QUICK Substance Abuse: Club Drugs and 'Raves' LESSON ABOUT Description/Etiology Club drugs are a group of recreational drugs that are used primarily by teens and young adults, often at bars, nightclubs, concerts, and all-night dance parties called raves, although evolving patterns of use indicate users, circumstances, and locations outside of those implied by the name club drugs. The U.S. National Institute on Drug Abuse identifies MDMA (ecstasy), GHB, ketamine, and Rohypnol as club drugs and includes methamphetamine and LSD in this group also because they frequently are used in similar circumstances as club drugs. Raves are one of the most popular settings in which club drugs are distributed. Most club drugs cause some degree of temporary mental distortion, ranging from impaired judgment to memory loss. Individuals often use club drugs to increase social interaction, libido, and energy; to enhance sensory perception; or because they believe these drugs to be safer and less addictive than “harder” drugs (e.g., cocaine, methamphetamine, heroin). Raves, which began in the 1980s in England, feature fast, pounding electronic dance music, choreographed laser light shows, and manufactured fog; they often draw very large crowds of adolescents and young adults. Raves often take place in nightclubs, bars, open fields, or warehouses. Initially, raves were invitation-only dance parties, often held in gay clubs. Typically the location of the venue was kept secret until the night of the event, leading the rave culture to be described as an underground movement. Raves became increasingly popular, and in the late 1980s they emerged in the United States. Rave parties now take place throughout the United States and in countries worldwide. Although raves began in metropolitan areas, they increasingly are found in rural areas. The new rave culture is highly promoted, publicized, and commercialized, although underground raves that are similar to the original rave culture continue to take place. Promoters maximize profits by using raves to market clothes, toys, drugs, and music. Today’s ravers often pay a high entrance fee to dance in dark, often poorly ventilated rooms on overcrowded dance floors. Attendance can range from 30 ravers to tens of thousands, depending on the venue size. These events are characterized by the use of club drugs, overpriced bottled water, and “chill rooms” to help dancers cool down. Club drugs often are illegally diverted from laboratories, smuggled by mail or airline courier from other countries, and sold over the Internet. Club drugs generally are inexpensive to purchase and often are white, tasteless, and odorless. The drugs usually are ingested orally but can be snorted, smoked, or injected. The effects of club drugs are both physical and psychological, and may be intensified because club drug use often is accompanied by Author ingestion of alcohol and other drugs. Prolonged use of club drugs can produce tolerance, Laura McLuckey, MSW, LCSW Cinahl Information Systems, Glendale, CA dependence, and addiction. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), places Rohypnol (benzodiazepine) and GHB (a CNS depressant) with Reviewers the sedative, hypnotic, or anxiolytic substances. Ketamine falls under a new classification Lynn B. Cooper, D. Criminology in the DSM-5, phencyclidine use disorder, and MDMA (ecstasy) is included with other Cinahl Information Systems, Glendale, CA hallucinogen use disorder. Substance use disorders are defined by a recurrent pattern of Melissa Rosales Neff, MSW use within a 12-month period that adversely affects functioning or causes distress. The Cinahl Information Systems, Glendale, CA fifth edition of the DSM (published in 2013) combined the DSM-IV diagnoses of substance abuse and substance dependence into the single diagnosis of substance use disorder (SUD), with specific criteria for each substance (e.g., alcohol, amphetamine, phencyclidine). Thus, July 19, 2019 DSM-5 removes the distinction between abuse and dependence and instead divides each

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2019, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206 disorder into mild, moderate, and severe subtypes, depending on how many criteria are met. Drug craving has been added as a criterion for substance use disorder, whereas “recurrent legal problems” has been removed (American Psychiatric Association, 2013).

