Drug and Medical Tourism

Drug and Medical Tourism

I S S N 1725 - 5767
Travel and drug use in Europe: a short review
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THEMATIC PAPERS
Travel and drug use in Europe: a short review
Travel and drug use in Europe: a short review
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Contents
1. Introduction 2. Travelling and using drugs Young people Problem drug users 3. Examples of drug-related destinations 4. Prevalence of drug use among young travellers Young holidaymakers in Europe Young backpackers Young clubbers and partygoers 5. Risks associated with drug use while travelling Health risks Risk related to personal safety Legal risks Risks related to injecting drug use Risks to local communities 6. Potential for prevention interventions 7 Conclusions . Acknowledgements References 3 4 4 4 6 9 9 10 11 13 13 14 14 14 15 17 19 21 22
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1. Introduction
Recent decades have seen a growth in travel and tourism abroad because of cheap air fares and holiday packages. This has been accompanied by a relaxation of border controls, especially within parts of Europe participating in the Schengen Agreement. As some people may be more inclined to use illicit substances during holiday periods and some may even choose to travel to destinations that are associated with drug use — a phenomenon sometimes referred to as ‘drug tourism’ — this means that from a European drug policy perspective the issue of drug use and travel has become more important. This Thematic paper examines travellers and drug use, with a focus on Europeans travelling within Europe, although some other relevant destinations are also included. For the purpose of this publication, a ‘traveller’ is defined as someone who goes abroad for reasons ranging from a weekend visit to a music festival or a short holiday, through to backpacking for longer periods. Using drugs in a foreign country can be associated with additional risks and consequences. For example, while drug use anywhere may lead to adverse health consequences, using drugs abroad can be associated with increased risks due to additional uncertainties regarding the composition and purity of the substances and the lack of knowledge of local health and social services. In addition, under the influence of drugs, tourists may also engage in behaviours that put them at risk of various medical conditions, accidents and risky sexual practices. They also risk arrest and imprisonment for possessing, using, selling or smuggling drugs into and out of a country. Local populations may also be negatively affected. While visitors bring income to the host countries, drug use by some may lead to antisocial behaviour and public nuisance, an increase in those requiring health and social services, and the presence of gangs controlling the drug trade, thus putting pressure on the local law enforcement, health and social services. Little is known about the issue of drug use by travellers. This Thematic paper seeks to increase the interest in this topic both in terms of research and of developing adequate responses to problems related to drugs and travel. The paper aims to shed some light on this topic by investigating the following five questions: What is the profile of those who travel and use drugs? Which destinations have been associated with drug use among travellers? What is the prevalence of drug use among travellers? What are the risks associated with using drugs while travelling? What is the potential for prevention interventions? Information for this publication was collected from online reference resources, such as PubMed and Scopus, and with the help of Internet search engines. In addition, six Reitox national focal points (1) provided information about drugs and travel in their countries and about drug use among their citizens while the latter are travelling. These countries are presented as examples in the following pages but they should not be considered as necessarily having more extensive travel and drug use problems than other European countries.
(1) The Czech Republic, Greece, Spain, France, Cyprus and Croatia.
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2. Travelling and using drugs
This section briefly introduces two population groups who are susceptible to use drugs while travelling: young people and problem drug users. Of course, belonging to one or both of these groups does not necessarily lead to drug use while travelling.
Young people
According to a report published by the World Tourism Organization (Richards, 2008), youth travel (2) has become a major part of the tourist industry, and, over the last decade, both the length of time young people spend away and their spending as a proportion of income have increased. In 2008, youth travel accounted for an estimated 20 % of a total of 160 million international tourist arrivals (3). For example, Croatia — a country with 4.3 million inhabitants — registered 48.8 million foreign tourists in 2010. The average age of the tourists was 41 years, and 19 % were under the age of 30. Young travellers, however, are not a homogeneous group and their travelling style is one of the factors that may differentiate them. For example, one group of young travellers on short or sometimes extended trips are those who travel around carrying their belongings in a backpack. Many backpackers live on a low budget and some may seek employment while travelling. With the increase in youth travel, backpacking gained momentum in the 1990s to such an extent that it has now become mainstream among many young people. Backpackers vary, however, for instance in nationality, age, gender, stage in their life cycle and motivation for travelling. A relatively small group adopt the travelling lifestyle for years. These so-called ‘drifters’ (4) are similar to members of the hippie counterculture of the 1960s to the 1970s in their departure from the lifestyles of mainstream society (Cohen, 2011).
Problem drug users
Problem drug use is defined by the EMCDDA as injecting drug use or long-duration/regular use of opioids, cocaine and/or amphetamine. According to Focal Point reports, there are several reasons why problem drug users may travel to another country, such as to: •    ccess drug treatment programmes or harm reduction services (such as needle exchanges or  a injecting rooms) that •  – are unavailable in their home countries or   •  – have opening hours that are more convenient for drug users who are employed or •  – will enable them to hide their problem drug use or escape from their social environment because of the geographical distance;
(2) Young people were defined in that report as those aged 16–29, although certain sections of the report presented data referring to other age groups. (3) In addition, youth lifestyles, including travelling, are also found among older age groups. (4) Not only backpackers, but also ocean yacht cruisers and caravanners.
