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Thomas M. Lampinen, PhD, Doug McGhee, MD, Ian Martin, MD, CCFP

Use of crystal and other club among high school students in Vancouver and Victoria

A recent survey suggests that students who identify themselves as gay or bisexual are at increased risk of using club drugs.

ABSTRACT Background Background: The prevalence and cor- Results: Among 607 students sur- Crystal methamphetamine (MA) is a relates of British Columbian adoles- veyed (mean age 15.9 years), 81 stu- powerfully addictive central nervous cents’ use of four “club” drugs— dents (13.6%) reported previous use that is typically inhaled crystal methamphetamine (MA), of MA (5%), ecstasy (12%), (snorted), smoked, eaten, or injected. MDMA (“ecstasy”), ketamine, and (4%), or GHB (4%). Most of this use Heavy MAuse can lead to serious con- gamma-hydroxybutyrate (GHB)— appeared to be experimental or oc- sequences, including , psy- remain poorly defined. This is partly casional within a context of mul- chosis, , violence, and death.1 because past surveys have mea- tidrug use; every MA user but one In recent years, there have been wide- sured use in aggregate cate- reported also using and mar- spread reports of substantial increases gories rather than by specific drug. ijuana. In multivariate analyses ad- in MAuse and increasing attention has In addition, little research has been justed for age, a twofold greater risk been paid to its health effects on youth done regarding anecdotal evidence for use of ecstasy was observed and young adults in BC. Use of MA suggesting increased risk of drug among girls. The 2.5% of students represents a shift from organic stimu- use among gay and bisexual youth. who identified themselves as gay or lants (for example, ) to those The purpose of our study was to con- bisexual had significantly elevated easily synthesized in makeshift home sider this and to assess the preva- risk of previous year use of MA (odds laboratories. Crystal methampheta- lence, characteristics, and corre- ratio [OR] 26.28), ecstasy (OR 3.29), mine has a higher dependence liabili- lates of use of each of these four and ketamine (OR 8.26). ty: the single-isomer MAis more potent club drugs separately among grade 9 to 12 students. Conclusions: School-based initia- Dr Lampinen is a senior post-doctoral fel- tives may fail to reach many regular low at the BC Centre for Excellence in Methods: In 2003 we conducted a MA users. Interventions and clinical HIV/AIDS in Vancouver, BC, and is a clinical pilot-project survey of a convenience assessments involving youths at- assistant professor in the Department of sample in six schools in Vancouver tending high school should address Health Care and Epidemiology at the Uni- and Victoria using a confidential the individual’s use of multiple drugs versity of British Columbia. Dr McGhee is self-administered questionnaire to rather than MA or any other club medical co-director of the Victoria Youth assess students’ demographic char- drug specifically. Targeted substance Clinic, Victoria, BC. Dr Martin is a clinical acteristics, sexual orientation, and abuse research and intervention ini- instructor in the Department of Family Prac- substance use. tiatives appear warranted for stu- tice, UBC, and a physician at Three Bridges dents who identify themselves as Community Health Centre. gay or bisexual.

22 BC MEDICAL JOURNAL VOL. 48 NO. 1, JANUARY/ FEBRUARY 2006 Use of crystal methamphetamine and other club drugs among high school students in Vancouver and Victoria

80

70 Used ever 60 Used in previous year Used in previous month 50

40

30

20 Percentage of students 10

0 Alcohol Marijuana * Mush- Ecstasy Cocaine LSD Ketamine MA GHB rooms (crystal meth)

Figure. Prevalence of substance use reported by Vancouver and Victoria grade 9 to 12 school survey participants, by drug and timing of use.

