THE BLOG
12/04/2014 12:48 pm ET Updated Jan 30, 2015

Drug Deaths in the Dam -- Unfortunate Accident or Intention to Kill?

As drug death alerts in Amsterdam show us just how a city can respond to a drug crisis, we ask: could someone be killing people who use drugs intentionally?

Amsterdam has some of the most liberal drug laws in the world. What's more, they are well suited to their population. The Dutch government treats people who use drugs as adults and they educate their children about the harms of drugs in a way that is credible. They let people test the quality of their illicitly purchased pills and powders. They prescribe heroin, give out free needles and lifesaving naloxone. When drug warnings are issued they are taken seriously. The Dutch have some of the lowest rates of novel psychoactive drug use and injecting drug use in Europe. It's also a pretty safe place to take drugs in part due to ingrained acceptance of harm reduction and high levels of awareness among the general population, supported practically by an economic imperative to protect the health and well-being of income generating visitors. Equally, as international law enforcement agencies will tell you, the Netherlands is also a hub for the manufacture and distribution of drugs especially branded high potency herbal cannabis and synthetic stimulants, in particular MDMA. So it would be fair to say that drugs from the Netherlands have a certain air of quality around them. Call it a brand value.

The maintenance of this finely balanced landscape rests on the development of nuanced policies delivered by law enforcement and public health bodies. The results is a thriving city of culture, canals, vice and intoxication that for many global travelers represents a 'must see' place that has to be visited, experienced and often consumed. So the fact that 3 tourists have died in the last month and a further 17 hospitalized after snorting white heroin sold as cocaine purchased from what is thought to be a rogue street dealer, is basically terrifying and also very bad for Amsterdam. Warnings are everywhere and the city is responding as well as any major tourist destination could.

So what's going on? A quick A-Z (well C, D, H and O) of drugs is required to answer that so here goes.

Cocaine hydrochloride is usually a white/off-white powder. Pure cocaine has local anesthetic qualities -- numbs your gums and teeth. Cocaine is often cut with pretty inert bulking agents before the point of final distribution with other white powders most commonly the mild stimulant caffeine and local anesthetics benzocaine or lidocaine (see here). Adulteration increases profits. Purity ranges widely from 80% to less than 10%. Standard grade cocaine sells for about €50/gram in Amsterdam (you can pay more in the hope of getting a premium product). An average line of average cocaine (35-100mg) will give a noticeable (and to the experienced user, familiar) elevation in mood and arousal within 3-4 minutes of snorting. For most users too big a dose (a dose that exceeds expectation or tolerance) either as a result of using more than usual or unknowingly consuming a much purer/higher quality product can leave people panicky, agitated, with palpitations, tremor and sweating. It won't stop them breathing and kill them though (actually, very, very rarely a single average dose might induce a heart attack, so death is theoretically a possibility).

Heroin comes in two main types. Smokable brown heroin from Afghanistan and surrounding regions (the Golden Crescent) and easily injectable (dissolves without addition of citric acid that is used to make brown heroin injectable) white heroin. Most heroin in Europe is brown. White heroin originates from Burma, Thailand and the surrounding regions -- the Golden Triangle). It dissolves easily in water and has a low tar content and is better for injecting than smoking. It is very rare in Amsterdam and will sell for €70-100/gram. It can be snorted and looks like cocaine but does not have a local anesthetic action. Too much heroin can stop you breathing. Too much for a person who never used heroin could be not very much at all. Perhaps the amount a person might consider to be their typical line of cocaine. Instead of arousal and alertness, heroin can result in sedation and collapse. Many heroin overdoses occur in public. The person seemingly asleep and snoring. They can be saved by prompt action and delivery of the heroin blocker naloxone. If you see someone who you can't rouse, put them on their side in the recovery position and call emergency services (http://stopoverdoseil.org/narcan.html).

Drug dealers are business people. Many regular users will develop relationships with dealers hoping for some sort of quality control. Conversely dealers recognize offering some consistency and quality is good for return business. Most dealers, whilst keen to maximize profits, do not intentionally harm their clients by selling drugs that kill or result in serious damage. Dead clients don't buy more drugs off you and purveyors of shitty products in any landscape tend not to flourish -- bad dealer reviews are shared around drug using circles like bad movies (and wouldn't 'trip advisor' be so easily high jacked from the drug trade)

Now street dealers, especially those in tourist hotspots, don't hold out much hope for securing return customers. They will want to maximize their profit and as such as are unlikely to be offering a premium product. They will offer something that can pass for cocaine -- in looks and maybe in local effect, it might even have cocaine in it. But even these tourist traders don't have any motivation to harm their customers (rip them off to make money, yes, but intentionally harm them, no). It's wrong, totally unnecessary, attracts more police and is bad for the reputation of the area its activities. Social media and mobiles low people to talk and share exercises everywhere.

