UK Clubbers’ Drug Use: Health risk perception and harm reduction; results from the 1999 Mixmag Survey

Adam Winstock & Paul Griffiths

National Addiction Centre, Institute of Pyschiatry, 4 Windsor Walk, Denmark Hill, London, SE22 8RL. Phone no: +44 (0)207 836 5454 E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Accessing drug users is difficult because they are involved in an illicit activity and therefore it is useful to come up with ways to target high-risk populations. It is important that you are seen as somebody who comes from a credible organisation, at least to the people who are using drugs. A hospital is not going to be that credible to many people who use drugs, but if you can tap into a youth culture magazine such as Mixmag, then you are able to associate yourself with a credible source of information. This in turn can possibly attract the response you get, although it also means the results from this study are all subject to possible response and sample bias.

The magazine has previously been used in a few studies but Mixmag were not just interested in helping to get a good issue out of it. There was a genuine desire on their part to be altruistic. They accept that many of their readers use drugs and they are interested in trying to assist us in informing people how to use drugs in a safer fashion.

 

Methodology

The study consisted basically of a cross sectional survey of respondents to a magazine. This gave access to a very large number of people quickly and also relatively inexpensively. It was also self nominated. The questionnaire went out in the middle page of the June issue and people were free to look at it, free to fill it in, free to stick it in a freepost response if they wanted to. We also took the opportunity at this point to give people the chance to give us their name and address in case they wanted to be followed up. Out of the twelve hundred people or so who replied, three hundred people were quite happy to admit the level of their drug use. They gave their names and address with a little note at the bottom saying, "phone me if you want any help". That says a lot about people who are involved in the user scene; it shows they are very keen to participate in things that might actually benefit them.

The questionnaire covered a wide range of areas. We looked at basic demographics and patterns of drug use (not just recent but ever use). We also specifically looked at flatliners (4 MTA) because we were concerned by the findings which were coming from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) about this new drug that potentially was having negative consequences, despite the fact it had only been around for a year or so.

We wanted to look specifically at people’s pattern of use, not just in terms of trend use, but also with regard to their purchasing pattern. There is also a real issue with the courts in terms of what constitutes personal possession.

The next thing we looked at was drugs used with ecstasy. This is a poly-substance misusing group and we wanted to identify just how common different drugs were used as �on top’ drugs. There has also been recent concern over anecdotal reports of people using sedative drugs such as heroin to help them on the way down from their drug high, but that was not an area we looked at.

We specifically wanted to see what influenced people to change. There is a big assumption that if you give people knowledge it will lead to behavioural change. What we do not know is what knowledge we need to give to people that will result in a particular behavioural change, so that was something else we looked at. We also looked at the relationship between sex and drugs because we thought that was quite interesting, and we also specifically compared cocaine and ecstasy, but this paper will not present those results.

We also wanted to look at ecstasy worries because there are a group of high-risk users and, although people have long said this is not a dependent group of users, stimulant users as a whole do not fulfill the normal category of drug users. They are not daily users but binge users who use over a 2-3 day period and so we looked at the possibility of ecstasy dependency and the worries people have.

We also looked at the pattern of drugs over time. A lot of people mention that there seems to be a relative leveling off or even decrease in the levels of ecstasy use whilst at the same time cocaine use is going up. We wanted to see what was influencing people: was it the accessibility, availability, price, or purity? What was their obsession about the drug market that influenced them? We thought we would also look at people’s comparative health risk perception in terms of safety and addictiveness which we compared with stimulant drug users.

Alcohol is another important issue. We used a screening questionnaire, developed by the World Health Organisation (WHO), that picks up people drinking at harmful levels and is therefore a very well validated way of picking up harmful drinkers. Finally, we looked at the issue of people having accidents on stimulant drugs, misuse by women and men of drugs to control their weight and whether they became involved fights.

