1. health and fitness
2. addiction

Q J Med 2013; 106:1111–1117
doi:10.1093/qjmed/hct183 Advance Access Publication 17 September 2013
Monitoring trends in recreational drug use from the analysis
of the contents of amnesty bins in gay dance clubs
T. YAMAMOTO1, A. KAWSAR2, J. RAMSEY3, P.I. DARGAN1,4 and D.M. WOOD1,4
From the 1Department of Clinical Toxicology, Guy’s and St. Thomas’ NHS Foundation Trust and
King’s Health Partners, Westminster Bridge Road, London, SE1 7EH, UK, 2Barts and The London
School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AD, UK, 3TICTAC
Communications Ltd., St. George’s University of London, London, SW17 0RE, UK, and 4King’s
College London, Guy’s Campus, London, SE1 1UL, UK
Address correspondence to Dr. Takahiro Yamamoto, Department of Clinical Toxicology, St Thomas’ Hospital,
Westminster Bridge Road, London, UK SE1 7EH. email: [email protected]
Received 15 July 2013 and in revised form 21 August 2013
Background: In 2011/12, 8.9% of the UK population
reported use of recreational drugs. Problems related
to drug use is a major financial burden to society
and a common reason for attendance to hospital.
Aim: The aim of this study was to establish current
trends in recreational drug use amongst individuals
attending gay-friendly nightclubs in South London.
Method: Contents of drug amnesty bins located at
two night clubs were documented and categorized
into powders, herbal products, liquids, tablets and
capsules. These were then sent to a Home Office
licensed laboratory for identification through a preexisting database of almost 25 000 substances. If
required, further qualitative analysis was performed.
Results: A total of 544 samples were obtained.
Of them, 240 (44.1%) were liquids, 220 (40.4%)
powders, 42 (7.7%) herbal and 41 (7.5%) tablets
or capsules. Gamma-butyrolactone (GBL) was the
most common liquid drug (n = 160, 66.7%) followed
by poppers (n = 72, 30.0%). Powders provided the
widest range of drugs with mephedrone being
the most common (n = 105, 47.7%) followed by
ketamine (n = 28, 12.7%), 3,4-methylenedioxy-Nmethylamphetamine (MDMA) (n = 26, 11.8%), and
cocaine (n = 21, 9.5%). Tablets and capsules
included medicinal drugs, recreational drugs and
plaster of Paris tablets that mimicked the appearance
of ‘ecstasy’ tablets.
Conclusions: This study has provided a snapshot of
the pattern of drug use in the gay community which
compliments findings of the self-reported surveys
and other studies from the same population. The
information obtained will be helpful in guiding in
designing harm reduction interventions in this community and for monitoring the impact of changes in
legislation.
Introduction
interest to health professionals and local/national
organizations for designing prevention, education
and treatment approaches for problems related to
drug use.
Self-reported surveys are often used to identify and
measure trends in drug use.4–6 In 1996, questions
were added to the then British Crime Survey (now
Crime Survey for England and Wales)1 to examine
drug use amongst 16–59 year olds. In 2011/2012,
A total of 8.9% of the UK population reported using
recreational drugs in 2011/20121 and use is a
common reason for presentation to an emergency
department (6.9% of all attendances).2 Drug use is
also a major financial burden to society, costing
£15.4 billion a year in the UK.3 Therefore knowledge
of current trends in the use of recreational drugs is of
! The Author 2013. Published by Oxford University Press on behalf of the Association of Physicians.
All rights reserved. For Permissions, please email: [email protected]
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Summary
1112
T. Yamamoto et al.
bins, and whether the analytical results were comparable with self-reported surveys in individuals
attending the same clubs.
Methods
Sample collection
This opportunistic study, undertaken in South East
London in September 2011, was made possible
through joint co-operation between the nightclubs,
the police and ourselves. Amnesty bins were located
in two ‘gay-friendly’ nightclubs and the samples collected in the bins during club opening hours.
Samples were placed in sealed police evidence
bags and delivered securely by the Metropolitan
Police to a Home Office-licensed drug database
company situated at St. George’s, University of
London.
Sample analysis
The analytical methods used have been previously
described17 (Figure 1). Contents were categorized
into liquids, powders, tablets, capsules and herbal
products. Attempts were then made to visually identify all solid preparations using the pre-existing
TICTAC (The Identification CD-ROM for Tablets
and Capsules) database of nearly 25 000 known
products.20 A sample from each batch (determined
as products of the same size, colour and markings)
was then subjected to a Marquis Test21 for confirmation of contents. If the findings were inconclusive,
further qualitative analysis was performed by Gas
Chromatography Mass Spectrometry (GC–MS).
