Incidents and substance-related emergencies

Transcription

Mass Gathering Medicine at raves: Incidents and substance-related emergencies
Mass Gathering Medicine at raves:
Uitnodiging
Openbare verdediging van het proefschrift
Mass Gathering Medicine at raves: Incidents and substance-related
emergencies Vrijdag 29 november 2013, 11:45 uur in de Aula van
de Vrije Universiteit Amsterdam
De Boelelaan 1105 te Amsterdam
Receptie na afloop ter plaatse
Glamour & Glitter Blingbling Discofeest vanaf 21:30 uur in Huize Maas
Vismarkt 52 te Groningen
Jan Krul
[email protected]
Paranimfen
Björn Sanou Jan Krul
Jan Krul
[email protected]
Attie van der Meulen [email protected]
Jan Krul
ISBN: 978-90-8891706-6
Cover design:
Proefschriftmaken.nl || Uitgeverij BOXPress
Printed & Lay Out by: Proefschriftmaken.nl || Uitgeverij BOXPress
Published by:
Uitgeverij BOXPress, ‘s-Hertogenbosch
VRIJE UNIVERSITEIT Mass Gathering Medicine at raves: Incidents and substance-‐related emergencies ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. F.A. van der Duyn Schouten, in het openbaar te verdedigen ten overstaan van de promotiecommissie van de Faculteit der Geneeskunde op vrijdag 29 november 2013 om 11.45 uur in de aula van de universiteit, De Boelelaan 1105 door Jan Krul geboren te Groningen 5 promotor: copromotor: prof.dr. A.R.J. Girbes dr. E.L. Swart Voor Jan en Dannis
Contents
Chapter One
General introduction of the thesis
Chapter Two
Party drugs in the Netherlands A review on most-used
recreational substances
Chapter Three
9
23
Experience of health related problems during house
parties in the Netherlands: a report on nine years
experience and 3 million visitors: a prospective
observational study
Chapter Four
Substance-Related Health Problems During Rave Parties in
the Netherlands (1997-2008)
Chapter Five
65
Gamma-Hydroxybutyrate: Experience of nine years of
GHB-related incidents during rave parties in the Netherlands
Chapter Six
45
83
Medical Care at Mass Gatherings: Emergency Medical
Services at Large-Scale Rave Events
99
Chapter Seven Medical aspects of raves: a discussion and directions for
the future
113
Chapter Eight
Increase in serious ecstasy-related incidents in the Netherlands 123
Chapter Nine
Summary of the main findings
127
Chapter Ten
Summary in Dutch (Nederlandse samenvatting)
135
About the author
145
Acknowledgements, Epilogue in Dutch 147
7
8
Chapter One
9
Chapter One
Chapter 1: General introduction of the thesis
Since the early 90’s of the previous century a new phenomenon occurred in nightlife
in The Netherlands. “Dance”, with large-scaled organized public events called “house
parties”, also known as “dance parties” or “raves”, attended lots of visitors. Governmental
authorities feared these events, because many attendees were thought to use a “party
drug” in those days, called “ecstasy”, for its energetic and entactogenic effects. This
substance was notorious, because of its assumed danger to public. At the start of the
new century, again, party people discovered a new substance: Gamma-Hydroxybutyrate
(GHB). Next to this, the use of alcohol seemed to increase among youth.
In this chapter the terms “rave” as a mass gathering and “dance” are defined, an overview
of drug-use in The Netherlands in general and at raves specifically is given and the
objective of this thesis are described.
Dance
“Dance” is a collective name for all types of electronic dance music. The main feature
is that the music is performed with electronic instruments, is DJ-directed and usually
cannot be played live. Most dance styles are characterized by simple melodies in
quadruple time. Often, the tunes are repetitive and use bass drums. Sometimes old
songs are edited and acoustic instruments are added to the music.
Dance has many styles, which can overlap, ranging from very soft (“ambient”) to
hard and fast (“hardcore”) and from minimalist and monotone (“techno”) to melodic
(“trance”). Many subgenres are purely instrumental and electronic (“electro”), while
other genres contain vocals and acoustic instruments (“house”). In the Dutch charts
the styles “eurodance”, “house” and “trance” are dominant.
There are numerous clubs and parties where only dance music is played. At dance
parties, many people are sparingly dressed and people use drugs, especially ecstasy.
These events are therefore often mentioned negatively in media.
The first dance styles were created in the early 80’s the United. In the late 80’s Europe
was conquered, especially England, Germany, The Netherlands, Belgium and the party
island Ibiza. In the Netherlands, until about 1992, different kinds of dance were not
10
distinguished and everything was called “house”. In 1993, a separation between soft
and hard house arose. Soft house was called “mellow” and hard house “hardcore”.
Shortly after these two currents, countless subcategories were developed.
As mentioned earlier, “house” in the Netherlands was a collective name for dance music.
This led to confusion, since “house” is also the name of a subgenre. Therefore, “dance” is
now the most common over-all term. In other countries, “techno” and “progressive” are
used as collective names. Large dance events are worldly wide known as “raves” with a
range of 1000-60,000 visitors. They are considered to be mass gatherings, as explained
in the next paragraph.
Mass Gatherings
Large public gatherings are becoming increasingly common worldwide. These events,
called mass gatherings, have been defined as
 Any gathering of a large number of people attending an event that is focused at specific
sites for a finite time
 The potential for a delayed response to emergencies in an event of mass gathering,
regardless of the number of attendees 1-8.
Mass gathering attendees are typically isolated from regular services and medical care,
especially when these events are bounded and the visitors are relatively far from their
homes.