Facts and Figures › According to the 2018 U.S. Monitoring the Future survey, use of ecstasy during the 12 months prior to the survey among 8th-, 10th-, and 12th-gradestudents in the United States steadily declined between 2010 and 2018. In 2010, 2.4% of 8th graders had used ecstasy, and in 2018 1.1% had; for 10th graders prevalence declined from 4.7% to 1.4% and for 12th graders from 4.5% to 2.2%. Rates of use of Rohypnol, GHB, and ketamine during the 12 months prior to the survey also declined between 2010 and 2018 for 12th graders: Rohypnol from 1.5% to 0.7%, GHB from 1.4% to 0.3%, and ketamine from 1.6% to 0.7% (Johnson et al., 2019) › Lea et al. (2013) found that the use of club drugs among gay and bisexual men in Australia peaked at 45.1% of this population in 2006 and had declined to 32.4% in 2011. This decline may be due to the risks associated with drug use by this population (e.g., high-risk sexual practices such as unprotected sex, which increases risk of HIV infection) › In a study of club drug use and high-risk sexual behavior in 6 provinces in China, researchers found that 75.2% of the study participants disclosed having engaged in sex with multiple partners after club drug use during the past year, and 79.8% of the participants disclosed having had unprotected sex after using club drugs during the past year (Bao et al., 2015) › In a study of club drug users in Miami, researchers stated that 46.3% of the male participants and 33.7% of the female participants disclosed group sex experiences after club drug use. Group sex is associated with substance use disorders and a history of sexually transmitted infections (Buttram & Kurtz, 2015) › Authors of a survey of 1,604 female sex workers in China found that 7.4% had used club drugs in the prior 12 months, and that rates of sexually transmitted infections were higher among club-drug users than non-club-drugusers (Li et al., 2017)

Risk Factors Risk factors for using club drugs include participation in raves and desire to increase social interaction, libido, physical sensation, and energy level.

Signs and Symptoms/Clinical Presentation › Both desired user effects and adverse effects are listed below • Psychological: euphoria, amnesia, impaired judgment, confusion, anxiety, depression, paranoia • Behavioral: increased risk-taking behavior, increased impulsivity • Sexual: increased incidence of unsafe sex, increased risk of sexually transmitted diseases, anterograde amnesia (i.e., the inability to transfer current events into long-term memory), which exposes the individual to date rape • Physical: onset of action usually is rapid (< 1 hour); duration of action varies. Effects of the drug depend on whether the drug acts as a CNS depressant or stimulant; they may include increased heart rate, hypothermia, nausea, heat stroke, and dehydration • Social: empathy, self-confidence, feeling of connection, extreme friendliness

Social Work Assessment › Client History • Complete a comprehensive biopsychosocial-spiritual assessment with particular attention to risk factors associated with the use of club drugs (e.g., participation in the club scene, risk-takingbehaviors) • Ask about persistent physical complaints such as fatigue and lasting cough • Ask about mood fluctuations, irritability, depression, feelings of worthlessness, and suicidal ideation › Relevant Diagnostic Assessments and Screening Tools • There are multiple screening and assessment tools used to diagnose substance abuse, including the Addiction Severity Index, 5th ed. (ASI); Adolescent Diagnostic Interview (ADI); Drug Use Screening Inventory–Revised (DUSI-R); CAGE-AID Questionnaire; and AUDIT-Cquestionnaire. It is important to utilize tools that assess for co-occurring mental disorders, such as Substance Abuse Treatment for Persons with Co-Occurring Disorders and Beck Depression Inventory–II › Laboratory and Diagnostic Tests of Interest to the Social Worker • Because club drugs often are rapidly excreted in urine and not easily detected in the blood, routine toxicology screening tests may not be helpful in establishing recent drug use Social Work Treatment Summary A complete biopsychosocial-spiritual assessment is helpful to understand the extent and nature of a substance use disorder and its interaction with other life areas (e.g., employment, interpersonal relationships). This is essential for careful diagnosis, appropriate case management, and successful treatment. SUDs often coexist with mental health disorders, yet each has its own unique symptoms. It is important to treat both the mental health disorder and the SUD at the same time to prevent clients from being sent back and forth between substance abuse and mental health treatment settings. Social workers should use standardized screening tools, assessment instruments, and interview protocols that have been established for the population served (e.g., adolescents, adults). It also is important to explore possible barriers to treatment (e.g., housing, health insurance, transportation, finances) and provide referrals to ameliorate potential obstacles. Successful treatment includes a medical evaluation, detoxification, substance abuse treatment, and cognitive behavioral therapy. Cognitive behavioral interventions are designed to help modify a client’s behaviors, thinking, and expectations related to drug use, as well as to increase skills to cope with life stressors and to support a drug-freelifestyle. The harm reduction model is also being utilized in the treatment of alcohol and drug use. This motivational approach aims to increase the individual’s desire for improved health and well-being and minimize the potential hazards associated with alcohol and drug use. This model does not require total abstinence, but instead promotes changes in behavior that will decrease harm to the individual who chooses high-risk behavior. For example, as applied to club drug use, harm reduction steps might include chemical analysis of the substance before taking it; not mixing drugs with alcohol; not mixing drugs; taking a small “test” dose if the purity of the drug is not known; taking rest breaks while dancing and drinking water; and buying drugs from a known source. Social workers should be aware of their own cultural values, beliefs, and biases and develop specialized knowledge about the histories, traditions, and values of their clients. Social workers should adopt treatment methodologies that reflect their knowledge of the cultural diversity of the communities in which they practice. Social workers should practice with awareness of, and adherence to, the social work principles of respect for human rights and human dignity, social justice, and professional conduct as described in the International Federation of Social Workers (IFSW) Statement of Ethical Principles, as well as the National Association for Social Workers (NASW) Code of Ethics (if in the United States). He or she should become knowledgeable of the IFSW and NASW (if in the United States) ethical standards as they apply to clients with substance use issues, and practice accordingly.

