Pill testing at music festivals: can we do more harm?

Abstract

Recently, there have been calls for pill testing to be introduced at music festivals. Advocates say that this would inform consumers and reduce risks. However, there are a number of technical and laboratory limitations of such an intervention that need to be considered. This editorial will highlight these limitations. The recent deaths and hospitalisation of young people from illicit drug use has led to calls for the introduction of on-site testing of tablets and capsules containing illicit drugs (‘pills’) at music festivals and events.1, 2 Pill testing, both on- and off-site, is available in several European countries, with individuals submitting samples for drug identification and purity analysis. These services are aimed at both harm minimisation and providing information on the availability and emergence of new psychoactive substances.3 Death and morbidity data are unavailable to ascertain the effectiveness or harm of this intervention. Advocates for pill testing argue that by providing information on content, the person can reconsider taking the pill.4 To support that, an online survey by the Australian National Council on Drugs reported that most young people supported pill testing being available and wanted access to reliable and balanced information so that they would be more equipped to make informed decisions about the risks of using drugs.5 A field survey of Swiss attendees at dance music events reported that respondents were receptive to harm reduction measures, including pill testing. However, 27.4% responded that they would never use pill testing; 31.1% would use it systematically before taking a pill, and 41.6% would not use unless they did not know the substance, dealer or both.6 The introduction of pill testing is perceived as a way to monitor pill composition and encourage information exchange. However, it is possible that information received from this may also be seen as affirming the quality and purity of the pill.7 The testing of illicit drug formulations does not guarantee the safety of the product or protect the person consuming the drug from harm. In a research report on ecstasy pill testing, the authors concluded that pill testing at best gave an artificial ‘shine of safety’, and other simpler harm reduction mechanisms were more likely to be effective.7 Although some would consider some information better than nothing, false reassurance because of false negative results is a concern. Thus, this editorial focuses on the technical and laboratory limitations of such an intervention. On-site pill testing procedures include pill identification, reagent testing kits and chromatographic techniques. Pill identification relies on visually comparing pills supplied by the consumer with formerly analysed pills. This approach has limited utility if testing is to be performed at different geographically distinct locations. Even if the tablets are similar in appearance, it assumes that each batch contains the same excipients and the same dose and that each tablet in a batch contains a uniform dose or that the same tablet press has not been used to manufacture another batch of tablets containing a different drug. Reagent testing involves mixing a small sample of powder scraped or removed from the illicit drug formulation with chemical reagents to produce a colour change. The class of drug present is identified by the colour produced. Some kits are labelled semi-quantitative and use colour intensity to classify tablet content from very low to very high. Problems with reagent testing include lack of specificity between similar compounds, cross-reactivity with non-related compounds producing incorrect results and the inability to detect other potentially dangerous compounds that may be present. As the distribution of the illicit drug in the tablet may not be uniform, samples taken from multiple scrapings of the same tablet surface may give results varying from little or no drug to high concentration. In terms of actual dose that will be administered, the interpretation of what low or very high means is variable. It may be argued that, given the flaws of pill identification and chemical reagent testing, sophisticated techniques, such as liquid or gas chromatography with mass spectrometry, could be employed for on-site pill testing. These techniques involve expensive and technical equipment and highly trained personnel just to undertake the analytical work. For chromatography to be effectively used, there needs to be a previously determined reference library of drugs, likely contaminants and harmful excipients in a tablet or capsule to which test samples can be matched. Any drug testing method needs to know what drug or chemical it is looking for. Therefore, unknown substances in a preparation may not be detected if the testing method is not set up to detect this. The analysis may find the substance it is looking for but miss a dangerous adulterant or, if a new designer drug is present that is not in the assay library, it could be missed completely. This testing method also suffers from the fact that a scraping or sample of powder from one tablet or capsule will not accurately reflect either the dose in that particular tablet or capsule or indeed the dose in any of the tablets or capsules from the same batch. Commonly used chromatographic testing will also not determine the ratio of isomers present if the drug is a racemic compound. Different processes used to manufacture the illicit drug may