Engaging with problem Ketamine users

The use of ketamine has been on the increase in the past few years, particularly on the gay clubbing scene. Although not included in the British Crime Survey (BCS) until 2006/7, when it was made illegal, the proportion of 16-24 year-olds reporting using it ever in their lifetime has gone from 1.3% in 2006 to 2% in 2009/10. Although this may not sound a lot statistically, it equates to around 113,000 persons having used it at some time.

Although most use it for recreational purposes (occasionally, in the context of a night out clubbing) with few problems, anecdotal evidence from outreach workers in several areas is emerging which does give cause for concern. Some ketamine users have developed more chaotic, daily, even dependent patterns of consumption with a range of negative and unwanted side-effects.

What is ketamine

Ketamine is an anaesthetic drug with dissociative properties. First developed in the1960s, it was routinely used in surgery up until the 1980s. Because of its speed of action and safety (unlike traditional anaesthetics it does not affect breathing) it was recommended for use on the very young and the elderly.

Ketamine seems to have the unusual capacity to disconnect the physical being from the psychic self, which some describe as an ‘out-of-body’ experience. This was often interpreted as a near-death experience, although patients were in no physical danger as overdose is very rare. Because of this, ketamine is more commonly used in severe trauma cases, such as burns or traffic accidents.

Although ketamine is not used as a primary anaesthetic in humans it is more widely used in veterinary surgery, which is probably where the popular ‘horse tranquilliser’ misnomer has arisen. As a marketing ploy, something that could knock out a horse sounds like a winner for dealers. Even though it is mainly used on a wide range of small animals, ‘hamster tranquilliser’ just doesn’t have the same ring to it.

Non-medical use of ketamine

The non-medical use of ketamine became popular in the UK in the early 1990s rave scene, often sold in tablet form as ecstasy. These days ketamine is usually sold as ketamine and comes as a white powder that can be snorted (most common), swallowed (less common as it takes too long to work and acts as a laxative!), smoked (rare, as it tastes awful and wears off too quickly) or injected (very rare and not recommended).

When snorted, the effects begin within a few minutes and last around 30-45 minutes, depending on how much is taken. A common method in a club would be to dip the end of a key into the bag of powder and sniff a small amount (around 200mg) from the tip, known as ‘keying’. This short duration of action leads to re-dosing at regular intervals throughout the night. If swallowed, the effects begin around 15-30 minutes and last for 1-3 hours.

What are the effects of ketamine?

Despite what many users feel, ketamine is not a depressant-type drug and does not slow the heart. In fact, at anaesthetic doses it is a powerful stimulant that increases heart rate. However, at low doses the subjective effects of ketamine are experienced as a slowing down and heaviness of the body, what used to be known as ‘sledging’.

Sought after mental effects include a trance-like state, disconnection from the reality, feelings of floating or flying, and visual (sometimes shared) hallucinations. The ketamine experience is very dependent on the environment within which it is taken. Taken at low doses in a club or rave where there is loud music, lighting effects and the buzz of the crowd, it can be stimulating with increased energy and euphoria.

Consumed in a quiet, relaxed setting, at home with friends, users say it can provide a transcendental, spiritual experience, with apparent travel to other worlds and places (the ‘out-of-body’ experience), a welling up of long-forgotten (or suppressed) memories, apparent insight into the nature of existence, distortion of time, and the belief that one has died and been re-born. There can also be panic and very unpleasant feelings and nightmare-like experiences.

Physical effects can include loss of control over the body, loss of coordination, difficulty speaking, moving, hearing and seeing (delirium), numbness, and nausea. Ketamine has been described as ‘psychedelic heroin’ and ‘L.A. coke’, emphasising the mixed and complex nature of the effects.

Short-term side-effects of Ketamine

• Increase in heart rate
• Slurred speech
• Confusion, disorientation
• Out-of-body experience
• Shifts in perception of reality
• Nausea
• Cardiovascular effects, including hypertension and tachycardia
• Respiratory depression
• Hypersalivation
• Pleasant mental and/or body high
• Increase in energy
• Euphoria
• Sense of calm and serenity
• Meaningful spiritual experiences
• Enhanced sense of connection with the world (beings or objects)
• Distortion or loss of sensory perceptions (common)
• Open- and closed-eye visual hallucinations (common)
• Dissociation of mind from body
• Analgesia, numbness
• Ataxia (loss of motor coordination)
• Significant change in perception of time

What are the problems?

The main problem associated with ketamine is physical helplessness as disconnection from the body can be dangerous, especially in the disorienting environment of a club or rave. This is similar, in many ways, to being extremely drunk in a public place where accidents are more likely. This can leave the user vulnerable to assault (both physical and sexual) and having unprotected sex, increasing the risk of unplanned pregnancy, sexually transmitted infections (STIs) like gonorrhoea, and blood-borne viruses (BBVs) such as hepatitis and HIV.

Fatal overdose is extremely rare as the upper limit for safe use in medicine is very high. What is more likely is that the user would pass out before reaching a fatal dose, which is dangerous in itself. Unconsciousness is an emergency situation and should be treated as such.

Mixing ketamine with other drugs

Nowadays, very few people use one drug on its own, and ketamine is no exception. Ketamine is often used, on a night out, in combination with a range of substances including alcohol (avoid!), cocaine (CK1), and the plethora of new and emerging compounds (“legal highs”) that are becoming more readily available. There is also the added risk that ketamine is contaminated with other substances (such as nitazenes) without the users knowledge. Most illegal drugs these days are contaminated with other substances. Obviously, mixing drugs increases the risks and should be avoided as the outcome is difficult to predict.