 

Results

We had 1159 replies, of which 1051 were suitable for further analysis. The circulation figures of Mixmag are almost 60,000 worldwide and, although most responses were from within the UK, people wrote in from Warsaw, New York and even Sydney. We received responses from 2.3% of the total circulation. However, one must not assume that every single reader of Mixmag takes drugs or that this questionnaire would be relevant to them and, although it is a large number, there will be a response bias that we are not necessarily able to avoid.

The mean age of Mixmag readers is 21-23 and the gender split is 70: 30 male to female. Demographically, the results are not too far off the average readership. The split between students and those employed fairly closely matches Mixmag’s circulation: about 75% of their readers are in work and the other 25% are students. These results suggest that we are not too far off the mark.

There is a significant minority, maybe 30-40% of people, who regularly take a great number of pills on a night, as opposed to one or two, which was not the case ten years ago. So something has changed in the way that people are using drugs. They are either using more because they are becoming tolerant; because the quality has changed; or because the pattern of use and the culture of using drugs has changed. Underground parties may have been around on a Saturday night ten years ago but now you can go clubbing in most European cities seven days a week if you want and on a Sunday morning if you are up for it. So I think that represents a target we need to focus on. Like most drug users, it is the people at the heavy end of the spectrum who are most vulnerable to damage and need to be targeted with health interventions.

With regard to poly-substance use, the respondents take a lot of drugs at the same time as ecstasy. Particularly worrying are amphetamines and cocaine and there are a couple of reasons for concern. They increase the risk of dose dependent adverse physiological effects such as overheating, dehydration, sweating, cardiac problems, and high blood pressure. Another particular worry, with something like cocaine especially, is the neurotoxicity. You need both serotonin and dopamine levels to be regulated in order to guard against neurotoxicity and drugs such as cocaine and ecstasy upset the body’s means of regulating these levels. Laboratory studies demonstrate that if you increase the amount of dopamine in a rat’s brain when you give them ecstasy, you massively increase the level of neurotoxicity. That is exactly what cocaine is doing, training the brain so that when ecstasy comes on board it increases the amount of neurotoxicity. This is the kind of information we need to try and get across to people. You want to give them the scientific background to any harm reduction you want to implement. There was a small minority who used Prozac in the belief that this protected against neurotoxicity. In fact, it is much more likely that you are going to get serotonin overload and end up with something which is called serotonin syndrome. It was pleasing see it had not become more prevalent.

We also wanted to look at what harm reduction procedures were being implemented. There is a lot of good advice out there but what information are people willing to take on board? The first question, "The time I would take to stop dancing or to go to a chill out room", is under the umbrella of taking efforts to stay cool and it is fairly reassuring to see that the vast majority actually take note of that bit of harm reduction and have then tried to reduce the risk of hypothermia. The next area of harm reduction, which has been very popular over the last few years, was about drinking fluids - as opposed to water. Following the death of Leah Betts in the UK six or seven years ago, massive ad campaigns said, "Drink a pint of water every hour you are dancing". Although that might not be the most accurate advice to give clubbers, they seem to have picked up on the fact that they need to stay hydrated and this is another change that people are implementing.

So harm reduction works in some areas. You should avoid alcohol when you take stimulant drugs for several reasons. One, it is going to increase the risk of dehydration because alcohol acts as a diuretic. Two, if you take alcohol when you have stimulants, you are subjectively a lot less intoxicated so you might be someone who at the end of a night clubbing, after drinking six or seven pints and an extra couple of pills, actually feels reasonably safe to drive. Unless you drive home when the pill wears off, you actually find you are much more intoxicated than you thought you were and even at more risk of harm while you are intoxicated with any drug. About a 30% group actually never consider reducing the level of alcohol they take, so there is one group we are not getting through to.

Eating something first before taking any drug is probably not a bad thing just in terms of lining your stomach. Some clubbers said they actually avoid eating anything before taking a pill because it means they get a slower onset effect, which means they do not rush so much. People who take food beforehand may at least be giving themselves a vitamin load that may in some way reduce the effects of the come-down afterwards, so one safe thing we can educate people about is to have good nutrition when they use drugs. This is another form of harm reduction.

