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Olsen A., Wong G., McDonald D.
Australian National University, 2019
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[Consultation draft subject to amendment and correction.] Assessing the implementation and outcomes of drug safety testing at an Australian festival, this independent evaluation found reasons to have confidence in, and in the future extend, the harm reduction benefits.
Summary Pill testing (also known as ‘drug checking’ and ‘drug safety testing’) is a public health intervention allowing the general public to submit illicit substances for chemical analysis, the aim being to reduce drug-related harm by giving people the opportunity to learn about the content of their drugs before deciding whether to take them (and if so how much) or dispose of the drugs.
A pill testing service was trialled at an Australian music festival in 2019, providing information on the content of illicit drugs to service users, the police and healthcare providers.
The service was found to be well-executed and associated with both attitudinal and behavioural changes. In line with previous research, non-concordance was associated with a lower likelihood of taking the drug and concordance was associated with a higher likelihood of taking the drug.
Unlike many other pill testing services abroad, information about drugs was not conveyed to other festival-goers in real-time, which could be considered in future iterations.
The featured paper evaluated the roll-out of pill testing at the Groovin the Moo music festival in Canberra, the capital of Australia. This was the site of the first government-approved trial of pill testing in Australia, but took place a year later in April 2019.
The pill testing service was implemented by the Pill Testing Australia consortium, which included Harm Reduction Australia, the Australian Drug Observatory at the Australian National University, DanceWize, and Students for Sensible Drug Policy Australia, and run by volunteer medical staff, analytical chemists, and peer-based harm reduction workers. It was established as a stand-alone service in close proximity to the medical area at the event. This helped ensure that service staff could maintain regular communication with medical and ambulance personnel, briefing them on the results of pill testing and helping to inform medical procedures in the event of an overdose or other drug-related emergency.
Research indicates that people attending music festivals are more likely to use illicit drugs than the general population, and among Australian festivalgoers, the most commonly used substances are alcohol, cannabis, ecstasy/MDMA the same drug in either pill or powder form), and cocaine (1 2).
In settings such as festivals, pill testing can help to connect hard-to-reach populations with health services, monitor drug markets for new or particularly dangerous substances, provide assistance to emergency services when there are drug-related emergencies, and contribute to an early warning system for dangerous substances (1 2). However, it is a highly contested intervention. Opponents argue there is limited evidence that pill testing reduces harm or deaths, that testing outside a laboratory setting may not accurately identify all substances present in a sample, and that the intervention may encourage or normalise drug use or give a false sense of security by implying that some drugs are ‘safe’ to consume (1 2).
The latter point – the fear about conveying the message that drugs are ‘safe’ – was addressed in the design of the service. Staff agreed to advise each patron that drug taking is inherently unsafe and disposal of the drugs is the best way to avoid risks to health. They also agreed to communicate the limitations of pill testing, including that testing cannot guarantee the identification of all substances.
Other service model specifications included ensuring that staff were trained appropriately in the use of drug testing equipment and drug counselling, that an amnesty bin was provided for safe disposal of drugs, and that data collected would be shared with key stakeholders to inform future uses of pill testing and for operational and safety needs (eg, contaminated drugs, novel psychoactive substances, and high-purity substances circulating in the drug market).
Service users were asked to provide a scraping of the substance for testing. After the substance was tested, chemists and medical staff provided patrons with the results and reiterated that no level of drug use is ‘safe’. Patrons then received a brief personalised harm reduction intervention from a DanceWize key peer educator to discuss the risks involved in consuming the substance and how to minimise these. Referrals to health or alcohol and drug services were provided where necessary. A card with their sample number was provided to service users which could aid emergency services in the event of a drug-related presentation.