Addiction to ketamine

Although not considered physically addictive, tolerance to ketamine builds up very quickly and higher doses are needed to achieve the desired effects. As mentioned earlier, some users are getting into patterns of compulsive binges. This can lead to problems with memory, word/name recall, reduced attention span, damage to relationships, loss of productivity, isolation, and neglecting other interests. Despite evidence of harm the compulsive user often finds it difficult to cut down, all the hallmarks of dependence.

Long-term use of ketamine

Occasional use of ketamine (once or twice a month) is not thought to cause any long-term or irreversible damage. Persistent use, however, has been linked with a wide range of distressing psychological effects, including anxiety, panic attacks, flashbacks, post-traumatic stress disorder, persistent perceptual changes, mania, depression, suicidal thoughts, insomnia, nightmares, night terrors, an unpleasant feeling of being unreal or that the world is unreal, paranoia, grandiose delusions, and fragmentation of the personality.

Ketamine bladder

There is evidence of some physical damage caused by excessive use, particularly to the bladder and urinary tract. One study linked urinary tract disease with ketamine as users reported a range of symptoms associated with ulcerative cystitis, including an increased need to urinate, passing blood in urine, leakage of urine and pain on urination. It is thought that these may be associated with scarring and shrinking of the bladder which, if use continues, could go on to cause irreversible damage and harm the kidneys.

Another, more commonly reported symptom is K-pains or K-cramps. The cause of these abdominal pains are, as yet, unclear, but seem to be linked to high dose use of more than a gram a day.

Ketamine is illegal. Under the Misuse of Drugs Act (1971) it is a Class C drug. The maximum penalty for possession is two years in jail plus an unlimited fine. The maximum penalty for supplying to another person (dealing or giving away) is 14 years imprisonment plus an unlimited fine.

How you can help

The law

Let’s take that last point first. Ketamine is illegal. If the client wants to avoid the risk of arrest, prosecution, fine, jail or a criminal record – don’t go near ketamine. Simple. All ketamine users should be made aware of the legal risks they run.

Engagement

It is quite likely that mainstream drug services will not see ketamine users presenting for help. This is due, in part, to services being set up to deal with other drugs and are not geared towards the needs of ketamine users. This will also be the perception of ketamine users who don’t see themselves in the same league as heroin or crack users and may feel unwilling to attend such a service.

Contact is more likely to be made through advertising, in the appropriate places, your agency as a more broad-based service, ready and willing to support all forms of drug user. It is not the drug that is important but the behaviour. If you can get this across you may attract a more diverse clientele.

Even more effective will be outreach workers who can get to know ketamine users on their own terms. This approach has proved useful in many areas and helps to provide a bridge into mainstream provision. Outreach workers can also act as an early warning system, picking up on new trends developing in the community before individuals arrive on your doorstep needing help.

If you don’t currently have an outreach team, get one.

Education

Making ketamine users aware of the potential risks, particularly when mixed with other drugs, and ways of reducing harm is vital. How this information is put across will also determine the uptake of the service. Unrealistic, scaremongering will put people off, whereas honest, non-sensational, culturally attuned awareness raising will engage more effectively.

But, to be effective, it’s the credibility of the sender rather than the message itself that is often more important. If your agency has a user-friendly, non-punitive reputation in the community then individuals will feel more comfortable about coming forward. This is where outreach, again, can prove useful. Outreach workers can gain the trust of clients and explain what your service has to offer, as well as providing advice and information at the point of contact.

Vulnerability

Friends shouldn’t need reminding that, on a night out, they must look after each other. Even so, it’s worth reinforcing the message that if someone is really out of it they are vulnerable to all kinds of danger.

So make a plan before going out – stick together, agree meeting places if you get separated, before you go out order a taxi to pick you all up afterwards, make sure everyone has got each other’s phone numbers, try to keep tabs on who has taken what and how much. If someone is really out of it they should never be left alone or put in a taxi to be taken home on their own. They may not be in a fit state to make rational decisions, so they should not go off with their new ‘best friends’.

This may sound improbable, and boring, but if it’s not discussed no-one will think about it.

Collapse and unconsciousness

All drug users need to know how to react if someone collapses and this is important knowledge that you can pass on. Because of the ‘sledging’ effects of ketamine, this may prove very important.

Simple First Aid techniques (recovery position, stay with them + call an ambulance), applied at the point of need, saves a lot of bother. If you don’t currently teach First Aid to your clients, see about setting something up.

Compulsive use

Remember, it’s the behaviour not the drug. Some ketamine users find the escape from reality is a relief from feelings or memories they can’t control, in the same way that users of heroin, for example, find solace in the numbness that drug brings. Clients who feel they can’t control their ketamine use are no different from the alcohol or heroin user who feels they can’t control their use either. An experienced worker will know where to use a brief intervention, how to assess need, or when to suggest more in-depth interventions such as CBT or MI.

Brief interventions, such as quantifying consumption, exploring the pros and cons of using or keeping a diary of use, has been shown to be very effective in reducing alcohol consumption. It has been used successfully with other drugs, so why not ketamine? Helping a client to define their frequency and level of use, and the gains to be made by cutting down, can help to break up patterns of consumption.

Cognitive Behavioural Therapy (CBT) has been used successfully in helping clients understand their motivation to use other drugs and could be equally applied to ketamine. Understanding how patterns of behaviour develop, identifying cues and triggers that stimulate the desire to use, and devising strategies to cope with high-risk situations can all help to bring about change.

And change is the goal. If a client is concerned enough about some aspects of their ketamine use, a Motivational Interviewing (MI) approach can help to identify how change can be incorporated into behaviour. Maintaining that change over time will help move the client through the process and into a less harmful situation.

