Commentary on Vrolijk et al. (2017): The paradox of the quality control problem.

‘Obviously there is no official ‘quality control’ over the manufacture of ecstasy. Each batch is different, and can be made using different chemicals—depending on what’s available at the time. This means that the drug effects and toxicity of each batch will vary and be unpredictable—making overdose a possibility with each and every pill’ [1]. Vrolijk and colleagues [2] assess the reliability of the content and dosage information provided by ecstasy pill report websites by comparing it with matched information from the Dutch drug information monitoring service (DIMS). The government-sponsored DIMS database provides validated information on the content and dosage of tablets sold as ecstasy in the Netherlands, gathered through offering an anonymous testing service to consumers. The study found that most of the website information should not be considered dangerous, at least for Dutch reports (extrapolating results to reports from other countries is fraught). Vrolijk et al. found that website pill reports were more likely to overestimate than underestimate MDMA concentrations. From a safety perspective, overestimation is less likely to result in harm should consumers follow the advice of pill reports. More concerning were the minority (15%) of reports categorized as dangerous. While much could be said about the Vrolijk study, the most striking aspect is something the authors do not comment on: why the existence of dual systems? Given the existence of dangerous information on pill report websites, why does DIMS not share their more accurate information directly with the wider public? A collaboration between DIMS and the peer networks that create pill report websites would make the most timely and accurate information available to people who consume drugs to inform their consumption patterns. However, the DIMS database, government-owned, is confidential: the information is providedonly totheconsumersubmitting thesubstance,unless there is a public health emergency prompting broader distribution. This peculiar situation (of dual systems, with one having greater accuracy but not being publically available) relates to the paradox of the quality control ‘problem’: while drugs are illegal, the provision of accurate information to improve consumer choice seems unable to be endorsed officially by governments. The quality control problem could be changed substantially with legislation allowing controlled supply of (in this instance) 3,4-methylenedioxy-methamphetamine (MDMA). In the absence of such legislation, governments find themselves in an apparently untenable bind. The use of MDMA may become more attractive if consumers can be guaranteed of its composition and dose. On this basis, the quality control problem becomes a convenient deterrent: the assumption inherent in many drug prevention campaigns is that people refrain from illegal drug use precisely because ‘you don’t know what you are getting’ (see opening quotation from a recent Australian antidrug campaign). This suggests that the quality control problem provides a prop to avoid acting on improved consumer information. However, the argument that providing more accurate consumer information will reduce deterrence is not grounded in evidence. Testing illegal drugs to determine their pharmacological composition and sharing these results with consumers and service providers has a long history, dating back to the 1960s [3]. Due to the often clandestine nature of such services, we lack a comprehensive body of research to evaluate the overall effects of testing services [4,5], but research has shown that consumers would discard a pill if they were told it did not contain MDMA but instead contained ‘suspicious’ substances [6,7]. Indeed, in July 2016, festival drug testing results deterred 25% of service users who discarded their drugs as a result [8]. The utility of the DIMS as a monitoring system for understanding new drug trends is unparalleled [9,10], and we continue to argue for the implementation of a similar system in Australia [11]. Vrolijk et al. have demonstrated that most Dutch pill report website content is not dangerous, but is that really the best we can do? Living in a digitally connected world means that information about drugs will inevitably be available [12]: the question should not be ‘should the information be available? ’, but rather ‘how reliable and accurate will the information be? ’. We have the capacity to test and disseminate accurate information that could help people avoid harms and help health workers treat people more effectively [5]. Do we really care more about deterring use of MDMA than we do about the safety of people who use it?