Rave parties are held at (evening and) night in exhibition centers and sports halls,
indoor, during the winter, and in the daytime at recreational areas, outdoor, in summer.
They usually last nine to twelve hours, and attract 3,000 to 60,000 visitors per event. In
the Netherlands, rave parties are granted on the condition that preventive measures,
including the presence of an effective medical service system, are taken.
The need for medical care at mass gatherings has been expressed in various ways. In
the United States, the term Medical Usage Rate (MUR) is commonly used, and is defined
as the number of first aid attendees per 10,000 event visitors1;2;9. Other countries use
Patient Presentation Rates (PPRs), which are calculated as the number of patients per
thousand event visitors presenting to on-site health care services4. Reported Patient
11
Chapter One
Presentation Rates at First Aid Stations (FASs) vary from 0.14 to 90, but most reported
ranges are between 0.5 and two per thousand visitors. PPRs have been described as
event-specific4. In other words, different events have different PPRs.
Mass gatherings can generate many patients for general practitioners, ambulance
services and hospitals. Therefore, health care planning is important for all involved
health service providers, in order to allow for timely treatment on-site and to provide
adequate referral and transport resources. To ensure primary care and to reduce
hospital admittance and ambulance transport, event medical services are designed
to provide first aid, advanced life support, event-specific care, health education and
prevention, hygiene monitoring and infection control and disaster planning.
Dutch Dance
In The Netherlands, rave parties attract up to 60,000 visitors. Approximately 650,000
youngsters (15-35 year old)10 attend these events yearly. Since the nineties of the last
century, the number of raves and the diversity of these events are booming. Different
studies confirmed, after extensive research, that youngsters are using alcohol and/or
drugs during nightlife11-26.
Next to a music trend, “Dance” became a cultural movement as well. People, who
liked hardstyle dance called themselves “gabber”. The literal translation of this word is
“friend”, but it includes a way of living and appearance as well. “Gabbers” were expected
to perform specific manners, like particular handshakes (the “gabber handshake”),
worrying about fellow gabbers, not interfering when people speak and showing respect.
Both power and friendliness were needed. Ecstasy, specific known as an energizer and
entactogenic substance, could enforce this and was well accepted19;27-29. However, it
was known as dangerous, as well. Cardiovascular problems, hyperthermia, neurologic
emergencies, psychosocial harm and brain damage have been reported15;17;25;30-57.
At the late 90’s GHB was introduced at raves. It is a liquid substance, with, in a recreational
dose, a more or less similar effect as ecstasy. It could make you happy, induce a kind
of fuddle and moved boundaries of shyness and sexuality58;59. Nevertheless, in a larger
dose, GHB could induce unconsciousness and respiratory depression22;57;60-78.
12
Drug-use in nightlife in The Netherlands
National prevalence surveys on drug use were carried out in the Netherlands in
1997, 2001, 2005 and 2009 among the general 15-64 years old population. As far as
recreational drugs are concerned most actual data are: In 2009, 92% of respondents
reported lifetime prevalence of alcohol, 25.7% of cannabis, 6.2% of ecstasy, 5.2% of
cocaine, 3.1% of amphetamine and 1.3% of gamma-hydroxybutyrate (GHB). Ketamine,
LSD and methamphetamine are rarely used. Use of magic mushrooms, decreased
strongly after the drug was banned in 2008. Only African-Arab immigrants use khat, a
mild stimulating substance14;21;24;26.
Next to prevalence surveys, substance use in The Netherlands was mainly monitored in
two ways. The Trendwatch-studies79 looked for trends and developments in a qualitative
way, while national quantitative data about substance use in nightlife were reported
in the “Feestmeter” (“Party-monitor”) by the Trimbos-institute, Netherlands Institute of
Mental Health and Addiction and the Bonger Institute for Criminology (University of
Amsterdam)22.
Trendwatch concluded recently different trends in nightlife, parties and substance use.
First of all, three major developments were seen:
1. Police forces took more stringent action against (alleged) trade in and use of drugs
at parties,
2. In 2009, the ecstasy market in the Netherlands was described as instable, because
of a decline in MDMA-like substances in tablets. From 2004-2008 the percentage
of MDMA-like substances in ecstasy tables was approximately 90%. In 2009 this
percentage decreased up to 40%. After the collapse, the ecstasy market was very
restless, but in the late 2009 a re-set appeared to occur with a 90% percentage of
MDMA-like substances in ecstasy tablets80;
3. The use of GHB increased.
Furthermore, it was found that raves grew larger and the number of visitors remained
the same, in contrast of the decreasing number of club attendees. Drug use is most
common with people in their twenties. Music genre and lifestyle appear to be predictors
of the nature and extent of current drug use among adolescents and young adults. At
13
Chapter One
the mainstream level, the drug consumption is highest in the rave environment, with
the use of mostly energetic substances, along with alcohol and cannabis. Although
the use and distribution has increased, the market of GHB remains smaller than that of
ecstasy and cocaine.
Specific nightlife segments have specific substance profiles:
-
Alcohol: the highest among mainstream (mixture of different music styles) and
dance,
-
Cannabis: the highest in the alternative scenes,
-
Cocaine, amphetamine and GHB: higher in dance than in all other scenes,
-
Ecstasy: much higher in dance than in other scenes.
In the “Feestmeter”, data on the use of recreational drugs were collected among 2,964
youngsters and young adults (15-35 years), while going out. It was aimed at two
different nightlife-locations: clubs and discotheques (in short: clubs) and large-scaled
parties and festivals (in short: parties).