The drug testing was performed using fourier-transform infrared spectroscopy (FTIR) – a robust technology for drug testing at the point of care (ie, at the time and place of seeing the patient or client). FTIR carries a range of advantages in the festival setting, including its ability to accurately identify a wide range of substances, its compact size, relatively quick runtime (five minutes or less), and ease of operation (including minimal sample preparation). While a technique called mass spectrometry remains the current ‘gold standard’ in forensic drug testing, the cost and technical skills needed, along with the extended time period for completing the analysis, make it more challenging to implement in a setting like a festival. Despite the limitations of FTIR, it met the criteria of the service in being able to reliably identify the major drug present in an unknown tablet or powder, provided this was a previously discovered substance on the database.
A total of 234 people entered the service, and 158 were included in the evaluation; 53 people were not permitted to participate under university ethics committee rules as they were under 18 years of age, 22 people declined to enrol in the evaluation, and one participant who agreed to participate was subsequently excluded from the analysis as they knowingly presented a sample of candy for testing.
Participants ranged in age from 18–51 years old, though almost half of participants (46%) were 18 or 19 years of age, and the average age was 21 years. There was roughly equal representation of men (51%) and women (48%).
All participants answered questions before their drugs were submitted for analysis (the ‘pre-test’ survey) and most of those (147) also completed a survey afterwards (the ‘post-test’ survey). A further 11 service users agreed to a follow-up interview four months after the festival. Eleven stakeholders were also interviewed four months after the festival, including three Pill Testing Australia personnel, two Pill Testing Australia volunteer chemists, three people associated with DanceWize, one senior ambulance service officer, one senior health officer, and one senior policing member.
Expected lines of communication between the pill testing service, the police, ambulance service, other health representatives, and festival promoters were maintained prior to and during the event, and co-location of the pill testing service with festival medical services facilitated information sharing and care for festival patrons.
Of the 158 patrons included in the evaluation, most (106) were there for pill testing; the remaining attendees were accompanying someone using the service. Most participants using the pill testing service (96%) personally received the test result from staff or were present when the result was given, and most (84%) also received a brief intervention.
Seven samples of a potentially harmful substance, N-ethyl pentylone, were identified, and all seven patrons subsequently opted to dispose of their drugs in the amnesty bin provided.
There was some misunderstanding around the known purity of substances, which seemed to be largely down to the communication of what the drug testing method could (and couldn’t) test for:
• FTIR allowed for components of drugs to be identified, and those components to be ranked in order from most to least in terms of their relative quantity in a mixture.
• Although it was not possible to measure the purity of the drugs tested, terms such as ‘purity’ and ‘strength’ were regularly used by people delivering the drug testing service to describe the substances that were tested, and subsequently to make inferences about relative safety.
This misunderstanding was reflected in the language of patrons and stakeholders:
“Yeah, it was pretty interesting how they did it. The one thing that I found interesting was that they said that they couldn’t give us, like when we first entered in, they were like, “This is what we can tell you, this is what we can’t tell you,” and one of the things that they said they couldn’t tell us was the purity. But then when we got it analysed, they said, “Oh, it’s about 80% pure.”” Female, 29
“ … [they] were coming to me and reading the actual sample results, it was reported in different ways. So one person might say, it’s a high strength MDMA, another person might tell me, oh, it’s 0.87, so I found that the results were reported inconsistently, and I didn't know if that would make a difference in terms of how you’re trying to interpret it.” DanceWize
“So the year before, about half of all pills tested were inert or non-illicit whereas this year they were predominantly MDMA of high purity. So from that perspective, that’s really good intel and good knowledge.” ACT Ambulance Service
“I think for the first time … I had a decent understanding of the relative purities of drugs that were floating around.” Chemist
Fortunately, these misunderstandings did not appear to have had any adverse consequences in terms of drug consumption or safety.
Patrons rated the service highly and considered the clarity of the information provided by the service to be good or very good. Most reported that they would tell others about the service and would use a pill testing service again if it were available. Patrons reported that the information provided in the pill testing service increased their knowledge about illicit drugs and harm reduction and valued the opportunity to discuss their drug use in a non-judgmental environment.
