Introduction The aim of this study was to investigate the pattern of recreational drug use in patients attending a genitourinary medicine clinic, and to determine whether drug use was greater among men who have sex with men (MSM) patients, when compared to non-MSM male patients.
Methods A questionnaire was given to all patients attending the genitourinary medicine clinics at two inner city teaching hospitals over 3 months (July to September 2011). The questionnaire was self-completed by patients while waiting to be seen by a clinician. Data were collected on age, gender, gender of sexual partner(s), and previous/current recreational drug use (type/frequency of drugs used). Only data from male respondents have been analysed in this paper.
Results 1328 questionnaires were completed. Of the male respondents (n=729), 475 (65.2%) were identified as non-MSM and 254 (34.8%) were identified as MSM. The mean±SD age of male respondents was 31±9 years years. Lifetime and last month use of mephedrone, ketamine, volatile nitrites (‘poppers’), sildenafil (Viagra), GHB, and GBL were all significantly higher in the MSM group compared to the non-MSM group. Lifetime use of cocaine powder, MDMA, amphetamine, and methamphetamine were also significantly higher in the MSM group; however, there was no significant difference in last month use of these drugs between MSM and non-MSM groups.
Conclusions Both lifetime and last month use of most recreational drugs was more common in MSM, when compared to non-MSM males. Sexual health clinics may provide an opportunistic encounter to identify patterns of recreational drug use, explore motivations for use, and implement strategies to reduce harms related to drug use. This will require a multidisciplinary approach to address the psychosocial aspects of drug taking behaviours, in combination with healthcare professionals experienced in the management of recreational drug use.
- Sexual Medicine
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Recreational drug use is a global phenomenon, with potentially significant health implications, ranging from acute toxicity associated with drug use, to dependence and psychological/psychiatric complications.1 Recreational drug use is common. At a population level, the Crime Survey for England and Wales (CSEW, formerly the British Crime Survey until 2010/11) collates data annually on drug use via a self-completion computerised module, from approximately 67 000 households. For the purposes of this paper the term recreational drug use will describe the use of a psychoactive compound for social, recreational or enjoyment purposes.
The CSEW 2011/12 showed 8.9% of the sampled UK population (16–59 years old) admitted recreational drug use in the last year, with 3% reporting last year use of a class A drug.2 Overall, last year recreational use of cannabis was most common (6.9%), followed by powder cocaine (2.2%), ecstasy (1.4%), and ketamine (0.6%). Illicit drug use was most common among the 16–24 year age range.2
Use is significantly greater in certain sub-populations such as clubbers and those who frequent the night-time economy environment (nightclubs, bars etc). The recent Global Drugs Survey, which is an extended version of surveys previously administered through the dance magazine/website MixMag to include other populations, recruited 7700, mainly heterosexual (82.7%), UK clubbers in 2012 and found high levels of last year use of cannabis (68.2%), MDMA (3,4-methylenedioxy-N-methylamphetamine) (53.7%), cocaine (41.8%), ketamine (24.5%), and mephedrone (19.5%). Lower levels of use were reported by this cohort of amyl nitrite (‘poppers’) (13.1%), γ-butyrolactone (GBL, 1.6%), γ-hydroxybutyrate (GHB, 1.5%), and crystal methamphetamine (0.8%).3
International data suggest that recreational drug use is also more prevalent among the lesbian, gay, bisexual, transgender (LGBT) community.4–15 Project BUMP (Boys using Multiple Party Substances), a longitudinal investigation of 450 club drug using men who have sex with men (MSM) in New York, assessed the frequency of use of MDMA, ketamine, powder cocaine, GHB, and crystal methamphetamine in 4-month blocks, over a 12-month period. At baseline, last 4-month use of MDMA (74.7%), ketamine (55.1%), cocaine (78.9%), GHB (29.1%), and methamphetamine (65.1%) were all higher than levels reported in previous MSM studies in the USA. Polydrug use was prevalent, with many individuals reporting simultaneous use of cocaine, ecstasy, methamphetamine, and GHB.8
In contrast, UK prevalence data on recreational drug use in the MSM community is scarce.2 ,16–21 The National Gay Men's Sex Survey (NGMSS)16 ,17 is an internet based survey conducted annually to collate epidemiological data on sexual practices among the UK MSM community. In 2007, the survey focused on recreational drug use among MSM; levels of last year use of cannabis (27.7%), cocaine (21.2%), Ecstasy (MDMA) (20.7%), ketamine (12.2%), GHB (7%), and (crystal) methamphetamine (4.7%) were reported.16 This suggests that overall use within the MSM population is greater than the general population, but since this is a ‘whole population’ survey, it is not as high as those who frequent the night time economy. In 2010, NGMSS joined the European MSM Internet Sex Survey (EMIS). UK results are now amalgamated with other countries in Western Europe, including Belgium, France, Republic of Ireland, and the Netherlands. As a result no data are available on trends solely from a UK perspective.