Mental health

Ketamine has profound psychological effects. It can take the user to some very strange places inside their own head. If they do have unpleasant or suppressed memories, or do have an underlying or overt mental health issue then ketamine could exacerbate these. If the client does have a bad experience they should stop using ketamine immediately. If something has come to the surface that won’t go away, they should seek help from their GP.

Most people who have a bad, transitory ketamine experience will return to normal and will have learned an important lesson - Ketamine is an interesting place to visit, but you wouldn’t want to live there. For many, this will help them re-evaluate the desire for a trip to the dark side and possibly deter them in future.

Physical health

Most of the physical problems associated with ketamine are due to accidents whilst under the influence. At high doses, numbness in the extremities (mainly fingers and toes) is not unusual, but this might mask a broken bone that does not become apparent until the ketamine wears off. Looking after each other when on a night out is good advice, but if everyone’s in the K-hole it’s not much use. In the event of an accident or fall, making others (bar staff, security, First Aiders, etc.) aware that ketamine has been used could help avoid major injuries going unnoticed.

As stated above, some heavy users of ketamine have developed bladder problems. If any of the symptoms outlined above are experienced, it makes good sense to stop using ketamine altogether and seek medical advice. As for K-cramps, even though the exact cause is unclear it has been suggested that Tyrosine, used only under medical supervision, can help alleviate the pain.

The bottom line is this – If you want to avoid harm don’t do ketamine.

Buy the Alcohol Aware booklet in the Substance shop

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Alcohol is one of the most commonly-used drugs in the UK.

It affects individuals differently, depending on when and where you drink, who you’re  with, and how you feel.

The information in this booklet will help you identify the risks associated with alcohol and give advice on how to stay safe.

ALCOHOL

What we usually refer to as alcohol is a chemical called ethanol, which is made through a process called fermentation.

During fermentation, yeast is combined with fruits or grains in order to convert the sugars into alcohol. 

Spirits, such as vodka, rum, gin, and whiskey, are fermented and then filtered/distilled to separate the ethanol from water.

HOW ALCOHOL WORKS

Your body absorbs alcohol into the bloodstream through the stomach and intestines. It’s broken down by the liver and expelled as urine at the speed of about one unit an hour (see page 4 for unit info).

While your liver works to break down the alcohol it can manage, the rest is circulated into your body and sent to your brain, where it depresses your heart rate and breathing and affects your brain's ability to control what your body does. 

Initially, one or two drinks generally produce feelings of relaxation and cheerfulness, but any more can lead to blurred vision and coordination problems.

Drinking even more alcohol can lead to a loss of control, blurred/double vision, dizziness, wobbly legs, vomiting and even loss of consciousness.

The effects start within 15-20 minutes of drinking and can last a few hours, depending on how much you drink. 

Stronger drinks (like spirits) and fizzy drinks (like alcopops) are absorbed quicker into the bloodstream and will affect you sooner.

How alcohol makes you feel depends on lots of things:

> How quickly you drink it 

Your liver processes alcohol at a steady rate no matter how quickly you drink. Drinking quickly increases the levels of alcohol in your bloodstream, making you drunker, faster.

> How recently you’ve eaten 

Food helps slow down the speed that alcohol is released into your system.

> Your body weight 

In general, the less you weigh, the more you’ll be affected by a given amount of alcohol.

> Your mood before drinking 

If you feel a bit down before drinking, it may make you feel even more depressed. If you feel angry, it can make you aggressive.

> Sex

Women's bodies contain less water than men's, so alcohol is less diluted, meaning women feel the effects more than men. This is particularly true either just before or during a period.

KNOW YOUR UNITS

This section contains advice on units, the term used to describe the amount of alcohol, and therefore the strength of your drink.

A unit is defined as 10ml by volume, or 8gm by weight, of pure alcohol. Units are normally displayed on alcoholic packaging in a similar style to the label below

Government Guidelines

Government recommended safe drinking limits.

Unit guidelines are the same for men and women. Both are advised not to regularly drink more than 14 units a week.

Working out the units for yourself: Multiply the ABV by the total liquid (ml) and divide by 1000 12 x 750 ÷ 1000 =

Approximate units for popular drinks

KNOW YOUR LIMITS

Guidelines for both men and women recommend drinking no more than 14 units a week to reduce the risk to your health.

The more you drink, the more your risk of developing a range of health problems (including cancers of the mouth, throat and breast) increases.

If you drink up to 14 units a week, spread them over a few days and include drink-free days.

There are no safe limits for young people: not drinking is the healthiest option.

Positive effects of drinking at ‘recommended’ levels

• Increased relaxation

• Increased sociability

• Possible reduced risk of heart failure*

*New evidence shows fewer heart health benefits than previously thought (primarily for women over 55 at around five units a week or lessirrespective of the type of alcoholic drink).

Drinking over limits: short-term negative effects

• Low energy
• Accidents
• Injuries or violence
• Unplanned sexual encounters
• Problems with friends and families

 Drinking over limits: long-term negative effects

• Alcohol dependence
• High blood pressure
• Liver disease
• Cancer

SPOTTING THE WARNING SIGNS

Different people react in different ways to alcohol. For some people, alcohol helps them relax and enjoy social occasions; for others, it might damage their health and personal life.

Signs that you’re developing an unhealthy relationship with alcohol: 

• Finding it difficult to stop drinking once you've started.
• Neglecting work, college or school.
• People close to you worrying about the amount you drink.
• You’re taking risks when you've had a drink, such as driving a car or getting into fights.
• Drinking more than five days a week and more than nine units each time.
• You’re regularly thinking about when you can have your next drink.
• Being unable to enjoy yourself or relax without alcohol
• Getting involved in violence
•  

If any of the above apply to you, you should consider cutting down. If a few of these apply to you, contact your GP for help and advice, or contact any of the organisations on the back page of this booklet.