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•    scape legal and social problems connected with their drug use; e •    arry out illegal activities related to their drug use (such as dealing); and/or c •    ccess drugs that are expensive or unavailable in their home countries. a Most problem drug users, however, have limited financial means. Travelling for longer duration or distances, therefore, may be proportionately more likely among socially integrated than socially marginalised drug users (Gyarmathy and Neaigus, 2005). Information is scarce on problem drug users travelling to access treatment, which may reflect the fact that this type of travel is relatively limited. Several examples, however, have been provided by reporting countries that indicate that this phenomenon does exist. For example, the focal point in Cyprus reported that 30 nationals from Greece received treatment, including detoxification with Suboxone (buprenorphine and naloxone) and naltrexone implants, at a therapeutic programme in Cyprus in 2010. Some problem drug users from France (including those from non-border areas) reportedly travel to Belgium to obtain treatment with methadone. These include professionals who travel abroad for purposes of discretion, or because the opening hours of French treatment centres are inconvenient for those who have working hours with limited flexibility. There are also reports that about one in five clients of the safer injecting facility in the German city of Saarbrücken is a French national. Although they cannot officially access the centre, their presence is tolerated. Some Hungarian injecting drug users are sent by their families to receive treatment in western Europe in order to break off social ties with their injecting friends (Gyarmathy and Neaigus, 2005). In addition to travelling to other countries within Europe, problem drug users may travel within their country or to destinations outside Europe. For example, socially marginalised injecting drug users may travel extensively within Hungary during poppy season around May and September to milk poppies and make their own drugs (a phenomenon referred to by drug users as ‘country tourism’), to participate in residential drug treatment or to visit relatives (Gyarmathy and Neaigus, 2005). Lithuanian drug users who inject liquid drugs travel from Vilnius to surrounding settlements in order to purchase cheap drugs in pre-loaded syringes (Gyarmathy et al., 2010). Some of the injecting drug users in a drug treatment programme in Slovenia (Kostnapfel et al., 2011) reported travelling to distant locations, such as Asia or America. The majority had obtained a medical certificate to be allowed to transport their substitution medications.
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3. Examples of drug-related destinations
Certain groups of travellers may seek out destinations with the specific goal of either using drugs or engaging in activities that involve drug use (5). Such locations include those where drugs are more available than in the home country or that are famous for their music festivals, clubs and party scenes. Focal points report that problem drug users may choose certain destinations because those destinations offer drug treatment and/or harm reduction services that are unavailable in their home countries or to distance themselves from their drug-using friends. Amsterdam in the Netherlands and Prague in the Czech Republic are sometimes mentioned as examples of European destinations where travellers may use drugs. According to media reports (6), Amsterdam receives 4.5 million tourists from abroad annually, about a quarter of whom visit coffee shops. These are establishments where patrons can purchase cannabis for personal consumption. About a quarter of Dutch municipalities have at least one coffee shop, although the number of shops has dramatically decreased in recent years — from about 1 200 in 1997 to about 640 in 2011. It is also foreseen that, in the near future, Dutch coffee shops will no longer be accessible to travellers from foreign countries (see below). According to the Czech national focal point, Prague is sometimes referred to as ‘little Amsterdam’ by people who travel there with the purpose of obtaining methamphetamine (Pervitin). Drug users from neighbouring countries (especially Germany and Slovakia) visit Prague and border areas to procure this drug and then return to their home countries with quantities not exceeding the legal threshold for personal use in the Czech Republic. Ibiza, one of the Spanish Balearic Islands, is referred to as the party capital of the world for its lively electronic music scene. Since the late 1980s, top DJs within the electronic dance music genres of house, trance and techno have come to the island to play at various clubs, attracting crowds of young people from around the globe who love dancing and partying and who, in some cases, also use legal or illegal substances. In addition to Ibiza, several other locations and cities throughout Europe — such as Amsterdam, Athens, Barcelona, Berlin, Budapest, Munich and Mykonos — are dubbed ‘party capitals’. In many countries, there is a large variety of music festivals featuring all musical styles (see Box ‘Examples of European music festivals’). Many of these festivals are several days long and attract tens or even hundreds of thousands of visitors from different countries. Several holiday locations in Europe also attract young people to a busy nightlife scene comprising many clubs, hosted by top disc jockeys (DJs). Some young people may extend their time abroad by mixing holiday travel with paid casual work in foreign bars and nightclubs (Hughes et al., 2004).
