tag:theconversation.com,2011:/africa/topics/drug-deaths-41346/articlesDrug deaths – The Conversation2024-03-20T22:21:47Ztag:theconversation.com,2011:article/2262232024-03-20T22:21:47Z2024-03-20T22:21:47ZElon Musk says ketamine can get you out of a ‘negative frame of mind’. What does the research say?<p>X owner Elon Musk <a href="https://thenightly.com.au/business/cnbc-elon-musk-suggests-his-prescription-ketamine-use-is-good-for-investors-c-14000709?utm_source=sendgrid&utm_medium=email">recently described</a> using small amounts of ketamine “once every other week” to manage the “chemical tides” that cause his depression. He says it’s helpful to get out of a “negative frame of mind”.</p>
<p>This has caused a range of reactions in the media, including on X (formerly Twitter), from strong support for Musk’s choice of treatment, to allegations he has a drug problem.</p>
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<p>But what exactly is ketamine? And what is its role in the treatment of depression?</p>
<h2>It was first used as an anaesthetic</h2>
<p>Ketamine is a <a href="https://doi.org/10.3389/fnhum.2016.00612">dissociative anaesthetic</a> used in surgery and to relieve pain. </p>
<p>At certain doses, people are awake but are disconnected from their bodies. This makes it useful for paramedics, for example, who can continue to talk to injured patients while the drug blocks pain but without affecting the person’s breathing or blood flow. </p>
<p>Ketamine is also used to sedate animals in veterinary practice. </p>
<p>Ketamine is a mixture of two molecules, usually referred to a S-Ketamine and R-Ketamine.</p>
<p>S-Ketamine, or esketamine, is stronger than R-Ketamine and was approved in 2019 in the United States under the drug name Spravato for serious and long-term <a href="https://doi.org/10.1080/14740338.2022.2066651">depression</a> that has not responded to at least two other types of treatments.</p>
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Read more:
<a href="https://theconversation.com/fda-approves-promising-new-drug-called-esketamine-for-treatment-resistant-depression-111966">FDA approves promising new drug, called esketamine, for treatment-resistant depression</a>
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<p>Ketamine is thought to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717708/">change chemicals in the brain</a> that affect mood.
While the exact way ketamine works on the brain is not known, scientists think it changes the amount of the neurotransmitter glutamate and therefore changes symptoms of <a href="https://doi.org/10.3389/fnhum.2016.00612">depression</a>. </p>
<h2>How was it developed?</h2>
<p>Ketamine was first synthesised by chemists at the Parke Davis pharmaceutical company in Michigan in the United States as an anaesthetic. It was tested on a group of prisoners at Jackson Prison in Michigan in 1964 and found to be fast acting with <a href="https://pubs.asahq.org/anesthesiology/article/113/3/678/10426/Taming-the-Ketamine-Tiger">few side effects</a>.</p>
<p>The US Food and Drug Administration <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126726/">approved</a> ketamine as a general anaesthetic in 1970. It is now on the World Health Organization’s core list of essential medicines for health systems worldwide as an <a href="https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2021.02">anaesthetic drug</a>. </p>
<p>In 1994, following patient reports of improved depression symptoms after surgery where ketamine was used as the anaesthetic, researchers began studying the effects of low doses of ketamine on <a href="https://pubmed.ncbi.nlm.nih.gov/8122957/">depression</a>. </p>
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<img alt="Depressed woman looks down" src="https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/583066/original/file-20240320-16-cf5ntq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Researchers have been investigating ketamine for depression for 30 years.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-attractive-latin-woman-lying-home-1147331690">SB Arts Media/Shutterstock</a></span>
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<p>The first clinical trial results were <a href="https://www.biologicalpsychiatryjournal.com/article/S0006-3223(99)00230-9/abstract">published in 2000</a>. In the trial, seven people were given either intravenous ketamine or a salt solution over two days. Like the earlier case studies, ketamine was found to reduce symptoms of depression quickly, often within hours and the effects lasted up to seven days. </p>
<p>Over the past 20 years, researchers have studied the effects of ketamine on <a href="https://doi.org/10.1016/j.neuropharm.2022.109305">treatment resistant depression, bipolar disorder</a>, <a href="https://theconversation.com/ketamine-can-rapidly-reduce-symptoms-of-ptsd-and-depression-new-study-finds-216077">post-traumatic sress disorder</a> <a href="https://pubmed.ncbi.nlm.nih.gov/34199023/">obsessive-compulsive disorder, eating disorders and for reducing substance use</a>, with generally positive results. </p>
<p>One study in a <a href="https://www.sciencedirect.com/science/article/pii/S0165032723006110">community clinic</a> providing ketamine intravenous therapy for depression and anxiety found the majority of patients reported improved depression symptoms eight weeks after starting regular treatment.</p>
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Read more:
<a href="https://theconversation.com/ketamine-injections-for-depression-a-new-study-shows-promise-but-its-one-of-many-options-209591">Ketamine injections for depression? A new study shows promise, but it's one of many options</a>
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<p>While this might sound like a lot of research, it’s not. A <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00304-8/fulltext">recent review</a> of randomised controlled trials conducted up to April 2023 looking at the effects of ketamine for treating depression found only 49 studies involving a total of 3,299 patients worldwide. In comparison, in 2021 alone, there were 1,489 studies being conducted on <a href="https://www.centerwatch.com/articles/25599-oncology-trials-outpacing-rest-of-the-field-in-complexity-and-duration-study-shows#:%7E:text=The%20number%20of%20investigational%20drugs,genetic%20sequencing%20technologies%2C%20CSDD%20says.">cancer drugs</a>. </p>
<h2>Is ketamine prescribed in Australia?</h2>
<p>Even though the research results on ketamine’s effectiveness are encouraging, scientists still don’t really know how it works. That’s why it’s not readily available from GPs in Australia as a standard depression treatment. Instead, ketamine is mostly used in specialised clinics and research centres. </p>
<p>However, the clinical use of ketamine is increasing. <a href="https://www.tga.gov.au/sites/default/files/auspar-esketamine-hydrochloride-210507-pi.pdf">Spravato nasal spray</a> was <a href="https://www.tga.gov.au/resources/auspmd/spravato">approved</a> by the Australian Therapuetic Goods Administration (TGA) in 2021. It must be administered under the <a href="https://adf.org.au/insights/ketamine-treat-depression/">direct supervision</a> of a health-care professional, usually a psychiatrist. </p>
<p>Spravato <a href="https://www.tga.gov.au/resources/auspmd/spravato">dosage</a> and frequency varies for each person. People usually start with three to six doses over several weeks to see how it works, moving to fortnightly treatment as a maintenance dose. The nasal spray <a href="https://www.unsw.edu.au/newsroom/news/2023/10/why-low-cost-ketamine-is-still-inaccessible-to-many-with-severe-">costs</a> <a href="https://www.medicalrepublic.com.au/esketamine-snubbed-by-pbac-again/17835">between A$600 and $900</a> per dose, which will significantly limit many people’s access to the drug. </p>
<p>Ketamine can be prescribed “off-label” by GPs in Australia who can prescribe schedule 8 drugs. This means it is up to the GP to assess the person and their medication needs. But <a href="https://www.medicalrepublic.com.au/caution-as-esketamine-approved-for-depression/4975#:%7E:text=GPs%20and%20other%20clinicians%20can,8%20drug%20poses%20serious%20risks.">experts in the drug</a> recommend caution because of the lack of research into negative side-effects and longer-term effects. </p>
<h2>What about its illicit use?</h2>
<p>Concern about use and misuse of ketamine is heightened by highly publicised deaths connected to the <a href="https://www.pbs.org/newshour/arts/autopsy-report-shows-actor-matthew-perry-died-from-effects-of-ketamine">drug</a>. </p>
<p>Ketamine has been used as a recreational drug since the 1970s. People report it makes them feel euphoric, trance-like, floating and dreamy. However, the amounts used recreationally are typically higher than those used <a href="https://pubmed.ncbi.nlm.nih.gov/16529526/">to treat depression</a>. </p>
<p>Information about deaths due to ketamine is limited. Those that are reported are <a href="https://journals.sagepub.com/doi/10.1177/02698811211021588">due to accidents or ketamine combined with other drugs</a>. No deaths have been reported in <a href="https://pubmed.ncbi.nlm.nih.gov/36410032/">treatment settings</a>.</p>
<h2>Reducing stigma</h2>
<p>Depression is the third leading cause of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717708/">disability worldwide</a> and effective treatments are needed. </p>
<p>Seeking medical advice about treatment for depression is wiser than taking Musk’s advice on <a href="https://www.washingtonpost.com/wellness/2022/05/04/wellbutrin-elon-musk-antidepressant/">which drugs to use</a>. </p>
<p>However, Musk’s public discussion of his mental health challenges and experiences of treatment has the potential to reduce stigma around depression and help-seeking for mental health conditions. </p>
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Read more:
<a href="https://theconversation.com/ketamine-can-rapidly-reduce-symptoms-of-ptsd-and-depression-new-study-finds-216077">Ketamine can rapidly reduce symptoms of PTSD and depression, new study finds</a>
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<p><em>Clarification: this article previously referred to a systematic review looking at oral ketamine to treat depression. The article has been updated to instead cite a review that encompasses other routes of administration as well, such as intravenous and intranasal ketamine.</em></p><img src="https://counter.theconversation.com/content/226223/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julaine Allan receives funding from the Australian Government to conduct research on mental health and substance use interventions, treatments and outcomes. </span></em></p>What exactly is ketamine and what is its role in the treatment of depression?Julaine Allan, Associate Professor, Mental Health and Addiction, Rural Health Research Institute, Charles Sturt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2250242024-03-08T17:12:03Z2024-03-08T17:12:03ZAnxiety drug pregabalin linked to rising number of deaths – here’s what you should know<figure><img src="https://images.theconversation.com/files/580673/original/file-20240308-30-m9sql2.jpg?ixlib=rb-1.1.0&rect=16%2C0%2C5557%2C3673&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pregabalin on its own is typically not dangerous – but can cause harm if taken alongside certain drugs.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pouring-capsules-pill-bottle-into-hand-141666325">Brian A Jackson/ Shutterstock</a></span></figcaption></figure><p>There has been a significant rise in deaths linked to the commonly prescribed anxiety drug, pregabalin. While in 2018 there were 187 deaths linked to pregabalin in England and Wales, this number was <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/adhocs/1765deathregistrationsrelatedtogabapentinorpregabalinenglandandwales2018and2022">more than double</a> in 2022 – with 441 deaths linked to the drug.</p>
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<p>Recent press reports have framed these deaths as signalling a “<a href="https://www.thetimes.co.uk/article/7ad460de-b356-4965-81d2-e7dfa2051bfa">US-style opioid epidemic</a>” caused by a medicine that “<a href="https://www.dailymail.co.uk/news/article-13154113/pregabalin-anti-depressant-anxiety-drug-effects.html">destroys lives</a>”. This is not an equitable comparison, given <a href="https://www.cdc.gov/drugoverdose/deaths/index.html">hundreds of thousands</a> of Americans have died due to opioids. These reports may only serve to cause undue panic about the drug, especially among those who have been prescribed it.</p>
<p><a href="https://www.nhs.uk/medicines/pregabalin/">Pregabalin</a> (also known by the brand names Lyrica and Alzain) is used to treat a variety of health conditions, including epilepsy, nerve pain and anxiety. The drug was <a href="https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(22)00275-7/fulltext">first approved for use</a> in Europe and the US in 2004. </p>
<p>Pregabalin has <a href="https://link.springer.com/article/10.1007/s40264-020-00985-6">rewarding properties</a>, and can produce feelings of <a href="https://www.talktofrank.com/drug/pregabalin#how-it-feels">euphoria, calmness and relaxation</a>. These effects may explain why even people who don’t have a prescription seek out pregabalin. </p>
<p>Pregabalin on its own is typically not dangerous, although as with all medication there are <a href="https://www.mayoclinic.org/drugs-supplements/pregabalin-oral-route/side-effects/drg-20067411?p=1">potential side effects</a> – including confusion and headaches. It can also carry the <a href="https://cks.nice.org.uk/topics/neuropathic-pain-drug-treatment/prescribing-information/pregabalin/">risk of dependence</a>, especially if taken long term. </p>
<p>But where pregabalin can become dangerous, whether <a href="https://link.springer.com/article/10.1007/s40264-020-00985-6">used as prescribed or not</a>, is if it’s taken alongside <a href="https://www.mayoclinic.org/drugs-supplements/pregabalin-oral-route/precautions/drg-20067411">other drugs</a> that it interacts negatively with. Pregabalin should ideally be avoided alongside other opioids, certain sleep aids, benzodiazepines (another class of anxiety drug), muscle relaxants and even certain diabetes and epilepsy drugs. Most fatalities attributed to pregabalin are due to interactions with other drugs, leading to a suppression of breathing.</p>
<p>An analysis of <a href="https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.15352">pregabalin deaths in England</a> between 2004-2020 has shown that in over 90% of deaths, the presence of other opioids (including methadone or morphine) was detected. However, in only a quarter of cases were these opioids actually prescribed to the person. This suggests that people were probably sourcing these drugs through illicit means and not through their doctor. Likewise, it’s not clear from the data whether pregabalin had been prescribed, or if the person sourced it without a prescription. </p>
<p>Although this data only goes up to 2020, it’s likely that the picture is similar for the recent deaths linked to pregablin.</p>
<h2>Fatalities</h2>
<p>The recent rise in pregablin deaths partly coincides with an increase in the number of people prescribed the drug. In the UK alone, there were <a href="https://academic.oup.com/jat/article/47/1/e20/6839276">8.4 million prescriptions</a> for pregabalin in 2022. This is up from 5.5 million in 2016. </p>
<p>This might suggest that more support needs to be provided to reduce patient risk – particularly in relation to co-use of other drugs. Prescribers and patients both <a href="https://www.gov.uk/government/publications/misuse-of-illicit-drugs-and-medicines-applying-all-our-health/misuse-of-illicit-drugs-and-medicines-applying-all-our-health">need to be educated</a> about the potential risks of using pregabalin – including the <a href="https://www.gov.uk/government/publications/prescribed-medicines-review-report">potential of dependency</a>. Patients and prescribers also need to be aware of the drugs that pregabalin interacts with and the effects such combinations might have. </p>
<p>Prescribers should also <a href="https://www.nice.org.uk/guidance/ng215">regularly review</a> pregabalin prescriptions to ensure that patients are still <a href="https://bmjopen.bmj.com/content/9/3/e021535">benefiting from it</a>. If not, recommending other treatments – such as <a href="https://www.tandfonline.com/doi/full/10.3109/09540261.2011.606803">psychological therapies</a>, if a person is taking the drug for anxiety – might be more suitable.</p>
<p>But in light of the profile of drugs involved in deaths previously linked to pregabalin, it’s clear that drug education alone won’t be enough.</p>
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<img alt="Three vials of methadone." src="https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Methadone is one drug that should never be taken alongside pregabalin.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/vial-methadone-injection-syringe-on-black-1758754181">Bernard Chantal/ Shutterstock</a></span>
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<p>Certain groups may be at greater risk of harm from pregabalin. For example, people with a history of substance use disorder have a high level of <a href="https://link.springer.com/article/10.1007/s40265-020-01432-7">co-occurring</a> mental health problems, and may be prescribed pregabalin as a short-term treatment for anxiety. But because mental health and drug treatment support are typically provided by <a href="https://meam.org.uk/wp-content/uploads/2022/06/Co-occurring-conditions-briefing-FINAL-June-2022.pdf">different services</a>, a lack of communication between these services can sometimes mean that one service is not always fully aware of what drugs the other is prescribing – potentially leading to <a href="https://www.emerald.com/insight/content/doi/10.1108/ADD-04-2013-0010/full/html">harmful drug interactions</a>. </p>
<p>Evidence also suggests that illicit pregabalin use is a <a href="https://link.springer.com/article/10.1007/s40265-020-01432-7">growing problem</a> in both Europe and North America. Its <a href="https://www.gov.uk/government/publications/circular-0192018-control-of-pregabalin-and-gabapentin-under-the-misuse-of-drugs-act-1971/control-of-pregabalin-and-gabapentin-under-the-misuse-of-drugs-act-1971">availability as a street drug</a> may mean users aren’t aware of the risks of taking pregabalin alongside other drugs – such as the synthetic opiate, methadone.</p>
<p>There’s the added complication of fear of negative consequences. Someone prescribed pregabalin who uses illicit drugs may not declare this to their doctor. People who use illicit opioids less frequently (such as for recreational purposes or to self-treat pain or mental health problems) are also at <a href="https://www.tandfonline.com/doi/abs/10.1080/14740338.2023.2193397">elevated risk</a>.</p>
<p>Evidence also shows that more people living in the <a href="https://bmjopen.bmj.com/content/10/3/e029624.abstract">north of England</a> are prescribed pregabalin compared to those living in the south. Other research has also shown a link between <a href="https://academic.oup.com/pmj/article/98/1157/193/6958957">social deprivation and drug prescribing</a> – with people living in more deprived areas of England being prescribed drugs such as pregabalin at higher rates. Those living in deprived areas may not get the support they need – including support to know the risks of taking or combining certain drugs, putting them at greater risk of harm.</p>
<p>Understanding exactly why these deaths are happening is important for developing strategies to reduce harm and deaths from the drug. Simply stopping pregabalin prescriptions does not seem practical or safe, as it’s considered a <a href="https://bnf.nice.org.uk/drugs/pregabalin/">useful and effective medicine</a> that many people benefit from. Placing tougher restrictions on illicit pregabalin would also not be practical, and could even lead to greater harm – which is exactly what happened after it was made a <a href="https://blogs.bmj.com/bmj/2019/03/29/ian-hamilton-reclassifying-pregabalin-gabapentin-only-moves-problem-other-drugs/">Class C drug</a> in 2019.</p>
<p>Understanding why people are combining pregabalin with other drugs, prescribed or not, is crucial for anything meaningful to be done.</p><img src="https://counter.theconversation.com/content/225024/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Sumnall receives funding from public grant awarding bodies for alcohol and other drugs research, and fees from (international) not-for-profit organisations and government departments for consultation work. He is an unpaid member of the Scientific Advisory Board of the Mind Foundation, an unpaid advisor to the UK Drug Education Forum, and an unpaid co-opted member of UK Government Advisory Council on the Misuse of Drugs (ACMD) Working Groups.</span></em></p><p class="fine-print"><em><span>Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Pregabalin is prescribed for a number of conditions – including epilepsy, anxiety and nerve pain.Ian Hamilton, Honorary Fellow, Department of Health Sciences, University of YorkHarry Sumnall, Professor in Substance Use, Liverpool John Moores UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2205172024-01-12T16:12:10Z2024-01-12T16:12:10ZFour street drugs that could pose the biggest threat to UK public health in 2024<figure><img src="https://images.theconversation.com/files/569021/original/file-20240112-25-j3jcoe.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4025%2C3017&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Xanax pills</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/muncie-indiana-united-states-june-5-1416893333">gremlinworks/Shutterstock</a></span></figcaption></figure><p>As with fashion and music, illicit drugs go through peaks and troughs of popularity. There are popular staples, such as cannabis, and more disruptive and transient substances, such as <a href="https://theconversation.com/meow-hear-this-mephedrone-is-a-curious-khat-2164">mephedrone</a>. As with <a href="https://youtu.be/Ja2fgquYTCg?si=AjGVwuw92NiEPnMS">clothing fashion</a>, the drugs that most people are able to buy are <a href="https://www.emcdda.europa.eu/publications/eu-drug-markets_en">determined by</a> the choices of designers, manufacturers and logistical operations, rather than consumers. </p>
<p>Predicting how the UK drug market may change in 2024 relies not only on recent trends in drug use but also on international developments. Geopolitical events in <a href="https://geographical.co.uk/news/myanmar-becomes-worlds-biggest-producer-of-opium">south-east Asia</a> or <a href="https://www.bbc.co.uk/news/world-latin-america-67912242">South America</a> are just as important as organised crime activity in cities such as London or Liverpool. We suggest that there are four types of drugs that will be of increasing concern in 2024. </p>
<h2>1. Opioids</h2>
<p>Heroin sold in the UK is primarily sourced from opium grown in Afghanistan. Any change in the <a href="https://theconversation.com/afghanistan-what-the-conflict-means-for-the-global-heroin-trade-165995">production and distribution</a> of opium has a direct effect on the <a href="https://theconversation.com/nitazenes-synthetic-opioids-more-deadly-than-fentanyl-are-starting-to-turn-up-in-overdose-cases-212589">UK heroin market</a>. </p>