Last year prevalence of substance use among club- and party people differed from
general population, and between club- and party visitors (2009):
Last year prevalence
Alcohol Cannabis Ecstasy
Cocaine
Amphetamine
GHB
General 15-34 years
74.4%
9.5%
2.7%
1.0%
0.7%
##
Clubs
96.4%
39.0%
15.6%
10.0%
6.3%
3.4%
Parties
96.5%
45.6%
30.8%
18.7%
11.0%
7.8%
##=Unknown
Party- en club people used more cannabis, ecstasy, cocaine and amphetamine than
general people and at parties more stimulants and GHB were used than at clubs.
Furthermore, some differences in characteristics and last month prevalence of
substance use were found between party visitors in general and specific segments of
rave public:
14
Total party visitors
Dance ##
Hardcore & Techno##
Alcohol
90.9%
92.9%
92.0%
Cannabis
31.0%
33.9%
39.9%
Ecstasy
23.7%
30.6%
36.4%
Cocaine
11.8%
13.9%
19.9%
Amphetamine
7.6%
6.0%
13.2%
GHB
4.9%
6.2%
8.3%
Men
49.7%
48.8%
57.0%
Men < 20 years
25.3%
19.8%
23.4%
Men 30+ years
20.3%
23.1%
13.4%
## Dance is a relatively mellow style, while Hardcore & Techno are considered harder ones.
Ecstasy and GHB appeared to be used more at Dance and Hardcore & Techno (H&T)
than at other festivals and cocaine and amphetamine more at H&T. More men than
women attended H&T; Dance was more popular among men older than 30 years and
H&T among younger men22.
Novel synthetic drugs with stimulant, entactogenic and/or hallucinogenic properties
have become increasingly popular among recreational drug users in recent years81.
However, the popularity in the Netherlands is very limited. Both novel drugs and
methamphetamine do not strike Dutch youngsters, probably because of the quality
and availability of lots of illicit substances in the Netherlands. In the Netherlands, drugs
can be (legally) tested at several places. The Drugs Information and Monitoring System
research these tests. Potential users can get reliable information about substances and
make people prefer recreational drugs with known effects and risks82.
15
Chapter One
Purpose of this thesis
The use of substances at raves is confirmed, as well as large numbers of visitors attend
raves. Hardly, however, the health risks of these events were identified nor the specific
need for medical care.
The purpose of this thesis is answering the following questions:
-
How many visitors attend the first aid station on scene at raves, what is the average
-
What is the prevalence of visitors of first aid stations at raves with substance-related
-
Which substance-related incidents are reported, what is the frequency and
-
What are the requirements for medical support at raves?
number of first aid attendees per 10,000 party visitors, how long do patients stay
on a first aid station and what types of incidents can be identified?
health problems? And what kind of drugs are involved?
severity?
In the period 1997-2010, the reports of first aid stations during raves were analyzed.
Millions of youngsters attended these parties and ten thousands of patients were
identified.
Chapter two is a review about six most used drugs in nightlife in The Netherlands. The
next chapter (Three) is a general report about health related problems during raves. In
this chapter, all incident-related substances are identified. Chapter Four is about specific
substance-related short-tem problems in general; Chapter Five proceeds with GHBrelated incidents specifically. Chapter Six concerns medical care at mass gatherings.
The thesis is concluded with an evaluation of all items and with future perspective and
directions (Chapter Seven).
16
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75. Galloway GP, Frederick-Osborne SL, Seymour R, Contini SE, Smith DE. Abuse and therapeutic
potential of gamma-hydroxybutyric acid. Alcohol 2000;20:263-9.
76. Dietze PM, Cvetkovski S, Barratt MJ, Clemens S. Patterns and incidence of gammahydroxybutyrate (GHB)-related ambulance attendances in Melbourne, Victoria. Med J Aust
2008;188:709-11.
77. Zvosec DL, Smith SW, Porrata T, Strobl AQ, Dyer JE. Case series of 226 gamma-hydroxybutyrateassociated deaths: lethal toxicity and trauma. Am J Emerg Med 2010;29(3):319-32.
78. Schep LJ, Knudsen K, Slaughter RJ, Vale JA, Megarbane B. The clinical toxicology of
g-hydroxybutyrate, g-butyrolactone and 1,4-butanediol. Clin Toxicol (Phila) 2012;50:458-70.
79. Doekhie J, Nabben T, Korf DJ. Nl.Trendwatch. Gebruikersmarkt uitgaansdrugs in Nederland
2008-2009. Amsterdam: Rozenberg Publishers, 2010.
80. Brunt TM, Niesink RJ, van den BW. Impact of a transient instability of the ecstasy market on
health concerns and drug use patterns in The Netherlands. Int J Drug Policy 2012;23:134-40.
81. Hill SL, Thomas SH. Clinical toxicology of newer recreational drugs. Clin Toxicol (Phila)
2011;49:705-19.
82. van der Gouwe D, Niesink RJ. Drugs Informatie en Monitoring Systeem. Jaarbericht 2011.
Utrecht: Trimbos-instituut, 2012.
21
22
Chapter Two
Party drugs in the Netherlands
A review on most-used recreational
substances
23
Chapter Two
Chapter 2: Party drugs in the Netherlands
A review on most-used recreational substances
Introduction
National prevalence surveys on drug use1-4 were carried out in the Netherlands in
1997, 2001, 2005 and 2009 among the general 15-64 years old population (table 1).
In 2009, from a representative sample (N=5,769), 92% of all respondents reported a
lifetime prevalence of alcohol. This was 25.7% for cannabis (of which 30% uses almost
daily), 6.2% for ecstasy, 5.2% for cocaine, 3.1% for amphetamine, 1.3% for gammahydroxybutyrate (GHB) and 0.5% for heroin (and methadone). Crack-cocaine, ketamine,
magic mushrooms, LSD and methamphetamine are rarely used but exact data for the
Dutch situation are not available. With respect to the use of ‘khat”, a vegetable product
containing cathine and cathinone, is only used by African-Arab immigrants.
