CPG Meeting Opening remarks and formalities

Peredur Owen Griffiths MS welcomed everyone to the fifth meeting of the Cross Party Group on Substance Use and Addiction and thanked all of those involved in the life saving work of supporting those with substance use and addiction issues.  

This event sought to explore the unique challenges faced by people who use Image and Performance Enhancing Drugs, and also the subset of the LGBT+ community who participate in Chemsex.

Richard Amos

Richard Amos from the Gwent Drug and Alcohol Service (GDAS) spoke on IPEDs.

Richard spoke about the routes into Image and Performance Enhancing Drug (IPED) use, including both body dysmorphia and the pressure of competitive sports.  He used his lived experience of being a high performing sports person who suffered injury to illustrate the temptation and societal pressures to use IPEDs to hasten recovery from a range of injuries including (in his case) cruciate ligament damage and the need for bone marrow and stem-cell transplants.

Richard explained how typically service users take multiple drugs depending on where they are in the competitive cycle of their sport of choice.  He described the sequencing of different IPEDs to compliment one another and how the calendar of drug use fits around competition and performance.  He described the different drugs that you use at the end of the cycle of testosterone use, including anti-breast cancer drugs, rest and recovery drugs.

He used his own experience to illustrate the psychological and social pressure to achieve physical extremes.  When preparing for the Mr Wales bodybuilding competition he ate just broccoli and chicken for 8 weeks achieving a 5.2% body fat ratio.  He shed fat off his internal organs and overstretched to the extent of passing blood.

Whilst harm reduction advice and services do exist for IPED users – particularly in terms of needle exchanges (NSPs) since IPEDs are typically injected, there remains a hierarchy of substance use.  IPED users look down on other service users, or disassociate themselves from ‘drug users’ because they don’t conform to the same physical and cultural stereotypes.

As a result of this IPED users can be resistant to engaging with harm reduction services, which leaves them vulnerable to the consequences of the criminal activity in IPED supply.

There are 3 types of steroid – those clinically designed and manufactured for human consumption (which can be supplied medically, but not legally sold on a commercial basis), those clinically designed for veterinarian use, and those made in underground laboratories, uncontrolled, unsupervised, often involving complex criminal networks.

Richard illustrated the challenges facing IPED users in sourcing ‘legitimate’ IPEDs clinically controlled and intended for human use by giving out 6 sets of empty packaging and asked people to assess if they are legitimate or fake. There was one clinically approved set of packaging, but all had a variety of legitimising markings, holograms, braille, medical advice leaflets, QR codes to health websites etc, which showed the extent to which criminal gangs will go.  These complexities place IPED users at risk of extreme harm.

Richard noted that a pharmaceutical steroid might cost £2 for 2ml.  However on the black market 2ml (whether real or fake) could trade for £25 to £50, which illustrates the appeal to the criminal gangs.

Richard concluded by talking about the campaign to raise awareness of the role of diminishing testosterone levels in men in mental health issues.  He expressed the ambition that in Wales the NHS start to test for testosterone levels in men who manifest issues such as depression, loss of energy, low libido and problematic thoughts which are often misdiagnosed as being in need of anti-depressants and mood stabilisers, with a view to increasing testosterone prescribing in suitable cases.  Currently studies overseas suggest that a portion of male suicide might be caused by or triggered by responses to low testosterone levels.

The audience asked what the cases were for the legitimate prescription of steroids?

Richard replied they were used in cases of coma, muscle wastage, HIV and other wasting conditions.

One of the audience commented that this was similar to HRT for women, who similarly get misprescribed and misdiagnosed.

Richard described how perimenopausal women have faced this for many years, and that issue is only now starting to be properly recognised.  Male testosterone levels testing remains well behind the curve in terms of awareness and action.

Useful Links: 

·         The GDAS Needle Exchange:

https://www.gdas.wales/reduce-the-harm/needle-exchange

Jack Wilkinson

Jack Wilkinson from the Bristol Drugs Project PRISM Service (BDP) spoke about working with the LGBT+ community in general, and the people who practice Chemsex in particular.

The BDP PRISM Service was set up in 2016 to address the specific barriers that LGBT+ population face.