. Problem Goal Intervention Risk-taking behavior, poor Increase knowledge of CBT addressing skill judgment, insufficient effects of club drugs, deficits, brief motivational information about the increase self-efficacy interviewing addressing the consequences of club drug and self-esteem, develop consequences of substance use decision-making skills use, and suggesting alternatives and practicing them _ Evidence of substance use Determine whether criteria Conduct a complete disorder for diagnosis are met psychosocial history, obtain history related to drug use, use assessment tools Client meets criteria for Harm reduction and sobriety Referral for medical substance use disorder (mild, evaluation and a drug moderate, or severe) treatment program that works with a multidisciplinary team to provide comprehensive treatment

. Applicable Laws and Regulations › Under the United States Controlled Substances Act, club drugs are classified from Schedule I to Schedule IV based on their potential for abuse, risk of dependence, and medical utility › Both GHB and Rohypnol induce anterograde amnesia; they are sometimes placed in beverages without the drinker’s knowledge to facilitate rape. The United States Drug-Induced Rape Prevention and Punishment Act of 1996 allows for harsh penalties for giving a controlled substance without knowledge or consent for the purpose of committing a criminal act › Local laws and professional requirements for reporting abuse, neglect, and self-harm must be known and observed › Each country has its own standards for cultural competence and diversity in social work practice. Social workers must be aware of the standards of practice set forth by their governing body (e.g., National Association of Social Workers in the United States, British Association of Social Workers in England) and practice accordingly › Internationally, social workers should practice with awareness of and adherence to the social work principles of respect for human rights and human dignity, social justice, and professional conduct as described in the International Federation of Social Workers (IFSW) Statement of Ethical Principles, as well as the national code of ethics that applies in the country in which they practice. For example, in the United States, social workers should adhere to the NASW Code of Ethics core values of service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence; and become knowledgeable of the NASW ethical standards as they apply to substance use disorders and practice accordingly

Available Services and Resources › Dance Safe, Promoting Health and Safety within the Electronic Music Community, https://dancesafe.org/ › National Institute on Drug Abuse (NIDA), https://www.drugabuse.gov/drugs-abuse/club-drugs › NIDA for Teens, https://teens.drugabuse.gov/ › Substance Abuse and Mental Health Services Administration (SAMHSA), https://www.samhsa.gov/ › Harm Reduction International, https://www.hri.global/?no-splash=true

Food for Thought › Street names for commonly used club drugs ecstasy, GHB, Rohypnol, and ketamine include XTC and X (ecstasy), G and Georgia home boy (GHB), roofies and roaches (Rohypnol), and K and special K (ketamine). In China, club drugs are now called “new-type” drugs › Rave promoters capitalize on the effects of club drugs: To manage dehydration and hypothermia, water, juice, and sports drinks are sold, often at inflated prices; lollipops and pacifiers can be purchased to prevent involuntary teeth clenching; menthol nasal inhalers, Vicks VapoRub, surgical masks, and glow sticks are available to enhance the sensory experience › Sharing needles used to inject drugs and unsafe sexual practices while under the influence of club drugs increase the risk of HIV infection

Red Flags › Other substances (e.g., caffeine, dextromethorphan) frequently are added to club drugs; this might occur without the user’s knowledge, increasing the risk of adverse effects › Raves frequently are advertised as “alcohol-free,” “drug-free,” “safe” parties with hired security guards. However, ravers often are exposed to rampant drug use and a high-crime environment › The use of club drugs is more prevalent among gay and bisexual men than among heterosexual men › In a study of club drug users in China, 88% did not believe that they were addicted to club drugs and did not perceive that they would benefit from treatment despite the results from assessment tools indicating that addiction was present (Ding et al., 2014)