<p>After seizing power in 2022, the Taliban announced a clampdown on opium farming in Afghanistan. While other growing regions have <a href="https://www.unodc.org/roseap/en/2023/12/southeast-asia-opium-survey-report-launch/story.html#:%7E:text=Bangkok%20(Thailand)%2C%2012%20December,Asia%20released%20in%20Bangkok%20today.">increased production</a>, this has not been at the level of the Afghan crop. </p>
<p>Large stockpiles of opium and heroin stored along trafficking routes have depleted. 2024 will see the impact of this. </p>
<p>The estimated number of people who use heroin has <a href="https://www.gov.uk/government/publications/opiate-and-crack-cocaine-use-prevalence-estimates/estimates-of-opiate-and-crack-use-in-england-main-points-and-methods">increased</a> over the past decade, with an estimated 341,032 current users in England. </p>
<p>This is a highly profitable market, and suppliers are adaptable and nimble in responding to changes like these. As a consequence of the shortfall in Afghan heroin production, new, highly potent <a href="https://www.bmj.com/content/383/bmj.p2421">synthetic opioids</a> have already emerged to fill the gap. These include the group of synthetic opiates known as <a href="https://theconversation.com/nitazenes-synthetic-opioids-more-deadly-than-fentanyl-are-starting-to-turn-up-in-overdose-cases-212589">nitazenes</a>, which have contributed to the <a href="https://theconversation.com/generation-x-hardest-hit-as-drug-deaths-rise-yet-again-in-england-and-wales-220064">record levels</a> of drug-related deaths recorded in 2023 in the UK. </p>
<p>Increased market penetration of these drugs could lead to a big rise in deaths in 2024. Worryingly, <a href="https://www.bbc.co.uk/news/uk-england-manchester-67777938">misselling</a> as other products and unintentional contamination of other non-opioid drugs could increase the harms further. Government and treatment services must act now to prepare for an increase in the supply of these drugs, as the costs of not doing so might lead to a <a href="https://www.sciencedirect.com/science/article/pii/S0955395923003614?via%3Dihub">“nightmare scenario”</a>. </p>
<h2>2. Cocaine</h2>
<p>Cocaine has never been purer, more affordable and more available to those <a href="https://www.theguardian.com/commentisfree/2023/dec/23/coke-consumption-uk-millennials-generation-x">who want it in the UK</a>. While <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/drugmisuseinenglandandwales/yearendingmarch2023">levels of use</a> have been relatively stable over the past 20 years, <a href="https://theconversation.com/generation-x-hardest-hit-as-drug-deaths-rise-yet-again-in-england-and-wales-220064">deaths and hospitalisations</a> have increased due the nature of the product on the market and increases in the frequency and length of use. </p>
<p>Unlike other class A drugs, such as heroin, there are few effective treatments, and users tend to be more socially integrated. This means that they are less likely to come into contact with police or present to treatment services. </p>
<p>They may not identify themselves as having a drug problem, despite the effect it may be having on their lives. When disposable income continues to be squeezed as it is in the current cost of living crisis, powder cocaine (as opposed to crack cocaine) is a drug that will continue to provide good “value for money”. Sadly, we predict yet another rise in poisonings and hospitalisations in 2024.</p>
<figure class="align-center ">
<img alt="Older man snorting coke." src="https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cocaine users tend to be more ‘socially integrated’.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/old-male-writer-smoking-cigarette-2284921057">Elnur/Shutterstock</a></span>
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</figure>
<h2>3. Ketamine</h2>
<p>Ketamine has been used in medicine as an anaesthetic for many years, and more recently as an <a href="https://theconversation.com/how-antidepressants-ketamine-and-psychedelic-drugs-may-make-brains-more-flexible-new-research-216025">antidepressant</a>. Taken recreational at lower doses, the drug <a href="https://www.talktofrank.com/drug/ketamine">induces</a> feelings of detachment and happiness. </p>
<p>This is another drug that has become increasingly <a href="https://bjgp.org/content/73/727/87">popular</a> because it is cheap, fast-acting and easy to get hold of. </p>
<p>Around <a href="https://news.sky.com/story/student-died-after-taking-ketamine-now-her-mother-wants-to-address-naivety-among-parents-13039959">3.8% of young people</a> (aged 16 to 24) report having used the drug. This has been steadily rising over the past decade. Police report that the weight of <a href="https://www.gov.uk/government/statistics/seizures-of-drugs-in-england-and-wales-financial-year-ending-2022/seizures-of-drugs-in-england-and-wales-financial-year-ending-2022">seizures</a> of ketamine that they made increased sharply from 187kg in 2021 to 1,837kg in 2022. Drug seizures are often used as a proxy for estimating levels of supply.</p>
<p>A range of problems can develop for those using ketamine in higher doses or over a longer period, ranging from mental health problems to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4544340/">incontinence</a>. An overdose of the drug can prove to be fatal.</p>
<p>As with most illicit drugs, combining ketamine with alcohol <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9323326/">increases</a> health risks. Sadly, it is the norm for people to use more than one drug at a time – including alcohol.</p>
<p>Given the widespread availability and <a href="https://www.timeout.com/uk/nightlife/how-ketamine-became-britains-go-to-party-drug">affordability</a> of ketamine in the UK, its use will continue to rise in 2024. Use is concentrated among younger people, many of whom won’t be aware of its potential for harm until it’s too late. </p>
<p>As with cocaine, there has been a distinct lack of health messaging, advice and support for people who use ketamine. Some youth organisations that have tried to do this have faced unhelpful <a href="https://www.thetimes.co.uk/article/how-ketamine-became-the-uks-hidden-campus-killer-9mp3pm6ht">national media backlash</a>. </p>
<h2>4. Benzodiazapines</h2>
<p>Benzodiazepines, more commonly known by brand names such as Valium and Xanax, have proved to be popular and dangerous in equal measure. While medical prescriptions have <a href="https://www.england.nhs.uk/2023/03/opioid-prescriptions-cut-by-almost-half-a-million-in-four-years-as-nhs-continues-crackdown/">fallen</a> in recent years illicit <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/drugmisuseinenglandandwales/yearendingmarch2023">demand</a> and supply has not. </p>
<p>Although doctors have been <a href="https://www.nice.org.uk/sharedlearning/benzodiazepine-hypnotics-deprescribing">encouraged</a> to reduce prescriptions for benzodiazepines, the black market has filled the gap in demand. Unlike legitimate supply, the illicit market has no quality control or reliable information on strength – both of which lead to deaths.</p>
<p>The rapid rise in deaths from <a href="https://www.sciencedirect.com/science/article/abs/pii/S0955395921004308">these drugs</a> in Scotland shows regional differences both in the use of drugs and the risks they pose. Reversing this trend in use and fatalities will prove to be difficult in 2024 as there are few signs of a change in demand for, or supply of these drugs.</p>
<h2>Can we prevent drug harms?</h2>
<p>It is not possible to entirely prevent all the harms relating to drug use and the drugs market, but they can be reduced. 2024 may see the emergence of new drugs or new ways of taking them, but what won’t change will be the continuation of more than 20 years of increasing drug-related harm. </p>
<p>In a year of a general election in the UK, there is the danger that drugs policy will be used for political point scoring – signalling to the electorate how tough on crime one party is, or how soft on crime their opponents are. Whatever the outcome of the election, unless there is a clear commitment to long-term investment in responses to drug use, new records will be set in drug-related deaths.</p><img src="https://counter.theconversation.com/content/220517/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Sumnall receives and has received funding from public grant awarding bodies for alcohol and other drugs research, and consultation fees from (international) not-for-profit organisations, and government Ministries for consultation work. He is an unpaid member of the Scientific Advisory Board of the Mind Foundation.</span></em></p><p class="fine-print"><em><span>Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Synthetic opioids called nitazenes are ones to watch in 2024.Ian Hamilton, Honorary Fellow, Department of Health Sciences, University of YorkHarry Sumnall, Professor in Substance Use, Liverpool John Moores UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2157912023-10-22T23:03:19Z2023-10-22T23:03:19ZNovel drugs are leading to rising overdose deaths in Victoria – drug checking services could help<figure><img src="https://images.theconversation.com/files/554906/original/file-20231019-22-zbi79a.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C6000%2C3970&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mans-hand-holds-two-transparent-plastic-2268792263">Farion_O/Shutterstock</a></span></figcaption></figure><p>Many of the harms people experience from using illegal drugs are a result of <a href="https://www.sciencedirect.com/science/article/pii/S0376871622001648">unregulated supply</a>. Drugs may be contaminated, or completely substituted with something unexpected. They may also be of variable and unknown dosage or strength. </p>
<p>Any of these factors can and do lead to overdoses. That’s why <a href="https://www.vaada.org.au/aod-advocacy/drug-checking-and-early-warning-systems-knowing-the-harms-can-prevent-the-harms/">77 health and community organisations</a> are urging the Victorian government to implement drug checking services. These could reduce overdose deaths, and provide an early warning system to flag any unusually dangerous substances in circulation. </p>
<p>The Victorian statement adds to similar calls in other Australian jurisdictions. Notably, in New South Wales, a <a href="https://www.theage.com.au/politics/nsw/nsw-labor-mp-speaks-out-in-support-over-pill-testing-20231019-p5edgw.html">Labor MP last week broke rank</a> with his party to voice his support for the implementation of drug checking services.</p>
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<strong>
Read more:
<a href="https://theconversation.com/drug-checking-and-an-early-warning-network-in-victoria-could-save-lives-new-coroners-report-157684">Drug checking and an early warning network in Victoria could save lives: new coroner's report</a>
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<h2>What’s the problem?</h2>
<p>In the <a href="https://www.unodc.org/res/WDR-2023/WDR23_Exsum_fin_DP.pdf">past 15 years</a>, the number of new psychoactive substances detected in drug markets has increased dramatically around the world. It’s easier for suppliers to circumvent laws that prohibit more traditional drugs (such as cocaine, heroin, MDMA or methamphetamine) by producing newer synthetic drugs. These drugs are also often cheaper to produce. </p>
<p>They then get added to or sold as other more established drugs. This means people don’t always know what they’re taking, or how strong it is.</p>
<p>According to the <a href="https://www.coronerscourt.vic.gov.au/">Coroners Court of Victoria</a>, novel substances were detected in three deaths in 2017-18. This figure has risen significantly over the past five years, to 47 deaths in 2021-22.</p>
<p>Escalating deaths involving novel substances are being identified nationally. For example, there have been 40 deaths involving <a href="https://doi.org/10.1016/j.forsciint.2021.111140">novel benzodiazepines</a> in Australia since 2015.</p>
<figure class="align-center ">
<img alt="A number of round, white pills on a table." src="https://images.theconversation.com/files/554912/original/file-20231020-25-akslzl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554912/original/file-20231020-25-akslzl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554912/original/file-20231020-25-akslzl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554912/original/file-20231020-25-akslzl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554912/original/file-20231020-25-akslzl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554912/original/file-20231020-25-akslzl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554912/original/file-20231020-25-akslzl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Illegal drugs can be contaminated with unexpected substances.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/backlit-white-pills-opioid-prescription-medication-694514731">Tomas Nevesely/Shutterstock</a></span>
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</figure>
<p>While harder to track, unexpectedly strong substances have been implicated in further deaths. In 2019, the <a href="https://coroners.nsw.gov.au/coroners-court/download.html/documents/findings/2019/Music_Festival_Redacted_findings_in_the_joint_inquest_into_deaths_arising_at_music_festivals_.pdf">NSW Coroner’s Court</a> investigated six deaths at music festivals resulting from consumption of unusually high-dose MDMA capsules. Last month, <a href="https://www.coronerscourt.vic.gov.au/highly-potent-mdma-pill-prompts-call-drug-testing-services">Victoria’s coroner</a> investigated a death that similarly followed consumption of an unexpectedly high-dose MDMA tablet. </p>
<p>Meanwhile, synthetic opioid drugs are causing an epidemic of <a href="https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates">drug fatalities</a> in <a href="https://www.sciencedirect.com/science/article/pii/S2667193X2300011X?via%3Dihub">North America</a>. Some of these novel opioids have recently been detected in Australia, including a new class called <a href="https://pubmed.ncbi.nlm.nih.gov/35983900/">nitazenes</a>, which have been identified in <a href="https://www.health.act.gov.au/public-health-alert/public-health-alert-dangerous-drug-warning-canberrans">the ACT</a>, <a href="https://www.health.nsw.gov.au/aod/public-drug-alerts/Pages/heroin-found-to-contain-nitazenes.aspx">NSW</a>, <a href="https://www.health.vic.gov.au/drug-alerts/yellow-powder-containing-protonitazene-may-be-sold-as-ketamine">Victoria</a>, and <a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/public+health/alerts/health+alerts/protonitazene+cases+in+south+australia">South Australia</a>.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/nitazenes-synthetic-opioids-more-deadly-than-fentanyl-are-starting-to-turn-up-in-overdose-cases-212589">Nitazenes: synthetic opioids more deadly than fentanyl are starting to turn up in overdose cases</a>
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<h2>What is drug checking?</h2>
<p>Often called “pill testing” in Australia, the term drug checking reflects that these services are inclusive of multiple drug forms (for example, powders and liquids in addition to pills) as well as multiple drug types (for example, cocaine, ketamine, heroin, methamphetamine and MDMA). </p>
<p><a href="https://www.emerald.com/insight/content/doi/10.1108/DHS-01-2022-0007/full/html">Drug checking services</a> can be at a permanent location or mobile (for example, on-site at venues and festivals). People visit these facilities to find out the content and strength of drugs they plan to use, including whether they contain unexpected substances or higher-than-usual doses.</p>
<p>Service users also have the opportunity to discuss the test results in a meeting with a health-care worker, in a conversation about their broader drug use and health.</p>
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<strong>
Read more:
<a href="https://theconversation.com/what-is-drug-checking-and-why-do-we-need-it-in-australia-51578">What is 'drug checking' and why do we need it in Australia?</a>
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<h2>How does it help?</h2>
<p>A recent <a href="https://onlinelibrary.wiley.com/doi/10.1111/add.15734">systematic review</a> analysing 90 studies found that drug checking services positively influenced the behaviour of people who use drugs. </p>
<p>In two recent studies conducted in <a href="https://www.sciencedirect.com/science/article/abs/pii/S0955395921001675">the UK</a> and <a href="https://www.tandfonline.com/doi/abs/10.1080/09687637.2022.2072187">Portugal</a>, most service users (86% in Portugal, 69% in the UK) who received test results indicating that the drug was different than expected didn’t consume the substance. About half of service users (50% in Portugal, 59% in the UK) whose test results indicated that their drugs were stronger than expected took a smaller dose.</p>
<p>Drug checking service data also provides real-time information about the status of local drug markets. Alerts can be published to rapidly warn people if an unusually dangerous substance is circulating. For example, the ACT drug checking service CanTEST has so far published <a href="https://directionshealth.com/cantest-health-drug-checking-service/">six community alerts</a> alongside monthly drug market snapshot reports.</p>
<h2>Responding to critiques</h2>
<p>One argument levelled against drug checking is that such services provide a “<a href="https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1360-0443.2001.96811397.x">shine of safety</a>” to drug use. But, as noted by an established drug checking service in <a href="https://www.trimbos.nl/aanbod/webwinkel/product/af1677-the-drugs-information-and-monitoring-system-dims">The Netherlands</a>, services never provide an endorsement of quality. Instead, they warn people how unpredictable drug markets can be by providing credible and relevant information.</p>
<p>Similarly, evidence doesn’t support claims that the availability of drug checking services leads to increased drug use. A recent <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/dar.13259">Australian study</a> that surveyed festival-goers about drug checking scenarios found the existence of a drug checking service wouldn’t increase intention to use ecstasy.</p>
<h2>What’s happening elsewhere?</h2>
<p>Drug checking services are now operating in <a href="https://hri.global/wp-content/uploads/2022/11/HRI_GSHR-2022_Full-Report_Final.pdf">at least 28 countries</a>, having expanded significantly around the world in recent years.</p>
<p>In 2021, <a href="https://www.health.govt.nz/our-work/regulation-health-and-disability-system/drug-checking">New Zealand</a> passed legislation to make drug checking services fully legal.</p>
<p>Australia’s experience so far with government-sanctioned drug checking has included fixed-site and mobile <a href="https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-022-00708-3">drug checking trials in Canberra</a>, and recently-announced approval for drug checking services to <a href="https://statements.qld.gov.au/statements/97250">commence in Queensland</a>. An <a href="https://www.health.act.gov.au/sites/default/files/2023-01/Interim%20Report%20Submitted%2019_12-22.pdf">interim report</a> on a pilot in Canberra’s city centre supports the continuation and development of the service.</p>
<figure class="align-center ">
<img alt="Three young people socialising at a festival." src="https://images.theconversation.com/files/554911/original/file-20231020-21-zkg0oy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/554911/original/file-20231020-21-zkg0oy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=447&fit=crop&dpr=1 600w, https://images.theconversation.com/files/554911/original/file-20231020-21-zkg0oy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=447&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/554911/original/file-20231020-21-zkg0oy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=447&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/554911/original/file-20231020-21-zkg0oy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=562&fit=crop&dpr=1 754w, https://images.theconversation.com/files/554911/original/file-20231020-21-zkg0oy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=562&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/554911/original/file-20231020-21-zkg0oy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=562&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Drug checking services could be set up at music festivals and other events.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/group-young-friends-sitting-on-ground-1563349978">Ground Picture/Shutterstock</a></span>
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</figure>
<h2>Support is growing</h2>
<p>In Australia, the implementation of drug checking services has been recommended by numerous <a href="https://www.nsw.gov.au/the-cabinet-office/resources/special-commissions-of-inquiry/drug-ice">government inquiries</a> and <a href="https://www.coronerscourt.vic.gov.au/highly-potent-mdma-pill-prompts-call-drug-testing-services">coronial inquests</a>, including the 2018 Parliament of Victoria <a href="https://new.parliament.vic.gov.au/get-involved/inquiries/inquiry-into-drug-law-reform/">Inquiry into Drug Law Reform</a> and the <a href="https://coroners.nsw.gov.au/coroners-court/download.html/documents/findings/2019/Music_Festival_Redacted_findings_in_the_joint_inquest_into_deaths_arising_at_music_festivals_.pdf">2019 inquest</a> into the death of six patrons at NSW music festivals.</p>
<p>In terms of public support, a <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/dar.13211">nationally representative survey</a> found that in 2019, 63% of Australians supported drug checking. Some 22% were opposed while 15% were unsure or didn’t answer.</p>
<p>The Victorian statement <a href="https://www.vaada.org.au/aod-advocacy/drug-checking-and-early-warning-systems-knowing-the-harms-can-prevent-the-harms/">released today</a> demonstrates support from a wide range of social and community organisations. These include professional societies representing medical and pharmaceutical sectors, such as the <a href="https://www.racgp.org.au/">Royal Australian College of General Practitioners</a> and the <a href="https://www.psa.org.au/">Pharmaceutical Society of Australia</a>. </p>
<p>Implementing drug checking will help prevent further overdose deaths that result from unregulated drug supplies.</p><img src="https://counter.theconversation.com/content/215791/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In the last 5 years, Monica Barratt has received funding from the National Health and Medical Research Council, the National Centre for Clinical Research into Emerging Drugs, the Criminology Research Council, New Zealand’s Marsden Fund and the U.S. National Institutes of Health. In addition to her academic role, she also serves as the Executive Director of Bluelight.org, a global drug harm reduction community, and leads research activities for The Loop Australia, a charity aiming to conduct drug checking interventions both at festivals and in the community.
