This chapter considers the current UK club drug market, the social and economic impact of club drug deaths, the disparity between the rhetoric of current policy and reality of club drug use in the NTE, and the emergence of formal NTE strategies among local authorities. From this, a clear picture of the current landscape of club drug use, its harms and wider impact on the NTE can be seen, and the magnitude of the current costs of drug-related harms and benefit of reducing them can be appreciated.
The Current UK Club Drug Market
Ecstasy-related deaths in the UK are the highest they have ever been, with 63 occurring in England and Wales in 2016. This number has risen steadily from 10 deaths in 2010: a six-fold increase.1 Scotland and Northern Ireland have also seen a marked increase, from one death between both countries in 2010, to 28 and 7 respectively in 2016.2 This has occurred alongside a five-fold increase in the average MDMA content of ecstasy pills according to analyses of police seizures, with the emergence of continually higher strength pills year upon year, up to an average of 165mg MDMA per pill in the first quarter of 2017.3 This is despite no significant increase in adult prevalence rates within the same timeframe: past year prevalence for ecstasy use has fluctuated at around 450,000-500,000 adults per year in England and Wales for over a decade, according to national statistics.4
Cocaine-related deaths have seen a similar trend, more than tripling from 112 in 2011 to 371 in 2016 in England and Wales, and quadrupling in Scotland during the same period, from 36 to 123.5 Again, this has occurred alongside an unprecedented increase in average cocaine purity in recent years.6 Recent increases in production, restrictions in the availability of common cutting agents and the impact of dark web imports have led to this increased incidence of high purity cocaine.7 Prevalence rates have also remained largely consistent with past year prevalence of powder cocaine fluctuating between 720,000 and 770,000 people per year since 2013 and prior to 2010, with a dip in usage to a minimum of 610,00 between 2010 and 2012.8
Another factor exacerbating harms from both drugs is that the unprecedented peaks now seen in the purity of cocaine and strength of ecstasy follows a period, from 2008 to 2010, when purity of both was unprecedentedly low.9 Part of the risk therefore, is that users, especially inexperienced and younger users, have little idea what’s in their drugs and little idea of this rapid change in purity. There is a time lag for this information to trickle through to the market and for users to adjust their dosage appropriately.
Polydrug use is widespread among many club drug users, although different subgenres may favour different drug combinations, with ketamine, nitrous oxide, psychedelic drugs including LSD, magic mushrooms and 2C-B, and GHB all featuring in the drugs repertoires of different groups within the NTE.10
The recreational drug market has changed dramatically over the past ten years, with the emergence of a host of New Psychoactive Substances (NPS) and some club drug users adopting new stimulants, psychedelics and dissociatives alongside more established street drugs. The arrival of new drugs has led to some club drug users supplementing and extending their palette with NPS, rather than simply replacing existing club drugs like cocaine, ecstasy and ketamine.11 Beginning with the rapid rise of mephedrone use from 2008 onwards,12 a number of psychoactive substances, including ethylphenidate, methoxetamine and alpha-methyltryptamine have seen increased use in subgenres of club drug users, with uptake typically increasing rapidly to a peak during periods when purity or availability of ecstasy, cocaine and ketamine was low, before subsiding to usage by core user groups. Drug related deaths attributable to each of these substances have seen increases since their initial adoption,13 although it should be noted that many of these deaths have been amongst low income, multiple deprivation and vulnerable drug using groups, not clubbers, who picked up cheap and easily available NPS. While basic advice on reducing drug-related harm remains broadly similar across all of these new drugs, advice on the specific harms of different drugs varies, increasing the need for provision of more detailed information and the likelihood that drug users will have incomplete knowledge of the variable risks they may encounter, especially when using new substances in combination with others. The greater range of drugs with similar superficial appearances or effects has also contributed the misselling of new drugs as older staples, such as substituted cathinones as MDMA and methoxetamine as ketamine.