LGBT+ adults are more likely to use drugs than heterosexual adults (3 – 4 times more likely).

Clear evidence shows that there are systemic barriers to members of the LGBT+ community accessing the health service, including stigma, discrimination and criminalisation.

There is an intersection between the LGBT+ community, substance use, mental and sexual health so there are some common themes, but also complexity.

Chemsex is a term used since the early 2010s, and whilst there are many definitions most agree it entails sex between men, where drug use is used to enhance or prolong sex.  There is a specific set of substances, often facilitated by digital technology, with events lasting for an extended period of time.  An added dimension is one of self acceptance and identity as it often includes  men who have sex with men but who do not identify as LGBT+

Crystal meth is one of the typical substances used during Chemsex.  Although the various App services typically say drugs are not traded via their sites, in fact buying and selling drugs such as crystal meth is often just a few clicks away on an App like Grindr.

In fact Apps specifically designed to promote the dopamine hit you get with the repeated small instant experienced of positive feedback you can get through social media and app use anyway.  In this community this can then lead into contact with and use of these substances.

In summary – there are complex reasons for use and this can make for complex interactions with services.

Chemsex often takes place over a prolonged period, and different substances have different half lives.  Crystal meth can work for 2 to 8 hours for example.  An accompanying problem of the chemsex drugs is they can supress appetite affecting the user’s physical condition and tolerance and response to substances.  Usage can also cause gaps in dosage of medicines taken for health conditions e.g. retrovirals for those with HIV.  This can be coupled with a dominant partner controlling the dosage of the chemsex drugs by a submissive partner which can exacerbate issues of lack of awareness and control of dosage, and also the moral and legal issue around consent both for consumption and for the intimate acts they undertake as part of chemsex.

Other drugs such as GBH and GBL reduce inhibitions increase desire, euphoria, lasting 3-4 hours.  It is very easy to overdose on these drugs, with 1ml able to make a difference between a buzz and dropping into depression. When used along with benzos and alcohol they can have a complicated impact. Sometimes these drugs are used as a date rape drug.  Even with consent just 1ml added to a drink at a party can lead to accidental spiking where someone takes a drink that was not intended for them.

With these factors at play during sessions lasting anything from 12 to 36 hours, the risks of harm increase substantially.

Withdrawal from using some of these drugs can be physical and emotionally difficult, and with limited control over dosage and a multi partner setting; if a person is in a withdrawn state consent can again become an issue.

Another common drug is mephedrone – part of first wave of legal highs in 2010.  A stimulant similar to ecstasy and amphetamine. Often it is cut with caffeine which in turn can lead to multiple days of not sleeping, with the associated physical and mental health impacts of that.

Alongside all of this there is high viagra use to offset negative impacts of other drugs..

These complexities make it challenging to determine how to approach the chemsex community.  It can be useful to approach all substance users as if they could be part of this community.  So for example offering every users in an needle syringe exchange condoms, not just sex workers.  This can provide a route in to a conversation with these communities and the ability to offered tailored Harm Reduction advice as trust and understanding is built.

It can be useful to have a presence at clinics where there are HIV post exposure assessments, again to become known and establish a connection.

Making an effort to keep up with the language used in the community – ‘unblackboxing’ the subject matter and letting service users know we understand and are available.

As some people who practice chemsex don’t identify as gay, ensure all staff are LGBT+ aware in terms of general issues but also specific to drug use and chemsex can be important, as some service users will not present themselves to an LGBT+ dedicated service.

With a community that is this complex it is import to be assertive in the approach to finding people.

·         Whilst hookup app developers like to say no one uses them to sell drugs you can actively reach out and find members of this community on such apps.

·         Go to venues pre-party.

·         Being seen, being known lets people know you are accessible.

·         Having leaflets is quite good for people in a waiting room. Often people in service waiting rooms don’t want to look at other people while they are waiting to ‘have that awkward conversation’ so leaflets can be a useful way in

Fundamentally this is a really difficult substance using group to access, so it takes a long time to establish the service and get people through the door. Persistence is required.