“It was good, it wasn’t judgmental, it was insightful.” Female, 22
“…it was a really positive experience. Everyone was really approachable and I guess you kind of forget that when in the media it’s always so negative. And, again, like I said before, being an anxious person, I was worried that there might be judgement behind their words but it was a safe space in there which was really nice.” Female, 25
In the follow-up interviews a couple of patrons felt that it was possible that pill testing could encourage more people to take drugs. However, most felt that pill testing services neither encouraged nor discouraged drug use, and focused on the provision of information about the safer use of illicit substances.
“People are going to take drugs anyway. And I think it was, like, six drugs or something that were discovered at Groovin the Moo Canberra were found to be dangerous, so those drugs would have been consumed … like, there’s obviously got to be education with it, because if I was really happy about mine being quite pure, and decided to take all of it, then that would have been horrible. So obviously it’s not just a number and an ingredient … I think it encourages safer drug use … I personally think the majority of people who have been taking MDMA for a little bit will continue to take it, so if they can test their pills and the substances obviously it will be a lot … the activity being a lot more safer.” Male, 20
No stakeholders reported concerns about the trial service. On the whole the service was perceived to have been run well and implemented as intended.
All stakeholders supported the pill testing service model trialled, especially the opportunity to deliver harm reduction information. However, many also expressed a desire to see other methods of delivering pill testing in the community (eg, back-of-house approaches at festivals, fixed sites separate from festivals, either with or without the provision of additional harm reduction services, and mobile services that attend parties, nightclubs, and locations of public drug use).
There was a significant increase in patrons’ self-reported knowledge of how to prevent the potential harms of drugs after accessing the service (from 38% to 44% ‘good’ knowledge, and from 23% to 44% ‘very good’). Those who had never taken any illicit drugs reported a greater increase in knowledge.
Most of the patrons had a generally accurate perception of the contents of their drugs (88% concordance rate). Slightly more than one tenth of patrons (12%) had drugs confirmed to be different from their expectations. All 17 patrons found the lack of concordance to be ‘somewhat’ or ‘very’ surprising. Approximately half of the patrons who reported concordance between their expectation and the actual content of tested drugs also reported being ‘somewhat’ or ‘very’ surprised.
When there was a difference between the expected versus actual content of drugs, patrons showed a statistically significant reduction of intention to consume the tested drugs. The reverse was observed among patrons who found confirmation of their drug content – they reported being more likely to consume the tested drug (again to a statistically significant degree). However, among those whose drug was identified to be what they expected and proceeded to take the drugs, they reported using harm reduction knowledge to reduce their risks of harm.
After attending the service, participants were more willing to access healthcare providers, brief intervention providers, peer counsellors, home pill testing kits, and written harm reduction materials. Furthermore, all those who were found to have a particularly dangerous substance disposed of that drug in the amnesty bin.
The service was perceived to produce valuable information about the availability of illicit drugs, including drugs new to the market in the Australian Capital Territory. The authorities used this information as planned – notifying service users, adjoining festival medical services, and health officials.
The proportion of drugs identified as MDMA was considerably higher than when the service was trialled in 2018. A range of key stakeholders considered this a particularly important finding, confirming other sources of information about high-purity MDMA in the Canberra drug market at the time.
Part of the agreement with the Australian Capital Territory Government before the service was implemented was that Pill Testing Australia would not provide any public information about drugs identified through the testing during the course of the festival. While there was a noticeboard with drug alerts inside the service, this information was not communicated publicly.
Information provided by the pill testing trial was valued by people in the health and law enforcement sectors. Pill testing provided “far more granular data” than, for example, border seizures and controlled purchases of illicit drugs by police, reflecting the fact that pill testing occurs close to the point of consumption.
Those with responsibility for the welfare of festival patrons felt there was little need for real-time public communications about the findings as there were no drug-related deaths or other serious outcomes at the festival, and all of the particularly dangerous substances detected were discarded by the pill testing patrons in the amnesty bin provided.
Stakeholders were in favour of an early warning system, which could get around the problem of physically identifying substances. Unlike the European markets, most Australian drugs are not identifiable by sight (ie, most consist of unmarked pills, capsules, powders and crystals).