</span></em></p><p class="fine-print"><em><span>Isabelle Volpe receives PhD stipends from the Australian Government Research Training Program and UNSW Arts, Design & Architecture, and has previously received funding from the National Centre for Clinical Research into Emerging Drugs. She volunteers with The Loop Australia (overseeing the communication of information about drug checking and drug alerts) and DanceWize NSW (providing care and education to music event attendees).</span></em></p>Drug checking services could also provide an early warning system to flag any unusually dangerous substances in circulation.Monica Barratt, Vice Chancellor’s Senior Research Fellow, Social Equity Research Centre and Digital Ethnography Research Centre, RMIT UniversityIsabelle Volpe, PhD Candidate, Drug Policy Modelling Program, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2103162023-07-31T15:26:30Z2023-07-31T15:26:30ZOpioids and cocaine are a deadly combination – and ‘polydrug’ deaths are rising<figure><img src="https://images.theconversation.com/files/540138/original/file-20230731-251277-bhfjl1.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C2987%2C1994&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mans-hand-holding-on-palm-plastic-1056695408">DedMityay/Shutterstock</a></span></figcaption></figure><p>Drug deaths in the US involving both opioids and cocaine have increased dramatically in the past decade, according to a <a href="https://stacks.cdc.gov/view/cdc/129733">new report</a> from the Centers for Disease Control and Prevention (CDC).</p>
<p>Drug-related deaths associated with stimulants, such as cocaine, methamphetamine, amphetamine and methylphenidate, doubled between 2011 and 2021. And deaths associated with using both stimulants and opioids, such as heroin, morphine, fentanyl and methadone, increased by about sevenfold over the same period. The biggest increases have been seen since about 2019. </p>
<p>Cocaine and methamphetamine are stimulant drugs, whereas opioids, such as heroin and methadone, are depressants. This means that cocaine and methamphetamine will, among other things, make you euphoric and more alert with more energy, while heroin has the opposite effect. After an initial rush of euphoria, heroin users report a long period of drowsiness. </p>
<p>It is unclear why people take both types of drugs together. It is not thought that the euphoric effects are changed significantly by taking these drugs together, but cocaine may help with acute withdrawal from heroin. Another explanation is that, by taking both types of drug together, the user balances the stimulant and depressant effects of the drugs. Some medicated opioid abusers take stimulants for an alternative high or to counteract the sedative effects of their medication. </p>
<h2>Different mechanism</h2>
<p>These drugs work via different mechanisms. The stimulants work mostly by activating the brain’s dopamine system. Dopamine is a neurotransmitter, or chemical messenger, important in the brain reward system, so it is critical to both feeling joy and euphoria.</p>
<p>Heroin and similar drugs such as methadone or fentanyl work via the body’s opioid system. The brain and body have various proteins attached to cell surfaces involved in transmitting the opioid signals. The most relevant proteins here are the mu opioid receptors. These receptors are activated by opioid painkillers.</p>
<p>Unfortunately, it is easy to overdose on opioids such as heroin. Overdose can lead to respiratory depression and then respiratory failure. This is when there are long pauses between breaths, which become more like sighs and then a loss of consciousness followed by cessation of breathing. </p>
<figure class="align-center ">
<img alt="Heroin addicts nodding off" src="https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Opioids can cause respiratory depression.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/no-drugs-concept-man-woman-aids-533628886">Lipik Stock Media/Shutterstock</a></span>
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<p>The exact mechanism whereby opioids cause respiratory depression is unknown but probably involves opioid receptors found in the brainstem.</p>
<p>Cocaine and methamphetamine are less likely to kill you but are still dangerous drugs causing heart palpitations, increased blood pressure and increased risk of stroke. Methamphetamine is especially associated with dangerous <a href="https://www.tandfonline.com/doi/epdf/10.4161/23328940.2014.982049?needAccess=true&role=button">hyperthermia</a> leading to multi-organ toxicity. </p>
<p>Taking stimulants together with an opioid clearly increases your risk of drug-related death.</p>
<p>One reason that we may be seeing more drug-related deaths is due to the increased use of fentanyl. Fentanyl is a synthetic opioid that is <a href="https://www.drugs.com/medical-answers/fentanyl-compare-heroin-opiates-3569710/">50 times</a> more potent than heroin and 100 times more potent than morphine, with a faster onset of action. It is therefore more likely to lead to respiratory depression than other opioids, such as heroin or methadone. </p>
<p>Fentanyl is increasingly being used as an <a href="https://www.clinicaterapeutica.it/2022/173/1/11_DI_TRANA.pdf">adulterant</a> in street drugs, such as heroin. This is because it is cheap and very powerful, so only a small amount is needed to have a large effect.</p>
<h2>Europe’s problem too</h2>
<p>It is not just the US that is seeing a rise in so-called polydrug-related deaths. Data from the <a href="https://www.emcdda.europa.eu/publications/european-drug-report/2023/drug-induced-deaths_en">European Monitoring Centre for Drugs and Drug Abuse</a>) show that deaths from polydrug use, especially those involving opioids, are also increasing in Europe. The European data shows that it is mostly men who are dying and that older age groups are increasingly dying from drug taking. </p>
<p>Taken together, it can be seen that there may be a worldwide increase in polydrug-related deaths and in particular those involving both stimulants and opioids.</p><img src="https://counter.theconversation.com/content/210316/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colin Davidson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The US has seen a huge rise in drug deaths in the past decade involving a stimulant and a depressant.Colin Davidson, Professor of Neuropharmacology and Head of School of Pharmacy & Biomedical Sciences, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1875482022-08-04T15:28:15Z2022-08-04T15:28:15ZAnother new high for drug deaths in England and Wales – here’s what needs to change<figure><img src="https://images.theconversation.com/files/477465/original/file-20220803-16-wmovad.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C3840%2C2149&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/clean-hospital-room-interior-night-bed-1641716899">Stokkete/Shutterstock</a></span></figcaption></figure><p>Drug-related deaths in England and Wales have been <a href="https://theconversation.com/drug-deaths-in-england-and-wales-rise-for-eighth-consecutive-year-145498">rising</a> year on year for the past decade. The <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2021registrations#main-points">latest data</a> shows another distressing increase. Drug-related deaths rose more than 6% to a new record of 4,859 deaths in 2021. </p>
<p>Some 3,060 of these deaths were related to “drug misuse”. This is a broad term that usually refers to the non-medical use of a range of drugs including cocaine and heroin.</p>
<p>During the pandemic there were <a href="https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide">reports</a> of deteriorating mental health and anxiety and loneliness in particular. Some people will have <a href="https://www.release.org.uk/publications/covid-drugs-market-survey">turned to drugs</a> to try to cope, which is likely to have contributed to the rise in drug deaths seen in 2020 and 2021.</p>
<p>Drug deaths are not spread equally. The north east of England continues to have the highest rate of deaths due to drug misuse at 104.1 per million, compared with the east of England with 27.4 per million. We know there’s <a href="https://www.gov.uk/government/news/government-to-improve-drug-treatment-in-most-deprived-areas">a strong association</a> between social deprivation and problems with drugs.</p>
<p>As we continue to see the same trends year on year, it’s well and truly time for the UK to reconsider its approach to this crisis. </p>
<h2>Current gaps</h2>
<p>In the past, government ministers have suggested that the rise in drug-related deaths is due to an <a href="https://www.gov.uk/government/publications/acmd-report-ageing-cohort-of-drug-users">ageing cohort</a> of people who use heroin. That is, the complex physical conditions these people often have are driving the record numbers of deaths. </p>
<p>While this may have some basis in fact, it shouldn’t be accepted as inevitable. Some academics <a href="https://www.addiction-ssa.org/can-the-ageing-cohort-theory-account-for-the-increase-in-drug-related-deaths/">have challenged</a> this idea, arguing that improvements should be made to the way this group accesses help with their physical problems.</p>
<p>It’s also worth noting this “ageing cohort” falls within the 35-to-49 age bracket. While we’ve seen <a href="https://theconversation.com/the-maximum-human-life-span-will-likely-increase-this-century-but-not-by-more-than-a-decade-164542">rising</a> life expectancy in the rest of the population, this group are dying decades before they should.</p>
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<strong>
Read more:
<a href="https://theconversation.com/drug-deaths-in-england-and-wales-rise-for-eighth-consecutive-year-145498">Drug deaths in England and Wales rise for eighth consecutive year</a>
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<p>One example of where government could make a positive impact and reduce drug-related deaths is in the criminal justice system. A recent <a href="https://www.york.ac.uk/media/healthsciences/documents/research/mentalhealthresearch/DRWsFinalPublishedReport.pdf">report</a> commissioned by the Department of Health identified that too many prisoners are released without any after care organised. </p>
<p>While in prison these people will have become abstinent or been provided opiate substitutes such as methadone. Prison release can leave them vulnerable to accidental overdose and potentially death without adequate follow-up care. The government should <a href="https://www.gov.uk/government/publications/acmd-report-custody-community-transitions">ensure</a> this is in place.</p>
<p>Indeed, opiate substitution treatment, which usually involves prescribing drugs like methadone or other opiates to substitute for heroin, is the <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2760032">most effective way</a> of reducing drug-related deaths. Yet the number of people entering treatment for problems with heroin has <a href="https://www.gov.uk/government/statistics/substance-misuse-treatment-for-adults-statistics-2020-to-2021/adult-substance-misuse-treatment-statistics-2020-to-2021-report">fallen 52%</a> in the UK over the past decade. </p>
<p>Other measures that could save lives, such as <a href="https://theconversation.com/safe-injection-rooms-save-lives-yet-the-uk-government-continues-to-oppose-them-124952">overdose prevention services</a> where people inject illicit drugs in a safe and supervised space, continue <a href="https://www.bmj.com/content/374/bmj.n1957">to be opposed</a> by the UK government. This is despite a successful <a href="https://linkinghub.elsevier.com/retrieve/pii/S0955-3959(22)00090-1">pilot</a> in Glasgow, and <a href="https://www.fph.org.uk/news-events/fph-news/call-to-amend-misuse-of-drugs-regulations-to-make-it-easier-to-pilot-overdose-prevention-centres/">calls</a> from multiple public health bodies and experts for these services to be trialled.</p>
<h2>Some progress</h2>
<p>The ability of drug treatment services to address health harms faced by people who use drugs is compromised by the government’s continued desire to <a href="https://www.gov.uk/government/consultations/swift-certain-tough-new-consequences-for-drug-possession-white-paper/swift-certain-tough-new-consequences-for-drug-possession-accessible-version">get tough on drug use</a>. There is clear <a href="https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2018/03/more-imprisonment-does-not-reduce-state-drug-problems">evidence</a> that <a href="https://pubmed.ncbi.nlm.nih.gov/24400910/">ratcheting</a> up punishment has no impact on overall drug use or the harms associated with it.</p>
<p>Pleasingly, a new ten-year drug <a href="https://www.gov.uk/government/publications/from-harm-to-hope-a-10-year-drugs-plan-to-cut-crime-and-save-lives">strategy</a> from the UK government includes the ambition to reduce deaths by 1,000. Yet there is little detail about how this will be achieved. </p>
<p>It does promise £533 million for comprehensive drug treatment and harm reduction services in England over the next three years. However, rebuilding a system that has been shattered by a decade of austerity will be a challenge, particularly recruiting skilled staff.</p>
<figure class="align-center ">
<img alt="A hand holds a packet of a powdered drug." src="https://images.theconversation.com/files/477466/original/file-20220803-23-c7ewj3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/477466/original/file-20220803-23-c7ewj3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/477466/original/file-20220803-23-c7ewj3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/477466/original/file-20220803-23-c7ewj3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/477466/original/file-20220803-23-c7ewj3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/477466/original/file-20220803-23-c7ewj3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/477466/original/file-20220803-23-c7ewj3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Drug deaths in England and Wales rose again in 2021.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-dealer-selling-junkie-man-hand-1688837680">fongbeerredhot/Shutterstock</a></span>
</figcaption>
</figure>
<h2>A look at Scotland</h2>
<p>Scotland’s national records office recently <a href="https://www.nrscotland.gov.uk/news/2022/small-decrease-in-drug-death-figures">reported</a> a slight fall in drug-related deaths after years of increases, down by nine people to 1,330 deaths in total in 2021. </p>
<p>An encouraging sign of how urgent the Scottish government views this issue is its establishment of a <a href="https://drugdeathstaskforce.scot/">national taskforce</a> on drug deaths. A <a href="https://drugdeathstaskforce.scot/news-information/publications/reports/final-report/">report</a> published by the taskforce in July made a number of recommendations. These include ensuring that drug treatment is on a par with treatments for other health conditions, that families and those with lived experience have a say in how drug and alcohol services are organised and delivered, and that the poverty that underlies so much problematic drug use is addressed.</p>
<p>The Scottish taskforce also produced <a href="https://www.gov.scot/publications/medication-assisted-treatment-mat-standards-scotland-access-choice-support/">standards</a> for medication-assisted treatment, which will fulfil the 2016 <a href="https://www.gov.uk/government/publications/reducing-opioid-related-deaths-in-the-uk">recommendation</a> from the UK Advisory Council on the Misuse of Drugs to invest in opiate substitution treatment of optimal dosage and duration. </p>
<p>The UK more broadly would be well-served to look to Scotland’s example in prioritising action on drug deaths. So far there has been no mention of the drug deaths crisis by the two Conservative candidates in their campaigns to become the next prime minister of the UK.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-labels-like-addict-and-junkie-mask-class-contempt-for-people-who-use-drugs-91088">How labels like 'addict' and 'junkie' mask class contempt for people who use drugs</a>
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<p>Expert and <a href="https://committees.parliament.uk/committee/83/home-affairs-committee/news/166071/effectiveness-of-drugs-strategy-examined-in-new-inquiry/">parliamentary</a> bodies have repeatedly called for a new approach to the drug death crisis. This would involve decriminalisation of drug possession and scaling up of effective opioid substitution therapies. It would mean expanding harm reduction services, including drug checking and overdose prevention centres. </p>
<p>Public health officials and treatment providers are ready to implement these measures. The new drug strategy provides some of the money needed. Ministers should have the courage to face down tabloid calls for ever increasing punishment of people who use drugs, and instead take steps that will actually save lives.</p><img src="https://counter.theconversation.com/content/187548/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alex Stevens is a trustee of Harm Reduction International and a member of the Green Party.</span></em></p><p class="fine-print"><em><span>Niamh Eastwood is affiliated with Release, the UK's centre of expertise on drugs and drug laws. </span></em></p><p class="fine-print"><em><span>Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The UK could learn from the kind of action Scotland is taking on drug deaths.Ian Hamilton, Associate Professor of Addiction, University of YorkAlex Stevens, Professor in Criminal Justice and Faculty Director of Public Engagement, University of KentNiamh Eastwood, Associate Member of the Drug and Alcohol Research Centre, Middlesex University, Middlesex UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1826292022-05-10T12:06:06Z2022-05-10T12:06:06ZWhat is fentanyl and why is it behind the deadly surge in US drug overdoses? A medical toxicologist explains<figure><img src="https://images.theconversation.com/files/462077/original/file-20220509-18-ruua59.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C683&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Only a small amount of fentanyl is enough to be lethal.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/OverdosesLosAngeles/9b9e2555c6654b1094d2be9f3ef43226">AP Photo/Jacquelyn Martin</a></span></figcaption></figure><p>Buying drugs on the street is a game of Russian roulette. From Xanax to cocaine, drugs or counterfeit pills purchased in nonmedical settings may contain life-threatening amounts of fentanyl.</p>
<p>Physicians like me have seen a rise in unintentional fentanyl use from people buying prescription opioids and other drugs <a href="https://doi.org/10.1016/j.drugalcdep.2022.109398">laced, or adulterated, with fentanyl</a>. Heroin users in my community in Massachusetts came to realize that fentanyl had entered the drug supply when <a href="https://www.bostonindicators.org/reports/report-website-pages/opioids-2018">overdose numbers exploded</a>. In 2016, my colleagues and I found that patients who came to the emergency department reporting a heroin overdose often <a href="https://doi.org/10.1080/15563650.2017.1339889">only had fentanyl present in their drug test results</a>.</p>
<p>As the Chief of Medical Toxicology at UMass Chan Medical School, I have <a href="https://scholar.google.com/citations?user=X55PT8EAAAAJ&hl=en">studied fentanyl and its analogs</a> for years. As fentanyl has become ubiquitous across the U.S., it has transformed the illicit drug market and raised the risk of overdose.</p>
<h2>Fentanyl and its analogs</h2>
<p><a href="https://doi.org/10.1016/j.jpain.2014.08.010">Fentanyl</a> is a synthetic opioid that was originally developed as an analgesic – or painkiller – for surgery. It has a specific chemical structure with multiple areas that can be modified, often illicitly, to form related compounds with marked differences in potency.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram depicting various functional groups that can be substituted in fentanyl." src="https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=435&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=435&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=435&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=546&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=546&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=546&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Fentanyl’s chemical backbone (the structure in the center) has multiple areas (the colored circles) that can be substituted with different functional groups (the colored boxes around the edges) to change its potency.</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1002/cpt.1418">Christopher Ellis et al.</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>For example, <a href="https://pubchem.ncbi.nlm.nih.gov/compound/Carfentanil">carfentanil</a>, a fentanyl analog formed by substituting one chemical group for another, is 100 times more potent than its parent structure. Another analog, <a href="https://doi.org/10.1097/ADM.0000000000000324">acetylfentanyl</a>, is approximately three times less potent than fentanyl, but has still led to <a href="https://dx.doi.org/10.15585%2Fmmwr.mm6643e1">clusters of overdoses in several states</a>. </p>
<p>Despite the number and diversity of its analogs, fentanyl itself continues to <a href="http://dx.doi.org/10.15585/mmwr.mm6910a4">dominate the illicit opioid supply</a>. Milligram per milligram, fentanyl is roughly <a href="https://www.cdc.gov/stopoverdose/fentanyl/index.html">50 times more potent than heroin and 100 times more potent than morphine</a>.</p>
<h2>Lacing or replacing drugs with fentanyl</h2>
<p>Drug dealers have used fentanyl analogs as an adulterant in illicit drug supplies <a href="https://doi.org/10.1021/ac00235a790">since 1979</a>, with fentanyl-related overdoses clustered in <a href="https://doi.org/10.1111/j.1556-4029.2008.00669.x">individual cities</a>. </p>
<p>The modern epidemic of fentanyl adulteration is far broader in its geographic distribution, production and number of deaths. Overdose deaths <a href="https://dx.doi.org/10.15585%2Fmmwr.mm6634a2">roughly quadrupled</a>, going from 8,050 in 1999 to 33,091 in 2015. From May 2020 to April 2021, <a href="http://dx.doi.org/10.15585/mmwr.mm7050e3">more than 100,000 Americans</a> died from a drug overdose, with over 64% of these deaths due to synthetic opioids like fentanyl and its analogs.</p>
<p>Illicitly manufactured fentanyl is <a href="https://www.dea.gov/documents/2020/2020-03/2020-03-06/fentanyl-flow-united-states">internationally synthesized</a> in China, Mexico and India, then exported to the United States as powder or pressed pills. China also exports many of the precursor chemicals needed to synthesize fentanyl.</p>
<p>Additionally, the emergence of the <a href="https://doi.org/10.2196/24486">dark web</a>, an encrypted and anonymous corner of the internet that’s a haven for criminal activity, has facilitated the sale of fentanyl and other opioids shipped through <a href="https://www.npr.org/2018/05/24/613762721/deadly-delivery-opioids-by-mail">traditional delivery services</a>, including the U.S. Postal Service.</p>
<p>During the 2023 Asia-Pacific Economic Cooperation summit, U.S. President Joe Biden and Chinese President Xi Jinping reached an agreement to <a href="https://apnews.com/article/biden-xi-apec-san-francisco-58d11e7e3902955302182c2bc41430e0">combat fentanyl trafficking</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/01QYV8nbHs0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Fentanyl is driving an increasing number of opioid overdose deaths.</span></figcaption>
</figure>
<p>Fentanyl is both sold alone and often <a href="https://theconversation.com/rat-poison-is-just-one-of-the-potentially-dangerous-substances-likely-to-be-mixed-into-illicit-drugs-163568">used as an adulterant</a> because its high potency allows dealers to traffic smaller quantities but maintain the drug effects buyers expect. Manufacturers may also add bulking agents, like flour or baking soda, to fentanyl to increase supply without adding costs. As a result, it is much more profitable to cut a kilogram of fentanyl compared to a kilogram of heroin. </p>
<p>Unfortunately, fentanyl’s high potency also means that even just a small amount can prove deadly. If the end user isn’t aware that the drug they bought has been adulterated, this could easily lead to an overdose.</p>
