In my line of work, early morning telephone calls are never good news. It doesn't matter whether you are on-call for your hospital, or anticipating a sleep-in of sorts, the incessant vibration of mobile phone in the wee hours is always a cause of apprehension.
So when I finally got up to silence the bleating phone, and blearily worked my way through the half dozen or so messages that were making such a racket, I had to turn on the light to make sure that what was being described was real, and not the exotic nightmare of an emergency physician: A mass overdose of GHB, in 2017? But that's so last decade!
I saw and treated my first overdose of gamma-hydroxybutyrate in Adelaide, soon after arriving in Australia in 1999. I had recently arrived from London, a town not unfamiliar with drugs. But 'G'? Never seen it before. A young person, comatose, unable to maintain their airway, from a liquid drug that I had never heard of? Australia was turning out to be a bit more interesting than box jellyfish and Bundaberg.
At the time, all we knew was how to keep the patient alive. Support the airway, and wait for the patient to wake up; we're a pragmatic bunch in ED. Once we had achieved that objective, we then had the chance to learn some more about what we were dealing with. Gamma hydroxybutyrate (GHB) is a naturally occurring neurotransmitter -- it is in all of us.
Legislators have been given the evidence and opportunity to show some moxie, and introduce the measures that now all experts are calling for. Failing to take that opportunity is a failure of leadership, and it will be punished.
Outside of us, it was developed by a French man to work out the inner workings of the human mind. Someone noticed it worked well as an anaesthetic in mice, and for a couple of decades it found a similar use in humans. It's still used medicinally in the form of sodium oxybate, as treatment for narcolepsy.
The route to illicit use was more circuitous. It was noted to increase human growth hormone in mice, and was subsequently embraced by the bodybuilding community as a supplement. Somewhere along the line, they noticed that at a point just shy of sedation, it caused euphoria -- as it turns out, a fairly significant euphoria. And so it took off, in the '90s in the U.S. and the '00s in Australia.
As is the way of things, GHB was banned, but predictably in the whack-a-mole game that is the War on Drugs, two precursor drugs -- 1,4-butanediol (1,4-BD) and gamma butyrolactone (GBL) -- quickly emerged to take its place. These were more problematic because they are 'dual use'; not only can they be used for recreational purpose, they are also very important chemicals in the solvent and plastic industries.
There were legitimate reasons for big business to have in their possession industrial quantities of these chemicals. Given the volumes shipped globally, it is impossible to account for every litre, and so some goes missing, diverted into the illicit market. It is far more likely that any overdose in Australia from a GHB-like substance was due to either of these than caused by the mother compound.
One of mythologies doing the rounds in the early days was that GHB, on its own, couldn't really hurt you. It's true that, in combination with another sedative like alcohol, it represents a particularly dangerous proposition. The perfect storm is the scenario where young people, already drunk, pass around a repurposed water bottle, and take unmeasured swigs of GHB/GBL/1,4BD. That's the likeliest scenario for what happened at Electric Parade last Saturday. But GHB and its analogues don't need alcohol to be lethal.
Our paper in the MJA in 2007, with Australia's National Coronial Inquest System, showed quite clearly that it was capable of doing the job on its own.
So, like Jack Nicholson hacking his way through a wooden door, why is this drug back in such a dramatic fashion?
We know that it's always around, but at less than 1 percent population prevalence, it's pretty 'niche'. By the late '00s, despite the 'Tough on Drugs' approach, the Australian health community had managed to get strong messaging to consumers about the hazards, and how to stay safe. A community knowledge developed, and other drugs emerged; the scene moved on.
A lot of that corporate knowledge has ebbed away, like the fading of a response to immunisation -- users from 'back in the day' now have jobs, and kids, and mortgages and while some wistfully reminisce about their youthful misdeeds, few are still involved.
Secondly, and perhaps more importantly, we are faced with a generation of consumers who are completely untouched by the Nancy Reagan message of 'Just Say No'. For generations where trends are measured in weeks, the failure of Australian drugs policy to keep up with the emerging market appears glacial in pace.
We are flailing in our attempts to reduce the supply of illicit drugs into Australia, and ignoring, almost entirely, any attempts to address the demand side of the equation.
This fault does not lie at the door of the doctors and scientists. They have indicated -- unanimously -- what is needed.
It lies squarely on the shoulders of legislators who are happy to dither in the face of an active public health emergency. Sure, when they read this, they'll howl about how much is being done, how much is being spent (overwhelmingly on law enforcement, and not health) -- but it's not what the experts are calling for.
We are flailing in our attempts to reduce the supply of illicit drugs into Australia, and ignoring, almost entirely, any attempts to address the demand side of the equation. This juxtaposition of a disaffected, unengaged group of users with a generation of politicians, paralysed with fear at the prospect of appearing anything other than a cold war "drug warrior", makes these sort of events ever more likely.
And that's the reality we now face in Australia. Legislators have been given the evidence and opportunity to show some moxie, and introduce the measures that now all experts are calling for. These measures, like MSICs, like pill-testing, place 'saving life' in the box seat.
Failing to take that opportunity is a failure of leadership, and it will be punished. Not by the experts, who can but stand by and watch their expertise being ignored. Rather, by the parents of children who don't come home.
I have yet to meet with one, in the course of treating thousands of drug overdoses, who would not have done anything to ensure their child's survival. Not one who has said "I don't mind them dying, as long as their death serves as lesson to others".
There will be more deaths in the months to come, and as the disparity between expert recommendation and government action becomes more apparent, so will the anger of (voting) parents and loved ones. And every time there is another tragic, unnecessary loss of a precious, precious young Australian, those who stand in the way of what the health community is demanding -- now -- need to take a long hard look at themselves.
Because they have just a little more blood on their hands.
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