(5) The term ‘alcotourism’, for example, refers to trips made for the main reason of drinking — often excessive quantities of — alcohol (Bell, 2008). Some holiday destinations are promoted for their possibilities of or permissiveness towards excessive drinking. (6) www.rnw.nl/english/article/foreigners-not-welcome-coffee-shops
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Examples of European music festivals Some of the most popular and best-known music festivals and parades in Europe are the Donauinselfest in Vienna, Austria, featuring an extremely broad range of musical genres and hosting an estimated 3 million visitors; the Zurich Street Parade in Switzerland in August; and the Lake Parade in Geneva, also Switzerland, in July. The last two report around a million visitors each. There is also a range of large electronic music festivals across Europe, such as the Paris Techno Parade in France in September with half a million visitors; the Sziget (Island) Festival in Budapest, Hungary, in August with about 400 000 visitors; the Exit festival in Serbia with about 200 000 visitors; the Glastonbury festival in the UK with about 130 000 visitors; the Sonar Festival in Barcelona, Spain, in June with about 85 000 visitors; the Fusion (Фузион) Festival on the former military airfield in Lärz, Germany, with 60 000 visitors; Nature One with over 60 000 visitors in the Frankfurt area in Germany; the Monegros Festival in the desert of Spain in June with about 40 000 visitors; the Loveland Festival near Amsterdam in the Netherlands with about 20 000 visitors; and Love Family Park in the Frankfurt area of Germany with about 15 000 visitors. The Outlook Festival in Croatia is recognised in its fifth year as Europe’s largest bass music and sound system culture festival. At many of these events, the majority of visitors are not local, but from abroad.
Crossing borders to attend nightlife events or music festivals is common in different parts of Europe. For example, information provided by the French national focal point indicates that, because of longer operating hours, less rigorous enforcement of age restrictions and, sometimes, cheaper drugs available in the neighbouring countries of Belgium and Germany, a majority of drug users and drug dealers at some events in these countries can be French nationals. They represented, for example, about 70 % of people arrested for drug use in music venues in the district of Tournai in Belgium in 2010. French dealers who specialise in supplying the mostly French party crowd with large amounts of drugs have also reportedly replaced the drug users who sold small quantities to fund their partying. On the southern side of the country, trips to Spain — mainly Barcelona — to attend large electronic music events are viewed as an initiation rite for many young people from Toulouse (the French city nearest to Spain), whereas during the grape harvest many Spanish party enthusiasts travel to the Bordeaux area for open-air gatherings in rural areas.7
Policing the party scene The ‘Free Party Movement’ started in the United Kingdom in the 1980s, and grew from smaller dance events to large techno-parties or raves, associated with the use of ecstasy. A week-long party with 25 000 people in Worcestershire in England, however, resulted in great public outrage and strong legal regulations governing such events (7). This was followed by an internationalisation of the music scene with parties being held ever more widely across Europe, and people travelling across borders to participate. Legal sanctions to curb the sometimes out-of-control parties were also used in other countries but they often pushed them across borders within Europe. For instance, the purpose of the French application order of 2002-887 (Mariani et Vaillant) was to break down large parties into relatively smaller ones, but it also sent many of the events and their visitors to neighbouring countries such as Spain and Germany.
(7) According to the UK focal point, however, raves have again become increasingly popular in the past 5 years in the UK, with at least one of them happening a week in London.
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Party destinations exist outside Europe as well. For example, the state of Goa in India became one such place during the 1970s and 1980s and turned from a ‘hippie paradise’ to a party scene, with trance and rave music (Saldanha, 2001). These parties typically take place in the northern Goa beach areas, with media reports of organised crime groups supplying drugs to an international group of young people (8). In addition, certain beaches in Thailand are also popular party destinations.
(8) http://articles.timesofindia.indiatimes.com/2011-01-24/goa/28372846_1_foreigners-russian-mafia-sunburn
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4. Prevalence of drug use among young travellers
Drug use surveys among travellers are not plentiful. Only a few research groups in Europe study the issue, and those that do tend to concentrate on young people. This section examines the prevalence of drug use among European holidaymakers aged 16–35, young backpackers, and young clubbers and partygoers.