THE RISKS

Getting hooked on alcohol

Regular use of alcohol can lead to tolerance: having to drink more and more to get the same effect. This can lead to physical dependence.

Mixing alcohol and other drugs

Mixing alcohol with other drugs, particularly depressants like sleeping tablets or heroin, is risky. The combination produces effects which are difficult to predict and can lead to an increased risk of passing out or death.

Overdose

Alcohol slows down breathing and heart rate. In large enough quantities, it can lead to loss of consciousness and even death.

Signs of alcohol overdose:

• Slow, shallow, or irregular breathing
• Confusion
• Difficulty awakening the person
• No reaction from painful stimuli (such as pinching)
• Unconsciousness (passing out)
• Blue-tinged skin or pale skin
• Seizures

If a person displays any of these symptoms, lie them on their side so they don't choke if they're sick, and call 999.

Alcohol and sex

Alcohol can affect your judgement and make you feel confused. You’re more likely to have unplanned sex when drinking, or sleep with someone you wouldn't have done had you been sober. 

You’re also at risk of rape, sexually transmitted infections (STIs) and pregnancy.

Always use a condom during sex.

Alcohol and violence

Alcohol lowers your inhibitions, causing you to overreact in certain situations, which can lead to aggressive behaviour. It's not much fun waking up in a police cell with a hangover and a criminal record.

It might also lead to problems with your friends and family. Being drunk isn't much of an excuse if you say something that you regret the next day.

Being drunk makes you an easy target for robbery and assault. So don't flash your mobile phone, or any other valuables, around. Be aware of your surroundings.

Drink Driving

Driving while drunk or being in a car with a drunk driver is very dangerous both for you and other people in the car. You, your friends or a pedestrian could be seriously hurt or killed.

STAYING SAFE

PASSING OUT

As already mentioned, it’s possible to overdose on alcohol which can be fatal. If someone you’re with passes out, turn them onto their side so they can't choke on their vomit and ring an ambulance or find someone to help you.

SPACE YOUR DRINKS OUT

Use soft drinks or water between alcoholic drinks. Your night will last longer, and it will stop you from getting dehydrated and reduce the effects of a hangover.

DON’T DRINK ON AN EMPTY STOMACH

Food slows the release of alcohol into your system and helps to limit how quickly the alcohol affects you. Eating a meal before you go out or a snack while you drink is a good idea. You’ll have more energy to enjoy yourself!

HAVE SMALLER DRINKS

Some measures in pubs and clubs can be very large and have 2 or 3 units in each drink. Where possible, choose a smaller glass.

HAVE THE DAY OFF

Give your liver a chance to 'detox' by having at least two alcohol-free days a week – this way, it has time to recover and repair itself.

DRINKING BEFORE YOU GO OUT

Drinking alcohol before you go out means you could already be drunk before you start your night out. 

You’re more likely to be involved in accidents and violence, or be refused more alcohol at the bar.

TRY TO STICK TO ONE TYPE OF DRINK

Avoid mixing your drinks. This’ll help you keep track of how many units you've had and avoid mixing different strength drinks.

MIXING DRUGS AND ALCOHOL

Mixing alcohol with drugs, particularly depressant drugs, can increase the chances of an overdose and can make the effects of the individual drugs unpredictable and dangerous.

GETTING HELP

If you feel your drinking is getting out of hand, consider talking to someone. Maybe a close friend, parent, teacher or a local advice centre.

Here are some organisations that can also help you:

Talk to Frank

National drugs awareness site for young people and parents/carers.
0800 77 66 00
www.talktofrank.com

Childline

Calls are free and confidential.
www.childline.org.uk
0800 1111

Addaction

UK - wide treatment agency, helping individuals, families and communities to manage the effects of drug and alcohol misuse.
www.addaction.org.uk

Brook

Free, confidential advice on sex for young people.
Call 0800 185 023 or
visit www.brook.org.uk

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

DRD Co-ordinator (Aberdeenshire)

Life+

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For most people having a drink can be a positive experience. Having a night out and a laugh with your mates after a long week's work or study helps you to relax and wind down.

Alcohol can help you chill out, make you less shy, and give you extra confidence.

But hammering it every weekend and sometimes during the week can lead to serious short- and long-term health issues.

This booklet will help you think about your drinking and offer practical and sensible information and advice about reducing the harm caused by alcohol.

ALCOHOL

Alcohol is a depressant drug. It's absorbed through the intestines and stomach into your blood and then sent to your brain. It slows down your central nervous system and alters your mood, perception, movement, vision and hearing.

Your body flushes out most of the alcohol through your liver and small amounts in your sweat and breath. A breathalyser measures the amount of alcohol in your system through your breath.

Short-term effects of alcohol

• Short-term effects of alcohol
• Relaxation
• Increased confidence
• Talkativeness
• Anxiety
• Sexual difficulties such as impotence
• Bad judgement, leading to accidents and injuries
• Alcohol poisoning. This could lead to a loss of consciousness and could be fatal

Long-term effects of alcohol

• Cirrhosis of the liver
• Inflamed stomach or pancreas
• Certain cancers such as throat cancer
• High blood pressure

People’s reaction to alcohol can vary and depends on things like

• Age
• Gender
• Body height and weight
• If you have eaten
• How quickly you drink
• If you have used any legal or illegal drugs

BINGE DRINKING

Binge drinking means different things to different people, but generally, it means drinking lots of alcohol over a short period to get hammered. 