<h2>Preventing fentanyl deaths</h2>
<p>As an emergency physician, I give fentanyl as an analgesic, or painkiller, to <a href="https://www.mayoclinic.org/drugs-supplements/fentanyl-injection-route/description/drg-20075614">relieve severe pain</a> in an acute care setting. My colleagues and I choose fentanyl when patients need immediate pain relief or sedation, such as anesthesia for surgery. </p>
<p>But even in the controlled conditions of a hospital, there is still a risk that using fentanyl can <a href="https://doi.org/10.1073/pnas.2022134118">reduce breathing rates</a> to dangerously low levels, the main cause of opioid overdose deaths. For those taking fentanyl in nonmedical settings, there is no medical team available to monitor someone’s breathing rate in real time to ensure their safety. </p>
<p>One measure to prevent fentanyl overdose is <a href="https://www.cdc.gov/stopoverdose/naloxone/index.html">distributing naloxone to bystanders</a>. Naloxone can reverse an overdose as it occurs by blocking the effects of opioids.</p>
<p>Another measure is increasing the availability of <a href="https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work">opioid agonists</a> like methadone and buprenorphine that reduce opioid withdrawal symptoms and cravings, helping people stay in treatment and decrease illicit drug use. Despite the lifesaving track records of these medications, their availability is limited by <a href="https://www.statnews.com/2021/12/22/inflexible-methadone-regulations-impede-efforts-reduce-overdose-deaths/">restrictions on where and how they can be used</a> and <a href="https://www.npr.org/sections/health-shots/2021/11/08/1053579556/dea-suboxone-subutex-pharmacies-addiction">inadequate numbers of prescribers</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/zWe_lPniEq4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Naloxone can rapidly reverse an opioid overdose.</span></figcaption>
</figure>
<p>Other strategies to prevent overdose deaths include <a href="https://doi.org/10.1097/adm.0000000000000555">lowering the entry barrier</a> to addiction treatment, <a href="https://www.cnn.com/2021/12/01/health/fentanyl-test-strip/index.html">fentanyl test strips</a>, <a href="https://doi.org/10.1007/s11904-017-0363-y">supervised consumption sites</a> and even <a href="https://doi.org/10.1192/bjp.bp.114.149195">prescription diamorphine (heroin)</a>. </p>
<p>Despite the evidence supporting these measures, however, <a href="https://www.ncbi.nlm.nih.gov/books/NBK541389/">local politics and funding priorities</a> often limit whether communities are able to give them a try. Bold strategies are needed to interrupt the ever-increasing number of fentanyl-related deaths.</p>
<p><em>This article was updated on Nov. 16, 2023 to note developments regarding fentanyl at the Asia-Pacific Economic Cooperation summit.</em></p><img src="https://counter.theconversation.com/content/182629/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kavita Babu receives research support from the National Institutes of Health, Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration, the Massachusetts Department of Health Bureau of Substance Abuse Services and royalties from UptoDate.</span></em></p>Fentanyl’s wide availability in the drug supply has led to an increase in unintentional overdoses. While prevention strategies are available, limited availability stymies their use.Kavita Babu, Professor of Emergency Medicine, UMass Chan Medical SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1454982020-10-14T11:00:31Z2020-10-14T11:00:31ZDrug deaths in England and Wales rise for eighth consecutive year<figure><img src="https://images.theconversation.com/files/363232/original/file-20201013-23-pfsind.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5184%2C3453&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-syringe-cooked-heroin-on-gray-378169966">Wasin Borisut/Shutterstock</a></span></figcaption></figure><p>Coronavirus is a public health crisis for all of society, but for the past decade, people who use drugs – especially those dependent on opioids – have been facing their own epidemic. In its <a href="https://www.ons.gov.uk/releases/deathsrelatedtodrugpoisoninginenglandandwales2019registrations">annual report</a> on drug poisoning in England and Wales, the Office for National Statistics (ONS) reveals that 4,393 died in 2019 – yet another rise from 2018. </p>
<p>This is the highest number of drug-related deaths since records began, and the north-east of England has a significantly higher rate than other English regions – another trend that has continued. The most deprived communities have rates of deaths that are five-and-a-half times greater than the least deprived.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/363391/original/file-20201014-19-12pqtd9.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/363391/original/file-20201014-19-12pqtd9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363391/original/file-20201014-19-12pqtd9.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363391/original/file-20201014-19-12pqtd9.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363391/original/file-20201014-19-12pqtd9.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363391/original/file-20201014-19-12pqtd9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363391/original/file-20201014-19-12pqtd9.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363391/original/file-20201014-19-12pqtd9.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">ONS drug deaths.</span>
<span class="attribution"><span class="source">ONS</span></span>
</figcaption>
</figure>
<p>Although drugs such as heroin still account for most of these deaths, this year sees a significant jump in deaths due to cocaine use. Male deaths attributed to cocaine rose 7.7% while female deaths rose by 26.5%. Men are <a href="https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/sex-gender-differences-in-substance-use">known</a> to take greater risks with drugs than women, so it is difficult to understand why there is such a marked difference between the sexes.</p>
<p>As with COVID, counting these deaths is far from perfect. Pinpointing the exact cause of death and then ensuring this is <a href="https://theconversation.com/coroners-are-less-likely-to-investigate-unnatural-deaths-in-women-78282">recorded</a> and reported in a timely way can be difficult. </p>
<h2>Decade of austerity</h2>
<p>There is a significant time <a href="https://www.gov.uk/government/publications/united-kingdom-drug-situation-focal-point-annual-report/united-kingdom-drug-situation-focal-point-annual-report-2019#drug-related-deaths">lag</a> between a death occurring and it appearing in official data. What we can say with certainty is that these tragic and avoidable deaths, like those resulting from the coronavirus, are more <a href="https://www.bbc.co.uk/news/uk-england-43641025">likely</a> to occur in communities living in deprivation. What these dual public health crises have shown is that structural inequalities are fuelling death. Leaving these communities paying for failed government policies and serious disinvestment in public services caused by a decade of austerity. </p>
<p>As the COVID pandemic has evolved, the government is happy to ignore its own expert advice, and <a href="https://www.theguardian.com/commentisfree/2019/jun/13/advising-uk-drug-policy-crisis-government-experts">block</a> critical voices on drug policy. The Advisory Council on the Misuse of Drugs, the UK government’s own expert drug advisers, <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/576560/ACMD-Drug-Related-Deaths-Report-161212.pdf">recommended</a> protecting and increasing investment in drug treatment and that consideration be given establishing drug-consumption rooms. Dame Carol Black, who was commissioned by the government to <a href="https://www.gov.uk/government/collections/independent-review-of-drugs-by-professor-dame-carol-black">review</a> the harm caused by drugs, found that there had been a 17% cut to treatment budgets since 2014-15.</p>
<p>Kit Malthouse, the UK’s minister for drugs, referred to drug-consumption rooms as a “distraction” at the UK Drugs Summit held in Glasgow in February 2020, again ignoring the advice of the government’s own experts. This left it to a member of the public in Glasgow to <a href="https://www.bbc.co.uk/news/uk-scotland-53991090">set up</a> a drug consumption van in the city, despite a risk of prosecution. </p>
<p>Beyond the tragic deaths reported today, Dame Carol Black <a href="https://www.gov.uk/government/publications/review-of-drugs-phase-one-report">found that</a> while 2,889 people in contact with specialist drug-treatment centres died in 2018-19, this rose to nearer 5,000 when other factors were included. The lower figure relates to those who have died from a fatal overdose, for example, but people who use drugs are at greater risk of liver disease or respiratory problems because of their lifestyles, which can also be fatal. Again, structural inequalities, lack of investment in treatment and the politicisation of evidence-based interventions have all contributed to this public health crisis. </p>
<p>There is some hope, COVID has, out of necessity, prompted an improved <a href="https://www.nhsapa.org/post/covid-digital-services">digital treatment</a> offering. This provides everything from video conferencing and virtual therapeutic groups to individual phone calls from therapists. Unfortunately, some patients don’t have access to this technology, but it could nevertheless go some way to improving engagement and retention in treatment for some. And being in treatment is associated with a <a href="https://www.emcdda.europa.eu/publications/topic-overviews/prevention-drug-related-deaths_en">reduced risk</a> of fatal overdose. </p>
<p>The downside is that digital-based services are only available to those with the ability to access and understand them. Equally, some may miss the human contact that therapists and therapeutic groups provide. A blend of both digital and face-to-face would provide an optimum offering. </p>
<p>Less restrictive prescribing practices, which have seen people moved off daily supervised consumption of their medication onto seven or 14-day prescriptions, has also yielded <a href="https://arc-w.nihr.ac.uk/research/projects/understanding-the-experiences-of-people-who-inject-drugs-during-the-covid-19-pandemic/">positive</a> results. This is important, as opiate substitute medications <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2760032">have been shown</a> to be the only treatment interventions that can prevent fatal overdoses. </p>
<h2>From denial to acceptance</h2>
<p>There is much we can learn from the COVID-19 crisis about reducing harm from drugs, not least that policy needs to be timely and not <a href="https://blogs.bmj.com/bmj/2020/02/28/ian-hamilton-they-talk-we-die-continuing-paralysis-uk-drug-policy/">hindered by political dogma</a>. The time for talking about reform of drug policy has passed, increasing numbers are dying due to this paralysis in policy. </p>
<p>The urgency and investment aiming to reduce mortality due to COVID must be applied to drug-related deaths. Change is possible, but as anyone who has recovered from addiction will attest, the first step is moving from denial to accepting that there is a problem. This government can change and act on expert scientific advice to halt the increasing number of drug-related deaths. Any political embarrassment associated with a policy U-turn looks trivial when compared with the suffering that the current policy position is responsible for.</p><img src="https://counter.theconversation.com/content/145498/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Office for National Statistics reports the highest drug deaths since records began in 1993.Ian Hamilton, Associate Professor of Addiction., University of YorkNiamh Eastwood, Associate Member of the Drug and Alcohol Research Centre, Middlesex University, Middlesex UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1249522019-10-24T11:03:23Z2019-10-24T11:03:23ZSafe injection rooms save lives – yet the UK government continues to oppose them<p>Urgent action is needed to stem the UK’s overdose crisis, according to a group of cross party MPs, who have <a href="https://www.theguardian.com/politics/2019/oct/23/decriminalise-drug-possession-to-stop-rising-deaths-say-mps">called upon the government</a> to properly tackle the issue. Drug-related deaths rose to <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2018registrations">record numbers in 2018</a> in England and Wales. A total of 4,359 people died due to drug poisoning – over half of them related to <a href="https://theconversation.com/without-safe-injection-sites-more-opioid-users-will-die-115979">opiate use</a>. </p>
<p>MPs have urged for a number of important policy changes. These include the decriminalisation of drug possession for personal use and the the creation of supervised injecting facilities.</p>
<p><a href="https://theconversation.com/what-goes-on-inside-a-medically-supervised-injection-facility-87341">Supervised injecting facilities</a> – sometimes known as overdose prevention centres or drug consumption rooms – are a critical tool in ending the overdose crisis. These are places where people are allowed to inject illegal drugs in hygienic conditions in the supportive presence of medical staff and peer workers. </p>
<p>They are primarily intended to provide services for vulnerable, poor or homeless people who would otherwise inject in public places – such as alleys or parks. Circumstances that significantly <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5811227/">increase the risk</a> of fatal overdose and transmission of blood borne infections via unsterile injecting equipment</p>
<p>According to the nongovernmental organisation, <a href="https://www.hri.global/files/2018/12/10/GlobalOverview-harm-reduction.pdf">Harm Reduction International</a>, which monitors global developments on programmes to reduce drug-related harms, there are almost 120 such facilities operating in 11 countries. This includes Canada, Australia, France and the Netherlands. And research by the <a href="http://www.emcdda.europa.eu/system/files/publications/2734/POD_Drug%20consumption%20rooms.pdf">European Monitoring Centre on Drugs and Drug Addiction</a> found that supervised injecting sites help to reduce unsafe injecting and fatal overdoses.</p>
<h2>Outdated logic</h2>
<p>Yet despite the record of success of safe injecting facilities too many governments continue to oppose their implementation. Over the summer, <a href="https://www.irishtimes.com/news/ireland/irish-news/dublin-city-council-refused-planning-permission-for-drug-injection-centre-1.3968222">Dublin City Council refused planning permission</a> to open Ireland’s first safe injecting room. This despite the Irish government <a href="https://www.thejournal.ie/supervised-injection-centres-2-3382276-May2017/">changing the law</a> two years earlier to clear legal barriers to their operation. </p>
<p>In Canada in 2011, the Conservative government of Stephen Harper went all the way to the Supreme Court to try to shut down the country’s first safe injecting facility in Vancouver. Only to have the government <a href="https://www.theglobeandmail.com/news/british-columbia/supreme-court-ruling-opens-doors-to-drug-injection-clinics-across-canada/article4182250/">lose in humiliating fashion in a unanimous decision</a>. Yet despite the court ruling in favour of safe injecting facilities, some provinces <a href="https://www.cbc.ca/news/canada/toronto/province-cut-some-injection-sites-because-area-residents-upset-ford-says-1.5079616">continue to obstruct their implementation</a>.</p>
<p>In the US earlier this month, health advocates won an important legal victory when <a href="https://www.nytimes.com/2019/10/02/us/injection-safehouse-philadelphia-ruling.html">a District Court judge</a> blocked an attempt by the US Justice Department to prevent the nation’s first legal supervised injecting facility from opening its doors in Philadelphia. The Justice Department sought to have the not-for-profit project, <a href="https://www.safehousephilly.org/">Safehouse</a>, declared unlawful under a 1986 federal law intended to shut down “crack houses”. </p>
<h2>Lifesaving programmes</h2>
<p>But not all efforts end in victory. In the UK in December 2016, the Advisory Committee on the Misuse of Drugs – the government’s expert body – <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/576560/ACMD-Drug-Related-Deaths-Report-161212.pdf">recommended</a> implementing safe injecting facilities in response to massive increases in overdose deaths. But in July 2017, the government of Theresa May <a href="https://www.bbc.co.uk/news/uk-england-40674453">rejected this recommendation</a>. And four months later the <a href="https://www.bbc.co.uk/news/uk-scotland-glasgow-west-41941699">Lord Advocate in Scotland blocked</a> plans by the City of Glasgow to open the UK’s first safe injecting facility.</p>
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<p>The Conservative government has even blocked the appointment of experts known to be supportive of these lifesaving programmes. In July 2019, it emerged that the <a href="https://www.release.org.uk/about/staff">CEO of the drugs charity Release, Niamh Eastwood</a>, had her appointment to the the Advisory Committee on the Misuse of Drugs <a href="https://www.theguardian.com/politics/2019/jun/11/drugs-expert-barred-from-policy-panel-after-criticising-home-office">blocked by the Home Office</a>. Her crime? Tweeting criticism of the government’s rejection of the recommendation for safe injection facilities in 2017. </p>
<p>Earlier this month, a leading UK drug expert, <a href="https://www.kent.ac.uk/social-policy-sociology-social-research/people/1536/stevens-alex">Alex Stevens of the University of Kent</a>, resigned his seat on the the Advisory Committee on the Misuse of Drugs citing “political vetting” of appointments by the Home Office. <a href="https://www.independent.co.uk/news/uk/politics/home-office-drugs-policy-adviser-quits-alex-stevens-acmd-a9146621.html">Stevens said</a> “if suitably qualified experts are excluded from membership on the basis of stated disagreements with government policy, this will erode the quality of advice that the Advisory Committee on the Misuse of Drugs can give”.</p>
<h2>Human rights crisis</h2>
<p>Since the 1970s, and the start of the “war on drugs”, punishment, policing and prisons, rather than health, became the core approach of drug policy. Alongside this has been an escalation of human rights violations linked to drug control. Denial of life saving programmes, such as safe injecting facilities, is but one example. </p>
<p>As I highlight in my <a href="https://www.cambridge.org/core/books/drug-control-and-human-rights-in-international-law/F741DAD5332289EE22DB1718D8B89F5B#fndtn-information">book</a>, in recent years we have examples of courts stepping in to defend the rights of people who use drugs against the excesses of government drug warriors. And the publication earlier in 2019 of <a href="https://theconversation.com/new-un-guidelines-to-mainstream-human-rights-in-the-global-drugs-debate-113221">International Guidelines on Human Rights and Drug Policy</a> marks a significant milestone in this slow process of reform.</p>
<p>Following the US court decision, a <a href="https://medium.com/philadelphia-justice/district-attorney-krasner-statement-on-safehouse-ruling-9fa2a8462ee">supporter of Safehouse</a> described it as “a resounding defeat for Donald Trump and his minions’ callous efforts to increase the suffering of people and communities struggling with addiction”. With the UK experiencing the <a href="https://www.bbc.co.uk/news/uk-49357077">highest levels of drug-related deaths in history</a>, how much more suffering and death will people who use drugs have to endure before the callous efforts of the UK government come to an end? Indeed, the <a href="https://www.telegraph.co.uk/news/2019/10/22/roll-drugs-shooting-galleries-part-decriminalisation-mps-say/">quick and negative response of the government</a> to the MPs call for health-centred drug reforms seems to suggest the overdose crisis will continue to escalate.</p><img src="https://counter.theconversation.com/content/124952/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rick Lines does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>How much more suffering and death will people who use drugs have to endure?Rick Lines, Associate Professor of Crimininology and Human Rights, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1218762019-08-25T19:53:47Z2019-08-25T19:53:47ZAfter 2 festival deaths, the NSW government rushed through a new drug homicide crime. But it may do more harm than good<figure><img src="https://images.theconversation.com/files/289167/original/file-20190823-170941-1hc4bap.jpg?ixlib=rb-1.1.0&rect=51%2C0%2C5760%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The first of its kind in Australia, the offence of 'drug supply causing death' carries a maximum 20 year sentence.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>As the state election loomed last year, the NSW government rushed through a new crime targeting drug suppliers. A person who supplies a prohibited drug for profit can now be prosecuted for homicide if another person uses the drug and dies as a result. </p>
<p>The first of its kind in Australia, the <a href="http://www5.austlii.edu.au/au/legis/nsw/consol_act/ca190082/s25c.html">offence</a> of “drug supply causing death” carries a maximum 20 year sentence. The law was enacted after the deaths of 23-year-old Joshua Tam and 21-year-old Diana Nguyen at the Defqon.1 music festival in September, 2018. </p>
<p>In its haste to “do something” in response to their tragic deaths, the NSW government failed to consider harmful consequences that may arise from treating drug-related fatalities as homicide. In fact, <a href="https://www.academia.edu/40072032/Dancing_with_Death_Why_the_NSW_Homicide_Offence_of_Drug_Supply_Causing_Death_May_Cause_More_Harm_than_Good">my research</a> of how <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3265510">similar laws</a> have operated in the US suggests the new crime of “drug supply causing death” may <em>increase</em> the risk of fatal drug overdoses. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/289170/original/file-20190823-170931-1bdlsuo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/289170/original/file-20190823-170931-1bdlsuo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/289170/original/file-20190823-170931-1bdlsuo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/289170/original/file-20190823-170931-1bdlsuo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/289170/original/file-20190823-170931-1bdlsuo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/289170/original/file-20190823-170931-1bdlsuo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/289170/original/file-20190823-170931-1bdlsuo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/289170/original/file-20190823-170931-1bdlsuo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Two deaths at the DEFQON.1 music festival led the NSW government to rush through the new crime of ‘drug supply causing death’.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/hanuska/37127862472/in/photolist-YyRZZS-YxgkwN-YdYvUs-YBvHJg-Yxh7jy-Yxh9Tb-YdZ6nu-YBvE4F-YySLY9-Xy8in3-YdZ9GL-YBvi5B-YQd1nP-Xy8g33-Xy9gJm-XAcQq4-YdYNL3-XAdowP-cpN1uJ-2f37sod-byMf45-byMfny-bMFVHt-bMFW2k-bMFUtV-9Xv6dE-2a3J7Tm-YxgwxL-bMFVcB-bMFYkH-byMkbS-bMFUBH-W6wJ8G-6q2PsN-nmhdgr-2b98FuB-njvGsK-28ofGx3-2a3J5qW-njvGDM-2b98Gpx-nhtgMu-nmhfSP-njxZdd-2a3J7jL-njxYDY-nhthKG-njvH7k-njeiWG-njxV3j">Dushan Hanuska/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<h2>An unprincipled approach</h2>
<p>Just three days after the festival deaths, NSW Premier Gladys Berejiklian commissioned a panel comprising three heads of government agencies to advise whether “new offences or increased penalties were needed to stop drug dealers endangering lives”. </p>
<p>The panel was directed <a href="https://www.liquorandgaming.nsw.gov.au/__data/assets/pdf_file/0004/209965/Keepingpeoplesafe.pdf">not to consider pill testing</a>, consistent with the government’s “zero tolerance” approach to illicit drug use.</p>