Young holidaymakers in Europe
A research group in the United Kingdom has conducted extensive and repeated studies on young European travellers and their drug-using behaviour (Bellis et al., 2003, 2007, 2009; Hughes et al., 2004, 2008, 2009, 2011). One of the group’s recent studies (Hughes et al., 2011) was among British and German holidaymakers (the highest proportion of international visitors to the Mediterranean) in airports in Cyprus, Greece, Italy, Portugal and Spain. Researchers approached all individuals who appeared to be aged 16–35 and who were travelling without children or older relatives. Of these, about two-thirds agreed to complete an anonymous self-administered questionnaire, giving a fairly unbiased sample of over 6 500 holidaymakers who travel by air to Mediterranean holiday destinations. Results included: •    bout one in five participants reported the use of illicit drugs at least once in the past 12 months  A in their home countries (12 % reported using cannabis only and 8 % reported using other drugs), with higher prevalence rates among UK than German nationals. •    ne in ten reported the use of illicit drugs during their holiday. Among those who used illicit  O drugs while on holiday, 87 % had used cannabis, 32 % ecstasy, 18 % cocaine, 6 % ketamine, 6 % amphetamine and 4 % gamma-hydroxybutyric acid (GHB). The prevalence of drug use varied by travel destination, but differences between UK and German nationals were less pronounced than at home. •    lcohol was used by almost all the holidaymakers (95 %), with 78 % of UK nationals and 61 %  A of Germans reporting that they had been drunk at least once during their stay. Furthermore, regular drunkenness (being drunk on at least half of the days of stay) was common, reported by 45 % of UK nationals and 24 % of Germans. Another study combined cross-sectional survey methods with ethnographic fieldwork to assess excessive drinking and drug use among over 1 000 young Danish holidaymakers in Bulgaria (Hesse et al., 2008): •    he ethnographic fieldwork delineated the role of travel agencies promoting package travel:  T many agencies promoted their packages with party activities, ‘pub crawls’, drinking games and a clear focus on drunkenness and sex. •    ver half (59 %) of package travellers drank 12 or more units of alcohol 6–7 days a week,  O compared with only about a quarter (27 %) of other travellers.
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•     minority of holidaymakers (about 2.7 %) reported the use of illicit drugs. Whereas excessive  A alcohol use might be encouraged, there are sanctions against illicit drug use: tourist caught taking illicit drugs lose the wristbands that enable them to access bars and discos for free.
Young backpackers
There is a scarcity of data on drug use among young backpackers, but the available evidence suggests that it might be more common among them than among young people in the general population, both while they are at home and while they are travelling. One study recruited about 1 000 young UK residents from backpacking hostels in Australia — a favourite destination for this population — to examine their drug use (Bellis et al., 2007). The researchers reported an almost ninefold difference in past-year ecstasy use among the sample compared with young people in the general population of England and Wales (34 % vs. 4 %). Results also showed: •    hile still in their home country, over two-thirds had ever used cannabis (over a quarter using  W weekly); about half had used ecstasy (one in ten using weekly); about a third had used cocaine (about 4 % using weekly); and about a quarter had used amphetamine (about 4 % using weekly). •    hile in Australia, half had used cannabis (about a third using weekly); about a third had used  W ecstasy (one in ten using weekly); and about 7 % had used cocaine or amphetamine (about 1 % using weekly) (9). About 3 % of participants reported using ecstasy and cannabis for the first time while travelling. When comparing the frequency of drug use while at home with that while travelling, three different patterns were identified: unchanged frequency of use, using more often while travelling and using less often while travelling: •    ost users (about half of cannabis users and about two-thirds of ecstasy, cocaine and  M amphetamine users) reported that drug use frequency was unchanged compared with that in their home country. •    annabis users were more likely to indicate an increase (28 %) rather than a decrease (16 %),  C whereas ecstasy, cocaine or amphetamine users recounted decreases more often than increases. In summary, only a small proportion reported using a drug for the first time while travelling in Australia and most drug users reported an unchanged frequency of use compared with home. Cannabis users were more likely to increase rather than decrease their drug use, whereas users of ecstasy, cocaine or amphetamine were more likely to report a decrease rather than an increase in the frequency of use compared with their use at home.
(9) The use of any illicit drug was higher among males, those who were surveyed in Sydney, those who had travelled without a partner or spouse, those who stayed in Australia for a longer time, those who spent a higher number of nights clubbing and/or those who drank alcohol or smoked tobacco daily.