The deals of death

Here's what we know based on piecing together information from police, hospitals, public health monitoring agencies, the 'victims' and the public including dealing networks and local informants. It is thought the first death occurred a month ago. White Anglo tourist is approached by an unidentified supplier on a bike. Cocaine is offered. Drugs and money are exchanged (we think €50 for a gram deal). The drug is snorted. The person collapses. Respiratory collapse and pin point pupils indicate a heroin overdose. He is rushed to hospital. Naloxone is given (the antidote to heroin/other opioid overdoes) but the person discharges himself and dies.

This is tragic. This is very unusual.

Vigilant authorities start looking for other cases. They find 17 hospital admissions in the Amsterdam area appearing in batches over the next three weeks. They alert the public and engage the media, put warning signs out in tourist spots, they talk to dealers, they try and get a description of the 'man' (they think it's just one dealer) -- huge electronic boards are put out flashing in orange neon: "Caution: white heroin sold to tourist as cocaine"; "Tourists in hospital"; "3 have died"; "Ignore street dealers." And yet last week two British tourist were found dead in their hotel room. A "Do Not Disturb" sign on the door. White heroin and racked lines on the table. The common threads in the cases: White heroin sold to Anglo (British/Australian) tourists by a man on a bike who approaches offering them cocaine. The police think there is just one supplier (if there were many dealers doing this the hospitalization count would be far higher). Some sources suggest he might offer a "taste" and switch bags. But remember the financial implications here.

Someone hands over heroin that could be sold for €70-100 to someone for €50 who is after cocaine. The descriptions are vague. The police are out looking. Regular dealers are looking -- this is bad for business. There is a €15000 reward.

One thing it does remind us of are simple harm reduction rules when using new drugs or randomly purchased pills and powders for the first time. Make sure your are not on your own, one person should test dose (a tiny, tiny amount and don't re-dose for at least an hour) while others remain unaffected so they can get help if problems arise, don't have anything else on board, and you don't feel as you expect to after a typical dose -- accept it's not the drug you were after and bin it.

Explanations?

1) Mix Up: Someone (maybe a new, inexperienced dealer) has got their drugs mixed up. They are packing up deals from the wrong supply. This is possible but I think unlikely. Firstly we are talking about mixing products with vastly different values -- so I think most business people would be real careful. The products in bulk have different stamps/logos. They smell different. They taste different. Only one numbs your gums. If he was unsure he could get it tested at a government testing facility -- for free, anonymously. And after the first group of hospitalization and subsequent media coverage and warnings you would to think that people would be checking (if only to make sure they weren't selling a product at way below its market value (and of course not to kill people). So unless this is the most stupid dealer in the world who has had his head buried somewhere away from the rest of Amsterdam you could not fail to know what was going on. But people bought white heroin last week and died. So I don't think this is it.

2) Accident: Someone has found a stash and doesn't know anything about drugs, thinks it's cocaine because most heroin in Amsterdam is brown and is selling it naively as that to people he spots as likely users. In which case he is not worried about markup because he is selling a ripped off stash. 2a) or he knows its heroin but thinks it's easier to sell to tourists as cocaine. I don't buy either of these, because I think it's unlikely that anyone so naïve would have been brave enough to rip a dealer off or just come across a stash of heroin and even more unlikely that he would feel comfortable or confident enough to start dealing drugs to strangers.

3) Intent to deceive and harm: So this makes the best headline for sure (the death dealer, cocaine killer, tourist topper. And to be honest whether this is true or not does not bother me as much as getting the story out so people can do everything possible to stay safe. So for the sake of making the story a bit more compelling as well as well as the fact it has to be a possibility let's run through what this would mean. It would mean there was someone who was targeting tourists selling them high quality white heroin as cocaine in the full knowledge that it might kill them. That's remote serial killing. What might motivate such a course of action is unknown. You could speculate it's an attempt to destroy local drug markets, educate the public about the risks of drug taking, tarnish Amsterdam as a tourist destination, and punish drug using tourists for supporting a criminal economy, perverse revenge for a drug death in their own lives. They all sound like nonsense. If heroin is be supplied as cocaine with the intention to deceive then regardless of the motivation the action is brutal and ruthless.

4) Something really random

While every effort is made to educate, warn and minimize the risks of further deaths it is worth asking yourself how well your own city would have responded to such an outbreak. I think Amsterdam is to be congratulated and wish the city, its residents and tourists a swift ending to this this dreadful story. The only safe advice at least for now is that highlighted in LED billboards: IGNORE STREET DEALERS. One interesting question is if there are no more deaths or close calls when does the city take down its warnings -- when everyone knows that drug taking is always at least a little risky... now that's a tough call even for a city like Amsterdam.

Dr Adam Winstock is the founder of the Global Drug Survey which runs the biggest drug survey in the world. GDS2015 is currently underway. With responses from 60,000 people so far we'd really appreciate it if you would take the time to complete it so we can continue to get good drug information out to people everywhere. https//www.globaldrugsurvey.com/GDS2015