In this chapter information about these substances will be provided. The overview will
be restricted to those drugs, which are recreationally used in the general population.
Recreational drugs
Ethanol (Alcohol)
Name
The generic name of alcohol is ethanol. Street names are booze, liquor, spirit; in Dutch:
borrel, drankje, druppel, hartversterkertje, neut, slok, slaapmutsje.
The scientific name is ethylalcohol.
24
Party drugs in the Netherlands A review on most-used recreational substances
Social
The status of ethanol in the Netherlands is legal. It is classified under the Licensing and
Catering Act. The way of recreational use is drinking.
Physiological effects
People use ethanol to feel pleasure and relaxation, and become talkative and socially
outgoing and to fulfill social expectations. They like to increase their self-confidence
and get some degree of intoxication, as well5.
Table 1. Prevalence on recreational-drug use in the Netherlands 3
Recreational drug
1997 (%)
Alcohol##
•
LTP
•
LYP
•
LMP
2001 (%)
2005 (%)
2009 (%)#
·
·
85
78
·
·
85
78
·
·
·
92
84
76
Amphetamine
•
LTP
•
LYP
•
LMP
·
·
·
2.2
0.4
0.1
·
·
·
2.4
0.4
0.0
·
·
·
2.1
0.3
0.2
·
·
·
3.1
0.4
0.2
Cannabis
•
LTP
•
LYP
•
LMP
·
·
·
19.1
5.5
3.0
·
·
·
19.5
5.5
3.4
·
·
·
22.6
5.4
3.3
·
·
·
25.7
7.0
4.2
Cocaine
•
LTP
•
LYP
•
LMP
·
·
·
2.6
0.7
0.3
·
·
·
2.1
0.7
0.1
·
·
·
3.4
0.6
0.1
·
·
·
5.2
1.2
0.5
Ecstasy
•
LTP
•
LYP
•
LMP
·
·
·
2.3
0.8
0.3
·
·
·
3.2
1.1
0.3
·
·
·
4.3
1.2
0.4
·
·
·
6.2
1.4
0.4
·
·
·
1.3
0.4
0.2
GHB###
•
LTP
•
LYP
•
LMP
# Because of a change of the research method, data can be influenced by this moderation
LTP=Life Time Prevalence, LYP=Last Year Prevalence, LMP=Last Month Prevalence
## Alcohol prevalence research was earlier focused on specific age groups
###First scored in 2009
25
Chapter Two
Chemistry
Pure ethanol is a colorless liquid. It is created during the fermentation
of sugar. To achieve a concentration of more than 14%, the liquid
must be distilled.
Structure formula of
Ethanol
The chemical formula is C2H5OH.
Epidemiology
The lifetime use percentage for ethanol is 92% of the population in the Netherlands.
The last year use is 84% and the last month use 76%. It is used by all age groups >12
years old3;6.
Pharmacokinetics
The amount of ethanol a person consumes will influence its distribution; a standard
drink is often defined as the amount of ethanol consumed in drink-specific glasses. For
example, the amount of ethanol in beer in a standard beer glass is just as much as in
wine in a standard wineglass. In the Netherlands, one standard dose has a mass of 9.9
gram or a volume of 12.5 ml of ethanol.7
Intake
Ethanol is a relatively small molecule that is easily and quickly absorbed in the GI
tract. After oral ingestion about 20% of a dose is absorbed through in the stomach
and 80% in the small intestine. This is also influenced by the rate of gastric emptying.
After entering the bloodstream, the ethanol molecules are distributed to almost all
the organs. Ethanol passes the blood-brain barrier easily and therefore the effects of
ethanol on the central nervous system are quickly present. The body composition will
influence ethanol levels in the blood, since ethanol is at first distributed over the bodywater and subsequently easily distributed in fat-tissue.
Elimination
Ethanol is mainly metabolized by the liver, where the enzyme alcohol dehydrogenase
(ADH) breaks ethanol down into acetaldehyde by oxidation. On its turn acetaldehyde
is eliminated by another enzyme called acetaldehyde dehydrogenase into acetate,
26
which is metabolized into water and CO2. The activity of ADH is genetically determined,
resulting in racial differences in e.g. Indians, Chinese and Japanese. A small proportion
of ethanol is eliminated through the lungs. The rate at which ethanol is metabolized
and eliminated from the body is constant across time: called a zero-order process. In
general, an adult metabolizes one dose ethanol in about 1-1.5 hour. The liver handles
this rate efficiently. If the consumer takes more than this amount, the system becomes
saturated and the additional ethanol accumulates in the blood and body. The liver is
responsible for the elimination through metabolism of 95% of ingested alcohol from
the body. The remainder of the alcohol is eliminated through excretion in breath, urine,
sweat, feces, milk and saliva.
Alcohol can be detected from 1-12 hours in urine, serum and plasma8.
Neurophysiologic
Ethanol has specific and powerful effects on the function of two particular types
of neuronal receptors: GABA receptors and glutamate receptors. Both chemical
neurotransmitters GABA and glutamate account for much of the inhibitory and
excitatory activity in the brain. When the terminals of one cell release GABA onto
receptors on the next cell, that cell becomes less active. When glutamate lands on a
glutamate receptor, that cell becomes more active. Ethanol increases the inhibitory
activity of GABA receptors and decreases the excitatory activity of glutamate receptors.
The enhancement of GABA is probably responsible for many of the sedating effects of
ethanol. Suppression of glutamate activity may have effect on forming new memories
and thinking in complex ways.