*Called cigarettes on the questionnaire. than the mixed-isomer since 1999, increasing proportions Methods previously in circulation and MA contain ketamine.5 Between March and June 2003, grade users typically ingest larger doses. The determination of the preva- 9 to 12 students in Victoria and Van- The recreational use of other club lence and correlates of adolescents’ couver voluntarily completed an anon- drugs, so named because of their fre- use of MA, ecstasy, ketamine, and ymous and confidential pilot-project quent use at adolescents’dance events GHB individually is important but has questionnaire. The study protocol was (called “”) and other dance venues, been hindered by past surveys that approved by the UBC Behavioural particularly gay clubs, has increased have tended to measure drug use in Ethics Board and school boards in substantially since the mid-1990s.2,3 aggregate categories (“methampheta- Vancouver and Victoria. Passive con- In the present study, we include the mine, speed, or ecstasy”) or have em- sent was obtained from parents and no following club drugs: 3,4-methylene- ployed broad and relatively technical incentives were provided (passive dioxymethamphetamine (MDMA, wording (“amphetamines”).2,6,7 Before consent=parents were notified by commonly known as “ecstasy”), an we undertook our survey in 2003, newsletter that the study was being analog with sympath- information from BC youth drug treat- conducted and were instructed to con- omimetic properties; ketamine, a de- ment facilities, early pro- tact the school if they opposed their rivative of hydrochlo- grams, and our clinical experience child’s participation.) ride used clinically as a suggested an elevated prevalence of In Victoria, a team that included anesthetic; and gamma-hydroxybu- MA use among gay and bisexual school district officials, board mem- tyrate (GHB), a gamma-aminobutyric youth, but relevant data were unavail- bers, principals, and a study investi- acid (GABA) analog with able. We therefore decided to conduct gator (D.M.) selected two Victoria properties.3,4 The Internet has facilitat- a pilot-project cross-sectional survey high schools to best represent a cross- ed dissemination of recipes for home using youths’ own language and in- section of the district’s school-attend- synthesis of some of these drugs and cluding questions about sexual orien- ing population. Within each school, so they are likely to continue to be tation to measure the respective preva- the team selected a sample of students readily available. Importantly, health lence, patterns, and correlates of use in each of grades 9 to 12 from among care providers need to be aware that of MA, ecstasy, ketamine, and GHB those students randomly assigned to approximately half the tablets and among high school students in Van- attend compulsory Career and Per- capsules presently sold in BC as ecsta- couver and Victoria, BC. sonal Planning classes that semester. sy contain methamphetamine; and In Vancouver, a study investigator

VOL. 48 NO. 1, JANUARY/ FEBRUARY 2006 BC MEDICAL JOURNAL 23 Use of crystal methamphetamine and other club drugs among high school students in Vancouver and Victoria

Table 1. Characteristics of crystal methamphetamine (MA) use among 27 students reporting Five percent of students reported any previous use. previous use of MA, half during the previous year. Only 0.8% reported Age of first use, mean years 14.7 (1.3) using MA during the previous month (standard deviation) (Table 1 ). Most users had smoked or Most recent use, n (%) During previous month 5 (18.5) snorted the drug; none reported inject- During previous year 14 (55.6) ing it. Half of the 27 students reported More than one year ago 12 (44.4) their peak frequency of MA use to be Mode of use, n (%) Smoke 19 (70.4) less than once per month. The median Inhale 14 (51.9) peak number of days awake on the Eat 8 (29.6) Inject 0 drug was 3, but ranged from 1 to 12. Other 3 (11.1) Five users (19%), all of whom used MA during the previous year, report- Maximum frequency during previous use, n (%) Daily 4 (15.4) Weekly 2 (7.7) ed previous treatment for alcohol or Monthly 7 (26.9) substance use. Less than monthly 13 (50.0) Although 12% of students had pre- vious experience with ecstasy, includ- Maximum days awake during previous use, 3 (2, 4) median (IQR) ing 9% during the previous year, only 4% reported its use during the previ- History of alcohol or 5 (18.5) treatment, n (%) ous month. In contrast, among the smaller number of students reporting any previous use of ketamine (4%) or (I.M.) selected four schools to ensure We compared groups using Pear- GHB (4%) most reported its use dur- participant heterogeneity with respect son’s chi-square or Fisher’s exact test ing the previous month (3% and 3%). to geographic location and family for categorical variables and Wilcox- Previous use of any of these four income. Within each school, the in- on rank sum tests for continuous vari- drugs—MA, ecstasy, GHB, or keta- vestigator and principal selected one ables. We evaluated potential corre- mine—was reported by 13.6% of stu- homeroom class in each of grades 9 to lates of substance use (age, gender, dents. Of these students, 10.7% report- 12 and administered the survey to all and sexual orientation) using adjusted ed use in the previous year and 4.5% four classes in a single day. After each odds ratios and 95% confidence inter- reported use during the previous survey, a brief information session vals, computed with multivariate lo- month; these students exhibited a dis- about MAwas provided. In both school gistic regression models. tinct pattern of use of many of the 12 districts, a standard protocol for ad- licit and illicit substances included in ministration of the survey ensured stu- Results theFigure . The median (interquar- dents’ privacy and their understand- The 607 student respondents had a tile range) number of substances pre- ing that participation was voluntary mean age of 15.9 years (range 13 to viously used by students with MA or and strictly confidential. 19); 54% were male and most were club drug experience was 6 (4, 8) and We used a 15-item questionnaire either white (identified as “caucasian” for those students without drug expe- to measure age, race-ethnicity, sexual on the survey) (45%) or Asian (39%). rience it was 1 (0, 2) (P <.0001). Sim- orientation (heterosexual, homosexu- TheFigure shows the prevalence of ilarly, greater numbers of substances al—“lesbian, gay, queer”—bisexual, students’ self-reported use of specific were reportedly used during the pre- or questioning/unsure); and time of substances by drug and timing of last vious month by students who used most recent substance use (within the use (ever, previous year, previous MA or club drugs during the same last week, month, year, or more than month). Alcohol consumption was time frame (median 7 [5, 11]) than by one year ago). Students reporting pre- most common, with 415 students (68%) students who did not (median 1 [0, 2]) vious use of MA were asked their age reporting its use during the previous P <.0001). All but one MAuser report- of first use, frequency and mode of year and 292 (48%) during the previ- ed use of alcohol and marijuana dur- use, and number of consecutive days ous month. More students smoked ing the previous month. awake while using. marijuana (28%) than tobacco (20%) during the previous month.