One of the theories of why neurotoxicity is a problem with ecstasy is because it boosts the production of free radicals. Free radicals are toxic by-products produced every day by chemical reactions and are implicated in things like cancer and heart disease. They are locked up by substances called antioxidants. That is why people are encouraged to eat fruit and vegetables so as to reduce the chance of premature death from cancer and heart disease. The same sort of mechanism that is in free radical production is thought to underline some of the neurotoxicity associated with MDMA. If you pre-dosed a rat with vitamin C and E before the rat was given ecstasy, you could markedly diminish the amount of neurotoxicity that the rat experienced. About a year ago now Mixmag ran a series of articles on how to use drugs safely and one was about food and how people could protect themselves. One of the things we talked about was vitamin C. About 40% of people have at least taken that on board. There may be some responsible drug manufacturers who are going to pick up on this and they will be knocking out E and C tablets. Again, some people have claimed individuals were taking Prozac to protect themselves from brain damage, but this actually seems to be fairly rare.

There are far more concerns about people being safe after using drugs. Staying with a sensible peer group, or at least somebody that you know, can possibly reduce the risk if you do face problems. If you have an adverse physical or psychological reaction, there is somebody around the place whom you can trust and therefore can hopefully get you to somewhere where you might feel better.

Finally, to the level of alcohol use among this group. Ten years ago I carried out a lot of studies looking at clubbers and virtually none of them drank. They were not interested. Using a screening tool to identify harmful drinkers, 70% of this group of clubbers were drinking above harmful levels. They do not just skip past five: men were scoring 7, woman scoring 6.5. Men were obviously scoring more highly as that is the normal trend but what was particularly worrying was that there was a greater proportion of hazardous women drinkers than men. Certainly Mixmag shows women are able to hold their own. The worrying thing is that women are far more sensitive to both the physical effects of alcohol and its psychological effects, so again it is the more vulnerable group using the higher levels of the substance.

 

Conclusions

The majority of people who go clubbing do implement some context specific harm reduction techniques: staying cool and drinking fluids. That is like driving your car, putting your seat belt on and having your air bag. What they do still carry on doing is taking an awful lot of ecstasy and an awful lot of stimulant drugs which is the equivalent of having a seat belt on, an air bag and putting your foot flat down on the accelerator.

The fear is that some of the harm reduction messages disseminated to people make them feel safe about their drug use. They think that if they go out, drink a bit of fluid and make sure they cool down that they will be fine. We do not know that. It is certainly going to do them some good but you do not know how effective it is going to be and the concern is that those context specific changes will be made at the expense of implementing other changes, specifically the use of other drugs, and alcohol.

We should not give up on harm reduction because clearly an awful lot of the work that people are doing is successful, but we may now need to change the focus of our message towards the ways in which people use drugs. People should be told that neurotoxicity is drugs related; the more pills you get the greater risk you are at; combining drugs is also going to increase the risk of adverse physical and psychological and possibly long term effects. We should give people information so that they are able to make an informed choice and can reduce their risk. Finally, the issue of alcohol is particularly worrying. We have safe alcohol levels but in this group they do not seem to be listened to.

There are some big caveats. The first is that these are some very preliminary results and there is still a lot more to come, so they should be taken with a pinch of salt. The second is the question of whether Mixmag readers are your average reader. They were chosen specifically because they are involved in youth culture and may they have an interest in drugs, but they may not be representative of all clubbers. It is unclear whether the people who replied to the questionnaire were particularly concerned users, people who had predominantly good experiences or people who had had predominantly bad experiences.

This was a self-reporting, anonymous questionnaire. Studies carried out at raves have shown that people’s self-reported patterns of drug use are fairly good. What we do not know is that if someone says they have taken flatliners for example, whether they have truly taken a pill that contains 4MTA or whether they contain something else, and that goes for all pills. Finally, I do not know how generalised things are out in the UK but certainly a lot of other studies have similar results.