Stakeholders reported that the pill testing service was delivered as expected and that all parties were supportive of the trial and development of a pill testing programme in the Australian Capital Territory. Stakeholders and patrons identified elements of the service that could be improved, but none reported unintended consequences (ie, outcomes outside of the consideration of the trial). This reflected, to a large extent, the fact that those responsible for designing and implementing the service had the experience of the 2018 trial, plus sufficient lead time in 2019 to plan.
The service model was perceived to function well in the festival setting, for example:
• Waiting times for patrons were brief, and the testing and brief intervention were well paced.
• Everyone who had drugs identified as being particularly dangerous disposed of them in the amnesty bin.
• Co-location of the pill testing service and the medical service aided information-sharing and improved patient care.
The lead chemist held a licence permitting him to possess otherwise illicit substances for the purposes of scientific chemical analyses. This contributed positively to the trial, as he was able to take some substances for further investigation.
A particular strength of the pill testing service was its collaboration with medical services at the festival. Another strength was the agreed protocol regarding policing at the festival site; police undertook their work at a distance from the service site, while still being available to support the service if an incident occurred there.
While the evaluation showed that the trial service was adequately staffed and the space provided was sufficient, during peak periods the service operated at full capacity. In planning future services, efforts should be made to estimate the likely level of demand for pill testing so as to ensure that sufficient resources are available, keeping patron wait times to a minimum. Future planning should also consider how to best deliver testing results to patrons. Current testing equipment provides information on the contents of the substance, but not the purity or dose. This appears to be misunderstood by patrons and stakeholders.
The evaluation assessed the implementation and outcomes of a pill testing service in a real-world context, finding that it was well-executed and associated with positive attitudinal and behavioural changes, even given constraints stemming from the lack of an official funding source and restrictions around pill testing signage at the festival.
Festival patrons valued discussing their drug use after the tests, and took harm reduction advice on board. However, in the transfer of information between the drug testing service and the service users, there was a tendency for results to be misinterpreted, emphasising the importance of developing a standardised language for conveying the scope and results of drug testing.
When there was a difference between the expected versus actual content of drugs, patrons showed a statistically significant reduction of intention to consume the tested drug, and when patrons found confirmation of their drug content, they reported being more likely to consume the tested drug. These results were consistent with prior research demonstrating an association between users’ behavioural intentions and drug-checking results, where divergence between the two was associated with a lower likelihood of taking the drug and convergence associated with a higher likelihood of taking the drug 1 2).
Unlike many other pill testing services abroad, information about the samples of drugs analysed was not conveyed to other festival patrons in real-time (eg, through noticeboards showing the drugs detected, or announcements on the stages of the festivals describing particularly dangerous drugs that have been found to be in circulation). Having gained experience in providing information to the people whose drugs were being tested, those planning pill testing at future Australian music festivals could consider strategies for broader dissemination of information.
Although a key rationale for pill testing is to reduce drug-related harm and drug-related deaths at music festivals, this was not included explicitly within the evaluation questions. Due to the small number of adverse drug-related incidents at festivals in the Australian region each year, it would not have been possible to say whether any changes were statistically significant. However, if pill testing was scaled-up to other locations in the Australian Capital Territory, and to other regions of Australia, it may be feasible to track its impacts on morbidity and mortality in a larger population of festival participants.
Overall, the evaluation provided support for the development of further pill testing trials in Australia, and highlighted the importance of independent, external evaluations to assist in building the evidence base around pill testing.
commentary The featured paper evaluated a pill testing intervention at an Australian festival, finding that it was successfully rolled out, valued by service users and stakeholders, and generated information that would support the development of further pill testing programmes in the region (including other models of pill testing).