Online darknet drug markets have had a profound effect on the availability of new and less common drugs. Recreational drug users are now no longer reliant on the inventory of their regular drug dealer, contributing to a widening of many club drug users’ repertoires. The UK has been one of the most prominent adopters of darknet drug markets, with the second highest quantity of online sales (in both value and weight) of any EU country.14 Online markets have also increased access to higher purity drugs, as user feedback discourages misselling and creates a competitive marketplace, leading some vendors to distinguish their products through selling higher strength and purity products.
Young People and Club Drug Use
While club drugs are used across a full range of demographics, with fastest growing rates of use currently among people aged 30 to 40, they are used most frequently by young people under 30.15 This demographic is more likely to suffer drug-related harm as a result of inexperience, lower tolerance and poor drug use practices, increased tendency to engage in risky behaviour, and lower body mass index, all potentially making them more vulnerable to negative impact. Challengingly, this group is also least likely to be in regular contact with public services, offering fewer opportunities to engage them with information on drug-related harm through other routes typically utilised by public health.
“It feels that there is a bit of a paradox when it comes to drug knowledge these days. The online world brings a huge amount of information that is accessible to young people whenever they want it. They can research pretty much any substance you’ve heard of and the opportunities to purchase through this route are greater than ever before. At the same time, something is missing. Despite some great projects and dedicated practitioners, drug education is suffering; pastoral teams and youth services have seen real cutbacks in recent times and there are fewer opportunities for young people to discuss substance use in an informed way where they feel they are not being judged. Added to this, with changing trends in recent years and different cohorts experimenting with substances, it also seems that many groups don’t have that ‘guru’ who can guide others around dosage and help their experiences to be managed more safely. Because of this and in spite of being better connected than ever before, in some respects it feels like some people are increasingly making decisions without the guidance and support of others.”
– Rick Bradley, Operations Manager, Addaction
Both interviewees and recent reports note that, compared to previous generations of club drug users, there has been a marked reduction in intergenerational use, and the current generation are less likely to acquire knowledge from older, more experienced “drug gurus”. This reflects a broader reduction in intergenerational socialising in the NTE with the growth in increasingly niche and age-targeted licensed leisure venues with the growth of café bar culture in the late 1990s and early 2000s, and a shift away from the intergenerational traditional working men’s pubs of previous decades.16 Interviewees working in young people’s drugs services noted that this, combined with greater levels of misinformation from the media, a dearth of reliable drugs education in schools, and a decline in funding for harm reduction outreach services, has left many young people more ignorant of information regarding the content and strength of street drugs, the severity of risk that excessive consumption and co-consumption may pose, or basic harm reduction practices, compared to previous generations of club drug users.17
Young people who engage in club drug use have very few spaces readily available to them to talk about drugs with a trusted and informed point of contact. Young people who are engaged with drugs services through all-too-rare early intervention schemes are typically highly receptive to information on reducing drug-related harm, with interviewees noting that these young people are often “hungry for knowledge”, as the popularity of social media-based harm reduction groups and videos also attest to.
The Impact of a Club Drug-Related Death
The most extreme and well-recognised manifestation of harm from club drug use is a drug-related death (DRD). A DRD in or connected to a night time venue, while being a deeply tragic event, also has a hugely damaging impact on a venue itself and the wider community. When compared to levels of consumption, DRDs relating to club drugs are still a relatively rare occurrence. Newcombe estimates that in 2015, mortality rates equated to 7 deaths per 100,000 episodes of ecstasy use, based on the average ecstasy user consuming the drug twice a year.18 Nutt and colleagues have assessed ecstasy to have a low level of physical and social harm compared to most other legal and illegal drugs using their multicriteria decision making model use.19 However, despite their rarity, DRDs have a profound impact, both socially and economically, and this must be fully considered if measures to reduce DRDs in night time environments are to be fully appraised.
“The impact that a drugs fatality can have on an event in terms of the operation is significant, a very temporary team can be stretched to breaking point, it can also of course have a massive impact to reputation, but the one area that shouldn’t be underestimated is the emotional impact on the event team, medics, welfare and emergency services. We’re all working towards creating a safe environment and to have the complete opposite occur can be very upsetting.”