Liquid and powder samples were initially analysed
using Attenuated Total Reflectance Fourier
Transform Infrared Spectroscopy (ATR FTIR). If further analysis was required, these were also analysed
by GC–MS. Herbal products (incorporating substances including herbs, herbal materials, herbal
preparations and herbal products that contain the
active ingredients of the plant or plant materials)22
were identified by visual inspection only and were
not tested further.
Results
A total of 544 samples were obtained; 240 samples
(44.1% of the total) were liquids, 220 (40.4%)
powder, 42 (7.7%) herbal and 41 (7.5%) tablets/
capsules. Herbal drugs were identified as cannabis;
no further analysis performed and there is the potential
that these products may have contained synthetic
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the most common drugs used were cannabis (6.9%),
powder cocaine (2.2%) and ecstasy (1.4%).1 Subpopulation analysis of those who frequent the nighttime economy,7–9 have shown that nearly one-third
(30.7%) of those who visit nightclubs four or more
times in the past month have used drugs in the past
year compared with 6.5% of their peers who do not
visit nightclubs.1 In this higher drug-using group, the
pattern of use is also different to the general population, with a higher proportion using ecstasy, mephedrone and LSD.7,10
Self-reported surveys however are not without
limitations. Recreational drugs are often adulterated
with other drugs or chemicals to enhance the
desired effects or to mimic the appearance of the
drugs.11–16 For the drug user, this can be a source
of potential harm due to an increase in adverse
effects directly from the adulterant or its interactions
with the drug. This variation may limit the validity of
self-reported surveys as users are recalling the drugs
they intended to use rather than what they actually
used.11–13 In addition, drug use can be stigmatized
in society and this may influence survey response as
respondents may fear self-incrimination despite
guarantees of anonymity.4 Methods such as audio
computer-assisted self-interviewing (CASI), which
eliminates some bias associated with face-to-face
interviews, have been shown to achieve higher
frequency of self-reporting on drug use14 but this
requires additional resources and therefore cannot
be carried out as easily when compared with more
traditional survey methods. Validity testing by way
of biological sampling has been used to check the
accuracy of self-reporting and this has shown that
self-reporting alone is not a good way to measure
drug use.4 However, biological assays can be liable
to producing false results (most commonly falsenegative) depending on type of sample, collection
device and time elapsed from drug consumption15
and may themselves require confirmatory assays.
A different way to assess trends in drug use is
through the analysis of drugs in circulation by collecting them in drug amnesty bins.16–18 Work by our
group established this technique and more recently
a protocol has been published by the London Drug
& Alcohol Policy Forum.19 In addition to this analysis, amnesty bins also: (i) provide a safe place for
security staff to dispose of any substances they find;
(ii) decrease drugs entering premises; (iii) advertise
that venues do not tolerate the use of drugs;
(iv) allow clubbers to dispose of drugs without fear
of arrest; and (v) provide a secure method of storing
potentially controlled drugs/substances before collection/disposal by the correct authorities.19
This study looked at the trends in local recreational drug use by analysing contents of amnesty
Trends in recreational drug use gay dance clubs
1113
Sealed Police
Evidence Bags
Tablet/
Capsule
Liquid
Herbal
Powder
Idenfied on
database?
Liquid
idenfied
Cannabis
Infrared
spectroscopy
No
Unidenfiable
Tablet/ Capsule
idenfied
GC-MS
GC-MS
Perform Marquis Test for
confirmaon
Tablet idenfied
Powder idenfied
Powder
idenfied
Figure 1. Flow diagram of the analysis of samples using the Home Office Licence method protocol.
cannabinoid receptor agonists. The remaining items
were analysed for further identification (Figure 2).
Liquids
These were colourless or pale yellow and contained
in a variety of packaging ranging from brown medicinal dropper bottles to nail polish remover pads.
Analysis found gamma-butyrolactone (GBL) in
66.7% (n = 160) of the samples and ‘poppers’
(alkyl nitrites) in 30.0% (n = 72). The remaining
3.3% (n = 8) of the samples were found only to contain water or aqueous solutions. None of the liquids
contained gamma-hydroxybutyrate (GHB).