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Young clubbers and partygoers
Several studies have shown that people who visit clubs, parties, music festivals and dance events are more experienced with the use of drugs than other young people (Measham et al., 2001; Van Havere et al., 2009, 2011). The combined use of alcohol and illicit drugs at party scenes is also a public health concern (Van Havere et al., 2011). Drug use among partygoers, however, varies widely based on music preference and venue choice (Calafat et al., 2008). A study assessing past-year drug use among visitors of music events in Belgium showed, for example, that, although alcohol was the most common drug used (92 %), the majority of respondents (52 %) reported having used at least one illicit drug (Van Havere et al., 2011). The majority of Goa partygoers (four out of five) reported having used at least one drug during the past year. Overall, cannabis was the most frequently used illicit drug during the past year (44 %), followed by ecstasy (19 %) and cocaine (17 %). The proportion of those using drugs during electronic music dance events may vary widely, with studies reporting 10 % testing positive for drug metabolites (Gripenberg-Abdon et al., 2012), and half reporting the use of ecstasy during an event and using an average of five drugs at the same time (Fernandez-Calderon et al., 2011). Ibiza and Majorca are two of the largest Balearic Islands. Despite their geographical proximity, however, the two islands offer different activities for their visitors. Ibiza, as described earlier, is famous for its nightlife and electronic music scene, whereas Majorca attracts holidaymakers mainly because of its warm weather and natural beauty. A study in 2007 compared drug use on Ibiza and Majorca among just over 3 000 young UK, German and Spanish visitors (Bellis et al., 2009; Hughes et al., 2009). Results included: •    isitors to Ibiza were more likely than visitors to Majorca to have used illicit drugs both in their  V home countries in the past year and while on holiday. For example, one-third of UK nationals in Ibiza reported using ecstasy (vs. 7 % in Majorca) and cocaine (vs. 9 %) at home, 20 % used cannabis (vs. 14 %) and 8 % used ketamine (vs. 2 %). •    hile on holiday, 54 % of UK nationals in Ibiza and 14 % in Majorca reported using any illicit  W drug: 44 % vs. 4 % reported using ecstasy, 34 % vs. 8 % cocaine, 20 % vs. 10 % cannabis, 14 % vs. 2 % ketamine, and 5 % vs. 2 % amphetamine. •    hile on holiday in Ibiza compared with Majorca, 20.3 % vs. 12.4 % of UK nationals, 5.2 %  W vs. 4.2 % of Germans and 15.4 % vs. 9.5 % of Spaniards had used at least one illicit drug they had not used previously. •    hereas 95 % of all interviewees reported drinking at least some alcohol while on holiday, UK  W nationals were the most likely and Spanish nationals were the least likely to get drunk. Regular drunkenness (being drunk on five or more days a week) was reported by 61 % of UK nationals and 7 % of Spaniards in Majorca, and 53 % of UK nationals and 15 % of Spaniards in Ibiza. Overall, among visitors in Ibiza the prevalence of drug use during this holiday period was higher than past-year prevalence at home for all drugs except cannabis, whereas among visitors in
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Majorca there was a detected increased use of only alcohol and tobacco. A significant proportion of the visitors, especially from the UK, had used a new drug while away from home. The results from the same team of researchers’ earlier studies in 1999 and 2002 show that those who used drugs in Ibiza were more likely to indicate excessive use than when using in the United Kingdom (Bellis et al., 2003): about half of cannabis users and ecstasy users, and about a quarter of cocaine users — especially if they had been to Ibiza before — reported using on five or more days a week. The prevalence of drug use and the types of drugs used among young visitors to Ibiza reported in 2009 are similar to those reported from these earlier studies, indicating that Ibiza is an established location for drug use related to extensive clubbing and partying.
Drug use among casual workers at international nightlife resorts A study compared the drug use of young UK tourists working in bars and nightclubs at an international nightlife resort in Ibiza with that of individuals visiting the island solely for the purpose of vacationing (Hughes et al., 2004). Workers were more likely than visitors to have used drugs at home during the past year. For example, about 80 % of workers reported using ecstasy (vs. 40 % of visitors), cocaine (vs. 33 %) and cannabis (vs. 46 %) at home, and 51 % used amphetamine (vs. 16 %) and ketamine (vs. 9 %). While on the island, a higher proportion of workers than visitors reported drug use: 91 % vs. 41 % reported using ecstasy, 87 % vs. 22 % cocaine, 82 % vs. 35 % cannabis, 71 % vs. 7 % ketamine, and 44 % vs. 7 % amphetamine. Some of these differences, however, might be explained by the different length of the stay; the average stay on the island was 100 days among workers and 7 days among visitors. The average number of different illegal drugs used was higher among workers than among visitors (5 vs. 2 both at home and on the island).
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5. Risks associated with drug use while travelling
The literature accessed for this publication identifies several risks that drug-using travellers take: health risks, risks related to personal safety, legal risks and those related to drug injecting. While many of the risks are general risks related to drug use, there are some that are specific to the phenomenon of travelling, for example the risks to the local communities affected by drug-using visitors, which are also discussed in this section. The combination of drug use with alcohol, especially with excessive drinking, may increase some of the risks described below.
Health risks
Being under the influence of drugs while on holiday may result in consequences ranging from minor medical conditions to major physical and mental health problems or death. Minor medical conditions include sickness, diarrhoea, hangovers, headaches and sunburn (10) (Elliott et al., 1998). Dehydration may result from overexposure to the sun, diarrhoea, vomiting and excessive perspiration without adequate hydration while using stimulants and dancing for a prolonged period of time. The Spanish focal point gave an account of cases that were handled by hospital emergency services in Ibiza in 2010: •    f a total of 805 medical emergencies, 33 % were patients from other countries, with this  O proportion peaking in the summer months. •    he majority of individuals were between the ages of 20 and 30, and 68 % were female. T •    rugs played a major role in these hospital emergencies: 41 % of the interventions were due to  D cocaine use, and 26 % were due to amphetamines or designer drugs. Consuming drugs of unknown purity in an unfamiliar environment may lead to unwanted physiological and cognitive damages or even overdose. This may be a particular risk for travellers who have no previous experience of the drugs they use while away. To prevent such consequences, some drug users may opt to use drugs they consider safer, such as cannabis, which is seen by some as a drug that allows users to ‘stay in control’ (Bellis et al., 2007). While travelling, some users may use drugs excessively or consume a wider array of substances than they do at home, or use them in combination or while drinking alcohol excessively (Bellis et al., 2003). Although they may revert to different patterns of use when returning home, the cumulative effect of consuming large amounts of a range of substances — in some cases nightly, for possibly as long as several weeks — may exacerbate adverse physical and physiological effects of the drugs. Being under the influence of drugs or alcohol while travelling on holiday may lead to unprotected sex, the consequences of which include acquiring or spreading sexually transmitted diseases.