– Jon Drape, Managing Director, Ground Control
The profound effect that DRDs have in the NTE means that these events have disproportionately shaped the policy landscape and licensing responses. The emotional impact of a DRD upon the victim’s family and friends is immense and well recognised, but also extends to the staff and management of venues affected, and to local police.20 A sense of responsibility is recognised by both venue management and police, provoking an increased drive to act to prevent future deaths. A pattern has emerged of the response from authorities following a DRD at a licensed venue or event, they typically fall into one of three courses of action:
- A venue’s licence is reviewed and revoked. Closure of Rainbow Venues in Birmingham following the deaths of Michael Truman and Dylan Booth, and the initial closure of Fabric in London following the deaths of Ryan Browne and Jack Crosley exemplify this response.
- Stricter licensing conditions are placed on the venue to limit its business or appeal with groups with whom high levels of club drug use is likely. This in turn may lead to the closure of the venue due to unviability of the business under the new terms. Closure of The Arches following the death of Regane MacColl, and the attempted closure of Fabric in 2014 following the deaths of four people and hospitalisations of four others between 2011 and 2014 exemplify this response.
- A venue agrees with local authorities to introduce measures to better protect customers. Initiatives adopted at Warehouse Project in Manchester following the death of Nick Bonnie and the eventual reopening of Fabric in 2017 following appeal exemplify this response. This may include both welfare-oriented measures (such as introducing or enhancing on-site paramedical and/or harm reduction support, increased access to free tap water, increased fans/ventilation to address ambient temperatures) and security-oriented measures (such as enhanced searches upon entry). For example, The Loop has provided a welfare and harm reduction service at every Warehouse Project event in the five seasons (4½ years) since Nick Bonnie’s death. This third option is also the most common response to DRDs at festivals. For example, following the death of Christian Pay at Kendal Calling in 2015, and a number of deaths at Boomtown Fair between 2011 and 2016, both festivals reviewed all their drug-related services, shifted their stated drug policy from ‘zero tolerance’ to the ‘3Ps’ and introduce the Loop’s Multi Agency Safety Testing on site at both festivals from 2016 onwards at Kendal Calling and from 2017 onwards at Boomtown Fair.
Of these three responses, only the third is likely to have a positive impact on reducing DRDs, as the end result of the first two options is simply displacement of club drug users to other venues and events, which may or may not have increased provision for protecting against drug-related harm. Increased closure of licensed venues is likely to lead to greater attendance and prevalence of unlicensed events in particular, which are far less likely to have sufficient public health and safety provision. A doubling in the number of unlicensed events in London in 2017 has been largely attributed to the closure of licensed venues.21
Media coverage of a DRD can be damaging to both the venue affected and to the wider image of the night time industry. While a venue may operate for years without incident and have in place adequate measures to counter drug-related harm, a single DRD is likely to attract more negative media attention than all their combined years of maintaining good practice, and strengthen the public association between a venue, the wider industry and drug use. Disproportionate media interest in ecstasy DRDs,22 particularly in ecstasy DRDs in the NTE, further pressurises police and authorities to “be seen to be doing something”. Consequently, incidents that might otherwise be judged as being accidental deaths or not in the public interest to investigate, warranting no significant action from police or authorities, are far more likely to be investigated in detail. A common consequence of such investigations is the arrest and conviction of the person who supplied the victim, typically either a low level professional dealer, or someone from the victim’s social circle. Such arrests do little to mitigate against future drug-related harm or to reduce supply, but have significant consequences for the arrestees.