Powders
Powders provided the widest range of drugs, including
novel psychoactive substances (NPS), with mephedrone being the most common (n = 105, 47.7% of
total powder items). Other drugs were ketamine
(n = 28, 12.7%), 3,4-methylenedioxy-N-methylamphetamine (MDMA) (n = 26, 11.8%), cocaine
(n = 21, 9.5%), methylamphetamine (n = 6, 2.7%),
para-methoxy-N-methylamphetamine (PMMA) (n = 3,
1.4%), 4-methylethcathinone (4-MEC) (n = 3, 1.4%),
piperazines (n = 2, 0.9%) [N-benzylpiperazine (BZP)
and 3-trifluoromethylphenylpiperazine (TFMPP)], amphetamine (n = 2, 0.9%) and 5-iodo-2-aminoindane
(5-IAI) (n = 1, 0.5%). The remaining 10.5% of samples
(n = 23) contained no recreational drug or novel psychoactive substance. Instead these were medicinal
drugs including caffeine, ibuprofen, acetaminophen,
chloroquine or substances such as lactose and calcium carbonate which were presumably intended to
mimic the appearance of other drugs.
Tablets and capsules
Both medicinal and recreational drugs were found
in the tablets and capsules. Medicinal drugs (43.9%
of tablets), of which there were 14 different types
(Table 1), included two sildenafil tablets which
could have potential use as a recreational drug.
A further 12.2% contained plaster of Paris (calcium
sulphate dihydrate). It is likely that this was intended
to mimic the appearance of ‘ecstasy’ tablets. The
remaining samples were MDMA (n = 8, 19.5%),
TFMPP (n = 4, 9.8%), benzodiazepines (n = 1,
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Yes
1114
T. Yamamoto et al.
GBL
160
Mephedrone
105
Alkyl Nitrites
72
Herbal/Cannabis
43
MDMA
34
Medicinal drugs
30
Ketamine
28
Cocaine
21
Plaster of Paris
8
Aqueous Soluon
8
Methylamphetamine
6
Piperazines
6
Caffeine
6
Other
6
3
3
Amphetamine
2
Benzodiazepine
1
6-APB
1
5-IAI
1
Figure 2. Graph showing the types of samples collected in the amnesty bin.
Table 1 Different types of pharmaceutical drugs found
in the tablets
Drug
Numbers found
Paracetamol
Sildenafil citrate
Ibuprofen
Atripla
Nicotinamide
Truvada
Nicardipine Hydrochloride
Detrusitol (Tolterodine)
Viramune (Nevirapine)
Folic acid
Imirpamine
Ferrous sulphate
Tramadol
Co-fluampicil
3
2
2
1
1
1
1
1
1
1
1
1
1
1
2.4%) and 5/6-(2-aminopropyl)benzofuran (5/6APB) (n = 1, 2.4%). Five samples had a physical
appearance not previously been seen and were
added to the TICTAC drugs identification database;
these were MDMA (2 samples), combination of
TFMPP/BZP (1), 5/6-APB (1) and plaster of Paris (1).
Discussion
This study provides further evidence that drug use is
common amongst those attending nightclubs. The
gay community is often seen as early adopters of
the latest trends in drugs23 and the wide variety of
drugs, including numerous NPS, seen in this study
reflects this. The study has found distinct differences
in types of drug found when compared with the results of previous analyses of amnesty bins in 2005
and 2008.16,17 The most common form of drug
found in this study was liquid, followed by
powder, herbal and tablet/capsule. In past studies
tablets and powders were the most common.16,17
The difference seen here is likely to be due to the
high use of GBL and ‘poppers’ which are used in
liquid form and are drugs favoured by the gay community. Another important difference compared
with previous studies is that no GHB was detected;
this is discussed in more detail below.
Comparison to surveys and other local
data on drug use
Data collection on drug use in the local area has
previously been conducted through the use of surveys, web-mapping projects and analysis of pooled
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4-MEC
PMMA
Trends in recreational drug use gay dance clubs
1115
Table 2 Comparison of findings from the amnesty bin samples, the results of self-reported surveys and analysis
of urine from nightclub urinals
Drug
Amnesty Bin (%)
Urinal study concentration
ng/ml21
Survey 120 (%)
Survey 222 (%)
GBL
Mephedrone
Alkyl nitrites (poppers)
Cannabis
MDMA
Ketamine
Cocaine
Methylamphetamine
Piperazines
4-MEC
PMMA
Amphetamine
Benzodiazepine
6-APB
5-IAI
29.4
19.3
13.2
7.9
6.3
5.1
3.9
1.1
1.1
0.6
0.6
0.4
0.2
0.2
0.2
23000
2965.1
–
–
1922.9
2273.3
154.9
35.6
123.7
–
–
57.7
–
–
–
14
27
–
15
11
14
16
3
–
–
–
–
–
–
–
24
41
–
14
–
13
17
–
–
–
–
–
–
–
–
Drug adulteration
Drugs are often adulterated to enhance desired
effects or to mimic the appearance and reduce the
proportion of the active drug.26 Adulterants may
include active pharmaceutical ingredients, which
can have their own inherent toxicity, or pharmacologically inactive substances such as plaster of Paris
which has historically been used as an adulterant in
foods.27 Although substances such as plaster of Paris
have no inherent toxicity, the user may take a
number of these tablets/powders and not find the
desired effect. This may cause the user to take the
same or possibly more of the drug on the next occasion they use it; posing a risk to the user should
the next batch of drugs contain a higher proportion
of the active substance.
