Pill-testing: Harm reduction or just a bitter pill to swallow?

Adam Winstock & Louisa Vingoe

National Addiction Centre, Institute of Pyschiatry, 4 Windsor Walk, Denmark Hill, London, SE22 8RL. Phone no: +44 (0)207 836 5454 E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

There is a fairly consensus opinion about the benefits of pill testing but I am going to try and present another side of pill-testing, looking first at why pills are different from other drugs, then at the different methods that exist for looking at drugs. I then want to look at the pros and cons of pill testing. I think there are two sides to this. Finally, I will contemplate the future.

Are pills really that different to the rest of drugs that young drug users use? They probably are because usually people know what a drug actually is; they can taste it, smell it, sniff it, rub it on their gums or have some other indication as to what the drug is. When tablets came out in the mid 1980s, they represented a foreign way of taking drugs. A lot people therefore, (a) did not have a clue what they were taking, but (b) suddenly thought (bearing in mind the contemporary concern over HIV and injecting drugs) that here was a very safe, almost medicinal way, of taking a drug.

Obviously in terms of content, powders are going to be very difficult to assess because you can dilute them with adulterants. People who buy hash or weed probably have a fair idea of what they are getting for their money but you have no real idea when you purchase a tablet. Ecstasy is clearly not alone and LSD tabs vary in concentration all the time, as do substances like heroin and GHB. Pill testing emerged because drugs like ecstasy and LSD were sold in a different form that did not give people a clue as to the contents and it was recognised very early on that you could not always rely upon the consistency of what was in a tablet. After a few deaths, the media was full of reports that this was due to fatal contaminants - which is of course very rarely the case.

The people we have to thank for implementing this are the Dutch and it follows on from their policy of harm reduction. There was also another side to this. In the early 1980s and late 1970s, in order to track the production of illicit amphetamine, forensic scientists would profile amphetamines, enabling them to uncover its origin and discover whether the different sorts of amphetamine were produced from the same source batch. One of the advantages of pill profiling for people like Europol and other drug testing agencies is that it enables the source of the drug to be traced. Purity is obviously an issue in this case because, unlike drugs such as cocaine and heroin, pills are not derived from a bulk product like a plant. In other words, when you buy cocaine, you know what you are going to get.

MDMA is made from a wide range of synthetic precursors and the final content of a pill is very dependent on what precursors are available. In 1997, when the Dutch clamped down on certain precursors, the quality of ecstasy plummeted. Due to the fact that there is a wide range of precursors, it means you occasionally end up with drugs that have a similar chemical structure to MDMA such as MBDB and MDBA and lots of other things like that, so occasionally you get dangerous contaminants.

Most of the time pills contain analogues. Occasionally they will contain combinations of drugs which will try and mimic the effects of ecstasy - that is, partly hallucinogenic, partly amphetamine. There have even been tablets found in the UK that contain shredded LSD tabs but of course there have been circumstances where dangerous contaminants have been picked up, although there have been fairly few. Contaminated pills might contain atropine, DOB and 4MTA.

Types of test

The one that is most commonly employed in an initial DIMS testing station is a simple colouring agent. The normal test is something called the Marquis test which is based on sulphuric acid and formaldehyde. This will allow you to differentiate between different sorts of drugs depending on the colour that the drugs turn. You can now buy these for NLG7,50 in a lot of smart shops.

The DIMS test compares the content of the pill with previously analysed substances, and that obviously adds a degree of security as to what the drug is. These colouring agent tests are non-specific. Sometimes in dark rooms, it is really difficult to tell the difference between black, black-violet, violet and blue-violet. If you took a pill in a club that came up as black, blue, violet or whatever you could end up being any one of the seven dwarfs: happy, smiley, dopey, sleepy, but not quite sleazy. If you took a drug that came up orange you could be up or you could be down. If you took a drug that was yellow you could be tripping or falling down and if you took a drug that was brown you would either be tripping or you would realise that your headache had gone. So these sorts of rapid tests have serious limitations. The third test is the sort of thing that we have heard is done at the DIMS laboratory where you get a full analysis of the results and a lot more data.

Benefits and disadvantages

I would like to compare the different tests in terms of how they can be used in providing information for the users, and monitoring agencies, as well as open to possible misuse by drug dealers. In terms of the rapid test, you are only going to be able to identify the group of drugs. Interestingly, the Marquis test would not have picked up 4MTA which is being sold as ‘flatliners’ and has been responsible for at least six fatalities worldwide over the last nine months. A DIMS comparison chart gives slightly more information but it is really only the full lab analysis that will give the full breakdown. Most important is the dose. A lot of drug effects are dose related and this is a particularly important failing of the rapid test. There is huge potential for misuse by dealers, although I understand from people in the Netherlands that they will not test pills for people they know to be dealers and they will not test liquids that can be another form of MDMA.

In terms of the immediacy of the results, for a population that tends to be fairly impulsive, it is only going to be the rapid ones they are interested, unless you buy a large batch and wait for the results in a week. The more information that can be gained and disseminated, the better for the user and it is the full laboratory analysis from monitoring agencies that will give the greatest benefit. The identification of new pills from full laboratory analysis is essential for early warnings.

There is no such database in the UK. The nearest thing we have is something called ‘Tic Tac’ which is run at St George’s Hospital, London. They have a special licence from the Home Office to test what is know as a ‘sin bin’ at the Ministry of Sound nightclub where altruistic clubbers come in and throw a pill in a bin to be analysed. Unfortunately, the drawback for this is that the Home Office licence means the results cannot actually be given out.