Discharge Planning › Assist client in identifying triggers for substance abuse. Discuss alternatives to drug use and identify strategies to improve coping and problem-solving skills › Provide referrals to substance abuse treatment programs, mental health services, and recovery support groups to support long-term drug-freerecovery; and for pregnancy testing and testing for HIV, hepatitis, and other sexually transmitted diseases if indicated References 1. American Academy of Family Physicians. (2018). Club drugs: What you should know. American Family Physician, 98(2), 1-2. 2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Arlington, VA: American Psychiatric Publishing. 3. Bao, Y., Liu, Z., Li, J., Zhang, R., Hao, W., Zhao, M., ... Lu, L. (2015). Club drug use and associated high-risk sexual behavior in six provinces in China. Addiction, 110(1), 11-19. doi:10.1111/add.12770.pmid:25533860 4. British Association of Social Workers. (2012). The code of ethics for social work: Statement of principles. Retrieved May 23, 2016, from http://cdn.basw.co.uk/upload/basw_112315-7.pdf 5. Buttram, M., & Kurtz, S. (2015). Characteristics associated with group sex participation among men and women in the club drug scene. Sexual Health, 12, 560-562. doi:10.1071/SH15071 6. Ding, Y., He, N., Shoptaw, S., Gao, M., & Detels, R. (2014). Severity of club drug dependence and perceived need for treatment among a sample of adult club drug users in Shanghai, China. Social Psychiatry & Psychiatric Epidemiology, 49(3), 395-404. doi:10.1007/s00127-013-0713-z 7. Fernandez-Calderon, F., Lozano-Rojas, P., Rojas-Tejeda, A., Bilbao-Acedos, I., Vidal-Gine, C., Vergara-Moragues, E., & Gonzales-Saiz, F. (2014). Harm reduction behaviors among young polysubstance users at raves. Substance Abuse, 35(1), 45-50. doi:10.1080/08897077.2013.792760 8. International Federation of Social Workers (IFSW). (2018). Global social work statement of ethical principles. Retrieved April 26, 2019, from http://ifsw.org/global-social-work-statement-of-ethical-principles 9. Lea, T., Prestage, G., Mao, L., Zablotska, I., de Wit, J., & Holt, M. (2013). Trends in drug use among gay and bisexual men in Sydney, Melbourne and Queensland, Australia. Drug and Alcohol Review, 32(1), 39-46. doi:10.1111/j.1465-3362.2012.00494.x 10. Li, J., Gong, X. D., Yue, X., & Jiang, N. (2017). Dual epidemics of club drug use and sexually transmitted infections among Chinese female sex workers: New challenges to STI prevention. BioMed Research International, Article ID 2093421. doi:10.1155/2017/2093421 11. Johnston, L. D., Miech, R. A., O'Malley, P. M., Bachman, J. G., Schulenberg, J. E., & Patrick, M. E. (2019). Monitoring the Future - national survey results on drug use 1975-2018: 2018 overview, key findings on adolescent drug use. Ann Arbor, MI: Institute for Social Research, University of Michigan. 12. National Association of Social Workers. (2017). Code of ethics of the national association of social workers. Retrieved May 23, 2019, from https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English 13. Shimane, T., Hidaka, Y., Wada, K., & Funada, M. (2013). Ecstasy (3,4-methylenedioxymethamphetamine) use among Japanese rave population. Psychiatry and Clinical Neurosciences, 67(1), 12-19. doi:10.1111/j.1440-1819.2012.02402.x 14. Talbert, J. J. (2014). Club drugs: Coming to a patient near you. The Nurse Practitioner, 39(3), 20-26. doi:10.1097/01.NPR.0000443227.72357.72 15. Wheeler, D. (2015). NASW standards and indicators for cultural competence in social work practice. Retrieved May 23, 2018, from https://www.socialworkers.org/Practice/Practice-Standards-Guidelines 16. Wilkins, J. N., Danovitch, I., & Gorelick, D. A. (2019). Management of stimulant, hallucinogen, marijuana, phencyclidine, and club drug intoxication and withdrawal. In S. C. Miller, D. A. Fiellin, R. N. Rosenthal, & R. Saitz (Eds.), The ASAM principles of addiction medicine (6th ed., pp. 757-780). Philadelphia, PA: Wolters Kluwer.