Impact of legislation
One notable finding was the absence of GHB
amongst the samples analysed. In a study of samples
seized from the same nightclubs in 2006, 37.8% of
the liquid drugs were aqueous solutions of GHB
with the remaining samples containing GBL.18
GHB was classified under the UK Misuse of Drugs
Act, 1971 as a class C drug in June 2003. GBL
which is a pro-drug of GHB was also classified as
a Class C drug in December 2009, but only when
intended for human consumption. It therefore
remains available when used in products which
are not aimed for human consumption such as nail
varnish remover and other chemical products. Our
study suggests that the GHB legislation has had a
greater impact than the GBL legislation.
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urine from portable urinals located at the same
nightclubs.23–25 These studies were held at different
times, concentrating more on Friday night/weekends
when clubs were at the busiest. Comparison of
results from this study and these previous studies
are shown in Table 2. This shows that GBL and
mephedrone, which were the most common drugs
found in the amnesty bins, were also the drugs of
choice amongst clubbers in the surveys25 and commonly detected in the urine samples.24 However,
there are also differences between the datasets,
with drugs such as cocaine and ketamine found
less frequently in amnesty bins ranked higher in
the surveys and also found in greater concentration
in urine analyses. One potential explanation for
this is that users may be selectively keeping drugs
they intend to use and dispose of any that are not
required upon entering the club; however this
would not explain the positive correlation between
the sample sets for GBL and mephedrone. The ease
with which drugs can be concealed and consequently not detected during a door search by nightclub security staff is also an important factor. Wraps
or small ziplock plastic bags containing powder are
likely to be more easily concealed than liquids.
The discrepancies in results between the different
datasets suggest that each method of collecting data
on drug use do not always validate each other but
they perhaps complement each other. Therefore,
they each provide information which can in combination give a more accurate picture of drug use.
Awareness of the limitations of each technique
allows efficient data triangulation between the
techniques.
1116
T. Yamamoto et al.
Mephedrone was classified as a Class B drug in
April 2010 but studies and surveys conducted nationwide after this date found ongoing evidence of
mephedrone use25 despite the rising price of the
drug since classification.8,28 This was also demonstrated in surveys in these nightclubs where mephedrone was the most commonly used drug on the
night and also the most favoured drug.25 This
study, approximately 18 months since classification,
confirms that mephedrone continues to be present.
New formulations of drugs
Novel psychoactive substances
(‘legal highs’)
In recent years, there has been an emergence of
a range of different NPS.5 In this study the NPS
detected were 4-methylmethcathinone (mephedrone), 4-methylethcathinone (4-MEC), 5-Iodo-2-aminoindane (5-IAI) and 5/6-(2-aminopropyl)benzofuran
(5/6-APB). Of these, mephedrone and 4-MEC are
classified under the UK Misuse of Drugs Act, 1971.
Another controlled substance para-methoxy-Nmethylamphetamine (PMMA), which was held responsible for 12 fatal intoxications in Norway31 and
further outbreak of cases in Israel,32 was also found in
the amnesty bin analyses. Previous studies analysing
the content of such ‘legal high’ products have shown
that these products can contain active ingredients
which are not declared as such.33 These additional
active ingredients may be other ‘legal’ substances or
controlled substances such as PMMA, mephedrone
and 4-MEC.34,35 The finding of controlled substances
in the samples suggests that there may be a close
association between the NPS and illicit markets.35
Limitations of the study
Although this study removes the recall and responder bias seen in self-reported surveys, it is not without its limitations. Analysis of amnesty bin samples
Conclusions
The analysis of the amnesty bins of two gay-friendly
nightclubs in South East London has provided a
snapshot of the likely pattern of drug use in the
gay community. Comparison of data from this
study with previous amnesty bin studies has shown
a change in the drugs—in particular a switch from
GHB to GBL. Use of data from this study together
with data from self-reported surveys and other studies such as the analysis of pooled urine can provide
a more accurate picture of drug use.
Information found from this study will be useful in
designing targeted drug prevention and education
and also in informing clinicians and legislative
authorities. Wider use of this technique has the
potential to allow comparison of drug availability/
use in different sub-populations and geographical
regions.
Conflict of interest: None declared.
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