There are limited systematic data available on levels of recreational drug use among the LGBT population in the UK. The 2008/9 British Crime Survey (now the CSEW) compared recreational drug use between heterosexual adults and LGBT adults (2% of those surveyed). LGBT adults were more likely to have taken any drug than heterosexual adults (32.8% and 10%, respectively), and any class A drug (11.1% and 3.6%) or stimulant (20.8% and 4.3%, respectively) in the last year. MSM reported the highest levels of recreational drug use in the preceding year (38.2%) compared to 26.9% of lesbian/bisexual women, 13.3% of heterosexual men, and 6.8% of heterosexual women.18
Part of the Picture,19 a national UK lesbian, gay and transgender drug and alcohol database, collected information on drug and alcohol use among the LGBT population by recruitment through local LGBT organisations and events in England from 2009–2011. Last month reported use of cannabis (20%), poppers (29%), cocaine (10%), MDMA (9%), ketamine (7%), GHB (2%), and amphetamine (5%) were all significantly higher in MSM than population based survey results from the British Crime Survey for last year use (cannabis 6.8%, poppers 1.0%, cocaine 2.2%, MDMA 1.4%, ketamine 0.6%, GHB 0%, and methamphetamine 0.1%).2
In Nottingham, assessment of the substance use needs of the local LGBT community collected data via online surveys and paper questionnaires from 122 members of the local LGBT community and recorded high levels of lifetime use of cannabis (54%), poppers (43%), GHB (31%), MDMA (30%), amphetamine (30%), cocaine powder (26%), ketamine (23%), Viagra (16%), and methamphetamine (13%).20 Last month use of cannabis (16%), poppers (16%), MDMA (7%), amphetamine (5%), Viagra (5%), cocaine (4%), and ketamine (4%) was also high. No respondents reported last month use of methamphetamine or GHB. Forty-four per cent reported using more than one substance during a typical episode in the previous month, with the most popular combinations being alcohol/cannabis/poppers or alcohol/cocaine/ MDMA/ketamine.20
The local picture
Lambeth borough in London has a substantial LGBT social and commercial scene with gay saunas and gyms, bars, clubs and cafes catering for the LGBT community. There are also several large nightclubs in the area, providing an environment in which people can socialise continuously from Thursday evening until Tuesday morning, without leaving the local area. This encourages large influxes of people to the area at the weekends from the Greater London Area, elsewhere in the UK, and further afield.
High levels of recreational drug use are reported in surveys performed within local nightclubs.21–23 In 2010, a survey of 308 clubbers in two ‘gay-friendly’ dance clubs in Lambeth borough reported high levels of last month use of cocaine (44%), MDMA pills (30%), MDMA powder (30%), ketamine (30%), mephedrone (41%), methamphetamine (10%), GHB (14%), and GBL (19%).23 Mephedrone was the most popular recreational drug used on the night of the surveys (27%).21 In a repeat survey performed in 2011, 41% of individuals reported using mephedrone on the night of the survey.23 Reported last month use of mephedrone increased from 41% in 2010 to 53.2% in 2011, while last month cocaine use remained static at approximately 40% of respondents.21–23
High levels of last year crystal methamphetamine use have been reported in cohorts of MSM attending HIV treatment clinics, HIV testing clinics and gay gyms in central London (8.3–23.3%).24 Individuals who used methamphetamine were more likely to admit to high risk sexual behaviours. Eighty per cent had taken other recreational substances during the past year.24 Other studies suggest that methamphetamine use is higher in HIV positive MSM and those between the ages of 30–49 years.18 ,25
Recreational drug use is most prevalent in young adults who are usually otherwise fit and healthy and infrequently come into regular contact with healthcare providers. In recent years there has been growing interest in the potential association between the use of recreational drugs and sexually transmitted infections (STIs), particularly among MSM.11–15
Attendance at sexual health clinics is common in this population; therefore it was hypothesised that this may be a potential access point to determine the prevalence of recreational drug use and provide a suitable environment for the development of targeted education and support to reduce use.
We have been able to only identify one previous study that has formally assessed the prevalence of recreational drug use in 259 patients attending a sexual health clinic in the UK which was undertaken in 2002. Lifetime illicit drug use was reported by 64% of patients, with 28% reporting use within the last month; however, this study did not comment on sexual orientation of the respondents.26
The objectives of this study were to assess the prevalence of recreational drug use among patients attending outpatient sexual health clinics, based in two large UK teaching hospitals, and to determine if the rates of use were different between MSM and non-MSM males.