The economic impact of a DRD in the NTE can be considered on two fronts, policing and community. The policing costs of a death in the immediate aftermath are substantial and can be a major draw on resources for a police force, not least as they often occur on Friday and Saturday nights in busy areas, when demands on policing are already stretched. Attempted Freedom of Information requests by the authors found the exact figures on the cost of police responses to DRDs in night time venues are not kept, although the typical police procedure can provide an indication: staffing the scene of death with multiple officers for 8 hours, interviewing witnesses, oversight of the case by a Detective Inspector, forensics investigations, commissioning a toxicology report, investigating supply, coroner’s court and file building, arrests, maintaining public order, and any subsequent legal costs. From interviews with police, it is estimated that such a case, exempting further complications, requires a week of police time, and typically costs in excess of £10,000.
The economic costs to the community can be considered in terms of the loss of venues, which has a direct impact through the loss of local jobs, tax revenue, contributions to Business Improvement Districts or Late Night Levies. The direct contribution of Rainbow Venues to the local economy in the year prior to its closure was estimated at £2 million and included the employment of 64 staff.23 Fabric employed 200 staff prior to its closure in 2016. Many licensed venues are multifunctional, operating as night clubs, gallery spaces, theatres, cinemas, live music venues, sponsors of local charities, conference spaces, artists’ studios and more, and so the negative social and economic impact of closure may extend beyond the NTE. The wider appeal of an area may also be reduced following the loss of a venue, and so the closure of one venue may also negatively affect surrounding businesses that rely on the passing trade. The size of a venue directly relates to the cost of its closure, with even small venues likely to cost the community in excess of tens of thousands of pounds, while closure of larger venues, as evidenced by Rainbow Venues, can cause losses that stretch into millions of pounds.
If the value of preventing an unnecessary loss of life is not sufficient enough reason, the simple economic damage that can result from a single DRD is a compelling reason to ensure reasonable measures are in place to prevent them. Rather than repeating history and only taking action in response to DRDs once they have already occurred, it behoves local authorities, police and venues to invest in measures pre-emptively, to reduce the likelihood of such deaths occurring in night time environments in the first place.
The Impact of Increasing Drug-Related Harm and Poor Drug Use Practices
While deaths from club drug use are the most common drug-related harm to be recognised by the press and the public, the impact of drugs on the NTE goes far beyond DRDs. In terms of costs to policing, healthcare, venue security and creating orderly and inclusive night time environments, other harms associated with club drug use play a far more significant role. All of these harms are exacerbated by poor drug use practices such as consuming excessive amounts or unknown substances, polydrug use, co-consumption of alcohol, and engaging in other risky behaviours while intoxicated.
The consequences of such practices can be anything from minor forms of public disorder, such as acting aggressively or intimidatingly, or showing signs of being visibly intoxicated, through to more major incidents, such as admissions to hospital or being arrested. Such practices increase the likelihood of requiring the attention of health services, becoming the concern of police or security services, can discourage other members of the public from entering night time entertainment districts, and increase the burden on night time staff. Policing the NTE is made significantly more difficult, and hence more costly, by greater numbers of people experiencing drug-related harm, putting ever-decreasing policing budgets under increasing strain.
Club drug-related hospital admissions figures available from NHS digital give a clear indication that there has been a significant increase in harms in recent years. Between 2011-2012 and 2016-2017, admissions where cocaine was listed in the primary diagnosis rose by 91 percent, while primary diagnosis admissions for other stimulants, including ecstasy, rose by 16 percent, and admissions for hallucinogens, including both psychedelics and ketamine, rose by 62 percent. Of those, acute intoxication and psychosis are shown as a leading cause for all substances, both of which are indicative of consumption of high dosages.24
Additionally, freedom of information (FOI) requests to the all 116 NHS Trusts in the UK have revealed that, from the 54 NHS Trusts that returned figures, Accident and Emergency admissions between 2013 and 2017 where cocaine was cited in the attendance record has more than doubled, rising dramatically from 1767 to 3750 mentions. A&E admissions in which ecstasy and ketamine were cited also saw moderate increases over the same period, from 188 to 271 mentions and 427 to 548, although these increases were not of the same magnitude as those seen for cocaine. Full details of figures from FOI requests are given in the Appendix.