<p>And the <a href="https://static.nsw.gov.au/1540188213/Keepingpeoplesafe.pdf">panel</a> warned “more analysis and consultation” was needed before enacting the offence, given the “legal complexities” involved. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/testing-festival-goers-pills-isnt-the-only-way-to-reduce-overdoses-heres-what-else-works-118827">Testing festival goers' pills isn't the only way to reduce overdoses. Here's what else works</a>
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<hr>
<p>But the government ignored this advice. Without any known consultation with criminal law experts or the NSW Law Reform Commission, it hastily enacted the offence of “drug supply causing death” in November last year.</p>
<h2>The crime of ‘drug supply causing death’</h2>
<p>Like the <a href="https://criminalcpd.net.au/wp-content/uploads/2016/09/JQ_Article_OnePunch_Laws_Mandatory_Minimumus_as_Published_1_April1.pdf">controversial</a> “one-punch” homicide offence introduced in 2014, the new drug homicide offence is an attempt to quickly “fix” a complex public health problem. </p>
<p>The offence is in <a href="https://www.legislation.nsw.gov.au/#/view/act/1900/40/part3/div1/sec25c">section 25C</a> of the Crimes Act 1900, and says the supply must be for “financial or material gain”, as opposed to what Attorney-General Mark Speakman called the <a href="https://www.parliament.nsw.gov.au/Hansard/Pages/HansardResult.aspx#/docid/HANSARD-1323879322-104603">“young friends” scenario</a>. In other words, people who pass on drugs to their friends without making a profit shouldn’t be prosecuted for this offence (but may be liable for <a href="http://www8.austlii.edu.au/cgi-bin/viewdb/au/legis/nsw/consol_act/dmata1985256/">other</a> drug supply offences).</p>
<p>The legislation was drafted before the government could consider the recommendations of the NSW coronial inquest into the drug-related deaths of six young people at music festivals. The coroner is <a href="https://www.abc.net.au/news/2019-07-20/music-festival-drug-inquest-wrap/11326050">expected</a> to hand down her findings in October. </p>
<p>The music festival deaths have been linked to ecstasy (MDMA) use. However, section 25C targets drugs beyond ecstasy and contexts beyond music festivals. It extends to the supply of <em>any</em> <a href="https://www.legislation.nsw.gov.au/#/view/act/1985/226/sch1">prohibited drug</a> (except cannabis) including crystal methamphetamine (ice), cocaine and opioids such as heroin. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/law-and-order-is-no-get-out-of-jail-card-for-floundering-politicians-107701">Law and order is no get-out-of-jail card for floundering politicians</a>
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</em>
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<hr>
<p>On the other hand, if a person supplies another person a legal — albeit potentially harmful — drug, such as alcohol or tobacco, and the user dies from ingesting or inhaling that drug, the supplier cannot be prosecuted under section 25C. </p>
<h2>New crime may do more harm than good</h2>
<p>Similar drug-induced homicide laws in the US, which have existed since the 1980s, show how the NSW crime might exacerbate, rather than prevent, drug-related harms. </p>
<p>In many US states, drug suppliers are zealously prosecuted for homicide, with police opting to pursue low-level dealers as opposed to major traffickers. </p>
<p>Charges are <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3265510">disproportionately</a> laid against people of colour in cases involving white victims. People of colour also serve longer sentences for these offences than white defendants.</p>
<p>Disturbingly, evidence from the US <a href="https://theappeal.org/charging-dealers-with-homicide-explained/">suggests</a> drug homicide offences <em>increase</em> the risk of death to drug users. Faced with the prospect of prosecution and a lengthy prison sentence, suppliers and bystanders are more likely to abandon people experiencing drug overdose symptoms than seek medical help. </p>
<p>The NSW parliament could have, but did not, enact a “Good Samaritan” immunity alongside the crime of drug supply causing death. This immunity would allow dealers to avoid prosecution for homicide when they immediately seek medical help for users showing signs of distress.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/unlawful-strip-searches-are-on-the-rise-in-nsw-and-police-arent-being-held-accountable-121986">Unlawful strip searches are on the rise in NSW and police aren’t being held accountable</a>
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</em>
</p>
<hr>
<h2>Independently-made choices</h2>
<p>Section 25C is a radical departure from NSW homicide law. For the crimes of murder and manslaughter, the prosecution must establish a <a href="http://www.austlii.edu.au/cgi-bin/viewdoc/au/cases/cth/HCA/1991/27.html?context=1;query=Royall%20;mask_path=">causal link</a> between the defendant’s actions and the victim’s death. </p>
<p>Applying established rules of causation, in 2012, the High Court <a href="http://eresources.hcourt.gov.au/showCase/2012/HCA/35">held</a> that a methadone supplier was not criminally responsible for the death of the person who self-administered the methadone. The High Court reasoned that the voluntary and informed decision of an adult to take a prohibited drug broke the “chain of causation” between supply and death.</p>
<p>Section 25C departs from the <a href="https://books.google.com.au/books?id=wTa8AQAAQBAJ&dq=JS+Mills+harm&source=gbs_navlinks_s">libertarian</a> principle that individuals are responsible for independently-made choices that may bring about harm to themselves. </p>
<p>For the crime of drug supply causing death, a “causal link” need only be established between the <em>drug user’s</em> action in taking the drug and their death. As a result, a person might be prosecuted for drug supply causing death when: </p>
<ul>
<li>a person overdoses on drugs to intentionally end their own life </li>
<li>a person drives under the influence of drugs, crashes their vehicle and dies</li>
<li>a person loses their inhibitions from taking drugs, jumps off a bridge and dies. </li>
</ul>
<p>These are just some of the unintended consequences that may arise from the failure to subject this law to <a href="http://www.austlii.edu.au/au/journals/CICrimJust/2015/9.html">rigorous scrutiny</a>. </p>
<h2>Assessing risk of death</h2>
<p>One aspect of the offence that is <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=326551">narrower</a> than its US counterparts is the “mental” element. The prosecution must prove the person who supplied the drug knew, or should reasonably have known, the drug supply would expose another person to a “significant risk of death”. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-hard-is-it-to-say-no-to-drugs-111536">How hard is it to say 'no' to drugs?</a>
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</em>
</p>
<hr>
<p>Assessing whether a risk of <em>death</em> is <em>significant</em> will be no easy task, and will depend on the unique facts of each case. <a href="https://theconversation.com/how-does-mdma-kill-109506">Variables</a> include whether the accused knew, or should have known, about the quantity, strength and toxicity of the drug; whether the drug was consumed with other drugs including alcohol; environmental factors; and the user’s health. </p>
<p>What’s clear is this punitive criminal law response to a serious public health problem, without adequate consultation or evidence, will produce unintended consequences. Failing to learn from the US experience, the new offence of drug supply causing death is likely to result in more harm than good.</p><img src="https://counter.theconversation.com/content/121876/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elyse Methven does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Similar laws in the US have actually led to increasing the risk of fatal drug overdoses.Elyse Methven, Lecturer in Law, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1204492019-08-15T08:53:16Z2019-08-15T08:53:16ZUK drug deaths continue to rise – time for action<figure><img src="https://images.theconversation.com/files/287990/original/file-20190814-136203-zdgykg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1215689563?src=WdYmyGcwLDAVNT9Ex5VBQQ-1-14&size=medium_jpg">Impact Photography/Shutterstock</a></span></figcaption></figure><p>Every year since 2013, the UK’s Office for National Statistics has reported an <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2018registrations">increase</a> in drug-related deaths in England. Last year, we reported that drugs had <a href="https://theconversation.com/record-level-of-drug-deaths-in-england-and-wales-latest-official-figures-99710">overtaken traffic accidents</a> as a leading cause of death. This year, they have <a href="https://www.telegraph.co.uk/news/2019/08/06/drug-overdose-eclipses-suicide-biggest-killer-middle-aged-men/?WT.mc_id=tmg_share_tw">outstripped suicides</a> among men aged 35-49. As these deaths continue to rise ever higher, the government continues to cut funding for drug treatment and actively blocks services that would save people’s lives.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/288147/original/file-20190815-136176-1774mvt.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/288147/original/file-20190815-136176-1774mvt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/288147/original/file-20190815-136176-1774mvt.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288147/original/file-20190815-136176-1774mvt.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288147/original/file-20190815-136176-1774mvt.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288147/original/file-20190815-136176-1774mvt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288147/original/file-20190815-136176-1774mvt.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288147/original/file-20190815-136176-1774mvt.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drug deaths chart.</span>
<span class="attribution"><span class="source">ONS</span></span>
</figcaption>
</figure>
<p>Just this week, prime minister Boris Johnson promised to spend billions of pounds on <a href="https://www.theguardian.com/politics/2019/aug/12/boris-johnson-crime-crackdown-policing-prisons">ineffective criminal justice policies</a>, including <a href="https://news.sky.com/story/how-much-do-all-of-boris-johnsons-promises-cost-11783796">£2.5 billion</a> a year to expand the prison population by another 10,000 people. It is highly doubtful whether these pledges will be any more real than <a href="https://www.bbc.co.uk/news/uk-49318400">previous unfulfilled promises</a>, but they stand in stark contrast to sharp cuts in investment in preventing people from dying from drugs.</p>
<p><a href="https://www.gov.uk/government/collections/local-authority-revenue-expenditure-and-financing#2018-to-2019">Government figures</a> show a 27% reduction in spending on drug treatment services for adults since 2015-16. In some places with very high rates of drug-related deaths - such as Blackpool, Hartlepool, Liverpool and North Tyneside - the budget for drug treatment has been cut by more than half. </p>
<p>Drug-related deaths are not spread equally among British communities. The greatest burden is among those living in the most <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/articles/middleagedgenerationmostlikelytodiebysuicideanddrugpoisoning/2019-08-13">deprived</a> areas. Until recently, the media has largely ignored communities which lose middle-aged opiate users on a daily basis. More attention has been paid to young people dying as a result of party drugs, such as ecstasy. </p>
<p>As the deaths mount, this is beginning to change. Heartbreaking stories of deaths, such as <a href="https://www.walesonline.co.uk/news/wales-news/son-heroin-addict-grieving-mothers-16724022">Kevin Lane</a>, are getting more coverage. Lane had struggled with drug dependency for several years. He also had mental health problems – an all too common combination for people who have problems with drugs. His life ended prematurely when he was found in a shop toilet having overdosed on heroin aged just 32. </p>
<p>The shocking practice of “<a href="https://www.bbc.co.uk/news/uk-wales-46738016">cuckooing</a>” - where drug dealers take over the homes of vulnerable people - also shows that people who use drugs deserve protection, not just blame. </p>
<h2>Ignoring the evidence</h2>
<p>In Scotland, record levels of drug deaths have been recognised as a symptom of <a href="http://www.sdf.org.uk/blog-poverty-is-the-root-of-scotlands-fatal-drug-overdose-crisis/">entreneched poverty</a>. Deaths both north and south of the Scottish border are a <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(19)30209-3/fulltext">public health crisis</a> triggering calls for a <a href="https://www.thenational.scot/news/17829530.scottish-drugs-forum-warns-urgent-rethink-required-street-valium-deaths/">different approach</a> by bereaved families, advocacy groups and many others. But Westminster has failed to implement evidence-based measures, recommended by the <a href="https://www.gov.uk/government/publications/reducing-opioid-related-deaths-in-the-uk">Advisory Council on the Misuse of Drugs</a>, for reducing deaths. </p>
<p>Instead of investing in effective opioid-substitution treatment, it has slashed the available funding. It has left it to cash-strapped local authorities to provide <a href="https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/heroin-on-trial-systematic-review-and-metaanalysis-of-randomised-trials-of-diamorphineprescribing-as-treatment-for-refractory-heroin-addiction/A3C4F1D0F709099E47472B42507FF97C">heroin-assisted treatment</a>. And it has refused to support <a href="https://transformdrugs.org/the-governments-arguments-against-drug-consumption-rooms-have-fallen-one-by-one/">drug consumption facilities</a>. These facilities <a href="https://theconversation.com/what-goes-on-inside-a-medically-supervised-injection-facility-87341">save</a> lives, but they need political support and funding – not easy when the <a href="https://www.jrf.org.uk/sites/default/files/jrf/migrated/files/9781859354711.pdf">public</a> perceive these as facilitating drug use rather than a means to reducing drug-related harm.</p>
<p>All drug-related deaths are avoidable. We know how to reverse this dreadful trend in mortality, but this knowledge needs to be acted on by politicians. Unless this happens, we fear that next year yet another record in drug-related deaths will be reported.</p><img src="https://counter.theconversation.com/content/120449/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alex Stevens is a member of the Advisory Council on the Misuse of Drugs, but does not speak for it here.</span></em></p><p class="fine-print"><em><span>Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There are proven ways to reduce drug deaths in the UK. But the government is ignoring them.Ian Hamilton, Associate Professor, University of YorkAlex Stevens, Professor in Criminal Justice and Faculty Director of Public Engagement, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1188272019-07-07T20:10:50Z2019-07-07T20:10:50ZTesting festival goers’ pills isn’t the only way to reduce overdoses. Here’s what else works<figure><img src="https://images.theconversation.com/files/282609/original/file-20190704-126376-1qy5c4g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Festival goers bring their phones. So why not use them to receive tweets about high-dose drugs in circulation, as the UK is doing?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/grodno-belarus-september-17-2016-teenagers-1258396705?src=4km6UC1HndwfYPP9pnphCA-1-8&studio=1">from Vinnikava Viktoryia/www.shutterstock.com</a></span></figcaption></figure><p>The <a href="https://www.smh.com.au/national/nsw/music-festival-deaths-inquest-set-down-for-july-20190228-p510sz.html">NSW inquest into recent drug deaths at music festivals</a> is due to start this week. So focus is turning to how to make music festivals safer by reducing drug-related incidents. </p>
<p>We know that <a href="https://theconversation.com/australias-recreational-drug-policies-arent-working-so-what-are-the-options-for-reform-55493">prohibition doesn’t work</a> to reduce either harms or drug use. But what does?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australias-recreational-drug-policies-arent-working-so-what-are-the-options-for-reform-55493">Australia's recreational drug policies aren't working, so what are the options for reform?</a>
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</em>
</p>
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<h2>How do drugs cause harm?</h2>
<p>Most illicit drugs used at festivals, including <a href="https://adf.org.au/drug-facts/mdma/">ecstasy</a> (methylenedioxymethamphetamine or MDMA), started out as relatively benign pharmaceuticals. </p>
<p>MDMA is most commonly implicated in drug-related harm at festivals. Fatal and non-fatal MDMA overdoses <a href="https://theconversation.com/how-does-mdma-kill-109506">are usually a result</a> of high-purity MDMA, dangerous contaminants, or environmental factors such as overheating or drinking too much or too little water. So to reduce harms we need to address all these problems.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-ecstasy-the-party-drug-that-could-be-used-to-treat-ptsd-55149">Weekly Dose: ecstasy, the party drug that could be used to treat PTSD</a>
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</em>
</p>
<hr>
<h2>What doesn’t work</h2>
<p><a href="https://www.sciencedirect.com/science/article/pii/S0955395916303899">Police presence, random drug searches and drug detection dogs</a> don’t deter drug use and may increase harms. Yet they are common at festivals and come at a substantial financial cost to festival goers, which has to be covered in the price of the ticket. </p>
<p>People who go to festivals say that <a href="https://www.ncbi.nlm.nih.gov/pubmed/30176423">police presence doesn’t discourage them</a> from taking drugs; and there are many documented cases of people <a href="https://www.ncbi.nlm.nih.gov/pubmed/30176423">taking multiple pills at once</a> to avoid searches and sniffer dog detection, which increases the risk of overdose.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-drug-detection-dogs-are-sniffing-up-the-wrong-tree-57343">Why drug-detection dogs are sniffing up the wrong tree</a>
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</p>
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<p>Publicly, the police focus is on drug dealing, but the reality is that most people who are arrested at festivals are people who use, rather than sell, drugs. NSW police reported that, at <a href="https://www.abc.net.au/triplej/programs/hack/nearly-200-drug-arrests-at-field-day-music-festival/10679504">Sydney’s 2019 Field Day Festival</a>, of the 28,000 people who attended, there were 155 drug-related arrests: 149 for possession and 6 for supply.</p>
<p>When police dogs are present, people are more likely to <a href="https://www.sciencedirect.com/science/article/pii/S0955395916303899">buy drugs inside the festival</a> rather than risk detection by carrying drugs in. This means they are more likely to buy from unknown sources, which <a href="https://www.sciencedirect.com/science/article/abs/pii/S0955395918302755">increases their risk</a> of harm compared with buying from a trusted source.</p>
<p><a href="https://theconversation.com/australias-recreational-drug-policies-arent-working-so-what-are-the-options-for-reform-55493">Decriminalising illicit drugs</a> would significantly reduce harms and allow festival police to focus on public safety issues, such as antisocial behaviour and public drunkenness.</p>
<h2>What works</h2>
<p>There are already effective <a href="https://www2.health.vic.gov.au/Api/downloadmedia/%7B672393DE-E7DB-4118-8C9F-7BD1D5F045DB%7D">harm reduction strategies</a> in place at festivals. These include:</p>
<ul>
<li>presence of peer-led organisations, like <a href="https://www.hrvic.org.au/dancewize">Dancewize</a>, which provide harm reduction information and support</li>
<li>emergency services and first aid</li>
<li>chill out spaces</li>
<li>availability of cool clean water</li>
<li>good ventilation in indoor spaces, and</li>
<li>staff and volunteer training in responding to drug affected people.</li>
</ul>
<h2>Pill testing direct to consumer</h2>
<p><a href="https://theconversation.com/six-reasons-australia-should-pilot-pill-testing-party-drugs-34073">On-site pill testing</a>, which identifies the content and purity of drugs brought in by festival goers, also includes contact with a health professional to provide a brief intervention, that can include advice about risks of taking drugs and harm reduction information. Festival goers are always told that it is safest not to take drugs at all.</p>
<p><a href="https://www.aracy.org.au/publications-resources/command/download_file/id/106/filename/Interventions_to_reduce_harm_associated_with_adolescent_substance_use.pdf">Brief interventions</a> from a health professional can reduce risky drug use among young people. But without a way to offer an intervention, most young people who go to festivals will not come into contact with a health worker to receive that information.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-why-doctors-are-backing-pill-testing-at-music-festivals-across-australia-109430">Here's why doctors are backing pill testing at music festivals across Australia</a>
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</p>
<hr>
<p>Some <a href="https://www.theage.com.au/national/victoria/festivals-face-permit-system-as-ashton-brands-testing-a-distraction-20190131-p50uq9.html">Australian police</a>, <a href="https://www.abc.net.au/news/health/2018-12-21/guide-to-pill-testing-at-australian-music-festivals/10638732">politicians and policymakers</a> are reluctant to consider pill testing at festivals. That may be because, so far, only on-site, direct-from-consumer testing has been offered as a viable way of reducing harm. </p>
<p>Some people have concerns about the idea of accepting and testing illicit drugs direct from the people using them, given that they are still illegal.</p>
<p>But there are many other ways of pill testing that can also reduce harm.</p>
<h2>Testing of police-acquired drugs</h2>
<p>We could also test drugs on-site that have been seized by police, acquired from emergency services after an incident or surrendered in <a href="https://www.theage.com.au/national/victoria/pressure-mounts-to-introduce-drug-amnesty-bins-at-festivals-20160131-gmhwoi.html">amnesty bins</a>.</p>
<p>This approach has been used at a number of <a href="https://wearetheloop.org/about-us">festivals in the UK</a> since 2013. When a potentially problematic drug is identified during the festival, <a href="https://wearetheloop.org/drug-alerts">an alert</a> is issued on-site through social media usually within hours, to alert others who may have bought drugs from similar batches.</p>
<p>As well as potentially reducing harm for people who use drugs, these alerts mean police are better able to monitor the local drug market; on-site paramedics, first aid and outreach workers are better informed about drugs in circulation, helping to improve responses; and according to the <a href="https://www.sciencedirect.com/science/article/abs/pii/S0955395918302755">UK testing facility</a>, medical services report having more confidence in dealing with presentations because of the alerts.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/282619/original/file-20190704-126376-rb2fhy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/282619/original/file-20190704-126376-rb2fhy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/282619/original/file-20190704-126376-rb2fhy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/282619/original/file-20190704-126376-rb2fhy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/282619/original/file-20190704-126376-rb2fhy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/282619/original/file-20190704-126376-rb2fhy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/282619/original/file-20190704-126376-rb2fhy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/282619/original/file-20190704-126376-rb2fhy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Medical services can also benefit from alerts letting people know which problem drugs might still be in circulation.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sign-pointing-hospital-emergency-room-melbourne-618969788?src=_Xu6Ho-TVA-Uon0TmZa_yw-1-35&studio=1">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>This approach is not as effective in reducing harms as direct-from-consumer testing. That’s because it doesn’t include contact with a health professional who can offer a brief intervention, and the information about pill contents doesn’t go direct to the people intending to use them. </p>