An anonymous double-sided A4 questionnaire was designed. The initial section collected basic demographic data on age and gender. Respondents were then asked to indicate if they: (a) only had sex with men, (b) only had sex with women, (c) had sex with both men and women, or (d) were not sexually active. Data on the geographical area in which participants lived was collected by asking individuals to indicate if they lived: (1) in boroughs immediately surrounding the hospital sites (Lambeth, Westminster, Southwark), (2) elsewhere in London, (3) elsewhere in the UK, or were (4) non-UK resident. No other identifiable data were collected to maintain confidentiality.
The main part of the questionnaire was a predetermined list of recreational substances: cannabis, MDMA, cocaine powder, amphetamine, LSD (‘acid’), ketamine, GHB/GBL, crystal methamphetamine, novel psychoactive substances including mephedrone, Ivory Wave, methylone, Spice (synthetic cannabinoid receptor agonist), volatile nitrates (poppers), and sildenafil. Study participants were asked to indicate whether they had previously used each of these substances, and if so whether they had used them in the last month.
The study questionnaire was given to each patient attending the sexual health clinics by outpatient clinic reception staff at the time of patient registration for completion while in the waiting area, over a 3-month period (July to September 2011). Completion of the study questionnaire was voluntary and confidential, took approximately 5 min, and was completed in the waiting area before assessment in the clinic. Completed questionnaires were posted in a locked secure box at the reception desk, which was opened by the principal investigator (LJH). Completed questionnaires were not available to the outpatient clinic staff. Where study participants had concerns about their use of recreational drugs, they were directed to discuss this further with the clinic staff during their subsequent consultation. All clinic attendees were enrolled into the study, although the data presented here only relate to male patients.
Data were extracted from the completed study questionnaires and entered into a purpose-designed Excel spreadsheet. Study participants were divided into the following two groups for data analysis: (1) men who indicated that they had sex with men (either exclusively or those men who indicated that they had sex with both men and women)—known as MSM; and (2) men who indicated that they only had sex with women—known as non-MSM. Data were analysed using χ2 test and Fisher’s exact test as appropriate based on the sample sizes.
The study was reviewed and approved by the local research ethics committee (IRB) (reference 11/LO/0217).
A total of 1328 individuals completed the questionnaire during the study period; overall this represented 15.5% of all attendances at the genitourinary medicine clinics during the study time period. Seven hundred and twenty-nine (45.1%) questionnaires were completed by male patients. Of these 729 male patients, 475 (65.2%) identified themselves as non-MSM and 254 (34.8%) identified themselves as MSM. The mean±SD age of male respondents was 31±9 years. Six hundred and forty (87.8%) resided in London, with 306 (42.0% of total respondents and 47.8% of London residents) living in the boroughs of Lambeth, Southwark, and Westminster adjacent to the hospitals. Seventy-four (10.2%) came from elsewhere in the UK, with 15 (2.1%) reporting that they were non-UK residents. Current smoking history was not significantly different between MSM (30.9%) and non-MSM (26.9%) (p=0.26), nor were levels of last month alcohol use (MSM 76.8% vs non-MSM 71.9% p=0.14).
Use of recreational drugs
We found that lifetime and last month use of many recreational drugs was significantly higher among MSM respondents, when compared to non-MSM respondents. Details of lifetime and last month use are shown in tables 1 and 2, respectively.
With the exception of mephedrone, reported levels of lifetime use of novel psychoactive substances (Ivory Wave, NRG, Spice, methylone) were low and not significantly different between MSM and non-MSM.
Overall, both lifetime and last month use of mephedrone, ketamine, volatile nitrites (poppers), sildenafil (Viagra), GHB, and GBL were all significantly higher in the MSM group compared to the non-MSM group. Lifetime use of cocaine powder, MDMA, amphetamine, and methamphetamine were also significantly higher in the MSM group; however, there was no significant difference in last month use of these drugs between MSM and non-MSM groups.
Reported levels of last month recreational drug use in our sexual health clinics were higher than those reported at a population level by the CSEW (table 3).