Through the action of GABA receptors the release of dopamine is increased. Dopamine
promotes the experience of pleasure. However, this mechanism only occurs when the
concentration of ethanol in the blood is rising – not while it’s falling. So, during the first
minutes after drinking the pleasure circuits in the brain are activated, but will disappear
after the ethanol level stops rising9.
Clinical effects (table 2)
Although the blood ethanol levels are influenced by sex, body weight and habit,
average effects can be found related to blood ethanol concentrations.
27
Chapter Two
Table 2. Effects of ethanol on Functioning and Physical State10;11
Ethanol dose/
hour
Blood Ethanol
(mg/100ml)
Function impaired
Physical State
1-4
< 100
Judgment
Fine motor coordination
Reaction time
Happy
Talkative
Boastful
4-12
100-300
Motor coordination
Reflexes
Vision
Staggering
Slurred speech
Uncontrolled walking
Aggression
Nausea, vomiting
12-16
300-400
Voluntary responses to
stimuli
Hypothermia
Respiratory depression
16-24
400-600
Sensation
Movement
Self-protection reflexes
Comatose
Respiratory insufficiency
24-30
600-900
Breathing
Heart function
Death
Chronic adverse effects
Chronic excessive ethanol use can contribute to the emergence of different diseases
and injuries, like cancer (of mouth, oropharynx, esophagus, liver and breast), depressive
disorders, epilepsy, hypertension, ischemic heart disease, atrial fibrillation, hemorrhagic
stroke, ischemic stroke, liver cirrhosis, traffic accidents, drowning and homicide12-17 .
Methylenedioxy-methylamphetamine (MDMA) or Ecstasy (XTC)
Name
The general name of MDMA is ecstasy. Street names are ecstasy, E, X, adam, love drug.
In the Netherlands the pills are usually called ecstasy, XTC or Adam, but due to the color and
the logo, they are also called names like ‘wit klavertje vier’, ‘roze tulp’ or ‘witte Mitsubishi’.
The scientific name is 3,4-methylenedioxy-N-methylamphetamine.
28
Social
MDMA has an illegal status in the Netherlands. The form of recreational use is usually
pills, but also powders and capsules.
People use MDMA, because it induces euphoria and it enhances a sense of intimacy
with others. Next to that it is used because of it energetic effects and to enhance
activities, like listening to music5.
Chemistry
The usual appearance of MDMA is tablets of different colors.
The sources are synthetic, pharmaceutical industry or illegal
production.
MDMA
The chemical formula is C11H15NO2.
Epidemiology
The lifetime use percentage for MDMA is 6.2% in the Dutch population in 2009 (4.3%
in 2004) and for last month use it is 0.4%. Lifetime prevalence is higher among males
(8.3%) than females (4.0%). MDMA is more often used in urban regions. People in the
age category 25-44 years old are most experienced with MDMA in 20093.
Pharmacokinetics
Intake
MDMA is usually taken orally and is well absorbed from the gastrointestinal tract. Peak
levels are reached in about one hour. The effects may last for three to six hours.
Elimination
Sixty-five percent of MDMA absorbed is excreted unchanged in the urine during the 24
hours after ingestion18. The elimination half-life of MDMA is 7-9 hours. MDMA has nonlinear pharmacokinetics with increasing doses, the bioavailability is much higher, the
29
Chapter Two
half-life longer and the total and hepatic clearance lower. MDMA also inhibits its own
metabolism after repeated ingestion19-22. MDMA can be found for 1-2 days in urine8.
Neurophysiologic
MDMA is a substance with stimulating and entactogenic (creates euphoria) effects, but
a much weaker stimulant than amphetamine.
MDMA is a potent releaser and/or reuptake inhibitor of presynaptic serotonin (5-HT),
dopamine (DA), and noradrenalin (NA). These actions result from the interaction of
MDMA with the membrane transporters involved in neurotransmitter reuptake and
vesicular storage systems. MDMA reverses the direction of the membrane transporter,
facilitating the efflux of NA, DA, and 5-HT to the synaptic cleft, with increased activation
of postsynaptic receptors. MDMA is a mild inhibitor of monoamine oxidase (MAO)
and reuptake but also has some direct actions in several types of receptors. It inhibits
tryptophan hydroxylase, the rate-limiting enzyme of serotonin synthesis, decreasing
the formation of serotonin18;22-38. Serotonin is thought to play a role in regulating mood,
appetite and body temperature.
Clinical effects
The most common effects are entactogeneity, stimulation, repression of sleep and
hunger, increased heart rate, blood pressure and body temperature, dilated pupils.
These characteristics occur with the use of 1-1.5 mg MDMA per kg bodyweight. MDMA
is maximized for the entactogenic effect.
The cardiovascular effects of 0.5mg/kg and 1.5 mg/kg were investigated in a double
blind, placebo-controlled study in eight healthy volunteers. Increased mean heart
rate (by 28 beats per minute) systolic blood pressure (by 25 mmHg), diastolic blood
pressure (by 7 mmHg) and cardiac output (by 2 L per minute) were found with an intake
of 1.5mg/kg39.
Toxicological effects include high body temperature, headache, palpitations, dizziness,
agitation, nausea and vomiting, confusion, panic attacks, bruxism, trismus, psychosis
and decreased libido.
Severe effects include arrhythmia, serotonin syndrome (which includes hyperthermia,
and/or seizures), excited delirium, rhabdomyolysis, liver failure and hyponatremia.
After repeated doses serotonin depletion occurs resulting in depression18;24-38.
30
Hepatitis and hepatic necrosis haven been described, as well as mild negative effects
on concentration, cognition and sleep22;40-43.