RISKS AND PROBLEMS

Accidents and violence

Alcohol can make you reckless and impulsive. Binge drinking can lead to an increased chance of falls, car accidents and becoming the perpetrator or victim of violence. 

Physical health

Consuming large quantities of alcohol over a short time means your body cannot process the alcohol quickly enough. Alcohol can build up to dangerous levels, and the extra stress on your body's organs can increase the risk of high blood pressure, heart disease and certain cancers.

Alcohol poisoning

Alcohol depresses the nerves that control your breathing and gag reflex (which prevents choking). A fatal dose of alcohol can stop these functions. You could choke to death if you vomit while not conscious because of alcohol.

HOW MUCH DO YOU DRINK?

Alcohol is measured in units. You can calculate the  the amount you drink by knowing how many units of alcohol are in your drink.

What is a unit?

A unit is 10ml by amount or 8gm by weight of pure alcohol (Ethanol).

To work out the number of units in a drink, multiply the volume (in millilitres) by %ABV, then divide the result by 1000.

What is  %ABV?

ABV means Alcohol By Volume. A 750ml (75cl) bottle of wine with 12% ABV on the label shows that 12% of the liquid in the bottle is alcohol. A 700ml (70cl) bottle of vodka with an ABV of 37/38% on the bottle would contain almost three times the amount of alcohol/units for roughly the same amount of liquid.

Alcohol limits

The suggested alcohol limit for males and females is the same: Don’t regularly drink more than 14 units per week (6 pints of 4% beer, or 6 glasses of 13% wine). These limits will help reduce potential health problems.

If you drink up to 14 units a week, spread these across a few days and have at least two drink-free days a week.

• Can of lager 440ml
  2 units
  (Normal strength)

• Small glass of wine
  125ml
  1.5 units

• Bottle of strong lager
  330ml
  2 units

• Bottle of wine
  750ml
  10 units

• Shot 35ml
  1.3 units
  (Tequila, Sambuca etc)

• Bottle of strong cider
  1000ml
  9 units

• Standard size bottle of spirits
  750ml
  26-28 units

• Single pubmeasure ofspirit
  25ml
  1.3 units

STAYING SAFE

The information in this section will help make your night out as enjoyable and safe as possible.

Pre-loading

A few drinks with your mate to loosen up as you get ready to go out can turn into a session. You are two and a half times more likely to get into a fight or have an accident than people who only start drinking when they go out. You are more likely to be refused entry to a club or pub if you are drunk.

ALCOHOL AND THE LAW

Drunk and disorderly

It is illegal to be drunk and disorderly in public. If you've had a skinful try not to attract attention by acting like an idiot. If the police arrest you, once you are fit to be dealt with, you will typically either be cautioned, be issued with a Penalty Notice for Disorder (PND - £80 fine in ticket form) or, depending on the offence, end up in court.

Drink spiking

Spiking drinks is illegal, even if the person affected is not attacked or assaulted. It can result in a prison sentence of up to 10 years for anyone guilty of doing this.

Drinking outside

It isn't illegal to drink in public, but many areas, such as city centres, have alcohol-free zones, where drinking outside is not allowed. Under-18s can have their alcohol confiscated if they drink outside, no matter where they are.

Entering the pub or club

It is illegal for a pub or club to sell alcohol to someone drunk or conducting themselves in a 'disorderly manner'. It is unlawful for you to refuse to leave licensed premises when asked by the police, the licensee or someone acting on their behalf, such as the door staff.

Pubs or clubs have the right to search anyone entering their premises. If you agree (you have the right to refuse), the search can only be on the outside of the clothes, pockets and inside bags.

MIXING DRUGS AND ALCOHOL

Using drugs or alcohol can make the effects of both very unpredictable. Your body will struggle to cope if you use too many substances, which can rise to dangerous levels.

Alcohol and cocaine used together produce a third toxic substance called cocaethylene, which can increase the chance of seizures, heart attacks and strokes, even in healthy young people. Cocaine will also increase the risk of violent, impulsive, and reckless behaviour.

Alcohol dehydrates you, so mixing it with other drugs that do the same, like cocaine, ecstasy or mephedrone, or some of the newer drugs (formerly legal highs), can be very risky.

VIOLENCE

Alcohol affects the brain and reduces our ability to think straight.

It makes us more likely to misread the signs; someone bumping into you or the 'dirty look' can be seen as an act of aggression when you usually wouldn't even notice it.

The more you drink, the more frustrated you can become; trying to get to the bar or queue to use the toilet can become a flashpoint.

If you lose your temper quickly, try not to get too drunk. Drink in pubs and clubs that are not so busy and avoid trouble hot spots where you know there are always kick-offs.

If you are on the receiving end of someone giving you grief, walk away. It can be hard to lose face in front of other people, but it has got to be better than being the victim of a serious assault or being locked up for giving someone else a hiding.

SEX

Alcohol increases your self confidence and makes it easier to approach someone you fancy, but if you’re too drunk you can end up going further than you intended.

Sexually Transmitted Infections (STI’s)

If you intend to have sex, use a condom. Having sex without a condom can open you to sexually transmitted infections (STIs) and unplanned pregnancies.

Women can get oral emergency contraception from their GP, Brook, or NHS Walk in-centre. It can be taken 72 hours after unprotected sex and is available to anyone over 16.

Brewers droop

Alcohol affects the part of the brain that sends messages that helps with sexual arousal; alcohol suppresses the signals and can lead to brewers droop.