It should be noted that the number of A&E admissions in which these drugs are implicated is likely to be significantly higher than those where they are mentioned in attendance records, but these figures at least give a strong indication of trends in admissions, which show increases for all three drugs, although it is cocaine for which the trend is by far the most significant. These figures corroborate the findings of Winstock et al., who found that the number of people seeking emergency medical treatment relating to cocaine and MDMA use had both increased by 50 percent from 2015 to 2017.25
Admissions figures reveal the increased burden being placed on healthcare services, particularly emergency healthcare services, due to club drug-related harm in recent years. While these figures only relate to the impact on health services, they indicate that other services dealing with drug-related harms will also have seen an increased burden placed on them in recent years.
‘Safe spaces’, of which there are currently 45 in operation,26 and responsible drinking campaigns have been introduced in recent years primarily to reduce alcohol-related harm. Hospital admissions with alcohol-related primary diagnoses have seen a 15 percent drop in numbers from 2011-2012 to 2016-2017.27 By contrast, measures to address the stark rise in drug-related harm in the NTE, and its impact on emergency services, have not been forthcoming. While there are various reasons for the significant rise in drug-related harm in recent years, such as increased purity and availability of commonly used drugs, and the rise in selling and misselling of NPS, measures to change poor drug use practices and educate club drug users on the associated harms of the current market could greatly reduce the costs currently incurred by emergency services.
Despite the rise in DRDs and hospital admissions relating to club drugs, alcohol is still far more problematic for many stakeholders in the NTE.28 The cost of public disorder associated with alcohol use in the NTE is substantial, and despite the number of hospital admissions with alcohol-related primary diagnoses decreasing in recent years, in 2016-2017, this figure was still an order of magnitude greater than hospital admissions for all other drug-related primary diagnoses combined.29
The burden placed on police and emergency health services by excessive alcohol consumption in the NTE is substantial, with alcohol-related arrests and hospital admissions surging on Friday and Saturday evenings, while a recent survey conducted for the All-Party Parliamentary Group on Alcohol Harm found ‘90 percent of police officers expect to be assaulted on a Friday and Saturday night when they police during the night time economy’, with alcohol being the primary associated factor.30
Addressing alcohol-related harm is one of the priorities of Public Health England,31 with the UK Government estimating the overall cost to society of alcohol related harm as £21 billion, and PHE estimating the economic burden of alcohol at 1.3 – 2.7 percent of annual GDP.32 Unique and effective approaches to reducing alcohol-related harm consequently have a clear economic motivator, as well as presenting a benefit to public health and policing of the NTE.
Reality and Rhetoric
“I am constantly reminded of a time when I was promoting a night in Brighton. A worried-looking young man approached me and said that he had dropped an entire gram of 2C-B on the floor, in a baggie. He had looked everywhere and could not find it. For those unaware, a single gram of 2C-B constitutes over 50 doses. If whoever found it took even a cautious tester bump, they could end up being hospitalised. I approached the venue owner with the problem, suggesting we turn the music off and make an announcement through the sound system. He said we absolutely could not do that, and that the policy had to be that drugs did not exist on the premises. Anyone standing on the dance floor would have laughed if you suggested the idea. There was a similar problem last year at a UK festival with a batch of NBOMe blotters being sold as LSD, with single tabs causing hospitalisations. We did eventually manage to get the word out using social media, but our requests to put up warning notices were strictly denied. Neither of those licence holders wanted it that way – but they felt they had to in order to protect their livelihoods.”
– Electronic music event promoter
Successive venue closures due to drug-related incidents have had a hardening effect on the language used by venues in relation to drugs. Examples of police and authorities using venues’ own drug confiscations or harm reduction provision as evidence that they have a problem with drug use on site has created a feeling among venue owners that any action they take to reduce drug-related harm could be used against them, and so a greater priority for many is communicating the message of ‘zero tolerance’. This has resulted in an increased reluctance among some venues to engage with spreading messages and making genuine attempts to reduce drug-related harm, especially those located in areas with authorities known to be unsympathetic to the night time industry.