Combination / impure
Sometimes ecstasy does not consist of only MDMA but also amphetamine,
3,4-Methylenedioxy-N-ethylamphetamine (MDEA) or 3,4-methylenedioxyamphetamine
(MDA). The main differences are found in the clinical effects and duration of effect.
MDEA is more of a stimulative drug and is effective for three to five hours. MDA
changes the perception more and works for six to eight hours. More information about
amphetamines can be found in the next section.
Amphetamine
Name
General names of amphetamine are benzedrin, dexedrin, pervitin. In the street
it’s called speed or pep (both in the Netherlands and in other countries) or crank,
bennies or uppers. The scientific names are alpha-methylphenethylamine; 1-phenyl2-aminopropaan.
Social
Amphetamine is illegal in the Netherlands. Recreationally, it is used by (mainly) snuffing
powder and swallowing pills.
People use amphetamines to keep going and to stay awake5.
Chemistry
Amphetamine is usually available as a white to brown powder,
pills or capsules.
The sources are synthetic, from the pharmaceutical industry or
Amphetamine
illegal production. The chemical formula is C9H13N.
31
Chapter Two
Epidemiology
The lifetime use percentage of amphetamine is 3.1% of the population in the
Netherlands in 2009 (in 2005 2.1%) and use in the last month is 0.2%. It is mainly used
by the 16 to 24 years age group3.
Pharmacokinetics
Intake
Amphetamine enters the bloodstream very quickly when users snore it. The effects last
two to eight hours.
Elimination
The elimination half-life of amphetamines is ten to twelve hours. It is excreted 20-65%
in urine, unaltered, the rest as metabolite. Metabolization takes place mostly in liver.
The substance can be detected for 1-2 days in urine8.
Neurophysiologic
The principal action of amphetamine is sympaticomimetic and based on the blockade
of the transporter protein that removes dopamine from the synaptic cleft, resulting in
an increase in the extracellular dopamine concentration. Amphetamine is a dopamine
reuptake inhibitor. This effect is reinforced because amphetamine also stimulates
the release of presynaptic dopamine (dopamine releaser). Stimulating the physical
and anorexic effects are caused by an increase in the amount of noradrenaline in the
synaps44.
Clinical effects
The most common effects when using 5-7.5 mg per kg bodyweight are stimulation of
the CNS, repression of sleep and hunger, increased heart rate, blood pressure and body
temperature, dilated pupils.
Users are very restless. Use of amphetamine can lead to increased self-assurance (‘I can
do it’).
32
Undesirable effects of amphetamine are headache, palpitations, dizziness, agitation,
vasomotoric disturbances, delusions, dysphoria, and delirious state. With high doses
cardiac arrhythmia, convulsions, coma and death occur. The lethal dose is 20-25 mg per
kg bodyweight.
Amphetamine has the potential to cause cardiovascular harm12;45;46.
Specific information
A stronger variant of amphetamine is methamphetamine, also known as crank, meth
or crystal.
A nationwide survey of youth risk behavior in the United States found that 9.8 percent
of students had used methamphetamine at least once47. In the Netherlands it is hardly
used.
Cannabis
Name
General names of cannabis are marihuana, weed and hash. Street names are pot, grass.
In the Netherlands it is known as hasj, wiet, blowtje, hennep, hasjiesj, marihuana, stuff,
skunk. The scientific name is delta-9-tetrahydrocannabinol.
Marihuana refers to the dried material (flower tops) of the hemp plant, Cannabis sativa.
The term hashish refers to dried resin made from hemp flowers. Hash oil is a liquid
extracted from the plant material, and this form is the most potent48.
Social
Growing and processing cannabis is illegal in the Netherlands. However, a maximum of
30 grams (or 5 plants) for private use is tolerated in the Netherlands. Recreationally, it is
used by smoking (“blowing”).
People use cannabis mainly to relax and get “stoned”.
33
Chapter Two
Chemistry
Appearances of cannabis are dried plant material, dried
resin and oil. The source is a plant, Cannabis sativa. The
chemical formula is C21H30O2.
Structure formula of Cannabis
Epidemiology
The lifetime use percentage of cannabis is 25.7% of the population in the Netherlands
in 2009 (in 2005 22.6%) and use in the last month is 4.2%. It is mainly used by the 16 to
29 years age group3.
Marihuana is the most frequently used illicit drug in the United States. Its use is on the
increase, especially among junior high and high school students49.
Cannabis is used medically amelioration of nausea and vomiting, stimulation of hunger
in chemotherapy and AIDS patients, for lowering eye pressure (in glaucoma) as well as
for pain relief for example in multiple sclerosis.
Pharmacokinetics
Intake
THC is rapidly absorbed via the lungs and binds to endogenous cannabis receptors
in the central nervous system. This binding is responsible for the psychoactive
properties that users seek50. Specific for THC is the two-step binding; after it entered
the bloodstream it is issued to the fatty tissue in approximately 30 minutes. After that
the fatty tissue slowly re-issues it to the blood. This can take 2 till 7 days51;52.
Elimination
The elimination half-life of cannabis is 24-36 hours. Metabolism occurs mainly in the
liver to many different metabolites. More than 55% of THC is excreted in the feces and
approximately 20% in the urine. THC can be found for 2 to 7 days (single use) upto 1 to
2 months with prolonged use in urine8.
34
Neurophysiologic
The psychoactive constituents of cannabis, delta 9-tetrahydrocannabinol (delta 9-THC),
produces a myriad of pharmacological effects in humans. The mechanism of action of
cannabinoids, compounds which are structurally similar to delta 9-THC, has been found
recently in characterizing cannabinoid receptors both centrally and peripherally and
in studying the role of second messenger systems at the cellular level. Furthermore,
an endogenous ligand, anandamide, for the cannabinoid receptor has been identified.