Drug safety testing is rooted in a harm reduction approach to substance use – aiming to minimise the harms people experience by warning them of particularly dangerous illicit drugs and/or illicit drugs that were not ‘as sold’. Harm reduction can be a contested goal, and the implementation of harm reduction interventions dependent on conducive policy environments and local agreement. In this iteration of the drug testing service it could be argued that the harm reduction benefits were not fully realised or tested. In particular, an agreement between the Australian Capital Territory Government and Pill Testing Australia beforehand stated that the service would not provide any public information about drugs identified through the testing during the course of the festival. Even after the festival, those responsible for the welfare of patrons felt there was little need for real-time public communications about the findings, citing for example the absence of drug-related deaths or other serious outcomes at the festival, and the fact that all of the particularly dangerous substances detected were discarded by the pill testing patrons in the amnesty bin provided.
Seven samples of the potentially dangerous substance N-ethyl pentylone were identified, and after discussing the results with the seven service users to which the drugs belonged, the drugs were subsequently disposed of in the amnesty bin provided. Seizures of this substance worldwide have documented it in powder, crystal, rock, capsule, and tablet forms, and indicate that it has been mis-sold as MDMA, which can leave users unaware of additional risks of harm including drug poisoning, or symptoms such as agitation, paranoia, and raised blood pressure:
“… It looks identical to MDMA in crystal form and has similar effects at first but the pleasurable effects wear off more quickly which causes people to take more and more to chase a high that never returns.”
“With all of the valerones (pentylone, N-ethyl pentylone, a-PVP, MDPV, pentedrone) redosing seems to disproportionately extend the time to clear the body and this makes sleep very difficult or impossible for up to 36 hours without further medication. The outcome of this in a festival setting can easily be either self medicating with depressant drugs to mitigate the long-lasting stimulant effects, or severe temporary psychosis… .”
In the featured evaluation there was no evidence to suggest that the extent of mis-selling ended with the seven samples of N-ethyl pentylone captured. Therefore, due to the restriction on sharing drug testing results with the remaining festival patrons, other people who may have inadvertently been in possession of N-ethyl pentylone would have remained unaware and at risk. In contrast, when similar batches of mis-sold drugs have been detected at UK festivals, alerts have been posted to social media with photographs and details of the contents, and shared by the social media accounts of festival management, police and other on-site agencies.
Returning to the general findings of the evaluation, the authors reported the frequent “misinterpretation” of drug test results by service users, though stressed this was not something associated with adverse effects. Digging into the root cause, it was unclear from the paper why the misunderstanding was attributed to the service users. The main point of confusion was over the “purity” of substances, which the authors said was not possible to determine using fourier-transform infrared spectroscopy. However, the term was used by patrons, staff, and professional stakeholders, and featured in a question in the post-test survey. One possibility is that staff were choosing to use everyday language at the expense of being precise or using terms that reflected the way service users spoke. The authors did not explain what a precise representation of the results would have been, and what staff ‘meant’ by purity, though the evaluation conclusions did advise that “careful consideration should be made in developing standardised explanatory language used to deliver the drug testing results as misinterpretation was common”.
Only a small proportion (8%) of participants reported that they would discard the drugs they had tested. As identified by the authors, this was a lower disposal rate than reported in some other studies and could be related to the high level of concordance between what patrons expected the drug to be and what the drug was identified as (1 2). When drug safety testing was piloted at a UK festival in 2016 (study analysed in the Effectiveness Bank), 20% of drugs were not what they were sold as. Upon hearing the test results, one in five service users (21%) chose to use the disposal service. Two thirds of those whose test result revealed their sample to be at variance with what it was sold as then handed over further substances in their possession compared with one in ten whose sample was confirmed to be as sold (67% vs. 9%).
The authors described one of the strengths of the featured paper as its “independent analysis” of the impact of pill testing at an Australian festival. In a research context, independence typically refers to researchers not having a personal stake in the outcomes of the trial, which would be in contrast to researchers who evaluate or examine interventions that they have developed, provided, or helped facilitate. In several social science research areas (1 2 3 2 4), programme developers and other researchers with an interest in the programme’s success have been found to record more positive findings than fully independent researchers – something termed the ‘researcher allegiance’ effect. There have been particular concerns about this form of bias in studies of psychotherapies, where researchers may believe in the superiority of a given treatment, including how and why the treatment generates positive change. The argument in favour of independent evaluations is that they are able to demonstrate a greater level of objectivity, and/or give the perception of objectivity, which may have particular value in relation to contested interventions – especially those that deviate from what is politically acceptable or neutral – where people close to the intervention may be accused of having a political motivation or bias.
