post drugs for analysis, attend a permanent site, or visit a mobile facility such as those provided at festivals. In Australia, the first government-sanctioned on-site drug checking trial was conducted in 2018 at the Groovin the Moo festival in the ACT, followed by a second trial in 2019. In October 2021, the ACT Government approved and provided funding for Pill Testing Australia (PTA) and Harm Reduction Australia (HRA) to pilot a fixed-site pill testing service in the ACT. ^3,4

The Pharmaceutical Society of Australia (PSA), Australian Medical Association (AMA) and Royal Australian College of Physicians (RACP) support further trials to inform the role of drug checking in Australia’s harm minimisation strategy.^5–7 The 2019 National Drug Strategy Household Survey (NDSHS) found that 57% of Australians supported drug checking at designated sites, while 27% were  opposed and the other 15% were unsure.⁸  

Illicit drug use and adverse events in Australia

Illicit drug use among Australians is common. The 2019 NDSHS found that 9 million people (43%) aged 14 years and over had illicitly used a drug (including pharmaceuticals for non-medical purposes) at some point during their lifetime.⁸ 

With respect to drug checking, the hallucinogenic amphetamine^3,4 methylenedioxymethamphetamine (MDMA, or ecstasy) is of particular interest, as it is commonly used and tested for at music festivals and events. The 2019 NDSHS found that 2.6 million people (12.5%) aged 14 and over had used this drug during their lifetime, with 3% of people aged 14 and over (600,000 people) reporting use in the last 12 months.⁸ 

Between July 2016 and January 2017, several young Australians tragically lost their lives following the consumption of substances they believed to be MDMA or psilocybin (magic mushrooms).⁹ In April 2021, the Victorian Coroner released findings related to the examination of five of these deaths. Postmortem analysis revealed that what they had taken was not pure MDMA or psilocybin, but rather the novel psychoactive substances 4-fluoroamphetamine and 25C-NBOMe.⁹ As a result of these findings, the Victorian Coroner recommended that drug checking services be implemented in Victoria as a matter of urgency.⁹ 

Prior to the Victorian Coroner’s report, the New South Wales Coroner released findings into the deaths of six young people between December 2017 and January 2019.¹⁰ In these cases, deaths occurred as a result of MDMA toxicity, with each individual found to have had dangerously high plasma MDMA concentrations.¹⁰ The NSW Coroner also noted 29 pre-hospital intubations, 25 intensive care admissions and 23 drug-related hospital admissions during the festival season between 2018 and 2019, which encompassed 25 music festivals.¹⁰ They considered the difficulty in discussing issues such as drug checking due to the illegality of drug use, and raised the inadequate nature of the ‘just say no’ message that is currently promoted. In addition, the NSW Coroner determined that the individuals involved lacked understanding of the risks associated with high-dose MDMA and were unable to identify signs of MDMA toxicity.¹⁰ 

Drug use occurs in a wide variety of settings, including music festivals, nightclubs and at home. While the NSW Coroner’s report focused on music festivals, several of the Victorian cases involved taking the drugs at home with friends.⁹ 

What are novel psychoactive substances?

Novel psychoactive substances (NPS), also known as ‘designer drugs’, have been designed to mimic the effects of popular recreational substances including amphetamines (such as MDMA), hallucinogens (such as lysergic acid diethylamide [LSD]), and cannabis. The NPS implicated in the Victorian Coroner’s report were 25C-NBOMe and 4-fluoroamphetamine. 

25C-NBOMe is a stimulant and hallucinogenic substituted phenethylamine, part of a group of drugs commonly referred to as an ‘N bomb’. It is highly potent and can be taken orally, sublingually or insufflated (nasally inhaled). Mild toxicity manifests as hallucinations, tachycardia, hypertension, sweating, agitation and confusion.

In severe cases, seizures, rhabdomyolysis, hyperthermia and death can occur.⁹ 4-fluoroamphetamine is a central nervous system (CNS) stimulant with dopaminergic and serotonergic effects. De Sousa et al noted elevations in blood pressure following administration of 4-fluoroamphetamine in volunteers.¹¹ Several case reports exist of haemorrhagic stroke and other cardiovascular complications following recreational use.¹² Both substances have since been the subject of public warning campaigns.¹³ 

Despite being considered a novel psychoactive substance, 4-fluoroamphetamine was first synthesised in the 1940s.¹⁴ NBOMes (including 25C-NBOMe) are newer, being first synthesised between 2008, when 25I-NBOMe was synthesised by a German chemist, and 2010, when they began to appear on the internet.¹⁵

The NPS seen on the market are highly variable, with substances disappearing and reappearing on the market.^9,13

What is MDMA?