(10) From failing to use sunscreen or falling asleep in the sun under the influence of drugs.
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Although sexual activity may diminish among those who use drugs while travelling, there are indications that sexual risks increase among young travellers under the influence of drugs and/or alcohol. A study assessing sexual risk among tourists found that 34 % of those who engaged in sexual activities while on vacation did so without using condoms, and unprotected sex was associated with using illegal drugs (Downing et al., 2011). For example, they may engage in casual, unprotected sexual activity with several new partners (Hughes et al., 2009) and the involvement of drugs in so-called ‘date rapes’ is well established (Jansen and Theron, 2006).
Risk related to personal safety
Being intoxicated with drugs or being drunk can lead to compromised personal safety. In studies of young holidaymakers in Spain (Hughes et al., 2008, 2009, 2011), up to 11 % of respondents (21 % of UK males in Majorca) reported being involved in fights — the majority against strangers of their own nationality. In addition, 13 % reported being victims of unintentional injuries and up to 11 % were robbed. Being involved in these incidents had a high correlation with regular drunkenness but also with drug use while on holiday: 92 % of those who reported being in a fight were under the influence of alcohol, and 9 % had been using drugs. In addition, many times the victims of fights were also under the influence of alcohol or drugs. The Spanish National report recounts the practice of ‘balconing’, when drunken young people climb from one hotel room to another or jump off from hotel balconies to swimming pools — an obviously dangerous activity. An inability to handle dangerous situations, such as overcrowding at large music festivals, may be another consequence of drug or alcohol use while travelling. For example, the annual Love Parade was a popular event in Duisburg, Germany, for over 20 years, until its final year in 2010, when a stampede caused the death of 21 people and led to the hospitalisation of 473 who were injured — 30 % of whom tested positive for drug metabolites (Ackermann et al., 2011).
Legal risks
Violation of the destination country’s drug laws is another issue for drug-using travellers (Uriely and Belhassen, 2006). Young tourists may not consider purchasing drugs as risky, especially in drugrelated destinations, perhaps thinking that drug use is tolerated among tourists and that they will not be arrested by local police or when smuggling drugs in and out of the country.
Risks related to injecting drug use
Bridge populations are people who connect groups that have lower infection prevalence to high-prevalence groups, which otherwise would be separated either by geographical distance or by the separation of social and risk networks. Injecting drug users who travel — such as those who move between eastern and central European countries — may form geographical bridges between higher and lower HIV/hepatitis C virus prevalence groups (Gyarmathy and Neaigus, 2005). Some of the injecting drug users in a drug treatment programme in Slovenia (Kostnapfel et al., 2011)
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reported travelling to distant locations, such as Asia or America. Finding drugs at the destination was regarded as easy, but difficulties in accessing sterile injecting equipment prompted them to share syringes with unknown drug users.
Risks to local communities
Tourism brings income to the host countries. For example, in 2009 Spain was ranked second in the world as regards revenues from international tourism (UNWTO, 2012), and both Spain’s eastern Mediterranean coast and southern Spain specialise as holiday destinations for young people who associate tourism with recreational nightlife. Travel and related drug use, however, can cause problems at the destination, including public nuisance and changes in the way of life of locals. For example, on the island of Ibiza, 80 % of 17-year-olds have already been to a discotheque, even though they would not be allowed to do so by law (Villar, 2008). The Greek National report presented the results of a study in the town of Pythagorion on the island of Samos, which revealed that local residents perceived drug use as worsening as a result of tourism. Local public health and social services are put under pressure by dealing with the effects of drugs on some users. For example, the national focal point in Spain recounted that private medical insurance policies do not cover the expenses arising from drug-related problems, so these patients are delivered to public hospitals in the event of drug-related emergencies. In these hospital settings, the language barrier often hinders communication with the patent and thereby diagnosis, making medical caretaking longer, or — if international calls or interpreters are required — very costly. Complications may happen while still in the hospital as a result of scant or misinterpreted information from the patient. Difficulties after being released from the hospital include seeking money or support to be able to return to the home countries (11). Local communities may complain about public nuisance related to drug use, especially drug tourism. In Prague, Czech Republic, special healthcare facilities exist for short-term detoxification of people involved in public nuisance as a result of being intoxicated with psychoactive substances. Foreigners made up 1 011 out of 12 720 individuals (7.9 %) treated at sobering-up stations in 2010. In relation to public nuisance related to drug tourism, two Dutch municipalities near the border closed all their coffee shops and, in Maastricht, five coffee shops were relocated from the town centre to the peripheries, to make them less easy for visitors from across the Belgian and German borders to access (Monshouwer et al., 2011). In addition, Maastricht and other border municipalities have introduced a number of measures to curb drug tourism related to coffee shops, including the restriction of sales to foreign nationals (12). The Dutch national focal point reports that the Dutch government reserved EUR 3.3 million for municipal pilot projects to evaluate the effect of these new measures to combat public nuisance related to drug tourism. One of these projects evaluated the effect of the new restrictions in Roosendaal and Bergen, towns located at the Belgian border, and found that 6 months after the closure of the coffee shops the number of foreign drug tourists had diminished by 90 % and the reported public nuisance and street trading had declined
(11) For more information: www.irefrea.org/uploads/PDF/informe%20urgencias.pdf (12) http://curia.europa.eu/jcms/upload/docs/application/pdf/2010-12/cp100121en.pdf
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considerably. The National report contrasted border towns with Amsterdam, where locals feel that tourists do not cause much public nuisance. Therefore, instead of establishing a closed coffee shop system catering only to Dutch nationals, Amsterdam’s mayor called for regulating cannabis cultivation. Certain districts such as the Amsterdam quarter of De Baarsjes, however, implemented a special street security system paid for by the coffee shops with the aim of maintaining order in public spaces by addressing antisocial behaviour and cleaning the streets daily.