Anandamide is a fatty-acid derived compound that possesses pharmacological
properties similar to delta 9-THC. The production of complex behavioral events by
cannabinoids is probably mediated by specific cannabinoid receptors and interactions
with other neurochemical systems. Cannabis also has great therapeutic potential and
has been used for centuries for medicinal purposes (as an antipsychotic and anxiolytic
substance). This force is attributed to cannabidiol (CBD), another psychoactive
constituent, which is found particularly in the fibers of hemp and appears to be a
serotonin receptor.
Clinical effects
THC reinforces the mood. It affects perception and relaxes.
Acute adverse effects can be tachycardia, elevated blood pressure, elevated respiratory
rate, dry mouth, increased appetite and impaired reaction time. Psychological effects
include euphoria, time distortion, anxiety, depression, impaired short-term memory,
paranoia and mystical thinking. Severe effects are extremely rare53-56.
Long-term use of cannabis can affect the pulmonary (by smoking), the immune and
the endocrine system12;56-58.
Cocaine
Name
Cocaine is the general name of the substance. Street names are coke or snow. (In the
Netherlands: wit) The scientific name is benzoyl-methylecgonine.
35
Chapter Two
Social
Cocaine is an illegal substance in the Netherlands.
Recreationally, it is snorted.
People use cocaine to get a fast kick. They also want to keep going and stay awake5.
Chemistry
The substance appears as white powder. The source is the leaves
of the erythroxylon coca plant. The scientific formula is C17H21NO4.
Cocaine
Epidemiology
The lifetime use percentage for cocaine is 5.2% of the population in the Netherlands in
2009 (in 1997 2.6%) and use in the last month is 0.4% (0.3% in 1997). It is mainly used
by the 15 to 24 age group3.
Pharmacokinetics
Intake
Cocaine is snorted (with an 80% absorption approximately) and inhibits the re-uptake
of noradrenalin and dopamine. Because of this the effects of these neurotransmitters
are reinforced. The effect on noradrenalin causes a reinforcement of the sympathetic
part of the autonomous nerve system.
Elimination
The elimination half-life of snorted cocaine is fifty minutes to three hours. Cocaine is
extensively metabolized, primarily in the liver, with only about 1% excreted unchanged
in the urine. The metabolite can be found for between 2-4 days in urine8.
Neurophysiologic
Cocaine mechanism of brain action is to block the reuptake of catecholamines, like
dopamine, noradrenalin and adrenalin.
36
Clinical effects
Cocaine is a stimulating, arousing and euphoric drug in a dose of 1.5-3 mg per kg
bodyweight. Tiredness is banished; activity increases, one feels fit and cheerful and
sexual feelings are stronger. Intensive use causes a stop in the production of dopamine,
which leads to feelings of craving and depression after use44.
Adverse acute effects are headache, palpitations, irritability, dizziness, agitation,
vasomotoric disturbances, disorientation, dysphoria and delirium. In high doses cardiac
arrhythmia, lung edema, myocardial infarction, convulsions, hyperthermia, coma and
death are described59-68. The lethal dose (if snorted) is 30 mg per kg bodyweight.
Frequent snorting of cocaine can led to nasal septum perforation69. Furthermore,
cardiac and respiratory problems, cerebral hemorrhage, renal infarction, seizure and
excited delirium have been reported related to chronic use68;70-72.
Specific information
Another apparition is crack cocaine. This form, also known as base coke, is smoked with
a base pipe or foil, and the vapors are inhaled through a tube. However, in contrary
to snorted cocaine, crack is not considered to be a recreational drug, but is related to
problematic (addictive) drug use.
Gamma-hydroxybutyrate (GHB)
Name
GHB is the general name of the substance. Street names are rape drug, elephant drug,
liquid ecstasy, G, G-Force. (In the Netherlands: vloeibare ecstasy, G, gti, kgb, buisje, dopje,
Geil Hemels Bronwater)73. The scientific name is gamma-hydroxybutyrate.
Social
GHB has an illegal status in the Netherlands. Recreationally, GHB is swallowed by
drinking from small bottles of approximately 5-10 ml or mixed with soft drinks.
37
Chapter Two
People use GHB to relax and to get “high” and because it enhances a sense of sexuality73.
Chemistry
GHB appears liquidly and sometimes as powder. It’s synthetic,
from the pharmaceutical industry or illegal production. GHB
is naturally found an endogenous compound in the human
Structure formula of GHB
brain peripheral. The scientific formula is C4H8O3.
Epidemiology
The lifetime use percentage for GHB is 1.3% of the population in the Netherlands and
for last month use it is 0.2%. Lifetime prevalence is higher among male (1.6%) than
female (0.9%). People in the age category 25-44 years old are most experienced with
GHB in 20093.
Pharmacokinetics
Intake
GHB is usually taken orally. It is sold as a light-colored powder that easily dissolves in
liquids or as a pure liquid packaged in vials or small bottles. GHB is typically consumed
by the capful or teaspoonful. The average dose is 1 to 5 grams and takes effect in 15
to 30 minutes, depending on the dosage and purity of the drug. Oral doses are rapidly
absorbed from the gastrointestinal tract and exhibit first pass metabolism74.
Elimination
The elimination half-life of GHB is twenty minutes to one hour. GHB is rapidly metabolized
by lactonase enzyme in plasma and the liver. Less than 2% is excreted unaltered in
urine. Because GHB is naturally present in the body, it will always be detected in blood.
GHB is detectable for up to 12 hours in urine75.