MDMA is a hallucinogenic amphetamine that produces effects such as euphoria, feelings of closeness and decreased fear, making it a popular party drug.^16,17  It is also currently being investigated as a potential adjunct to psychotherapy for the treatment of post-traumatic stress disorder (PTSD).¹⁸ A standard recreational dose of MDMA is generally 75–125 mg, though higher strength pills are not uncommon.^16,19,20 

Toxicity manifests as hyponatraemia leading to cerebral oedema and seizures.²¹ Hyperthermia may lead to complications, including rhabdomyolysis and disseminated intravascular coagulation.²² 

Drug checking in Australia

Given the lack of professional drug checking services in Australia, at-home reagent testing is the primary method of drug checking currently available. This is a rudimentary method of checking drugs that can be done using a small set of reagents at home. These reagents are legally available for sale in Australia, and in some cases have been distributed to users by harm reduction organisations such as Students for Sensible Drug Policy (SSDP).²³ Upon contact with the substance, a colour change will occur which can then be compared to a chart. This can provide an indication of the presence of a substance (expected or not), but gives no assurance as to its purity or dose. 

In combination with the development of an early warning network, to alert the public to dangerous substances in circulation, drug checking has the potential to reduce harm and deaths associated with the use of drugs obtained from an unregulated market.⁹ Quality control in the illegal drug market is non-existent, leaving individuals at risk of unknowingly consuming a drug that is not what they expected, adulterated or a higher dose than intended. Worldwide there has been a trend towards the manufacture of high-strength MDMA pills. For example, in 2019 UK-based drug checking organisation, The Loop, discovered 300 mg MDMA pills (three times the usual dose).¹⁹ Of particular note is the prevalence of NPS, which are often mis-sold as other drugs such as MDMA. 

The drug checking process

The drug checking process usually consists of two components: chemical analysis of the substance to give an indication of content and purity, and a healthcare consultation to provide tailored harm reduction information and support to the service users. A number of different models are used to provide this service.² 

Chemical analysis

Chemical analysis is a critical component of the drug checking process. It should be undertaken by professional chemists using specialised laboratory equipment and followed by a discussion with a harm reduction or healthcare worker, who interprets the result for the end user. 

The most sophisticated method of analysis uses gas chromatography in combination with mass spectrometry (GCMS).²⁴ This is a method that can be used to determine the concentration of the detected substance as well as any known adulterants or dangerous excipients.²⁴ There are downsides to this method – it is expensive, requires a trained chemist, the equipment is difficult to transport, and the results can take time.²⁴ Fourier-transform infrared spectroscopy (FTIR) is a somewhat more accessible method that is commonly used. It is cheaper and more portable, and can be used to identify known substances using a database.²⁴ It only requires a small sample to be submitted, such as a scraping from a pill or a small amount of powder. This method also has its downsides: it is not able to detect substances that are not in its database, and it doesn’t provide information on dose.²⁴ FTIR is used by The Loop and was used during the 2018 and 2019 Australian drug checking trials at Groovin the Moo in Canberra. 

Research conducted by Barratt et al in 2018 revealed that only one-third of service users would be willing to give up an entire pill, which is required for a comprehensive quantitative result where the amounts of individual ingredients are determined.²⁵ This type of analysis is particularly important where there is a trend towards pills of high potency, such as what has been seen with MDMA in both the UK and Australia.^19,20 However, the study also found that service users were only slightly more interested in quantitative results than qualitative results.²⁵ The limitations of the method of analysis used should be highlighted during the healthcare consultation phase. 

Healthcare consultation

The healthcare consultation component of the drug checking process, also referred to as a brief intervention, is fundamental for the promotion of harm reduction.

Qualified and appropriately trained healthcare workers, including doctors and pharmacists, deliver individualised counselling to assist the service user in understanding the implications of the chemical analysis result. There is usually no charge for the consultation, and advice is provided in a non-judgemental manner.

The healthcare worker takes into consideration individual factors such as weight, gender, tolerance, mental state and presence of other drugs (including alcohol or prescription medicines), as well as the environment (for example, hot days can increase risk). Service users may be counselled individually or in groups. They are given the opportunity to ask questions, and harm reduction resources including fact sheets and contact details for drug and alcohol services are made available. 

In the case of on-site facilities at festivals, attendees can be referred directly to medical services if deemed necessary. A survey of Australian festival and nightlife attendees who use drugs found that only 36% of respondents would use a service with no individualised feedback, highlighting the importance of this intervention and the willingness of users to engage with a health professional.²⁵  

An argument often highlighted by those opposed to drug checking is that the presence of these services equates to condoning drug use.²⁶ It is important to note that regardless of the result, drug use is never stated as being safe, but rather the focus is on minimising harms associated with use. It is made clear to the service user that the only way to guarantee safety is to avoid use. The focus is on pragmatic strategies to reduce harm, such as taking a lower dose, taking it over a longer period of time, or in the case of known dangerous adulterants, encouraging disposal. 

What is the evidence?