DON’T FLASH YOUR VALUABLES

Don’t flash your expensive phone around, it could end up being stolen. Buy a cheap phone to use when you are going out. If you are drawing cash from a machine be aware of who is around and don’t let anyone distract you, shield your pin and put your money away quickly. Where possible, use a machine in a well lit public area.

DRINK SPIKING

Spiking a drink means putting alcohol or drugs into someone's drink without their knowledge or permission. Following these tips will help you reduce the risks:

• Buy your own drink and watch it being poured if possible.
• Don't accept drinks from strangers
• Never leave your drink unattended
• Don't drink or taste anyone else's drink
• Throw your drink away if you think it tastes odd
• If you think your drink may have been spiked, you should get help from a friend you trust or the venue management.

LOOKING AFTER YOURSELF AND YOUR MATES

If you or one of your friends are going to leave the club or pub with someone you have just met, make sure your friends know what you are up to and where you are going, maybe you could take a pic of your new friend and text it to your friends. If a friend is telling you where they are going and who with, listen to what they are saying.

Feeling unwell

If someone goes too far and starts to feel unwell, take them somewhere quiet and calm. Keep them sitting up and awake, and give them water if they can drink. If you can't wake them and their breathing is erratic, lie them on their side in the recovery position and get medical help.

Getting home safely

Have a plan of how you will get home after a night out.

Try to pre-book and pay for a taxi to take you home from a pre-arranged location. Use this location as a meeting point if you get split up from your friends.

If you end up walking home alone, be aware of your surroundings, stay on well-lit public roads, and don't be tempted to take the shortcut across the dark, deserted park because you can't wait to crash into bed.

CUT DOWN

How often do you say, 'I am never getting that drunk again?' These tips will help you keep that promise during your next night out.

• Set yourself a limit

  Decide how much you will drink and only carry enough money for that number of drinks and your taxi or bus fare home.

• Eat something before you go out

  Having some food in your stomach before you start drinking will help your body release the alcohol at a steadier pace. While you are out, have some bar snacks or maybe eat the kebab halfway through the night rather than at the end.

• Mix your drinks 
  

  Mix your drinks with soft drinks. Have a shandy or mix your wine with soda or lemonade. Or alternate between alcoholic and soft drinks.

• Miss a round

  You don't have to get a drink in every round; when it's your turn to get the drinks, miss yourself out. Or say no and stick to it.

• Go for lower alcoholic drinks

  Some premium lagers, beers and ciders can have almost twice the alcohol content as the normal alternatives.

• Drink slower

  Sip your drink, put it on a table and do something else. Standing with your glass in your hand means you will end up drinking it quicker.

LONG TERM CHANGE

Regular heavy drinking sessions can become a habit. If you need to make long term changes the following advice will help.

Are you drinking too much?

Have a look at this list and see if any of the warning signs apply to you.

• Drinking larger amounts to get the same effect.
• Drinking more than nine units in one session, that’s roughly equivalent to five pints or 9 shorts or nearly a full bottle of wine.
• Have you started doing things you normally wouldn’t do (e.g. missing work or college, letting people down)?
• Do friends and family have a go at you about the amount you drink?
• Have you got into bother, or injured yourself or others after drinking?

If one of these applies to you then you might want to cut-down your drinking. If three or more of these apply to you then you may need help or support before you start to cut down or stop drinking. You can find more help on the back page of this booklet.

Think about how will you benefit from cutting down on drinking

There are lots of benefits to cutting back on the drinking sessions and for everyone they will be different.
Some benefits might be:

• Feeling less tired
• Losing weight
•  Having more money to spend on other things
•  Better relationships with friends and family
•  Healthier and less likely to develop serious health issues

Plan ahead and set your goals

Are you going to cut-down slowly or stop straight away? Think about how and when you are going to start.

You could make a decision to book your taxi home earlier than normal. Maybe just go to the local rather than going clubbing. Or choose a couple of days to be completely alcohol free.

Think about difficult situations and how to deal with them

Think of the situations you are in last time you got smashed, who were you with, where were you, how did you feel, what where you doing at the time? Situations that could trigger your drinking could be:

• The end of a stressful day
• After work
• Celebrating at a party or a club
•  Needing to relax
• Feeling down

Dealing with difficult situation

Stay active

Plan activities for the times you used to spend drinking. If you are getting bored, stressed, or craving a drink, do something, the feelings will pass. 

Do something new

Start a new hobby or enrol on a course. It will occupy your mind, stop you getting bored and fill the time you used to spend drinking.

Look after yourself
Stick to a healthy diet, try to get as much sleep as you can, drink plenty of water and try to get some exercise, this will help make you feel better.

Avoid your friends who drink heavily for a while
Some of your drinking friends can act as a trigger to your drinking sessions.

Clear your home of any alcohol
No need to keep temptation within arms length.

Tell your friends or family what you are about to do

Having support and someone to talk to will make it easier to achieve your goals. You can also get help and support from your local GP, nurse or support service. There are some contact details on the back page.

Keep going

Don’t worry if you don’t succeed the first time you try. Don’t beat yourself up if this happens, you haven’t failed, you have just taken the first step. Try again - it will probably be a bit easier next time.

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Consuming lots of alcohol quickly - known as binge drinking - will increase the chance of accidents, including falls, trips, violence and life-threatening alcohol poisoning (overdose).

The NHS estimates that as many as 70% of hospital emergency visits at peak times on weekends can be alcohol-related.

So when does drinking become an emergency? What’s the journey from a few drinks to a hospital casualty department?