24 BC MEDICAL JOURNAL VOL. 48 NO. 1, JANUARY/ FEBRUARY 2006 Use of crystal methamphetamine and other club drugs among high school students in Vancouver and Victoria

In multivariate logistic regression Table 2. Adjusted* odds for BC students’ substance use, by drug and timing of use. analyses, the 15 students (2.5%) who identified themselves as gay or bisex- Lifetime use of Previous year use of ual had markedly increased risk for drug OR (95% CI) drug OR (95% CI) reported use of MA, ecstasy, and ket- Crystal methamphetamine (MA) amine (Table 2 ). Their increased risk Age (per year increase) 1.56 (1.09–2.25)† 1.34 (0.82–2.21) for use of GHB was based on small Female gender 0.79 (0.33–1.85) 0.67 (0.20–1.85) † † counts and did not reach statistical sig- Homosexual or bisexual self-identity 17.02 (4.83–60.01) 26.28 (6.13–112.57) nificance. In these analyses, lifetime Ecstasy and previous year use of ecstasy were Age (per year increase) 1.43 (1.14–1.79)† 1.34 (1.04–1.71)† † † both positively associated with age, Female gender 1.82 (1.06–3.13) 2.00 (1.10–3.70) Homosexual or bisexual self-identity 4.89 (1.63–14.67)† 3.29 (0.98–11.05)† and female students had an approxi- mately twofold greater risk for its use. Ketamine Age (per year increase) 0.83 (0.57–1.21) 0.73 (0.48–1.10) Female gender 1.30 (0.53–3.23) 1.15 (0.44–3.03) Conclusions Homosexual or bisexual self-identity 9.44 (2.62–34.06)† 8.26 (1.98–34.34)† The results of our study of grade 9 to 12 students in Vancouver and Victoria Gamma-hydroxybutyrate (GHB) Age (per year increase) 0.85 (0.58–1.25) 0.71 (0.46–1.09) indicate that most students (86%) sur- Female gender 1.00 (0.40–2.48) 0.84 (0.31–2.33) veyed had never used MA, ketamine, Homosexual or bisexual self-identity 4.44 (0.89–22.18) 2.70 (0.32–23.11) GHB, or ecstasy. Only 5% of students * Adjusted for each of the other two variables in the table had ever used MA, including 5 (0.8%) † Statistically significant correlate (P <.05) who had used MA during the previous month. This infrequency of MA use was not attributable to previous sub- stance abuse treatment. We conclude that most MAuse was experimental or occasional; its regular use among the youths we surveyed in BC schools Most MA use was experimental or occasional; appears to be rare. Our results indicate its regular use among the youths we surveyed that school-based programs are unlikely to reach very many youth in in BC schools appears to be rare. BC who regularly use MA. Use of MA and club drugs among high school students we surveyed was strongly associated with the use of multiple licit and illicit substances. Indeed, every MA user except one high-risk multidrug users supports the campaigns, are ineffective9 and poor- reported consuming alcohol and mar- recommendation from the 2004 West- ly implemented.10 If monies are to be ijuana during the same time frame. ern Canadian Summit on Metham- spent on MA prevention through Thus, school-based initiatives that phetamine that “a methamphetamine- schools, programs should be evidence- aim to prevent problematic use of MA specific school-based prevention based and should involve skill-building and other club drugs should not target program is not indicated, but metham- and delivery of messages by peers.11-13 any of these drugs individually; in- phetamine should be part of a com- A unique strength of the present stead, they should aim to identify and prehensive in-school prevention pro- study is that we measured the rela- modify risk factors for individuals’ gram addressing substance use issues tionship between sexual orientation use of multiple substances (including in general.”8 While some strategies and substance use. The small number alcohol, tobacco, and marijuana). can effectively reduce drug use among of students (2.5%) who identified Our finding that most regular use adolescents, it is well established that themselves as gay or bisexual were at of MA and other club drugs is report- most school-based drug use preven- greatly increased risk for reporting use ed by an identifiable subgroup of tion programs, including fear-based of MA, ecstasy, and ketamine, and