Research shows that when seeking information about the contents of a substance, friends are the most common source of information followed by the dealer.²⁵ Drug check reporting websites that test substances and publish results are also frequently accessed by service users.²⁵ Only a minority of people who use drugs in Australia have their drugs tested, either with at-home reagent kits or through a professional service (where these have been available).²⁵

Despite critics of drug checking services citing a lack of evidence for harm reduction, a recently published systematic review suggests that the presence of drug checking services, in combination with healthcare consultations and an early warning system, is effective in reducing harms.²⁷ A study conducted by The Loop found a 95% decrease in drug-related hospital admissions at a festival in 2016 compared with the previous year, where no drug checking was conducted, with the change attributed to increased awareness of mis-selling (for example, selling NPS as MDMA) and the presence of contaminants, as well as alerts made via social media and word of mouth.²⁸ 

The results of chemical analysis, combined with a brief healthcare consultation, have been found to change consumption behaviours.²⁸ For example, a survey conducted following on-site drug checking at three music festivals in the UK found that 20.8% of people whose drugs were found to be ‘not as expected’ discarded the drug on-site at the drug checking facility.²⁹ A further 29.6% self-reported disposing of the drug after leaving the testing area.²⁹ Another 20.1% took a smaller dose than originally intended, and 9.4% returned the drug to their supplier, potentially reducing demand for these particular substances and subsequently supply.²⁹

Related to this is evidence to suggest that drug checking services can alter drug markets, so people can make more informed decisions about what they choose to purchase. For example, over the 30 years that the Netherlands’ DIMS service has been running, the contents of MDMA pills have been found to be increasingly more consistent with expectations, and there has been a decrease in poor quality, adulterated or dangerous substances.³⁰ 

Knowledge to practice

Pharmacists have played a role in drug-checking services overseas. Pharmacists possess a unique set of skills that make them particularly suited to delivery of healthcare consultations following drug checking. For example, a risk assessment is undertaken with consideration to the service user’s physical and mental health, environment, gender, weight and other consumed substances (prescription or recreational, including alcohol) to identify any ‘red flags’ that might require prompt referral or in-depth counselling. 

A 2016 Australian survey found that 85% of respondents would be willing to use a fixed-site service, external to events, and 61% of respondents would wait one week for results if the results were reliable.²⁵ As such, a model where fixed sites (such as pharmacies) are used as nominated drop-off points for off-site analysis could be considered.

Pharmacists in Australia and internationally have been involved in harm minimisation strategies.³¹ Currently, pharmacists in Australia are involved in the needle and syringe exchange and supply of pharmacotherapy for the management of opioid and nicotine addiction.³² The facilitation of drug checking services is in line with the harm minimisation work that pharmacists already do, and like other harm minimisation strategies, it is not intended to spread the message that illicit drug use is safe or without risk. Rather, it can be a way to provide support to hard-to-reach members of the population, including young people who use drugs. It is an opportunity for these people to engage with a health professional who is able to provide accurate and evidence-based advice and support without judgement. In some cases, referral to an external support service may be appropriate. Support services include:

• Alcohol and drug phone support services, such as the Alcohol and Drug Foundation drug information and advice line (https://adf.org.au)
• Local drug and alcohol services, which can be found by searching the Alcohol and Drug Foundation services directory (https://adf.org.au/help-support)
• On-site ‘chill out’ spaces at festivals and dance parties, such as those run by DanceWize in NSW and Victoria.

While many on-site drug checking models utilise the skills of analytical chemists to operate laboratory equipment, pharmacists are able to interpret the results of testing and provide tailored advice to help the service user understand the result and its relevance.

Drug checking is a harm-minimisation strategy that aims to provide service users with information on the chemical makeup of their drugs, and the risks associated with their consumption, to reduce drug-related harms, hospital admissions and deaths. Drug checking can also contribute data to early warning systems that can alert health professionals and law enforcement agencies to the current nature of illicit drug markets and enable them to tailor their response. Drug checking services are well established overseas with many utilising the expertise of health professionals, including pharmacists, to provide tailored and non-judgemental advice to service users based on the results of chemical analysis. With increasing local and international evidence supporting its use as a harm minimisation intervention, drug checking is expected to play an increasing role within Australia’s health system in coming years.

Key points

• Harm experienced by people who use drugs in Australia can occur as a result of taking drugs that do not contain what the user expects, instead containing different substances or a different dose. 
• Drug checking aims to reduce harm from illicit drug use by providing service users with an indication of chemical makeup and credible information on the risks associated with their use.
• The specific information obtained from chemical analysis depends on the method used; each method has different advantages and disadvantages.
• Pharmacists are able to assist with the healthcare consultation by interpreting and conveying the results of the chemical analysis and providing tailored harm reduction advice.

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References

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ALICE NORVILL BSc, BPharm is a pharmacist and specialist in poisons information working at the Victorian Poisons Information Centre, assisting in the management of unintentional and intentional exposures to various substances, including illicit drugs. In 2019 she volunteered with Pill Testing Australia to deliver brief interventions at the Groovin the Moo trial in the ACT.

The author would like to acknowledge: Rohan Elliott, BPharm, BPharmSc(Hons) MClinPharm, PhD, FSHP, and Dr Monica Barratt, BSc(Psych)(Hons), PhD, for their contribution to this paper.