<p>But if testing of police acquired drugs is combined with real-time alerts about potential problem drugs to festival goers, it can still reduce harms.</p>
<h2>Off-site testing</h2>
<p>Testing of pills brought in by festival goers can also occur off site before the festival. It works the same way as onsite testing, and includes brief intervention, but operates away from the festival site.</p>
<p>It’s the primary model used in <a href="https://www.trimbos.nl/aanbod/webwinkel/product/af1677-the-drugs-information-and-monitoring-system-dims">The Netherlands</a>.</p>
<p>Off-site testing removes the need to change the way the drugs are policed at festivals, so may be more acceptable to some. If both off-site and on-site testing are implemented, testing services will have greater reach and be more effective in reducing harm.</p>
<h2>Testing drug purity</h2>
<p>The only official pill testing that has been undertaken in Australia has been at <a href="https://www.harmreductionaustralia.org.au/wp-content/uploads/2018/06/Pill-Testing-Pilot-ACT-June-2018-Final-Report.pdf">Canberra’s Groovin’ the Moo in 2018</a> and 2019. The on-site facility tested samples provided directly by consumers and identified the drugs present. But they could only estimate the purity of drug powders and did not measure the dose of MDMA in the pills.</p>
<p>High-dose MDMA has been implicated in a number of the recent festivals deaths. Knowing the dose may help reduce overdoses from MDMA pills because people can choose to take a smaller amount of the drug if they know the strength is high.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-to-seek-help-after-taking-a-pill-109876">When to seek help after taking a pill</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://wearetheloop.org">The Loop UK</a> has developed a method of more accurately measuring the dose in MDMA pills, which could help reduce the harms associated with high purity. The process does not require any specialised equipment and is performed on-site by trained chemists. At this year’s <a href="https://parklife.uk.com">Parklife Festival</a> the organisation identified high-strength pills and send out warnings.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/280815/original/file-20190622-61737-1fu9brf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/280815/original/file-20190622-61737-1fu9brf.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=776&fit=crop&dpr=1 600w, https://images.theconversation.com/files/280815/original/file-20190622-61737-1fu9brf.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=776&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/280815/original/file-20190622-61737-1fu9brf.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=776&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/280815/original/file-20190622-61737-1fu9brf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=975&fit=crop&dpr=1 754w, https://images.theconversation.com/files/280815/original/file-20190622-61737-1fu9brf.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=975&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/280815/original/file-20190622-61737-1fu9brf.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=975&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Example of alerts from The Loop UK at this year’s Parklife Festival.</span>
</figcaption>
</figure>
<h2>Understanding drug use at festivals</h2>
<p>We also don’t really know how many young people use drugs at Australian festivals and how much they use. Most of what we know is from anecdotal reports. There’s probably differences between festivals.</p>
<p>We know both festival attendance and <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/ndshs-2016-detailed/contents/table-of-contents">illicit drug use</a> hit a peak among people in their 20s. So more research on how common drug use is at festivals and the kinds of drugs people use would help inform better and more targeted harm reduction policies.</p>
<p>We will never completely eliminate drug use at festivals but we can make them safer by implementing what we know works and stopping what we know doesn’t. It’s normal for young people to take risks. Whether you agree with drug taking or not, our young people don’t deserve to die just because they have taken drugs.</p><img src="https://counter.theconversation.com/content/118827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee works as a paid consultant in the alcohol and other drug sector. She has previously been awarded grants by state and federal governments, NHMRC and other public funding bodies for alcohol and other drug research. She contributes volunteer time to The Loop Australia.
</span></em></p><p class="fine-print"><em><span>Monica Barratt receives funding from the National Health and Medical Research Council, the Marsden Foundation (NZ) and the National Institutes of Health (US). In addition to her academic research role, she volunteers as Director of Research at Bluelight.org and as Victorian Strategic Engagement Coordinator at The Loop Australia.</span></em></p>There are many ways to reduce harm from drugs at music festivals beyond the much publicised pill testing. Here’s what else we can do.Nicole Lee, Professor at the National Drug Research Institute, Curtin UniversityMonica Barratt, Vice Chancellor’s Senior Research Fellow, Social and Global Studies Centre, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1095062019-01-22T18:38:10Z2019-01-22T18:38:10ZHow does MDMA kill?<figure><img src="https://images.theconversation.com/files/253596/original/file-20190114-43541-14qd0qa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">MDMA itself isn't a dangerous drug. But adulterants found in drugs made by at-home chemists can be deadly. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>MDMA (Methylenedioxymethamphetamine), commonly referred to as ecstasy, was manufactured as a potential pharmaceutical early last century. It had some limited use in the 1970s as a therapeutic aid in trauma treatment and in relationship counselling, and more <a href="http://www.maps.org/research-archive/mdma/ptsdpaper.pdf">recent studies</a> using MDMA for trauma have shown some promise.</p>
<p>Structurally, MDMA is similar to the stimulant methamphetamine and to the hallucinogen mescaline, and so has both stimulant and mildly hallucinogenic effects.</p>
<p>Most problems with recreational MDMA are acute. Dependence and other long-term problems are quite rare. Less than 1% of all drug <a href="https://www.aihw.gov.au/getmedia/6ada5e0f-40ff-459b-ae6c-b45845a37ccc/aihw-hse-207.pdf.aspx?inline=true">treatment presentations</a> are for ongoing problems with MDMA, such as dependence.</p>
<p>Most fatalities from taking ecstasy are a result of a <a href="https://www.tandfonline.com/doi/abs/10.1080/14659891.2018.1436607?tokenDomain=eprints&tokenAccess=Sn9BHegQ979bPzzjwjr5&forwardService=showFullText&doi=10.1080%2F14659891.2018.1436607&doi=10.1080%2F14659891.2018.1436607&journalCode=ijsu20">combination of factors</a>, not just the drug itself. </p>
<p>Most of these conditions don’t result in death if they are treated early, but because of the stigma associated with using illicit drugs, sometimes people don’t seek help early enough. Any unusual or unwanted symptoms experienced while taking ecstasy should be treated as soon as they appear.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/six-reasons-australia-should-pilot-pill-testing-party-drugs-34073">Six reasons Australia should pilot 'pill testing' party drugs</a>
</strong>
</em>
</p>
<hr>
<h2>Contaminants and polydrug use</h2>
<p>Most people are under the impression drugs are illegal because they are dangerous, but a <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61462-6/fulltext">drug’s legal status</a> isn’t necessarily related to relative danger. In fact, drugs are much more dangerous because they are unregulated, manufactured by backyard chemists in clandestine laboratories. </p>
<p>Unlike alcohol, which is a highly regulated drug, there’s no way to tell how potent illicit drugs are or what’s in them, unless you <a href="https://theconversation.com/six-reasons-australia-should-pilot-pill-testing-party-drugs-34073">test them</a>.</p>
<p>In Australia, what is sold as ecstasy may contain a lot of MDMA or very little. Pills can contain other more dangerous drugs that mimic the effects of MDMA, and benign substances, such as lactose, as filler agents. </p>
<p>A recent report on findings from Australia’s first official pill testing trial at the Groovin’ the Moo music festival last year, found nearly <a href="https://www.harmreductionaustralia.org.au/wp-content/uploads/2018/06/Pill-Testing-Pilot-ACT-June-2018-Final-Report.pdf">half the pills</a> tested were of low purity. Some 84% of people who had their pills tested thought they had bought MDMA but only 51% actually contained any MDMA.</p>
<p>Some of the more dangerous contaminants found in pills include <a href="http://www.drugs.ie/pma">PMA</a> (paramethoxyamphetamine), which is more toxic at lower doses than ecstasy; <a href="https://knowyourstuff.nz/2018/02/07/this-summers-crap-drug-n-ethylpentylone/">N-Ethylpentylone</a>, a <a href="https://adf.org.au/drug-facts/synthetic-cathinones/">cathinone</a> which is a lot more potent than MDMA making it easier to take too much; and <a href="https://www.vice.com/en_nz/article/4x7jen/nbome-in-australia-everything-we-know-about-what-it-is-and-why-its-killing-people">NBOMes</a> (N-methoxybenzyl), which is more toxic at lower doses than other hallucinogenic drugs and can cause heart attack, renal failure, and stroke. </p>
<p>Pills have also been detected in UK and NZ with up to <a href="https://healthcentral.nz/concerns-over-doses-in-ecstasy-pills/">three doses of MDMA</a> in a single pill.</p>
<p>Although it’s possible to take too much MDMA and experience severe toxic effects, as with other illicit drugs, most <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2016%7EMain%20Features%7EDrug%20Induced%20Deaths%20in%20Australia%7E6">ecstasy-related deaths</a> involve multiple drugs.</p>
<p>Sometimes these drug mixes are unexpected and sometimes people take multiple drugs deliberately. It’s safer for people using ecstasy to limit use of other drugs, including alcohol, to avoid risk of adverse effects.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/while-law-makers-squabble-over-pill-testing-people-should-test-their-drugs-at-home-109421">While law makers squabble over pill testing, people should test their drugs at home</a>
</strong>
</em>
</p>
<hr>
<h2>Heatstroke</h2>
<p>Heatstroke or hyperthermia (dangerously high body temperature) is one of the most common issues among people taking MDMA.</p>
<p>MDMA increases <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5008716/">body temperature</a> and sweating, and using it is often accompanied by physical activity (such as dancing) in a hot environment (such as a crowded venue or in the summer heat), exacerbating fluid loss. If you don’t have enough fluids your body can’t cool itself properly.</p>
<p>The effect of ecstasy can be exacerbated by consuming alcohol. Alcohol is a diuretic, so it makes you urinate more and increases dehydration. Dehydration <a href="https://www.hopkinsmedicine.org/healthlibrary/conditions/non-traumatic_emergencies/dehydration_and_heat_stroke_85,P00828">increases risk</a> of heatstroke.</p>
<p>Heatstroke can cause brain, heart, kidney and muscle damage, and if left untreated can cause serious complications or death.</p>
<p>If active, people taking MDMA should drink around 500ml (two cups) of water an hour and take regular breaks. Isotonic drinks (such as Powerade and Gatorade) are also OK.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/253598/original/file-20190114-43520-tm7uxr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/253598/original/file-20190114-43520-tm7uxr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/253598/original/file-20190114-43520-tm7uxr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/253598/original/file-20190114-43520-tm7uxr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/253598/original/file-20190114-43520-tm7uxr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/253598/original/file-20190114-43520-tm7uxr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/253598/original/file-20190114-43520-tm7uxr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/253598/original/file-20190114-43520-tm7uxr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">MDMA increases body temperature and sweating, so users have to stay hydrated.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Water intoxication</h2>
<p>People using MDMA can get really thirsty. Some is probably the direct effect of MDMA, some because they’re hot, and some from dehydration.</p>
<p>But if you have too much water the ratio of salts and water in the body becomes unbalanced – basically the level of salt in your body gets too low and your cells start swelling with water. The technical name is <a href="https://en.wikipedia.org/wiki/Hyponatremia">hyponatraemia</a>.</p>
<p>MDMA is an anti-diuretic, so it makes you retain water, which can <a href="https://cjasn.asnjournals.org/content/3/6/1852">increase risk</a> of water intoxication.</p>
<p>People may feel nausea with vomiting, confusion, severe fatigue, muscle weakness and cramps.</p>
<p>People taking ecstasy need to stay hydrated but only replace what is lost through sweating – around 500ml per hour if active and around 250ml an hour when inactive.</p>
<h2>Serotonin syndrome</h2>
<p>The main action of MDMA in the brain is an increase in <a href="https://www.medicalnewstoday.com/kc/serotonin-facts-232248">serotonin</a>, which among other things is responsible for regulating pro-social behaviour, empathy and optimism. This is why people who have taken MDMA feel connection with and positivity towards others.</p>
<p>But too much serotonin can result in “<a href="https://www.nps.org.au/australian-prescriber/articles/serotonin-syndrome-3">serotonin syndrome</a>”. It typically occurs when other drugs that also raise serotonin levels (other stimulants, antidepressants) are taken together with MDMA.</p>
<p>Signs include high body temperature, agitation, confusion, problems controlling muscles, headache and the shakes. People might also experience seizures or loss of consciousness. </p>
<p>It can be fatal if the symptoms are left untreated, so if anyone taking MDMA shows any of these signs they should be treated immediately. It’s safer not to mix different types of drugs, especially if you do not know what’s in them.</p>
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Read more:
<a href="https://theconversation.com/heres-why-doctors-are-backing-pill-testing-at-music-festivals-across-australia-109430">Here's why doctors are backing pill testing at music festivals across Australia</a>
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<h2>Other causes</h2>
<p>More rarely, fatalities have been reported as a result of other health complications after taking ecstasy, especially if the person has pre-existing risk factors, such as high blood pressure or a heart condition. Complications related to heart failure, liver failure and brain haemorrhage have been reported in people already at high risk of these problems.</p>
<p>The number of people who die from party drugs is <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2016%7EMain%20Features%7EDrug%20Induced%20Deaths%20in%20Australia%7E6">relatively low</a> compared to other drugs such as heroin, alcohol, and pharmaceuticals. But the media tend to <a href="https://www.sciencedirect.com/science/article/abs/pii/S0955395901000925">report</a> a higher proportion of these deaths compared to other drugs, increasing the perception of harm. Most of the deaths are not directly from the drug itself but other complications or contaminants.</p>
<p>It’s safest not to take drugs at all, but if you choose to, it’s safer to take a small amount first (like a quarter of a pill) and wait at least an hour to make sure there are no ill effects; drink about 500ml per hour of water if active; and don’t mix drugs, including alcohol.</p>
<p>In the absence of a legal, uncontaminated supply of MDMA, when pill testing becomes available in Australia it will at least help people make informed decisions about drug use and <a href="https://www.sciencedirect.com/science/article/abs/pii/S0955395918302755?fbclid=IwAR0AKmYupBDAhRL-LMV_-pkrLcfV2ty4nJbR29il2fqd-0-KqL1I3zTKqqY">reduce the risk</a> of fatalities and other harms. People often <a href="https://theindustryobserver.thebrag.com/study-finds/">choose not to take</a> their pills, or take smaller amounts, when they discover contaminants.</p><img src="https://counter.theconversation.com/content/109506/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee works as a paid consultant in the alcohol and other drug sector. She has previously been awarded grants by state and federal governments, NHMRC and other public funding bodies for alcohol and other drug research.</span></em></p>Every summer we hear of more deaths from drugs at festivals. But MDMA was originally a medicine, so how can it kill users?Nicole Lee, Professor at the National Drug Research Institute, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1095052019-01-15T19:12:28Z2019-01-15T19:12:28ZWeekly Dose: new drug MDPV, or ‘monkey dust’, found in Australia. What is it and what are the harms?<figure><img src="https://images.theconversation.com/files/253600/original/file-20190114-43532-z3jpk2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Users may or may not know they're taking MDPV. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Recent <a href="https://www.weeklytimesnow.com.au/news/national/health-warning-issued-over-new-monkey-dust-drug/video/2d04b0572c89c3bcf24c4a2031a24177">media reports</a> have suggested a rise in a dangerous new party drug known as “monkey dust”. This is a slang name for the drug MDPV (3,4-methylenedioxypyrovalerone), as well as other members of the chemical class known as “synthetic cathinones”, or “bath salts”. </p>
<p>The effects of monkey dust are similar to other stimulants such as ecstasy (MDMA) and cocaine. Revellers may be using the drug on purpose as a substitute for these, or may mistakenly think it’s MDMA. However, the potency and effects are different, and can lead to trouble.</p>
<p>Synthetic cathinones are synthetic derivatives of a stimulant found in the <a href="https://adf.org.au/drug-facts/khat/">khat plant</a>, a flowering plant native to the Horn of Africa and the Arabian Peninsula. <a href="https://www.unodc.org/wdr2017/field/Booklet_4_ATSNPS.pdf">More than 140 individual synthetic cathinones</a> have been identified as illicit drugs, so users can never be certain about a substance from its street name alone. </p>
<p>This class also includes drugs you may have heard of before including <a href="https://theconversation.com/weekly-dose-ephylone-the-dangerous-designer-stimulant-found-at-groovin-the-moo-96005">ephylone</a> (the dangerous drug detected recently via pill testing at an Australian music festival), methylone, and <a href="https://theconversation.com/meow-hear-this-mephedrone-is-a-curious-khat-2164">mephedrone</a>.</p>
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Read more:
<a href="https://theconversation.com/weekly-dose-ephylone-the-dangerous-designer-stimulant-found-at-groovin-the-moo-96005">Weekly Dose: ephylone, the dangerous designer stimulant found at Groovin the Moo</a>
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<h2>What is MDPV?</h2>
<p>MDPV was developed by pharmaceutical firm <a href="https://patents.google.com/patent/US3478050A/en">Boehringer Ingelheim</a> in the mid-1960s as a central nervous system stimulant. But development never got far enough for it to be tested on humans.</p>
<p>It <a href="https://doi.org/10.1111/1556-4029.12202">first reappeared</a> in internet drug forum discussions around 2005, and became increasingly prevalent in the United States, Europe and elsewhere over the following years. </p>
<p>MDPV has been illegal in Australia since 2010, and <a href="https://doi.org/10.1111/1556-4029.12202">around the same time</a> in many other jurisdictions including the United States, Canada, and much of Europe, accounting for a decline in its availability.</p>
<p>The Drug Enforcement Administration reported that MDPV accounted for <a href="https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS_SR_CathCan_508.pdf">more than 50%</a> of all synthetic cathinones encountered in law enforcement seizures in the US by 2011. The proportion had dropped to <a href="https://www.nflis.deadiversion.usdoj.gov/DesktopModules/ReportDownloads/Reports/NFLIS-SR-SynthCannabinoidCathinone.pdf">less than 1% by 2015</a>. </p>
<p>The <a href="https://www.afp.gov.au/news-media/media-releases/brisbane-men-arrested-following-importation-%E2%80%98bath-salts%E2%80%99">recent seizure</a> of more than four kilograms of MDPV imported into Australia suggests a market for the drug still exists.</p>
<p>MDPV is a white crystalline powder in its pure form, but manufacturing impurities often render it from off-white to pale brown. It’s usually sold as a powder, powder-filled capsules or tablets. MDPV and other cathinones are often misrepresented as MDMA for sale due to similar appearance and some common effects. <a href="https://www.ecstasydata.org/results.php?start=0&search_field=substance&s=mdpv">Laboratory testing</a> of street pills containing MDPV shows it’s commonly mixed with other drugs.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-ecstasy-the-party-drug-that-could-be-used-to-treat-ptsd-55149">Weekly Dose: ecstasy, the party drug that could be used to treat PTSD</a>
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<h2>What does MDPV do?</h2>
<p>An <a href="https://www.who.int/medicines/areas/quality_safety/4_13_Review.pdf">oral dose of MDPV</a> is estimated to be around 5-20 milligrams (compared to 100-150 milligrams for MDMA). The main psychoactive effects last two to three hours, and side-effects persist for several additional hours.</p>
<p>Users <a href="https://www.erowid.org/chemicals/mdpv/mdpv_effects.shtml">report</a> MDPV produces euphoria, feelings of empathy (although less so than MDMA), increased sociability, mental and physical stimulation, and sexual arousal. </p>
<p>Side-effects, particularly at high doses, can include anxiety and paranoia, delusions, muscle spasms, and an elevated heart rate. In extreme cases, <a href="https://doi.org/10.1007/s13181-011-0196-9">MDPV has been linked</a> to rhabdomyolysis (rapid muscle breakdown), brain injury, and death.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/253601/original/file-20190114-43538-1rh26wd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/253601/original/file-20190114-43538-1rh26wd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/253601/original/file-20190114-43538-1rh26wd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/253601/original/file-20190114-43538-1rh26wd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/253601/original/file-20190114-43538-1rh26wd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/253601/original/file-20190114-43538-1rh26wd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/253601/original/file-20190114-43538-1rh26wd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Animals in lab studies wanted to self-administer the drug, meaning it’s addictive.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>Like other cathinones, MDPV is a stimulant and shares some effects with other stimulants such as amphetamine, cocaine and MDMA. <a href="https://link.springer.com/chapter/10.1007%2F7854_2016_53">MDPV produces its effects</a> by inhibiting the reuptake of two important signalling molecules (neurotransmitters) in the brain; norepinephrine and dopamine.</p>
<p>Norepinephine is generally responsible for preparing the brain and body for action in the so-called “fight or flight response”, while dopamine is involved in more complex functions such as arousal, motivation, reward and motor control.</p>