This resource will help you in the following ways:

• Understand how alcohol influences behaviour and increases the risk of injury
• Recognise the signs of an alcohol overdose
• Identify immediate action to take
• Determine when medical help is needed
• Learn how casualty departments handle alcohol-related admissions
• Reducing alcohol-related harm

HOW ALCOHOL AFFECTS YOUR BRAIN

When you drink alcohol, it goes into your bloodstream and heads straight for your brain, altering how you feel and behave.
Alcohol influences neurotransmitters (brain chemicals) like dopamine and serotonin, which make you feel good and encourage you to drink more.

However, it also affects other neurotransmitters called glutamate and GABA. These regulate brain activity and keep you safe.

Quickly drinking alcohol causes alcohol levels to build up, leading to life-threatening conditions like alcohol overdose and landing you in the hospital - or worse.

There is no minimum amount a person has to drink to cause an overdose. It depends on many factors, such as age, sex (women ofteexperience the effects of alcohol more quickly and intensely than men), and weight. It also depends on how fast you've been drinking, how much you've eaten, your general health and if you have used legal or illegal drugs.

HOW ALCOHOL AFFECTS YOUR BEHAVIOUR

Alcohol affects chemicals in your brain and changes how you feel and act.

GETTING INVOLVED IN VIOLENCE

Alcohol doesn't directly cause violence, it affects the parts of your brain responsible for restraint and judgment. As a result, you may misinterpret social cues or act more aggressively after drinking.

SLURRING YOUR SPEECH

When you drink alcohol, it affects the signalling in your cerebellum and the basal ganglia, both of which play roles in motor functions. It has an impact on your reaction times and can impair muscle control, leading to symptoms like slurred speech.

TRIPS AND FALLS

Part of the cerebellum's role is coordinating your balance, movement and posture. Alcohol can slow down reaction times and disrupt the coordination of movements, leading to trips and falls.

SEX

Alcohol reduces inhibitions and impairs judgement, increasing the chances of engaging in risky sex. That's because alcohol affects the hypothalamus and pituitary gland, the parts of the brain related to sexual response and arousal.

Alcohol can increase libido but reduce performance, causing erection problems for men and reducing sensitivity and lubrication for women.

Impaired judgment can affect your ability to give or interpret consent. If there's any doubt over someone's ability to consent, it's safer and more ethical to avoid any sexual activity.

SLEEPINESS

You feel sleepy after drinking because alcohol acts as a central nervous system depressant, interacting with neurotransmitters to slow brain activity, leading to feelings of sleepiness. However, while it might help you doze off initially, it negatively impacts sleep quality by disrupting crucial REM sleep stages.

BLACKOUTS

You might have had nights out when you can't recall particular incidents or even the whole night. That's because alcohol affects your hippocampus, the part of your brain responsible for forming new memories. It prevents the hippocampus from making new connections between neurons, which are necessary for creating new memories.

WHEN TO GO TO THE EMERGENCY DEPARTMENT

Hospital emergency departments are only for critical injuries and life-threatening emergencies. Alcohol poisoning falls into the category of a medical emergency. If someone displays the symptoms of alcohol poisoning, don't hesitate — call 999 immediately, even if they don't exhibit every sign.

THE SIGNS AND SYMPTOMS OF ALCOHOL POISONING

• Mental confusion
• Difficulty remaining conscious or waking up
• Vomiting
• Seizures
• Slow breathing (fewer than eight breaths per minute)
• Irregular breathing (10 seconds or more between breaths)
• Slow heart rate
• Clammy skin
• Extremely low body temperature
• Bluish skin colour or paleness. On black or brown skin, this may be easier to see inside the lips, on the gums and under the fingernails

NOT SURE WHAT TO DO?
Call NHS 111 if you think you need medical help but are unsure what to do.

THINGS YOU CAN DO TO HELP SOMEONE WHO'S DRUNK TOO MUCH ALCOHOL

DO

• Stay with them. There's a risk they could choke on their own sick or stop breathing
• Sit them up if they're awake, preferably on the floor so they don't fall over
• Lie them down if they are unconscious. Put them in the recovery position, roll them onto one side with an ear toward the ground to prevent choking
  Check they're breathing
• If they're conscious and can swallow, give them water to sip
• Keep them warm with a jacket or blanket

DON'T

• Let them drink more alcohol
• Give them coffee or drinks containing caffeine because this can dehydrate someone with alcohol poisoning
• Walk them around, it won't reverse an overdose and they could fall and hurt themselves
• Put them in a cold shower or bath because there's a risk they could get too cold, fall, or lose consciousness in the water
• Try to make them sick. They could choke on their vomit

WHAT TO EXPECT IN HOSPITAL

If you arrive at the emergency department after drinking alcohol, medical staff will follow a particular procedure. Practices may vary between hospitals, but below is a general overview of what you can expect.

TRIAGE ASSESSMENT

Triage involves a nurse or healthcare professional evaluating the urgency of your condition. Medical staff will prioritise you for immediate care if your condition is serious or life-threatening.

MEDICAL ASSESSMENT

Once your triage is complete and depending on the severity of your condition, a doctor or healthcare provider will see you. They assess your medical needs, perform necessary tests, and determine the appropriate course of treatment.

MONITORING

If you've been drinking alcohol and are showing signs of being drunk, you'll be closely monitored to ensure your vital signs (such as heart rate, blood pressure, and breathing) are stable.

TREATMENT

If alcohol has contributed to your visit to A&E, it will be addressed as part of your overall care. That might involve giving you fluids or medication or intervening in other ways to address the effects of alcohol and possible alcohol withdrawal if you're alcohol-dependent.

SUPPORT AND ADVICE

You will be offered guidance and advice on responsible drinking, potential risks of excessive drinking and resources for seeking help if you have alcohol-related concerns.