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6. Potential for prevention interventions
Preventing drug use and associated risks among travellers raises two main considerations. First is the question of whether prevention efforts should take place in the home country or in the destination country: in both locations, it is difficult to find the appropriate target group, as not all travellers use drugs and not all drug users travel. Second, prevention interventions for different target groups of travellers require different strategies and involve different messages. Therefore, much of the currently available prevention strategies may be restricted to information provision, while other forms of prevention, such as environmental approaches or policing, may also be useful. Illicit drug use and drinking alcohol in nightlife settings may carry several risks. As these substances are often used in combination, preventive measures in recreational settings should aim to address them together. As the EMCDDA (2012) paper on responding to drug use and related problems in recreational settings concludes, the traditional approach of information provision must be replaced by a combination of prevention, harm reduction, legislation and law enforcement efforts. The publication also underlines the importance of environmental strategies, including but not limited to the role of nightlife staff and the physical context in which drug use may take place. As most of the young people who use drugs while travelling have also used drugs at home, interventions aimed at them should take advantage of their existing levels of awareness and beliefs (Elliott et al., 1998). These could involve prevention materials at the destinations and peer educators to increase the credibility of the messages. For these initiatives to be successful, collaboration is needed between health authorities and the stakeholders in the travel industry, both in the countries of origin and at the destination locations. In addition, interventions should take into account that there are different traveller populations with different substance use behaviours and different needs, and these differences should be addressed appropriately. For example, certain drugs may cause feelings of euphoria, whereas the use of others may result in aggression. Given this, prevention interventions may choose to focus on drugs such as cocaine (alone or in combination with alcohol) in order to decrease violence in the nightlife environment (Bellis et al., 2003). According to the Spanish National report, some large discotheques have engaged companies that provide private medical services. This enables clubs to deal effectively with emergencies due to excessive drinking or drug use that do not require hospitalisation. Electronic media, such as the Internet and text messaging, are other promising venues for interventions. Information on the effects of drugs that are available at different travel destinations could be placed on social networking websites and forums used by travellers, and on websites that advertise events where a sizeable proportion of attendees are expected to use drugs. Travellers could sign up to a service disseminating drug-related information by text messages. In addition, such information should also be available at airports and at travel agencies, and at stores that are used by those planning to travel, particularly to drug-related destinations (Uriely and Belhassen, 2006). All these methods should also be used to ensure that travellers who use drugs at their destination are aware of several aspects of drug use, including the local policy and law related to drugs, and access to local emergency and care services.
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Drug services should provide information for their clients who travel, to explain the legal and health risks involved in using drugs abroad, how to get help in an emergency situation, and the location of needle exchanges. These services also should inform their clients who intend to travel about the procedures for taking supplies of their substitution medications and injecting equipment with them (Kostnapfel et al., 2011). Further research and needs assessments could identify a profile of those who are likely to use drugs while travelling and the risks they may take, and information could be specifically developed for them (Bellis et al., 2007). Such tailored approaches have been found to be much more effective than the provision of ‘one-size-fits-all’ information that ignores the specific needs and characteristics of different target groups (EMCDDA, 2008).
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7 Conclusions .