VOL. 48 NO. 1, JANUARY/ FEBRUARY 2006 BC MEDICAL JOURNAL 25 Use of crystal methamphetamine and other club drugs among high school students in Vancouver and Victoria

they more commonly reported use of GHB as well. Interestingly, most of RESOURCES these students were girls who identi- BC Alcohol and Drug Information Referral Service fied themselves as bisexual. This Free, 24-hour information and referral line for providers and patients. novel finding is consistent with results Lower Mainland 604 660-9382 from a probability survey of adults in Elsewhere in BC 1 800 663-4242 14 Chicago and warrants further re- British Columbia Ministry of Health search to investigate the possibility of Report describing an integrated BC strategy for crystal methamphetamine and other an elevated risk of club drug use amphetamines. www.vch.ca/publications/docs/info/industry/Crystal_Meth.pdf among bisexual girls and women. It Crystal Meth Anonymous (CMA) remains unclear whether these elevat- Organization offering local support group meetings. ed risks reflect early contact with 604 633-4242 social networks with higher preva- www.crystalmeth.org (click on “Looking for a Meeting?”) lence of substance use3,14 or predispo- Medscape sition to substance use owing to prob- Article about crystal methamphetamine for clinicians (Colfax GN. Methamphetamine: lems with early self-identification as Important Clinical Guidance for Healthcare Providers.) Free Medscape site registration is gay or bisexual.15 required to view this article. Elevated substance use among www.Medscape.com self-identified gay and bisexual indi- New York Crystal Meth Anonymous Intergroup viduals is consistently observed in the Web site with self-assessment information. few school and population-based sur- www.nycma.org/lit_downloads/NYCMA_Addict.pdf veys that have examined this ques- Pacific AIDS Education and Training Centre 14-17 tion. Clearly, the identification of Fact sheet for clinicians working with methamphetamine users. modifiable antecedents of heavy drug www.aidsetc.org/pdf/p02-et/et-03-00/methusers.pdf consumption among gay and bisexual U.S. National Institute on Drug Abuse students represents an important Drug-specific fact sheets (including sheets about crystal methamphetamine, ecstasy, GHB, opportunity and priority for substance and ketamine). use prevention research and initia- www.nida.nih.gov/DrugPages tives. Vancouver Methamphetamine Response Committee (MARC) Another strength of our survey Web site with broad information content, including treatment referrals and supports. was assessment of MA, ecstasy, GHB, www.Methfacts.org and ketamine individually. These dis- aggregated measures were essential for discerning differing patterns of use statistical tests used to compare of these drugs among students who among club drugs and their respective groups. Although our use of a conve- identified themselves as gay or bisex- association with sexual identity. nience sample (i.e., those subjects ual. We conclude that sexual orienta- As with all school-based survey available to us) limits generalizabili- tion questions should be added to results, ours are subject to the limita- ty, the prevalence of and large, representative surveys of sub- tions inherent in self-reported data and other drug use we observed is highly stance use among BC high school stu- are likely to underreport stigmatized similar to that reported from probabil- dents in the future.6 We also conclude substance use. Our results are also ity samples of BC students.6,18 that school-based interventions should unlikely to generalize to youth having In summary, this 2003 pilot-pro- be evidence-based and should not an inconsistent connection to school. ject survey of selected high school stu- address MA or any other club drug in As well, the prevalence of MA and dents in Vancouver and Victoria sug- isolation. Greater benefit is likely to club drug use among BC students may gests that use of MA, ecstasy, GHB, be gained by identifying and modify- vary geographically. and ketamine is low. Most use of these ing determinants of multidrug use Perhaps the most important limi- drugs appears to be experimental or among high-risk individuals, includ- tation of this study is our nonrandom occasional and part of a pattern of use ing high school students who identify selection of schools surveyed, which of multiple substances. However, we themselves as gay or bisexual. violates the assumptions underlying noted a markedly elevated risk for use