While the rhetoric of ‘zero tolerance’ is maintained by venues to indicate that they are in no way complicit with any drug use that may occur on site, it often sits in contrast to reality. The well recognised practical difficulties of preventing drugs from entering venues whilst operating in a legal, responsible and non-discriminatory way, combined with the market forces of the NTE, mean that in many circumstances the prioritisation of maintaining an orderly venue and addressing more pressing safety and security concerns results in a level of discretion or ambivalence towards potential drug use within premises in order to operate.
Large venues would struggle to admit customers at sufficient speeds if overly thorough searches were required, particularly at peak times, while small venues would simply struggle to find the space or security capacity to undertake comprehensive door searches and indoor surveillance while addressing other safety and security concerns. LGBT venues in particular have noted that, if a central purpose of some leisure venues is to provide a space for their clientele to feel safe, door policies that create a sense of vulnerability or exclusion among customers may undermine the purpose of the venue.
The market forces of the NTE place venues in a position where strict adherence to zero tolerance drug policies is often infeasible, as certain genres of music and events attract high proportions of customers who use drugs. Attempts to harden door policies or policing of drug use within the venue would make a venue rapidly unpopular with both the public and promoters of these genres, who would simply seek alternative legal or illegal events within the same genre with more lenient policies, potentially placing them at greater risk of harm. A doubling of unlicensed events in London in 2017 has been attributed to the closure of licensed venues in the capital, a sign that clubbers will simply look elsewhere if a venue does not meet with their approval.33
Such discretion is not limited to venues. Police in event and night time environments are also faced with limited resources, and as such prioritise crimes relating to violence, sexual assault, theft and drug supply over possession offences. However, where police discretion is typically understood and accepted both in terms of prioritising limited resources and in terms of not wanting to unnecessarily criminalise people for simple possession, the same understanding is often not afforded to venues and their management.
The result of this necessity for venues to maintain explicit zero tolerance policies, yet operate with an implicit degree of discretion, is that situations are created whereby venues cannot actively put in place the procedures, protocols and initiatives that would reduce drug-related harm, because they are required to maintain a fiction of a supposedly drug-free environment. This disparity between rhetoric and reality is only exposed publicly after a major incident, such as a hospitalisation or a DRD, at which point venues are held solely responsible, despite the fundamental role played by police and authorities in placing venues in such an untenable situation.
As appreciation for the social, economic and cultural value of the NTE increases in many cities and towns across the UK, the importance of developing a NTE strategy, or leisure strategy, is increasingly being recognised, with the former chair of London’s Night Time Commission citing them as a fundamental requirement for a successful NTE.34 NTE strategies are designed to maximise public enjoyment and appreciation of the NTE, increase footfall and trade for night time businesses, reduce its negative impacts, and better coordinate its management, including optimising security, policing and public safety.
A key concern of night time strategies is to ensure that the NTE serves not just regular and core consumers, but all those who are affected, including night workers, residents and those who primarily engage with night life districts at other times of day. To this end, one of the key priorities of night time strategies is to create orderly and efficient NTEs that minimise disorder, disruption and overspill into the day time economy.35 Examples of policies addressing this include the agent of change principle, 24 hour transport plans and cumulative impact policies.
Night time strategies require close partnership working between all stakeholders if they are to be implemented effectively, as the priorities and preferences of all who are affected by the NTE need to be balanced, along with political, legal and commercial sensitivities, and all within a limited budget. This has created an increasing need from all stakeholders to find policy solutions that reduce demand on services without limiting the appeal of the NTE.
With the decreased focus on reducing drug-related harm in the NTE in recent years, measures to tackle drug-related harm have been conspicuously absent from night time strategies. While such initiatives may previously have been seen specifically as a niche concern, addressing only one subset of people affected by the NTE, the wider impact of initiatives to reduce drug-related harm is now in much need of re-evaluation, particularly in the context of creating a more orderly NTE and reducing demand on policing and other public services.
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