This publication has examined drug use in the context of travelling, examining some data on populations who travel, the destinations they travel to, the prevalence of drug use among different youth travelling populations, the risks involved in using drugs while travelling, and the potentials for prevention. Its goal is to increase the interest in this topic both in terms of research and of developing adequate responses to problems related to drugs and travel. One of the consequences of the growth of travel in recent decades is an increase in the number of young people travelling for longer periods of time. Travellers are, however, not a homogeneous group. There are subgroups of travellers, based on, for example, their travelling style (such as backpackers on a low budget) or their risk profiles (such as problem drug users or those visiting drug-related destinations). Drug use is more common among some groups of travellers and at some destinations. For example, drug use among backpackers is higher than among the general population, and drug use among partygoers in Ibiza is more common than among holidaymakers in Majorca. Certain travel destinations across Europe have a reputation of having a wide availability of a range of drugs. These include party locations, electronic music festivals and the nightlife scene on certain Mediterranean islands. While some countries have reacted with legal regulations to curb the public nuisance related to loud music and large numbers of unruly people under the influence of an array of illicit substances, these sanctions often led to an internationalisation of such parties. For example, it is common in the border areas of several western European countries to cross the border for a night or a weekend of partying, including illicit drug use. Other destinations where drugs are available include coffee shops in the Netherlands, where patrons can buy cannabis. In the Czech Republic methamphetamine, a drug otherwise relatively rarely available in most of Europe, is a rather common illicit drug that may attract drug users from neighbouring countries. Several risks are associated with taking drugs while travelling, ranging from minor medical conditions to major health problems. While some of these risks are related to drug use in general, others are specifically liked to the phenomenon of travelling. Using drugs of an unknown quality, which is a risk both at home and while travelling, may lead to physiological damages or overdose. Excessive drug use, even for a short time, may exacerbate any adverse physical and physiological effects of drug use. Travellers who use drugs may also violate the drug laws of the host country regarding purchase, possession, consumption and smuggling. Sexual activity while under the influence of drugs carries the risk of acquiring and/or transmitting sexually transmitted diseases, and sharing injecting equipment may contribute to the spread of HIV, hepatitis C virus and other blood-borne infections. Preventing these risks requires collaboration between health authorities and stakeholders in the tourist industry. Local communities may also be negatively affected by drug-using travellers. Although travel and tourism bring income to the host countries, small populations in tourist destinations may have a large influx of visitors who may have very different cultural norms. This may obviously have several
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implications for local policies and services. For example, some visitors’ drug use may lead to antisocial behaviour and public nuisance. There may also be an increase in the number of people requiring health and social services. These situations put pressure on the local law enforcement, health and social services. There is, however, little information about how drug-using tourists affect local communities across different countries and locations within Europe. Travel, of course, is not necessarily associated with illicit drug use. Rather, those who travel behave similarly to the way they behave at home: those who use drugs at home are more likely to use drugs while away and those who are abstinent at home tend to remain abstinent while travelling. In addition to such personal background behaviour, drug use during travel may increase, decrease or stay the same as it was at home, depending on the destination, the reasons for visiting it and the availability of drugs there.
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Acknowledgements
Author: V. Anna Gyarmathy (EMCDDA) Editor: Jane Fountain (University of Central Lancashire) Contributors: Renate Hochwieser, Dominique Lopez, Frank Zobel (EMCDDA) The EMCDDA would like to thank the heads of participating Reitox national focal points and their staff, and the services within Member States that provided the raw data, for their help in producing this Thematic paper.
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Legal notice
This publication of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is protected by copyright. The EMCDDA accepts no responsibility or liability for any consequences arising from the use of the data contained in this document. The contents of this publication do not necessarily reflect the official opinions of the EMCDDA’s partners, the EU Member States or any institution or agency of the European Union or European Communities. A great deal of extra information on the European Union is available on the Internet. It can be accessed through the Europa server (http://europa.eu). © European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2012 Cais do Sodré, 1249–289 Lisbon, Portugal Tel. (351) 211 21 02 00 • www.emcdda.europa.eu This publication is available in English. Cataloguing data can be found below. Reproduction is authorised provided the source is acknowledged.
About the EMCDDA The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is one of the European Union’s decentralised agencies. Established in 1993 and based in Lisbon, it is the central source of comprehensive information on drugs and drug addiction in Europe. The EMCDDA collects, analyses and disseminates factual, objective, reliable and comparable information on drugs and drug addiction. In doing so, it provides its audiences with an evidence-based picture of the drug phenomenon at European level. The Centre’s publications are a prime source of information for a wide range of audiences including policymakers and their advisors; professionals and researchers working in the drugs field; and, more broadly, the media and general public. The EMCDDA Thematic papers are scientific reports on selected, theme-based aspects of the drugs phenomenon. The series makes available the results of research carried out by the agency and its partners to a target audience of specialists and practitioners in the drugs field, including scientists, academics and policymakers.
Cataloguing data
European Monitoring Centre for Drugs and Drug Addiction Travel and drug use in Europe: a short review Lisbon: European Monitoring Centre for Drugs and Drug Addiction 2012 — 24 pp. — 21 x 29.7 cm ISBN 978-92-9168-558-5 doi: 10.2810/72199 TD-XA-12-004-EN-N

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