influence the ratio of each isomer present. As different isomers can vary significantly in potency and psychoactive effect, quantifying the total amount of drug present will not be a useful guide to pharmacological effect.7 Time taken for analysis is also a factor. A reagent test takes minutes, but how many potential pill takers would be willing to delay consumption for the still incomplete but more comprehensive chromatography testing, which may take hours depending on sample numbers. In comparison, production of tablets and capsules in the pharmaceutical industry is highly regulated and subject to strict quality control and safety guidelines to ensure products are safe for the consumer. Any tablet or capsule may contain diluents, disintegrant, binding agents and glidants in addition to the drug. Diluents are added to increase the powder mass. Tablets may also contain a binding agent to help the tablet maintain its shape after compression and a disintegrant so that the tablet breaks into small fragments when swallowed, aiding absorption. A glidant may be added to help powder flow evenly from the machine hopper into the tablet die or capsule shell. This ensures that each tablet or capsule contains the same amount of powder and therefore the same dose. The active ingredient and the excipients must undergo satisfactory mixing to ensure that every tablet or capsule contains the correct dose of drug. Determining the correct manufacturing procedure is in itself a time-consuming process that is strictly controlled. In registered pharmaceutical products, the active ingredient (drug) undergoes identity and purity testing to ensure that no harmful levels of residual ingredients, by-products or other contaminants are present. Excipients are also tested to ensure no effect on drug stability or the performance of the tablet or capsule when administered. During and post-production, tablets and capsules undergo tests, such as uniformity of content and weight, to ensure that each tablet or capsule produced contains the appropriate dose and dissolution and disintegration testing to ensure that the tablet or capsule will disintegrate, and the drug will dissolve at an appropriate rate to produce the desired effect. The stability of the drug in the dosage form over time is also tested to ensure that the drug does not break down to inactive or toxic products. In distinction, the production of illicit drug formulations is not controlled. Illicit drug dosage forms are not subject to any quality control measures, meaning that whilst a drug may be sold as ‘drug X’, it may in fact contain pure drug, no drug, another drug or a toxic or non-toxic diluent. The stability of an illicit drug in the formulation is not known, and there is less, if any, data on potential toxicity of decomposition products. Even if the product contains the active ingredient, it may also contain dangerous by-products of the drug synthesis process. Mixing of ingredients prior to preparing the tablets and capsules is unlikely to be satisfactory, resulting in uneven distribution of drug through the powder bed. This will result in some tablets from the same batch having very little drug while others have a very high dose. As distribution of drug within a tablet or capsule is usually not uniform, a portion of powder taken from one part of a tablet by scraping the surface of the tablet or by opening the capsule for testing may not be representative of what the entire tablet or capsule contains. The pharmacological effects of illicit drugs or other excipients also appear to have been forgotten. Even if the likely drug and dose is determined, drugs exhibit inter-individual variability in their pharmacokinetics and pharmacodynamics. The same dose of drug administered to different people may produce markedly different responses. Observed differences may be because of any number of factors, including genetic polymorphism, interaction with other co-administered drugs and physiological factors affecting drug distribution and elimination. Formulations may also influence how much of the illicit drug is absorbed. If a tablet disintegrates rapidly, a rapid rise in plasma drug concentration may occur, whereas if the tablet does not disintegrate in the gastrointestinal tract, the drug may not be released from the formulation. A delayed release of the drug resulting in delayed onset of action may result in the consumer taking additional pills, thinking the pills they have are ‘weak’.7 For many illicit drugs, the full pharmacological spectrum of action is not known. The lack of pharmacokinetic data for many illicit drugs also poses a concern in an emergency situation with illicit drug intoxication. Often, the pharmacological and toxicological effects of other excipients, by-products and contaminants are not known, producing an unpredictable spectrum of effect. Even reflecting on the small percentage of potential analytical factors discussed here, it is evident that the consumer considering taking an illicit drug may have a false sense of security, particularly if their decision to take the drug is based only on information provided by quantitative and qualitative on-site pill testing. The failure to detect an agent that could be life-threatening is of great concern. Although the ‘harm reduction’ argument is noted, equally, the many unknown and potentially unidentifiable factors that could cause mortality are noted. On-site testing will thus not solve this problem and could lead to other problems of an unpredictable and tragic nature.