REFERRAL OR DISCHARGE

Depending on your medical condition, you may stay in the hospital for further observation and treatment or be discharged with instructions for follow-up care. If necessary, arrangements will be made for additional support or referrals to specialised services.

Give honest and accurate information about drug or alcohol use. This information will help medical staff make better care decisions.

ALCOHOL AND DRUGS DON'T MIX

Mixing drugs and alcohol is dangerous. Both go through the liver, making it work too hard and increasing the harmful effects. Some drugs also mix badly with alcohol, creating toxic substances.

Mixing drugs and alcohol is dangerous. Both go through the liver, making it work too hard and increasing the harmful effects. Some drugs also mix badly with alcohol, creating toxic substances.

STIMULANTS

COCAINE/SPEED/ECSTASY/MEPHEDRONE

As a depressant, alcohol slows down your breathing and heart rate, while cocaine, speed and ecstasy are stimulants, speeding them up and putting your brain and heart under a lot of pressure.

COCAETHYLENE

Using alcohol and cocaine together produces a toxic chemical called cocaethylene, which increases the chances of heart attack and stroke.

Most deaths from stimulant drugs are related to overheating and dehydration, so mixing them with the dehydrating effects of alcohol increases the risk.

DEPRESSANTS

GHB AND GBL

GHB and GBL have a sedative effect, dulling inhibitions and making you sleepy. By themselves, they can cause unconsciousness, coma or death, so mixing them with alcohol is particularly dangerous.

HEROIN

Heroin and opioids like fentanyl and methadone are powerful sedatives and painkillers, so there's a much higher risk of overdosing when you mix them with alcohol.
Even a small amount mixed with alcohol can lead to a fatal overdose.

SPICE/SYNTHETIC CANNABINOIDS (known as spice or K2)

These are depressants, like alcohol. Their effects increase if you mix them with alcohol. They're usually potent and unpredictable, so combining them with alcohol increases the risk of overdose, resulting in seizures, coma and death.

PRESCRIPTION MEDICINES

Always check the instructions on the pack and consult your doctor about the risks of drinking alcohol with prescribed medication.

ANTIDEPRESSANTS

Alcohol can make you feel more depressed and can increase the effects of antidepressants.

It can also make the side effects of the medicine worse.

Using alcohol with MAOI-type antidepressants, such as Nardil, Parnate, and Manerix, can make your blood pressure go up a lot, which can lead to a stroke.

TRANQUILISERS

Valium (diazepam), Librium, Temazepam, Nitrazepam, Lorazepam
Mixing tranquilisers with alcohol can be deadly because they slow your heart rate, and breathing and lower your blood pressure.

SAFER DRINKING

These simple tips should help you reduce the chances of your drinking leading to a trip to casualty.

IF YOU'RE GOING OUT

Avoid drinking before you go out. But if you drink, try to set a limit on how much and try to eat something. Alternate alcohol with soft drinks. This will help you stay hydrated and means you drink less alcohol.

EAT BEFORE YOU DRINK

The food in your stomach will help absorb alcohol and release it steadily so your liver can cope better. Drinking on an empty stomach can also irritate the lining, causing you to vomit.

DRINK LATER

Go to the pub an hour later than normal or, if you drink at home, find something else to occupy you so you put off when you start to drink. Or drink soft or low-alcohol drinks instead.

NO AND LOWER ALCOHOL DRINKS

Check the label on the bottle or look for the ABV number on the pump or packaging and go for one with less alcohol content.

ONE MINUTE, YOU WERE OKAY . . .

If you play drinking games, your liver is unlikely to be able to keep up. Your alcohol level will rapidly build up, delivering a massive dose of alcohol to your brain.

MISS A ROUND

You can alternate with a soft drink or go for a kitty instead of a round.

KNOW THE STRENGTH OF YOUR DRINK

You can tell how strong your drink is by the number of units it contains. This list of drinks and units will help you understand the strength of some popular drinks:

Gin, rum, vodka, whisky, tequila and sambuca:
Large (35ml) single measures 1.4 units

Can of lager/beer/cider:
(440ml, ABV 5.5%) 2.4 units

Pint of lower-strength lager/beer/cider:
(ABV 3.6%) 2 units

Standard glass of red/white/rosé wine:
(175ml, ABV 12%) 2.1 units
SIZE MATTERS
Always check the standard measure in a pub/bar or club
and go for the smallest.

Your body can only process about a unit an hour.
The quicker you drink, the faster alcohol will build up to dangerous levels.

FURTHER HELP AND SUPPORT

We hope you find the information in this booklet useful. Below are some organisations that can also help you:

NHS ALCOHOL SUPPORT

Alcohol support · You often feel the need to have a drink · You get into trouble because of your drinking · Other people warn you about how much you're drinking
www.nhs.uk › Live Well › Alcohol advice

DRINKLINE - The National Alcohol Helpline

Drinkline runs a free, confidential helpline for people concerned about their drinking or someone else's. The purpose of the Drinkline service is to offer free, personal, accurate and consistent information and advice to callers concerned about their own or someone else's drinking regardless of the caller's age, gender, sexuality, ethnicity or spirituality.

Free, confidential helpline: 0300 123 1110 (weekdays 9am–8pm, weekends 11am–4pm)

www.drinkaware.co.uk/alcohol-support-services

TALK TO FRANK

National drugs awareness site for young people and parents/carers. 24 hrs a day, seven days a week.
Call 0800 77 66 00 (calls are free and confidential)
www.talktofrank.com

NHS 111

NHS 111 can help if you think you need medical help right now. You can get help from NHS 111: by using 111 online, in the NHS App, or by calling 111.

www.111.nhs.uk

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

DRD Co-ordinator (Aberdeenshire)

Life+