There are definitely some benefits to testing. For a start, I am certain that the early warnings when there were pills containing atropine and 4MTA have saved lives. I do not underestimate that as a potential benefit of anything. The Dutch DIMS project is about an exchange of information, and bringing people into contact with health care professionals who can advise on contextual and patterns of abuse risk is very important. I have spoken about the possibilities of monitoring the pattern of use and pill profiling but it also allows for the authorities to see just how effective their legislation on pre-precursor testing is.

Why else might pill testing be useful? Some people believe that people who use illicit drugs should have exactly the same consumer rights as anyone who goes into a high street department store to purchase a video. Making pill taking an informed choice is particularly important. One of my worries is that when people take a pill and have a bad time, if you ask them why they had a bad time, they will say it was the content of the pill. There is a definite advantage to someone going along, taking a pill that might contain MDMA, having a lousy time and then thinking it was not the pill but maybe it had something to do with them. That is an important lesson for people to learn.

There are some disadvantages as well. It gives pills a shine of safety; it implies that if you go along and get a pill tested and they say it is MDMA then that is a good pill. Some people, when they know a pill has a high dose of MDMA, go out and make sure they get another twenty. If you are testing an illicit drug some people will definitely perceive it as sanctioning use. There is obviously misuse by dealers and the whole perception of good pills versus bad pills is a worrying one because most of the deaths that have been related to synthetic drug use have been due to MDMA, not due to other synthetic counterparts.

Another concern is that people might go along, get a pill tested and then think, "This is MDMA. Excellent! We do not have to worry about any other sort of harm reduction devices because it has not got any sort of nasty contaminants in it". It might reduce people’s implementation of other possibly very useful ham reduction procedures. The effects of a drug is due to set, setting, and dose. No content analysis of a pill is going to tell you how you will react to that drug on the day. There seems to be more information implicit in drug dose information than there really is. A policeman in Rotterdam has run a health education campaign for parents in Holland showing them videos about ecstasy. A lot of them came out and said they were really worried about ecstasy before they came in but, now they had attended this talk, realised that if pills are tested they can be safer.

The other possibility is of course that testing may encourage use. It is assumed that knowledge of pill contents leads to behavioural change. It is known that smoking kills, and yet there are lots of people still puffing away absolutely regardless. It is also assumed that a user who purchases a pill that does not contain MDMA will not take it. I do not believe that. If you have spent money on your pill and it comes back as containing no MDMA but it has a bit of 2CB and amphetamine in, you may think that is near enough and take it. It is very similar to going along and buying a nice bottle of wine with a nice label that looks like a good vintage but when you get home you have a sip and it is actually not that great. Do you pour it down the sink? No. You drink it. The same thing happens with pills.

The other assumption is that these other contents are undesirable. I do not believe that either. We asked people in a survey of about 1200 clubbers what they did when they thought the quality of pills got better or worse. 40% of people said that when the quality of Es gets better they take more. So if they get that positive test they think "Great, that is a good pill. I will have a few more of those". Only 12% were put off taking more of the pills. Half of them did not care. What happens if the quality of the pills gets worse? A fifth of the sample would probably think, "They are obviously not that strong, so I need to take more", and for up to 40% it would not make any difference. There is a group whom it would lead to using less, but the impact that a good pill will have on people’s pattern of use is worrying. With regard to harm reduction, the amount of neurotoxicity you get is dose related. We are doing something here that may encourage people to take more pills.

So there are a couple of problems with pill testing. Firstly, it is set and setting which is going to determine the acute psychological effects of a drug. Most acute adverse psychological and physical reactions are not predictable from the content of a tablet. Moreover, most of the deaths in Europe, which probably number 200-300, have been due either to context specific risks such as dehydration and hypothermia, or due to adverse reactions to MDMA. Absolutely none of those deaths due to ecstasy could have been prevented by pill testing. You are still talking about a drug which has a very small, but for a few people, significant risk of morbidity. To those who say it is simply a screening procedure, I say that screening, at least if you look at other areas of health care is used for those things (a) which are common, and (b) into which you can intervene to make a difference. Deaths from ecstasy, on the other hand, are very, very rare and most people do not react badly to it.

We also need to consider that we have already seen that there is a significant minority, maybe 5-10% of users who use a lot of ecstasy: binge users who take 5,10,15, 20 tablets over a three or four day period. They are probably not the ones who are going along and getting their pills tested. The majority who go along and get their pill tested will be the more cautious people who think, "I have not been clubbing for a couple of months, so I had better go and check my pill’ and are therefore perhaps not the people who are at the greatest risk.

Conclusions

One, there are some benefits from pill testing that can be seen by individual users and by monitoring agencies, and it is definitely another form of harm reduction.

However, maybe there is such a vocal call for pill testing because most of the people

who use ecstasy are employed, students

and middle class. They might be a more articulate and vocal group who can push their point. I wonder if people would all be as sympathetic if it was the unemployed, people with heavy criminal records who were using crack cocaine and heroin who were asking for their drugs to be tested. Then there might be a different view upon testing that type of drugs.

The potential benefits are largely based on the assumption that knowledge will lead to behavioural change and, as we have seen, it is not always going to go in that direction. Moreover, most harm reduction will be achieved by context specific changes: getting people to reduce their level of drug use and reduce their level of poly-substance misuse. There is much evidence of the impact of this on individuals’ patterns of use but it is something that we need a lot more information on. If it ends up that pill testing actually encourages people to take a lot more pills, it is not a good idea. This is an area we need to look at carefully to see if this really is as useful a tool for reducing harm as we think.

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