The pilot study of the UK’s first drug safety testing service at a festival was conducted by the same researcher that co-founded the service (The Loop). The service was not designed to replace or supersede an alternative intervention, but to fill a perceived gap in services and address avoidable harms:
From 2010 onwards [Fiona Measham, Professor of Criminology at Durham University, and co-founder/Director of The Loop] shadowed Home Office and academic scientists who conducted forensic analysis ‘back of house’ or behind the scenes at festivals and nightclubs primarily for intelligence and evidential purposes and to collect drug market trend data. In 2013 The Loop was founded and started forensic testing behind the scenes for police and paramedics at a number of UK festivals and nightclubs, using similar equipment and analytical methods[…], to share intelligence with partner organisations and to reduce drug-related harm both on and off site. This ‘halfway house’ model of testing expanded the sample gathering and intelligence sharing from primarily police to paramedics and other stakeholders (1). It is this ‘halfway house’ model of onsite testing as a collaboration between stakeholders but without public access that has been recommended by the Victoria Parliament’s recent inquiry (2).
In 2016 the general public were added to this reciprocal information-sharing process and with police support, were able to bring samples for testing too, in a new ‘front of house’ testing service coined Multi Agency Safety Testing (MAST). The Loop’s MAST service places strong emphases on both the brief interventions delivered by experienced healthcare professionals ahead of disseminating test results, and also on the collaborative, multi agency partnership approach to the testing service. Test results and trend data are shared with partner organisations both on and off-site, as well as alerts issued on and off-site, with an overall aim of reducing drug-related harm at leisure events and more widely through greater monitoring of illegal drug markets. The Loop’s protocol is designed to operate within UK law and multi-agency safety testing only operates after obtaining the full support of police, public health, local authorities, event organisers and other stakeholders.
The study generated findings that could inform drug safety testing practices, as well as festival security and policing procedures, in UK festivals. For example, it revealed that substances acquired within the festival grounds were more than twice as likely to be at variance with what they were sold as compared with those bought offsite (27% vs. 12%), and as such, existing security procedures combined with onsite dealing practices could stand to increase drug-related harm. Through daily security advisory group meetings, all onsite agencies at the festival (including police, welfare, security and paramedical services) were updated on the results of drug testing, which revealed significant mis-selling onsite. This prompted the circulation of targeted alerts with the support of festival management and police, including for chloroquine and ketamine mis-sold as cocaine, and pills with high MDMA content.
Though festival- and club-based drug safety testing services have been run at different sites across the UK with the agreement of local law enforcement, central government has been reluctant to support this type of intervention. Volteface, an organisation which advocates for harm reduction and policy reform, documented the timeline of UK Government positions on drug safety testing. In 2018, Home Office minister Victoria Atkins said, “No illegal drug-taking can be assumed to be safe and there is no safe way to take them. The Government’s approach remains clear: we must prevent illicit drug use in our communities and help those dependent to recover, while ensuring that our drugs laws are enforced. While operational decisions are a matter for Chief Constables, the Government and the public expect the police to enforce the law.” However, the deaths of two young people at a music festival in May of that year, bringing the total deaths in two years to 11, may have put additional pressure on the government. In 2019, the Home Office issued the first drug testing license to the charity Addaction for a service in Somerset in order for research to be undertaken. The month-long pilot offered anyone over the age of 18 the opportunity to have their drugs analysed anonymously. Speaking to government concerns, Addaction emphasised that “All partners involved in this pilot agree that they are not condoning the use of illegal drugs”.
This draft entry is currently subject to consultation and correction by the study authors and other experts.
Last revised 27 February 2020. First uploaded 15 January 2020
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