26 BC MEDICAL JOURNAL VOL. 48 NO. 1, JANUARY/ FEBRUARY 2006 Use of crystal methamphetamine and other club drugs among high school students in Vancouver and Victoria

Disclaimer 6. McCreary Centre Society. Healthy youth paper. Toronto, ON: Centre for The views expressed in this article are development: Highlights from the 2003 and Mental Health; 1999. www.caw.ca/ those of the authors alone and not neces- Adolescent Health Survey III. www whatwedo/substanceabuse/pdf/CAMH sarily those of the institutions and agencies .mcs.bc.ca/rs_ahs.htm (accessed 26 PositiononAlcohol_DrugPreventionfor with which they are affiliated. October 2004). Youth.pdf (accessed 4 November 2005). 7. Lynskey M, White V, Hill D, et al. Preva- 14. Fendrich M, Wislar JS, Johnson TP, et al. Acknowledgments lence of illicit drug use among youth: A contextual profile of club drug use Many thanks to the students who com- Results from the Australian School Stu- among adults in Chicago. Addiction pleted the survey and to Ms Amy McArthur, dents’ Alcohol and Drugs Survey. Aust N 2003;98:1693-1703. Dr Peter Granger, Mr Ajay Puri, and the Z J Public Health 1999;23:519-524. 15. Garofalo R, Wolf R, Cameron MS, et al. many Vancouver and Victoria school district 8. Vancouver Coastal Health. Western The association between health risk staff members who made this survey pos- Canadian Summit on Methampheta- behaviors and sexual orientation among sible. Dr Lampinen is supported by the Mi- mine. Bringing Together Practitioners, a school-based sample of adolescents. chael Smith Foundation for Health Research. Policy Makers and Researchers. Consen- Pediatrics 1998;101:895-902. sus Panel Report, April, 2005. www.sfu 16. Orenstein A. Substance use among gay Competing interests .ca/dialogue/Meth_Booklet_2005_Final. and lesbian students. J Homosex 2001; None declared. pdf (accessed 4 November 2005). 41:1-15. 9. Cuijpers P. Effective ingredients of school- 17. Ryan H, Wortley PM, Easton A, et al. References based drug prevention programs. A sys- Smoking among lesbians, gays, and 1. Rawson RA. Treatment for Stimulant Dis- tematic review. Addict Behav 2002;27: bisexuals. A review of the literature. Am orders. Rockville, MD: US Dept. of Health 1009-1023. J Prev Med 2001;21:142-149. and Human Services, Substance Abuse 10. Hallfors D, Godette D. Will the “principles 18. Johnson JL, Tucker RS, Ratner PA, et al. and Mental Health Services Administra- of effectiveness” improve prevention Socio-demographic correlates of ciga- tion; 1999. Publication no. (SMA) 99- practice? Early findings from a diffusion rette smoking among high school stu- 3296. study. Health Educ Res 2002;17:461-470. dents: Results from the British Columbia 2. Landry MJ. MDMA: A review of epi- 11. Faggiano F, Vigna-Taglianti FD, Versino youth survey on smoking and health. Can demiologic data. J Psychoactive Drugs E, et al. School-based prevention for illic- J Public Health 2004;95:268-271. 2002;34:163-169. it drugs’ use. Cochrane Database Syst 3. Romanelli F, Smith KM, Pomeroy C. Use Rev 2005;2:CD003020. www.mrw Additional reading of club drugs by HIV-seropositive and HIV- .interscience.wiley.com/cochrane/clsys- Gallinger PM. Club drugs: MDMA, gamma- seronegative gay and bisexual men. Top- rev/articles/CD003020/frame.html hydroxybutyrate (GHB). Am Fam Physi- ics HIV Med 2003;11:25-32. (accessed 3 November 2005). cian 2004;69:2619-2626. 4. Ricaurte GA, McCann UD. Recognition 12. Health and Welfare Canada. The effec- Urbina A, Jones K. Crystal methampheta- and management of complications of tiveness of prevention and treatment pro- mine, its analogues, and HIV infection: new . Lancet 2005; grams for alcohol and other drug prob- Medical and psychiatric aspects of an epi- 365:2137-2145. lems: A review of evaluation studies. demic. Clin Infect Dis 2004;38:890-894. 5. Canadian Community Epidemiology Net- Ottawa, ON: Minister of Supplies and work on Drug Use, Vancouver Site Re- Services Canada; 1992. port, June 2005. www.city.vancouver 13. Centre for Addiction and Mental Health. .bc.ca/fourpillars/ppt/CCENDU.ppt Alcohol and drug prevention programs (accessed 2 December 2005). for youth: What works? A best advice

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