Dr David Caldicott, Clinical Lead, DEADset project

As the party season hots up, Emergency Physician David Caldicott* warns that prevailing attitudes to recreational drugs need an urgent re-think.

After an unseasonably cold and wet winter, we are beginning to see the sun in Canberra. For many, this marks the time to dust off the BBQ, clean the pool, or after the Melbourne Cup, put down this season’s crop of tomatoes.

For those of us involved in the acute management of medical presentations associated with recreational drug overdose, we also have other things on our mind. And for the Antipodean 2016/17 Season, like medically qualified meerkats, we are very nervously eyeing up the dark clouds rapidly gathering on the horizon.

There will be those of you who take exception to the phrase ‘recreational drugs’. I get that. Many of you will have never used any illicit product in your lives; some of you might even be teetotal, or non-smokers. I congratulate you on your abstemious ways.

But the values assumed by our very conservative profession are not the same as those of as many as 25% of your fellow citizens.

Assoc Prof David Caldicott

Associate Professor David Caldicott

Those rendered indignant about acknowledging the fact that young people use drugs for pleasure rarely end up being the same people that influence their behaviour. We have talked to thousands of drug users at Australian and European music festivals, and hundreds of patients in emergency departments, on both sides of the equator. And it is simply naïve to assume that the 21st century consumer seeks drugs for any reason other than ‘pleasure’ or ‘recreation’.

Avoiding the term is as about as effective an exercise in social marketing and public health as trying to re-brand ‘king hits’ as ‘coward punches’.

Once we get over this strange philosophical hurdle, we can then move from what we are good at to what we ‘own’ - talking to consumers about the known ‘costs’ associated with the perceived ‘benefits’ of drug consumption.

I am, of course, referring to the substantial and potentially devastating health ‘harms’ associated with any drug consumption. I don’t pay much heed to the differences between the licit and the illicit, for current global categorisations are far more to do with tradition, international lobbying and political influence than they are to do with health.

If a substance called ‘alcohol’ emerged on a modern market, it would rapidly earn its position on Schedule 9, well ahead of cannabis in terms of global harms caused to Australians. That these same laws place cannabis and methamphetamine in the same category of harm is a historical anachronism, which, coupled to the kind of facile ‘just say no’ message promulgated by those as medically qualified as Nancy Reagan, has achieved one thing - a generation that doesn’t believe anything that it’s told about drugs, except from its peers.

So instead of a morality approach to drug use, we speak to the harms that any drug, legal or not, can cause, particularly with immoderate use.

We try to be as non-judgemental as possible. When users or patients understand that we are keen to keep them alive, rather than put them in prison, they are happily forthcoming about their use.

In the last year, there has been a huge media focus on individual drugs, such as ‘ice’ or more recently, an apparently notorious, zombie-creating entity known as ‘flakka’ or ‘gravel’. These ‘moral panics do little to inform the public about the real story, which is far more disconcerting. For nerdy spectators such as myself, ‘flakka’ or alpha-pyrrolidinovalerophenone, a cathinone derivative, is old news. We provided the AFP with a detailed assessment of it neary two years ago, which in the modern market is a geological period of time.

The real story is the evolution of the market itself. Gone are the days when smugglers only moved large quantities of a relatively small number of different products, in the knowledge that while some might be seized, most would get through.

Multimillion dollar drug busts, while sounding impressive, are usually inflated in value, and represent irrelevant quantities as far as the overall market is concerned (if they were significant, one would anticipate downstream changes in price points, which never occur). The market has evolved to avoid even this ineffective form of interdiction. Young Millennials conduct their research on line, internationally, behind the secrecy of the Dark Web. They share experiences, and pay for drugs using untraceable cryptocurrencies. Drugs, manufactured to pharmaceutical purity, are delivered in small packages, by the postie. Many of them are undetectable in either basic urine screens, or by sniffer dogs, making them very attractive to those in occupations such as mining and long-haulage, as well as festival goers.

The drugs themselves are like mayflies - with incredibly brief commercial lives, partly in response to woefully inadequate attempts at sweeping interdiction, and partly due to the apparently insatiable appetite of consumers for something ‘new’.

In the early 00s, I remember being worried by less than 20 illicit drugs - I had their structures on a T-shirt! At a meeting of the UNODC Committee on Novel Psychotropic Substances in Vienna in October 2016, we were advised that the number had now exceeded 700. There is no way that our traditional models of interdiction can cope with this burden - the rate of evolution is proof of this.

So much of our effort - and expenditure - in Australia is spent on seeking to, but failing, to prevent drugs coming into the country. It amounts to billions of dollars. But what if we were to try something new? What if we were brave enough to focus our efforts on reducing the demand side of the equation?

One country has made that move with remarkable results is Portugal. Back in the early 2000s, then-prime minister António Guterres effectively reversed the funding imbalance between law enforcement and health, pouring resources into the latter.

The result was a dramatic improvement in nearly every measurable health metric pertaining to drug use. (Guterres is due to become the next UN Secretary General, with every expectation that he might have something to say about international drug policy).

Back in Australia we can learn from our colleagues’ experiences in the summer months of the Northern Hemisphere where at least two worrying trends have emerged.

The first has been the identification of ultra-potent fentanyl analogues in the illicit market. Some of you will recall the infamous ending of the Moscow Theatre siege in 2002, when Russia’s FSB gassed both patrons and Chechen terrorists alike to end the siege. One of the substances involved was carfentanil, active in humans at the weight of a snowflake. North America experienced numerous multiple overdoses this summer, often overwhelming emergency departments with ventilation requirements. Naloxone was required at 10-20mg doses, with subsequent infusions.

In Europe, colleagues conducting drug checking at music festivals, a process now in its second decade in the EU, have identified ecstasy pills containing over 200mg MDMA. When one considers that 75mg is what most will need to get them where they want to be - and it is not unusual for young Australians to ‘double-‘ or ‘triple-drop’ - it is not hard to get twitchy about the prospect of these agents reaching Australian music festivals, including those on the NSW North Coast.

On the subject of pill-testing, there are now no academics of repute left in the Alcohol and Other Drugs (AOD) sector in Australia who don’t believe that at least a pilot should be conducted here.

The opposition is entirely political, largely because to accept such a pilot might be construed as sending ‘The Wrong Message’, this apparently being that it is entirely acceptable for young people to die in the service of teaching a lesson to other consumers about the dangers of drug consumption.

No physician can support the barbarity of that approach.

What we know about pill testing is that it alters consumer behaviour - at the point of consumption - while giving us invaluable information about emerging products on the market, long before customs or police seizures. Far from encouraging drug consumption, it moderates it, making life-threatening overdose far less likely.

I have my own kids now. I would love to be able to give them the real fairies and the unicorns that they so desperately crave for their birthdays. At present, there is more chance of that than there ever being a drug-free Australia.

What we can do is to commit to trying anything that we can to stop another death, another sacrifice on an altar of a false ideology. It may not appear palatable to those relying on popularity contests for their careers, but that does not include the medical profession.

There will never be a drug free Australia, and not one life is worth trying to make it that way.

Associate Professor David Caldicott is a Consultant Emergency Physician, Emergency Department, Calvary Hospital, Clinical Senior Lecturer, Emergency Medicine, Australian National University (ANU), Associate Professor, Health & Design, University of Canberra, and Clinical Lead, Australian Drug Observatory, ANU.