This may be reflective of the younger age range within our sample (mean±SD age 31±9 years) compared to 16–59-year-old adults sampled by the CSEW surveys, and also the exclusion of data from female respondents, who are recognised to report lower levels of recreational drug use than men.18 The CSEW identifies higher levels of recreational drug use among young adults in the 16–24 year age group. When our sample was broken down into the age groups used by the CSEW only 128 respondents (MSM n=29, non-MSM N=99) fell into this age range. The small number of respondents in this age range, coupled with low levels of reported recreational drug use among these individuals, made it difficult to compare the data by age group or self ascribed sexual identity. Of the 128 respondents in the 16–24 year age group, 14% reported last month use of cannabis. Last month use of other recreational drugs in the 16–24 year age group included MDMA (5.5%), cocaine (2.3%), poppers (1.5%), ketamine (0.8%), and mephedrone (0.8%). None of those surveyed in the 16–24 year age group reported last month use of GHB/GBL, amphetamine, methamphetamine or Viagra. In the over 25 years age group, MSM (n=223) were significantly more likely to report last month use of poppers, ketamine, mephedrone, Viagra, GHB, and GBL than non-MSM (n=378) males (p<0.01).
Our results suggest that lifetime and last month use of most recreational drugs are more common among the MSM males attending our sexual health clinics when compared to non-MSM males. MSM reported significantly higher levels of lifetime use of cocaine, MDMA, mephedrone, ketamine, amphetamine, volatile nitrites, GHB, GBL, methamphetamine, and Viagra. Reported last month use of mephedrone, ketamine, volatile nitrites, Viagra, GHB, and GBL was also significantly higher among our MSM patients, when compared to non-MSM patients.
Levels of reported last month recreational drug use in our sexual health clinics were also higher than those reported at a population level by the CSEW. As mentioned previously this may be affected by the age range of individuals sampled and the exclusion of female data from this paper. However, when compared to data published by the national LGBT drug and alcohol database on reported levels of last month use of cannabis, cocaine, MDMA, ketamine, and amphetamine among MSM, the results from our study were actually lower than those reported by self-selecting MSM attending Pride events and LGBT organisations. Twenty-nine per cent of respondents in these surveys fell into the age range of 16–24 years, compared to a total of 17.6% in the 16–24 years age range in our survey.
Some recreational drugs that we enquired about, including GHB/GBL and novel psychoactive substances, are not recorded by the CSEW, and thus are not available for comparison. Although the higher levels of recreational drug use reported in our study may in part relate to our younger population, these higher levels of drug use suggest that sexual health clinics could provide a good environment to identify individuals who may be at risk of drug related harms, including acute toxicity requiring emergency hospital admission, and psychiatric and psychological harms, in addition to dependence.10 ,11 ,27–30
Recreational drug use and sexual health in MSM
For many years interest has focused on the potential association between recreational drug use and high risk sexual behaviours within the MSM community.9–11 13–15 ,27 ,30 ,31 Research in this field has increased recently due to upward trends in the diagnosis of HIV and STIs in this group.
In 2010, 61% of all newly diagnosed cases of HIV in the USA were MSM, with MSM now accounting for 56% of all individuals living in the USA with a diagnosis of HIV.28 In 2011, the number of new diagnoses of HIV in UK MSM surpassed those in the heterosexual population, with MSM diagnoses accounting for 48% of newly diagnosed cases. There has been a slow and steady increase in new diagnoses over the last decade in the UK MSM community, with current estimates suggesting that nationally 1 in 20 MSM is affected by HIV, with higher rates in London (1 in 11).29 It is suspected that 1 in 5 MSM affected by HIV in the UK are as yet undiagnosed.32 Rates of other STIs are also increasing in the UK, with an overall 2% rise in 2011, with pronounced increases in gonorrhoea (25% increase), syphilis (10% increase), and genital herpes (5% increase). When analysed by sexual orientation, the greatest increases are among the MSM community with significant increases in gonorrhoea (61% increase), chlamydia (48% increase), genital herpes (32% increase), syphilis (28% increase), and genital warts (23% increase). Overall MSM represented 75% of all newly diagnosed cases of syphilis and 50% of newly diagnosed cases of gonorrhoea.29 The contribution that recent improvements in both recording of sexual orientation and screening methods/uptake in genitourinary medicine clinics to these increases is difficult to determine.
The exact relationship between recreational drug use, participation in high risk sexual behaviours, and STI/HIV infection in the MSM community remains contentious. Many studies demonstrate that MSM who report recreational drug use are more likely to participate in unprotected anal intercourse and have an increased number of sexual partners.10 ,11 ,13–15 ,27 Particular research emphasis has been placed on certain drugs which are traditionally associated with sex within the MSM community, in particular amyl nitrite (poppers), methamphetamine and other stimulants, GHB, and erectile dysfunction drugs (eg, sildenafil), as there is evidence that these substances in particular may facilitate HIV/STI transmission and spread for a combination of reasons. A detailed review of the literature on this subject is beyond the scope of this paper.9 ,10 ,13–15 ,30 ,31
Recreational drug use is traditionally associated with the younger population, a group who may not frequently access healthcare services or professionals.