<p>By blocking the ability of certain brain cells (neurons) to reabsorb these neurotransmitters, MDPV effectively increases the intensity and duration of norepinephrine and dopamine signalling. Cocaine works in a similar way, but in a lab test, <a href="https://doi.org/10.1038/npp.2012.204">MDPV was a much more potent inhibitor than cocaine</a>.</p>
<p>Other norepinephrine-dopamine reuptake inhibitors (NDRIs) include pharmaceuticals such as methylphenidate (known as ritalin and used to treat ADHD) and buproprion (an antidepressant). But the psychoactive and stimulant effects of MDPV are much stronger than pharmaceutical NDRIs. </p>
<p>Pyrovalerone – a hybrid of mephedrone and MDPV – is an approved appetite suppressant used medically for weight loss. However, it’s rarely used due to its potential for abuse.</p>
<p>Studies in laboratory animals highlight the stimulating effects of MDPV, and also its potential for dependence. <a href="https://www.nature.com/articles/npp2012233">Mice trained to identify MDPV</a> find it similar to both MDMA and methamphetamine. MDPV stimulates movement in rats approximately ten times more potently than cocaine, and rats will <a href="https://doi.org/10.1111/j.1369-1600.2012.00474.x">readily self-administer MDPV</a>, suggesting it’s addictive.</p>
<h2>Dangers</h2>
<p>MDPV has been involved in dozens of deaths in Europe, detailed in a <a href="http://www.emcdda.europa.eu/system/files/publications/819/TDAS14001ENN_466653.pdf">report</a> by the European Monitoring Centre for Drugs and Drug Addiction, as well as in the <a href="https://www.who.int/medicines/areas/quality_safety/4_13_Review.pdf">United States, Australia, and elsewhere</a>. </p>
<p>But many of these deaths involved extreme doses, repeated dosing (“bingeing”), intravenous use or additional drugs. In <a href="https://www.europeanreview.org/wp/wp-content/uploads/268-274-Synthetic-cathinones-related-fatalities-an-update.pdf">fatal cases</a> involving a single synthetic cathinone, death has been attributed to complications arising from extremely high body temperatures or damage to the vessels of the heart. Fortunately, specialised drug testing can detect MDPV and its derivatives.</p>
<p>Although simple <a href="https://www.dea.gov/sites/default/files/pr/microgram-journals/2012/mj9-1_27-32.pdf">colour-based reagent tests</a> may identify MDPV, these tests may also cross-react with similar cathinones, some of which are less dangerous, and some of which are more so.</p>
<p>For reliable identification, more sophisticated technology such as mass spectrometry or infrared spectroscopy, of the type <a href="https://theconversation.com/heres-why-doctors-are-backing-pill-testing-at-music-festivals-across-australia-109430">drug experts are campaigning</a> to take place at festivals, is required. In this regard, small, portable, and relatively cheap infrared analysers may be useful for on-site testing services.</p>
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<strong>
Read more:
<a href="https://theconversation.com/while-law-makers-squabble-over-pill-testing-people-should-test-their-drugs-at-home-109421">While law makers squabble over pill testing, people should test their drugs at home</a>
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<img src="https://counter.theconversation.com/content/109505/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Banister receives funding from the National Health and Medical Research Council and The Lambert Initiative for Cannabinoid Therapeutics.</span></em></p><p class="fine-print"><em><span>Richard Kevin receives funding from The Lambert Initiative for Cannabinoid Therapeutics.</span></em></p>Monkey dust is in the “bath salts” family. Here’s what that means.Samuel Banister, Team Leader in Medicinal Chemistry, University of SydneyRichard Kevin, Postdoctoral research associate, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/997102018-08-06T11:59:43Z2018-08-06T11:59:43ZRecord level of drug deaths in England and Wales – latest official figures<figure><img src="https://images.theconversation.com/files/230743/original/file-20180806-191035-1x5gwsk.jpg?ixlib=rb-1.1.0&rect=0%2C41%2C997%2C516&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/572107339?src=xkrNWz93-ROm5-8EfxQDqw-1-0&size=medium_jpg">C_KAWI/Shutterstock.com</a></span></figcaption></figure><p>For the fifth year in a row, the number of drug-related deaths reported in England and Wales has risen to record levels, according to the latest figures from the Office for National Statistics. In 2017, 2,503 deaths were <a href="https://www.ons.gov.uk/releases/deathsrelatedtodrugpoisoninginenglandandwales2017registrations">recorded</a> as “drug misuse”. This comes on top of July’s announcement of an 8% increase in drug-related deaths in <a href="https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/drug-related-deaths-in-scotland/2017">Scotland</a>. </p>
<p>In Great Britain, as a whole, deaths from drugs overtook <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/668504/reported-road-casualties-great-britain-2016-complete-report.pdf">traffic</a> fatalities as a leading cause of death in 2008, and they have risen particularly sharply since 2012.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Drug deaths versus road deaths.</span>
<span class="attribution"><span class="source">ONS</span></span>
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</figure>
<p>Jump in a car and everything around you is designed with safety in mind, from the roads to the construction of the vehicle. But with drugs, you are on your own. Policy <a href="https://www.theguardian.com/commentisfree/2017/jul/15/home-office-drugs-strategy-users-policy-public-services">effort</a> is centred on preventing drug use rather than protecting people when they use substances. </p>
<h2>Blaming the dead</h2>
<p>The government’s response to these latest figures will undoubtedly be to deflect attention from the failure of policy and blame those who died instead, arguing that they were part of <a href="https://www.theguardian.com/politics/2018/apr/04/seaside-towns-are-hotspots-for-heroin-deaths-says-ons">an ageing cohort</a> of drug users whose lifestyles and poor choices contributed to their early deaths.</p>
<p>The people most likely to die are working class, over 40 and living in de-industrialised areas. Drug death rates are nine times higher in the most <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/halfofheroinmorphinemisusedeathhotspotsinenglandandwalesareseasidelocations/2018-04-04">deprived</a> neighbourhoods than in the richest areas. </p>
<p>Unfortunately, investment in treatment does not match local need, so those areas with the greatest need get the least <a href="https://www.theguardian.com/society/2017/oct/14/drug-overdoses-rise-most-treatment-cuts-are-deepest">resources</a>. </p>
<h2>Deaths could be reduced</h2>
<p>There is a lot of research on how to reduce these deaths. In 2016, the government’s scientific advisers, the Advisory Council on the Misuse of Drugs (ACMD), summarised this evidence for ministers in a <a href="https://www.gov.uk/government/publications/reducing-opioid-related-deaths-in-the-uk">report</a>. The ACMD’s recommendations include wider provision of naloxone, a medicine that reverses opioid overdose. </p>
<p>The ACMD also called for central funding of heroin-assisted treatment. It advised that areas with high concentrations of injecting drug use should consider setting up medically supervised drug consumption rooms. These have been <a href="https://www.bbc.co.uk/news/uk-england-40674453">shown</a> to reduce drug-related health problems. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Naloxone can reverse the effects of opioids.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1062517577?src=QGLUS5Jpmb64KqjXIA3yrQ-1-9&size=medium_jpg">Tomas Nevesely/Shutterstock</a></span>
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<p>The most important recommendation was to invest in opioid substitution therapy. This treatment prescribes substitutes for heroin – such as methadone or buprenorphine – to people who are dependent. It is effective in retaining patients, reducing crime and avoiding the spread of infectious disease, such as HIV and viral hepatitis. It is <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/add.12971">estimated</a> that the expansion of this treatment in the 2000s was saving about 880 lives per year by the end of that decade. </p>
<p>Since then, there have been substantial cuts to the funding of drug treatment services. Spending on adult drug treatment services is <a href="https://www.health.org.uk/blog/health-investment-needs-long-term-thinking">projected</a> to have fallen by 26% in the four years from 2014. This led the ACMD <a href="https://www.gov.uk/government/publications/commissioning-impact-on-drug-treatment">to describe</a> funding cuts as “the biggest single threat” to the outcomes of drug treatment. </p>
<h2>Empty promises</h2>
<p>In its response to the ACMD’s recommendations, ministers claimed to accept them all, except drug consumption rooms. But their actions have not lived up to this claim. There has been no new funding for opioid substitution therapy, which continues to be cut.</p>
<p>A <a href="https://www.release.org.uk/blog/take-home-naloxone-england">survey</a> of local authorities in 2017, conducted by the charity <a href="https://www.release.org.uk/">Release</a>, found that the provision of naloxone in England is still patchy and inadequate. Some areas with high levels of drug-related deaths, like <a href="https://fingertips.phe.org.uk/profile/public-health-outcomes-framework/data#page/3/gid/1000042/pat/6/par/E12000001/ati/102/are/E06000001/iid/92432/age/1/sex/4">Hartlepool</a>, had no plans to introduce this life-saving medication.</p>
<p>The government also failed to follow ACMD’s recommendation to improve reporting and research on drug-related deaths. Taken together, there has been a comprehensive failure to take steps to reduce deaths. And, predictably, deaths have risen.</p>
<h2>Death by indifference</h2>
<p>Fatal road traffic accidents have successfully been reduced, not by banning cars but by employing evidence of what is effective in protecting people while they drive. We won’t reduce drug-related deaths by continuing to focus on banning drugs. </p>
<p>It’s not lack of know how that’s killing people – we already know how to reduce <a href="https://scottishrecoveryconsortium.org/assets/files/Resources/drugs-related-deaths-rapid-evidence-review.pdf">deaths</a> – but, as with road traffic deaths, investment and political will are needed to stop people dying as a result of using drugs. Government policy has the veneer of caring about people who die and the family and friends they leave behind, but another 2,503 needless deaths suggest otherwise.</p><img src="https://counter.theconversation.com/content/99710/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Hamilton is affiliated with Alcohol Research UK. </span></em></p><p class="fine-print"><em><span>Alex Stevens is a member of the Advisory Council on the Misuse of Drugs. He was the lead author of its 2016 report on Reducing Opioid-Related Deaths in the UK. He does not speak for the ACMD, but writes here in his capacity as an academic.</span></em></p>There are proven ways to reduce drug deaths. Unfortunately, the UK government is not implementing them.Ian Hamilton, Lecturer in Mental Health and Addiction, University of YorkAlex Stevens, Professor in Criminal Justice and Faculty Director of Public Engagement, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/826502017-08-17T13:39:39Z2017-08-17T13:39:39ZScotland’s drug death crisis needs a radical harm reduction response – now<figure><img src="https://images.theconversation.com/files/182418/original/file-20170817-13501-m0lzfv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-syringe-used-660689209">Shutterstock</a></span></figcaption></figure><p>The newly published <a href="https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/drug-related-deaths-in-scotland">figures</a> of annual drug-related deaths (DRD) in Scotland are appalling. The National Records of Scotland figure of 867 represents the highest annual total recorded – a 23% increase on the previous year, and a 100% increase since 421 Scottish DRDs were reported in 2006.</p>
<p>The recent annual <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2016registrations#deaths-involving-new-psychoactive-substances-continue-to-increase">figures</a> for England and Wales covering the same period also reported a record high figure of 3,744 deaths, representing a 2% increase on the previous year.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/182427/original/file-20170817-28126-1fj8d6t.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/182427/original/file-20170817-28126-1fj8d6t.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182427/original/file-20170817-28126-1fj8d6t.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182427/original/file-20170817-28126-1fj8d6t.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182427/original/file-20170817-28126-1fj8d6t.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182427/original/file-20170817-28126-1fj8d6t.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182427/original/file-20170817-28126-1fj8d6t.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">National Records of Scotland</span></span>
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<p>This makes the Scottish figures even more concerning: it is estimated that the Scottish DRD rate is now <a href="https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/drug-related-deaths-in-scotland/2016">2.5 times</a> that of elsewhere in the UK, and among the highest in Europe. Drug use has been <a href="http://www.scotpho.org.uk/downloads/bod/The-Scottish-Burden-of-Disease-Study-2015-Overview-Report-July17.pdf">recently confirmed </a> as a leading cause of early death in Scotland, ahead of chronic liver diseases and colorectal cancer. </p>
<h2>Root causes</h2>
<p>An ageing cohort of polydrug users (those who use a combination of drugs), the availability of increasingly strong and diverse street drugs, <a href="http://www.heraldscotland.com/news/14241634.Health_boards_told_to_fill___15_million_cut_in_funding_for_drug_and_alcohol_care/">cuts</a> in drug treatment budgets, and wider economic austerity, all create a perfect storm for such a crisis.</p>
<p>The roots of the situation seem to be historic and intertwined with pervasive social inequalities. <a href="https://osf.io/wxsgu/">New research</a> on DRD has described a “cohort effect” for those born between 1960 and 1980, especially among men living in the most deprived areas in Scotland. The researchers conclude that “exposure to the changing social, economic and political contexts of the 1980s created a delayed negative health impact”. </p>
<p>Recent research on the needs of <a href="http://www.sdf.org.uk/wp-content/uploads/2017/06/Working-group-report-OPDPs-in-2017.pdf">older drug users</a> in Scotland found a group experiencing some of the most extreme health inequalities seen in Scottish society today. In addition to poor physical health, persistent and enduring mental health problems were common, exacerbated by loneliness, isolation, homelessness and stigma. It is not only older drug users who are affected, however: over a quarter (28%) of all deaths in 2016 involved those aged under 35.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/182435/original/file-20170817-28181-addc6f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/182435/original/file-20170817-28181-addc6f.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182435/original/file-20170817-28181-addc6f.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182435/original/file-20170817-28181-addc6f.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182435/original/file-20170817-28181-addc6f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182435/original/file-20170817-28181-addc6f.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182435/original/file-20170817-28181-addc6f.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>Although dramatic changes in the age profile of DRDs have been observed, the make up of DRD in Scotland has not changed much in 20 years in terms of the drugs used. The substantial rise in the number of DRDs is not driven by <a href="http://theconversation.com/fentanyl-widely-used-deadly-when-abused-60511">Fentanyl</a> use, as seen in North America’s <a href="https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis">opioid crisis</a>, nor is it due to the <a href="http://theconversation.com/blanket-ban-on-legals-highs-could-push-users-towards-more-dangerous-substances-42974">adverse effect</a> of the UK <a href="http://www.legislation.gov.uk/ukpga/2016/2/contents/enacted">Psychoactive Substance Act</a> which, in the banning of “<a href="http://www.bbc.co.uk/news/uk-32857256">legal highs</a>”, is believed to push some users towards more dangerous substances.</p>
<p>New drugs and behaviours come and go and influence the mortality data to varying extents but the main problem and cause of death in Scotland remains <a href="https://www.drugabuse.gov/drugs-abuse/opioids">opioids</a>, consistently involved in around 90% of cases and increasingly in combination with <a href="https://www.mind.org.uk/information-support/drugs-and-treatments/sleeping-pills-and-minor-tranquillisers/about-benzodiazepines/#.WZWSVlPysdU">benzodiazepines</a> (sleeping pills and anxiety medication). Encouraging people out of opioid substitution treatment (OST) prematurely can <a href="http://doi.org/10.1016/j.drugalcdep.2014.09.782">increase the risk</a> of relapse and overdose.</p>
<h2>How to respond</h2>
<p>Scotland’s Minister for Public Health and Sport, Aileen Campbell, <a href="https://news.gov.scot/news/treating-scotlands-changing-drug-problem">recently announced</a> a “refresh” of the <a href="http://www.gov.scot/Publications/2008/05/22161610/0">national drugs strategy</a>. Given the scale of the increase in DRDs since it was launched in 2008, the need for the refreshed strategy to be firmly evidence-based, with a measurable framework of actions, is of utmost importance.</p>
<p>In 2016, the Advisory Council on the Misuse of Drugs (ACMD) published a <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/576560/ACMD-Drug-Related-Deaths-Report-161212.pdf">report</a> on reducing opioid-related deaths in the UK. The report was <a href="https://theconversation.com/new-home-office-drug-strategy-same-old-rhetoric-80930">largely ignored</a> in the drugs strategy published in July by the UK government whose focus has switched from harm reduction to abstinence and recovery.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/182419/original/file-20170817-13469-1iewe9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/182419/original/file-20170817-13469-1iewe9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/182419/original/file-20170817-13469-1iewe9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/182419/original/file-20170817-13469-1iewe9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/182419/original/file-20170817-13469-1iewe9e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/182419/original/file-20170817-13469-1iewe9e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/182419/original/file-20170817-13469-1iewe9e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Widespread availability of street drugs, cuts in treatment programmes and general economic austerity have created a perfect storm for a drug crisis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-use-crime-addiction-substance-abuse-454891273">Shutterstock</a></span>
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<p>However, the ACMD report did make a number of recommendations that are within the gift of the Scottish government, including: continued investment in high-quality OST of optimal dosage and duration; provision of heroin-assisted treatment for patients for whom other forms of OST have not been effective; availability of the opioid antagonist <a href="https://www.gov.uk/government/publications/widening-the-availability-of-naloxone/widening-the-availability-of-naloxone">Naloxone</a> to people who use opioids, their families and friends; and provision of medically supervised drug consumption clinics in localities with a high concentration of injecting drug use. All these interventions are also recommended in the recently published UK <a href="https://www.gov.uk/government/publications/drug-misuse-and-dependence-uk-guidelines-on-clinical-management">treatment guidelines</a> for drug misuse and dependence.</p>
<h2>Making progress</h2>
<p>It is essential to also recognise the progress that has been achieved in Scotland. The <a href="http://www.isdscotland.org/Health-Topics/Drugs-and-Alcohol-Misuse/Publications/2016-10-25/2016-10-25-Naloxone-Report.pdf">national naloxone programme</a> was the first of its kind internationally and has been endorsed by the <a href="http://www.who.int/about/en/">World Health Organisation</a>. <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13265/full">Evaluation</a> of its impact concluded that it has had a significant effect in reducing opioid-related deaths following release from prison, a period of <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2010.02990.x/full">elevated DRD risk</a>. Without this, the latest DRD figures may well have been even higher. </p>
<p>Glasgow’s council and health officials have now approved the establishment of the UK’s first <a href="http://www.nhsggc.org.uk/about-us/media-centre/news/2017/06/proposed-sdcf-and-hat/">safer drug consumption facility</a> and a heroin-assisted treatment service. This development was largely in response to an ongoing outbreak of <a href="http://www.nhsggc.org.uk/about-us/media-centre/news/2016/004/hiv-warning-to-drug-injectors/">HIV in the city,</a> but also aims to respond to increasing drug-related mortality within this vulnerable population.</p>
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<figcaption><span class="caption">YouTube/Scottish Drugs Forum.</span></figcaption>
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<p>Less impressive is Scotland’s treatment record. Treatment is a known protective factor against DRD yet <a href="http://www.scotpho.org.uk/behaviour/drugs/data/treatment-for-drug-misuse">too few</a> of the country’s 61,500 problem drug users are engaged in treatment and, critically, retention rates are poor, particularly in comparison to countries like <a href="http://www.emcdda.europa.eu/publications/technical-reports/assessment-drug-induced-death-data_en">Norway</a>, which have achieved a turnaround in DRD rates over the past five years.</p>
<h2>What next?</h2>
<p>Reiterating the conclusions of both the <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/576560/ACMD-Drug-Related-Deaths-Report-161212.pdf">ACMD report</a> and Scotland’s <a href="http://www.sdf.org.uk/wp-content/uploads/2017/03/SDF_ORT_expert_review_submission_April_2013.pdf">Independent Expert Review on OST</a>, integrated services are needed across health and social care that are well tailored to each person. These should help them to achieve wider recovery outcomes, including those focused on general health and well-being. The new UK treatment guidelines should also be at the heart of achieving this ambition and improving the quality and effectiveness of Scotland’s treatment landscape. </p>
<p>The prevention of DRDs in Scotland requires an immediate and radical harm reduction led response, developed in collaboration with people who use drugs. Evidence-based solutions are available, but it is absolutely crucial that they receive support from all sections of Scottish society in order to destigmatise drug use and encourage people to seek help.</p>
<p>The tragedy of Scotland’s spiralling deaths from drug use is everyone’s problem. The time for brave leadership and concerted action is now.</p><img src="https://counter.theconversation.com/content/82650/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew McAuley has previously received research funding from the Scottish Government and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Andrew is a current member of the Scottish Government Partnership for Action on Drugs (PADS) Harms group and co-chair of the Sexual Health and Blood-Borne Virus Framework Prevention Leads group.