Useful Links: 

·         The Bristol Drugs Project:

https://www.bdp.org.uk/

·         The PRISM LGBT+ service:

https://www.bdp.org.uk/get-support/targeted-support/prism-lgbt/

Peredur asked – From a policy and commissioning point of view if we were talking about how to commission a new service – were IPED and PRISM specifically commissioned or were they driven by demand?

RA – the IPED service was established due to a personal passion based on my lived experience. There was nothing similar in Wales at the point we approached the commissioners.

JW – similar in PRISM – There has in fact been a fresh round of commissioning since PRISM was launched and PRISM was part of a bid that we pledged to provide but was not directly commissioned.  Commissioners view deliverables as being around Blood Borne Virus testing. From a provider’s point of view however it is there to drive support for these communities on a broader scale.

Peredur – How widespread at the problems and what should we be doing in Wales to address them?

RA – IPED user is endemic across the country. Other services have asked to shadow the clinic.  So word is spreading through word of mouth. 30-50% of Needle Syringe Exchange programme (NSP) users in Wales identify as using IPEDs.

RA & JW – said keeping these needs on the agenda even when there are barriers to accessing and supporting these communities that result in services taking time to break down doors and get access can help.

JW – There is nothing particularly revolutionary in our approach so it’s largely down to delivery style and points of access. Offsite working or separate premises – near to gay quarters in town for example.  Providing out of hours NSP programmes helps.  Often in chemsex it is weekends using air bnb when the activities take place.  People are coming down to cities from the valleys to have a great time. We are there when they are there.

Q – how much co production of services is there?

RA – we have a crack user acting as an IPED peer

JW – in PRISM it varies depending when people on their own journey.  At one end you have people who can give cultural sensitivity training and workshops; at the mid-point perhaps the NSP programme.

Q – can you work with the apps at all to reach out to users?

JW commented ‘Maybe they just don’t like me, but they are very closed off’.  RA remarked that IPED using settings such as gyms can vary radically; some welcome the support, others deny any of their customers use IPEDs.

Peredur remarked that ‘perhaps there is opportunity with the online harm bill? We can bring this into that discussion.’

MB – This is similar to the festival issue, where arguably certain sized festivals should be obliged to have a drug service presence at them to be available to the substance using population.  This would also touch on LGBT+ festivals.

Peredur remarked ‘there may be something around planning and licensing for these kinds of events.’

MB – Some events get overbooked for trade stands and we can’t even pay to be there.  We can’t get access to festivals such as Green Man. They won’t let us be there even if we want to pay.  There needs to be some compulsion on the organisers.

Q – how would regulation help with IPED harms?

RA – IPEDs are all a class C.  95% of what is on the street is not clinically tested and designed for human use, and some contain no active ingredient.  I don’t know if regulation could reduce harms as this is still such a new area we are exploring.  Some home made batches of IPEDs are made in a vat or bath, resulting in both under- and over-dose in individual ampules sold so in principle regulated supply could control safety and quality.

MB – what is the role of service identity in getting people to work in this field, and getting service users to engage

JW – designing specific pathways and being cute in design can help.  We have a 50+ service, and LGBT service.  Hiving off specific times of day in a service can help.  Putting the service in a separate building perhaps just over the road and making it visible and discrete.  PRISM is part of Bristol Drugs Project but is very much it’s own thing.

MB – for both these services it seems like a discrete location would help.  Even some cocaine users don’t want to come into main drug and alcohol services.

MB – is there any connection between IPED and Chemsex due to issues around body image?

JW – I don’t have the stats, but yes the stimulants can lead to loss of body mass and so steroids get used to compensate.  Also body image is key – being cute being sexy; being seen.

Comment from the floor - IPEDs 4x more likely in gay community than with straight males

Q – there appear to be so many situations here where stigma can occur, do you have to do something specific to combat that

JW – ensuring there is no knowledge gap anywhere in the service means that workers can work in the normal trauma informed compassionate way to engage with people.

From the floor – a substance misuse and sexual health service – SMASH – was created but died away during covid.  That could be revisited.  Likewise a national IPED training programme could be helpful.

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Peredur thanked the speakers and all the participants for ‘opening up a different world to one I’d had any experience of.  Really helps when exploring the plan for the next 10 years with the Minister.’