We know that there are significant levels of recreational drug use within the local area, both through our emergency department attendances and local nightclub surveys.21–23
Due to the levels of recreational drug use recorded in our study we suggest that sexual health clinics may provide a suitable environment to identify individuals who use recreational drugs, explore motivations for drug use, and implement strategies and education to reduce drug related harms. It is likely that this will require a multidisciplinary approach to address the psychosocial aspects of drug-taking behaviours, in combination with healthcare professionals experienced in the management of recreational drug use.
Limitations and future work
Participation in the study was voluntary. It is difficult to ascertain the reasons for low levels of recruitment. We recognise that enquiring about the use of illegal substances is a sensitive subject and concerns regarding this may affect the results obtained. In spite of this we were able to collect 1328 questionnaires over a 3 month period.
Our results show that MSM attending our sexual health clinics reported significantly higher levels of use of most recreational drugs, when compared to non-MSM males. We recognise that this may be affected by the geographical location of the hospital and its close proximity to the largest LGBT community in the UK.32 However, other available data from the UK demonstrate a high prevalence of recreational drug use among MSM, suggesting this group is at particular risk of drug related harm.
We did not collect any demographic data on race or ethnicity, and evidence from the USA suggests that recreational drug use is higher in MSM from racial and ethnic minorities, suggesting that this is an area for further investigation in the UK.33–35
There are limited UK data available on levels of recreational drug use among HIV positive MSM. We did not specifically enquire about HIV status of respondents. In view of the association between high risk sexual behaviours and recreational drug use, this is a particularly important topic in our local area, given the high prevalence of HIV.29 This work may also be extended to determine the relationship of recreational drug use to the incidence of other sexually transmitted infections. Further work is also required with regards to emerging patterns of injecting drug use among MSM.
Recreational drug use is a global problem with potentially significant health implications, ranging from direct acute toxicity associated with drug use, to dependence and psychological/psychiatric complications. Recreational drug use is common among young adults and particularly MSM, who may infrequently access healthcare services. However, young adults tend to be sexually active and may access sexual healthcare services, for screening and treatment of STIs and/or HIV. Our study suggests that these services may provide an opportunistic encounter to screen for recreational drug use, identify problematic use, and provide education and advice regarding recreational drugs by trained healthcare professionals. This is likely to require integrated service provision between sexual health advisors, genitourinary medicine physicians and others, such as clinical toxicologists and addiction specialists, to provide a complete assessment and treatment/advice service.
With regards to the increased rate of recreational drug use noted among our local MSM community, combined with published evidence of elevated levels of recreational drug use in MSM/LGBT populations elsewhere in the UK, this is an area that warrants further funding and research. It is important to determine the prevalence and patterns of recreational drug use, and potential methods to identify individuals who may be at higher risk of developing problematic recreational drug use, both in the MSM and wider population.
Harm reduction strategies must be relevant to the target population and consistent with their behaviours, beliefs and attitudes; therefore, exploration of reasons for drug use and the perceived barriers to accessing drug services is required.
Sexual health clinics may offer a method of capturing data, on a smaller scale but in a faster time period than is possible with national datasets such as the CSEW. This may be able to provide a more rapid system of collecting information on emerging patterns of recreational drug use and novel psychoactive substances, enabling quicker adaptation of existing services to meet changing demands with a resultant improvement in patient care and reduction in drug related harms.
In men attending a sexual health clinic, it was found that men who have sex with men (MSM) have a higher lifetime and last month use of recreational drugs and novel psychoactive substances (NPS) compared to non-MSM patients.
There is the potential to use similar surveys in genitourinary medicine clinics to obtain real-time data on trends in recreational drug and NPS use.
Sexual health clinics may provide an opportunistic encounter to identify and offer treatment for those with problematic drug use.
Current research questions
What is the relationship between recreational drug and novel psychoactive substance use and non-HIV sexually transmitted infections?
Are there ethnic differences between the MSM and non-MSM patterns of recreational drug and novel psychoactive drug use in the UK?
What is the optimal intervention to identify and reduce problematic drug use?
Contributors All authors contributed to the initial study design; LJH, PID and DMW obtained ethical and research and design approval; data collection and drafting of the manuscript was undertaken by LJH; initial data analysis was undertaken by PID and DMW; all the authors contributed to subsequent data analysis and finalisation of the manuscript.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.