The authors would like to thank David Liddell, CEO of the Scottish Drugs Forum, and Dr Saket Priyadarshi, Honorary Clinical Senior Lecturer at the University of Glasgow, for their advice in the preparation of this article. </span></em></p><p class="fine-print"><em><span>
Grants for drug related and HIV/AIDS research over three decades from Medical Research Council, the Royal College of General Practitioners and the Scottish Chief Scientist Office.
Chair of the Harms Group of the Scottish Government advisory committees.</span></em></p><p class="fine-print"><em><span>Tessa Parkes works as Research Director for the Salvation Army-funded Centre for Addiction Services and Research at the University of Stirling. She has received funding from the Scottish Government, NHS Health Scotland, the British Academy and the Economic and Social Research Council. She is a member of the Partnership for Action on Drugs in Scotland (PADS) Executive group, and of a SIGN Guideline group on foetal alcohol spectrum disorder. She is contributing to this article as an academic researcher, not as a member of any particular group. Her views are her own informed by the research she has done over the past twenty years. </span></em></p>Drug deaths in Scotland are now among the highest in Europe. What can be done?Andrew McAuley, Senior Research Fellow, School of Health & Life Sciences, Glasgow Caledonian UniversityJames Roy Robertson, Professor of Addiction Medicine, The University of EdinburghTessa Parkes, Research Director, University of StirlingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/819812017-08-08T13:48:48Z2017-08-08T13:48:48ZThe war on fentanyl, the drug linked to 60 deaths in the UK since 2016<figure><img src="https://images.theconversation.com/files/180872/original/file-20170803-5640-1uvyozy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even a tiny amount of fentanyl can be fatal, but the drug is turning up in batches of heroin the UK.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-syringe-cooked-heroin-388723501">TM_SALE</a></span></figcaption></figure><p>Could fentanyl, a synthetic opioid painkiller that has been linked to an alarming increase in <a href="https://theconversation.com/fentanyl-widely-used-deadly-when-abused-60511">drug overdose deaths in North America</a>, now be gaining a foothold in the UK? Drugs-related deaths are increasing in the UK, and the issue of fentanyl and its chemical relatives (or analogues, known as fentanils) require specific attention due to their potential for harm, having already killed thousands in the US including, in the form of a fake prescription drug, <a href="http://www.bbc.co.uk/news/world-us-canada-36436767">the singer Prince</a>.</p>
<p>Fentanyl is used in medicine as a strong, low-dose, short-duration, fast-acting pain reliever. But its potency and the perceived ease of smuggling it have made it attractive to illegal drug suppliers interested in profit margins, with little concern for users. In the UK, fentanyl is appearing as an additive in <a href="http://www.nationalcrimeagency.gov.uk/news/1073-uk-drug-users-at-risk-from-dangerous-heroin-mix">street heroin</a>.</p>
<p>Fentanils, and other controlled psychoactive substances such as the <a href="https://theconversation.com/what-is-spice-and-why-is-the-drug-so-dangerous-60600">synthetic cannabinoids found in “Spice”</a> (a former so-called “legal high”), have been manufactured largely in commercial laboratories in China. They are now being brought under international legislative control, but fentanils can be purchased on the dark web and couriered to buyers anywhere in the world, or supplied to drugs gangs locally who mix them with heroin. One such operation was <a href="http://nationalcrimeagency.gov.uk/news/1165-nca-charges-fourth-man-linked-to-supply-of-deadly-opioid">recently uncovered in Leeds</a>, while others have been arrested attempting to buy fentanils online. </p>
<p>The mere act of mixing heroin and fentanyl in bulk is extremely dangerous. Fentanyl is 50 times stronger than diamorphine (the active ingredient of heroin) and adding a small amount to heroin can simulate the effects of that drug – with even a small quantity of fentanyl to mimic the effects of heroin, drugs gangs can then replace most of the heroin with inactive substances instead, and so increase their profits. Getting the mixing calculations wrong can result in overdoses. </p>
<p>Exposure even to a few milligrams of pure fentanyl can be fatal, and professionals licensed to handle fentanyl and its even more potent analogues such as carfentanil – a sedative so powerful that its only official use is <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/carfentanil-drug-so-deadly-it-is-a-chemical-weapon-available-for-sale-on-internet-a7350186.html">sedating large zoo animals such as elephants</a> – take very careful precautions in laboratories. These precautions are unlikely to be found in illegal drug operations, <a href="https://www.dea.gov/druginfo/Fentanyl_BriefingGuideforFirstResponders_June2017.pdf">endangering investigators and law enforcement</a> arriving on the scene. </p>
<h2>UK response</h2>
<p>There is a certain inevitability about fentanyl’s arrival in Britain as an additive to heroin, given trends in the US and elsewhere. Concern at the UK National Crime Agency and the Home Office led them to take the relatively unusual step of releasing 2016-17 overdose figures for cases involving fentanyl separately from the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2016registrations">official 2016 figures</a> for all drugs deaths in England and Wales (drug-related deaths <a href="https://www.gov.uk/government/statistics/announcements/drug-related-deaths-in-scotland-2016">figures for Scotland</a> are due for release on August 15). These show that fentanyl has been detected in heroin samples and in post-mortems across the UK, <a href="http://www.nationalcrimeagency.gov.uk/publications/795-recent-deaths-possibly-linked-to-fentanyl/file">particularly in the north and north-east of England</a>, and is implicated in <a href="http://nationalcrimeagency.gov.uk/news/1165-nca-charges-fourth-man-linked-to-supply-of-deadly-opioid">at least 60 UK drug-related deaths since late 2016</a>.</p>
<p>Whether this is due to a single, localised supply network with limited impact, or whether this is a wider issue is a critical area for police intelligence, forensic scientists and toxicologists, as linking seizures to drug supply networks will provide a better understanding of the real scale of the problem. A <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/633067/HS_to_OBJ.PDF">recent letter</a> from the Home Office to the Advisory Council on the Misuse of Drugs requesting information on the potential harm shows the government’s concern.</p>
<h2>Lessons from the US</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/180869/original/file-20170803-5614-7trweb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180869/original/file-20170803-5614-7trweb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/180869/original/file-20170803-5614-7trweb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=830&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180869/original/file-20170803-5614-7trweb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=830&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180869/original/file-20170803-5614-7trweb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=830&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180869/original/file-20170803-5614-7trweb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1043&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180869/original/file-20170803-5614-7trweb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1043&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180869/original/file-20170803-5614-7trweb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1043&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Fentanyl has been killing people in the US for almost 10 years.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/peabodyproductions/32072124810/">peabodyproductions</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
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<p>While one drug market is not necessarily like another, there have been stark warnings about fentanyl from North America in recent years. In the US, the White House Opioid Commission calling for a Presidential <a href="https://www.washingtonpost.com/news/wonk/wp/2017/07/31/white-house-opioid-commission-to-trump-declare-a-national-emergency-on-drug-overdoses/?utm_term=.a27e09bb8b18">declaration of a national emergency</a>, while the <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm">Center for Disease Control and Prevention</a> and the <a href="https://www.dea.gov/resource-center/2016%20NDTA%20Summary.pdf">Drug Enforcement Agency</a> have reported that each year since 2009 more people have died from drug overdose than from <a href="http://www.cbsnews.com/news/drug-overdose-deaths-heroin-opioid-prescription-painkillers-more-than-guns/">shootings or traffic accidents</a>. In 2015, of the 52,404 deaths from drug overdoses, 63% were related to opioid overdoses, 9,580 of those involving synthetic opioids such as fentanyl. Fentanils have been found mixed with not just heroin but also <a href="https://www1.nyc.gov/site/doh/about/press/pr2017/pr043-17.page">cocaine in New York</a>, and in <a href="http://edition.cnn.com/2017/06/08/health/opioid-fake-pill-percocet/index.html">fake medicines</a>, which has led to several deaths. </p>
<h2>Playing cat and mouse</h2>
<p>The introduction of international controls on the manufacture of fentanyl and related chemicals has helped to some extent. In late 2015 China banned production and supply of 116 psychoactive substances including fentanyl, with <a href="https://beta.theglobeandmail.com/news/world/china-claiming-success-on-fentanyl-admits-it-is-being-outrun-by-criminal-chemists/article35356510/">further bans</a> including carfentanil following in 2017. Although a ban cuts off production, the drugs themselves will still be found in the supply chain for some time. Production may go further underground or move to different locations (much fentanyl production for the US market has moved to Mexico), and supply routes may change. </p>
<p>Inevitably, the banning of one chemical or family of chemicals leads to a surge of market interest in a wider range of yet-to-be banned psychoactive substances. Chemists in China simply <a href="http://www.sciencemag.org/news/2017/03/underground-labs-china-are-devising-potent-new-opiates-faster-authorities-can-respond">tweak the molecular structures</a> to create a chemical that provides a similar effect while escaping the ban on a technicality. This poses even greater challenges for forensic scientists and toxicologists to identify new compounds and assess their harms. While in the UK the Misuse of Drugs Act covers the fentanils and the Psychoactive Substances Act <a href="https://www.theguardian.com/commentisfree/2016/may/31/ban-legal-highs-drug-related-deaths-alcohol">bans all drugs with potential psychoactive effects</a> not covered by it, the same legislative measures are not in place elsewhere.</p>
<p>A multi-agency approach is now required to establish how prevalent fentanils have become in Britain. Toxicology and drug testing labs must be increasingly vigilant in order to identify substances that may indicate changes in market supply, and to analyse the effects of fentanils when taken with other drugs. Getting accurate data quickly is key – both for police enforcement and for the harm reduction measures that could save lives, and the debate on balancing enforcement and harm reduction is one that should continue in light of this information.</p>
<p>In June 2017 two of the largest dark web market places where drugs were sold, AlphaBay and Hansa, were <a href="https://www.europol.europa.eu/newsroom/news/massive-blow-to-criminal-dark-web-activities-after-globally-coordinated-operation">taken down by international law enforcement operations</a>. When the similar Silk Road marketplace was closed in 2013, others sprung up to fill the gap – a global game of cat and mouse <a href="http://www.bbc.co.uk/news/technology-40788266">that looks likely to repeat itself</a>.</p><img src="https://counter.theconversation.com/content/81981/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Craig McKenzie receives funding from EPSRC. </span></em></p><p class="fine-print"><em><span>Niamh Nic Daeid receives funding from the Royal Society, Home Office, Industry, EPSRC, Leverhulme trust, Carnegie trust, Nuffield trust and the EU. </span></em></p>UK must now respond to arrival of fentanyl, which has for years been a major drug problem in the US and Canada.Craig McKenzie, Senior Lecturer in Forensic Chemistry, University of DundeeNiamh Nic Daeid, Professor of Forensic Science, University of DundeeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817522017-07-30T20:10:42Z2017-07-30T20:10:42ZIce causes death in many ways, overdose is just one of them<figure><img src="https://images.theconversation.com/files/180158/original/file-20170728-23775-1tukwxi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most people are unaware of the severe impact ice has on the heart. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Methamphetamine (usually colloquially referred to as “ice”) is a major public health problem in Australia. When we think of methamphetamine-related death, however, we tend to focus on overdose. This is a very real and valid concern. But the extent of the problem extends far beyond drug toxicity. </p>
<p>Methamphetamine dependence is associated with an array of <a href="https://www.ncbi.nlm.nih.gov/pubmed/18368606">serious social</a>, <a href="https://www.mja.com.au/journal/2016/204/4/estimating-number-regular-and-dependent-methamphetamine-users-australia-2002">mental and physical</a> <a href="https://www.semanticscholar.org/paper/Global-burden-of-disease-attributable-to-illicit-d-Degenhardt-Whiteford/1a27d452fa5282dc415e30158d4549684e15e6b2">health problems</a> that include heart disease, stroke, suicide, mood and anxiety disorders, psychosis, and violence. The footprint of methamphetamine is far wider than that of many other drugs. Close to half of deaths occur in rural and regional areas, a great many users are employed, and half have never injected a drug. These are not the “usual suspects” for drug-related death.</p>
<p>In a <a href="https://www.ncbi.nlm.nih.gov/pubmed/28603836">new study</a> we looked at all of the methamphetamine-related deaths that occurred in Australia from 2009 to 2015. There were 1,649 such deaths over that period, and the annual rate doubled from around 150 a year to 300. Of these deaths, 43% were due to drug toxicity. </p>
<p>In the case of methamphetamine, overdose typically results in heart arrhythmias (where the heart isn’t beating properly) and seizures caused by the drug. Importantly, even modest amounts of methamphetamine may cause heart arrhythmia and death. The remainder, however, were due to other causes.</p>
<h2>How methamphetamine affects the heart long-term</h2>
<p>In a fifth of cases, death was due to methamphetamine combined with disease, most commonly heart disease. Methamphetamine is cardiotoxic, meaning it causes damage to our heart muscle, and causes disease in our arteries. </p>
<p>There’s a circular pattern here. Methamphetamine damages the cardiovascular system. The drug also places strain on this system by increasing the force of the blood against the artery walls (it’s a “hypertensive”). Users are then placing strain on damaged hearts. And this damage accumulates and does not reverse. </p>
<p>There’s also a real risk of stroke, and we saw 38 such cases among young people, a demographic not commonly affected by stroke. Importantly, the damage to the cardiovascular system occurs regardless of how the drug is used. Smoked, injected or swallowed – it is the drug that does the damage.</p>
<h2>How methamphetamine fatally reduces inhibition</h2>
<p>Methamphetamine is also associated with traumatic injury and death, as it causes a high degree of disinhibition, impulsivity, aggression and impaired critical judgement. There were 300 completed suicides related to methamphetamine over our study period. </p>
<p>There were around 300 deaths from suicide linked to methamphetamine, and the methods used were more violent, which is linked to the aggression, violence and aggravation caused by the drug. </p>
<p>Some 15% of all methamphetamine-related deaths were due to traumatic accidents, most commonly motor vehicle accidents. Methamphetamine users <a href="https://www.ncbi.nlm.nih.gov/pubmed/14756710">commonly believe the drug improves their driving</a>. It does not. What it does improve is the risk of injury and death. All of these deaths were avoidable.</p>
<h2>What can we do?</h2>
<p>Knowledge of the risks is a start. Many users might assume a racing heart and chest pains are part of the experience of using methamphetamine and not realise these are signs of a system under stress. The heart disease we are seeing in methamphetamine users will be a problem for decades to come, long after they cease use. </p>
<p>In terms of our treatment system, drug treatment centres need to be aware their methamphetamine patients may be at risk of heart disease. Doctors also should ask about methamphetamine involvement if young people are presenting with heart conditions.</p>
<p>Over the past few years there has a been an intense focus on methamphetamine in the wake of evidence of increasing use and harms, including in rural and regional areas. By examining the causes of these deaths we have uncovered that, unlike many other drugs, the harms are very diverse, particularly with regard to the extensive association with heart disease. </p>
<p>This suggests that even if use goes down, we will have a major public health problem for our hospital and community health services for many years to come.</p>
<p>Another striking finding of this research is that very few of those who died were in treatment at the time. Our treatment services are already under intense pressure and this underlines the urgent need for more resources to go into treatment and trials of new medications.</p><img src="https://counter.theconversation.com/content/81752/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shane Darke does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>When we think of methamphetamine-related death we tend to focus on overdose. The extent of the problem, however, extends far beyond drug toxicity.Shane Darke, Professor at the National Drug & Alcohol Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.