38
Neurophysiologic
GHB is a neurotransmitter, which also affects other neurotransmitter systems, including
gamma-aminobutyric acid (GABA). It produces a biphasic response on dopaminergic
activity, inhibiting dopamine release at low doses and increasing release at high doses.
Furthermore, GHB increases serotonin turnover in several brain regions, and inhibits
norepinephrine release in the hypothalamus. The substance has also been shown to
enhance the release of endogenous opioids by an indirect mechanism at high doses,
as well as to stimulate growth hormone secretion74.
Clinical effects
In a low dose (36mg/kg) the effects are mild relaxation, decreased inhibition and
euphoria, a reduction of fear and increasing sociability and sexual feelings. After one to
two hours the effects decrease and a feeling of alertness and increased energy appears.
In a moderate dose (40-50mg/kg) strong physical and mental relaxation is experienced.
In some cases articulation, co-ordination and balance is disturbed. In a dose of more
than 60mg/kg the symptoms are sleep to coma, amnesia, loss of motor co-ordination,
impaired speech, bradycardia, respiratory depression and hypoventilation73. Alcohol
has a potentiating effect.
The lethal dose is 1 gram per kg bodyweight.
At this time no human data are available concerning chronic effects or diseases. Longterm consequences of GHB are thus not well known yet.
39
Chapter Two
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44
Chapter Three
Experience of health related
problems during house parties in the
Netherlands: a report on nine years
experience and 3 million visitors: a
prospective observational study
Jan Krul, Armand RJ Girbes
This article has been published in Prehospital and Disaster Medicine 2009, Vol. 24, No. 2
45
Chapter Three
Chapter 3: Experience of health related problems during
house parties in the Netherlands: a report on nine
years experience and 3 million visitors: a prospective
observational study
Abstract
Objective: to report on a 9-years experience of medical support during house parties
(raves) in the Netherlands, where raves can be organised legally.
Design: prospective observational study of self-referred patients from 1997 till 2005
Setting: first aid stations with specifically trained medical and paramedical staff during
raves. Self referred patients were diagnosed, helped and recorded in a standardised
way.
Results: During 219 raves with approximately 3 million visitors during a 9-year period,
23,581 patients visited the first aid stations. Medical usage rate (MUR) varied from
59-170 patients per 10,000 rave participants. The mean age increased from 1997 till
2005 from 18.7 ± 2.7 to 23.3 ± 5.7 years. The mean stay at the first aid station was 18
± 46 minutes. Most health problems were mild. Fifteen cases of severe incidents were
observed with one death.
Conclusions: unique data from the Netherlands demonstrate a very low number of
serious health related short-term problems during raves.
46
Experience of health related problems during house parties in the Netherlands
Introduction
Since the early nineties a specific music culture has evolved. This phenomenon, called
dance, is characterized by music and lifestyle. Every year about 800.000 youngsters
in the Netherlands visit dance parties, also known as house parties or raves. Raves
are happenings for 500 to 60.000 visitors held in existing accommodations such as
exhibition centres, sports halls and outdoor recreational areas. At night these parties
usually last 9-10 hours. In summertime the raves are organized during daytime and last
11-14 hours. From 1996 till 2005 an increased number of visitors of house parties was
observed. The amount of raves increased as well as the average number of visitors per
house party1. Several studies have indicated that the use of recreational drugs during
house parties is common, and the majority of visitors, mostly youngsters, uses one or
more drugs2-6. Although data are lacking, health care authorities and public opinion
consider these events as a threat to health. Raves are therefore in general prohibited in
most countries. In the Netherlands an exceptional situation is present, where at every
legal rave an effective medical service system is available. A first aid station, staffed by
nurses, physicians and paramedics is prepared to give help to people with all common
health problems from minor severity cases to life-threatening disturbances. Medical
care at large events, indicated by the National Association of Emergency Medical
Services Physicians as Mass Gathering Medical Care is quantified by the number of
attendees, expressed in the medical usage rate (MUR)7. MUR can be used as a guideline
for the required need of care. Since 1996 medical incidents treated at the first aid
station of several house parties in The Netherlands have been registered to determine
MUR among other findings. In this study MUR includes consultations of physicians,
nurses and paramedics. The purpose of this study is to report on a 9-year experience of
medical support during house parties with approximately 3 million visitors and 25,000
self referring patients. Due to the legislation in the Netherlands unique data can be
presented.
47
Chapter Three
Table 1. Categorized health problems
Category
Definition
Questionnaire items
Medical
General medical complaints or
health disturbances
General unwell-being/fainting,
nausea, vomiting, dizziness, altered
consciousness, palpitations, altered
body temperature, stomach ache,
hyperventilation, dyspnoea, cramps
Trauma
Local injuries
Wound/laceration, burn, blister/skin
injury, contusion, distortion, fracture,
tooth injury, insect bite or stitch,
nail problem, foreign body, local
inflammation
Psychological
Psychological en psychiatric
symptoms
Anxiety, disorientation, psychotic
delusion
Miscellaneous
A combination of medical, trauma
and/or psychological, or
Not fitting in other categories
Table 2. Severity index
-
1 (Severe): Immediate life threatened by airway obstruction, breathing and/or circulation
disturbances
-
2 (Moderate): Life danger after some hours caused by airway obstruction, breathing and/
or circulation disturbances or chances of severe infection or disabilities if not treated
within 6 hours
-
3 (Mild): No threat of airway obstruction, breathing and/or circulation disturbances,
severe infections or disabilities
48
Methods
Design and participants
A prospective observational study of self-referred patients who reported to an available
health care station during Dutch rave parties was conducted. All users of medical care
were registered.
For the registration two different systems were used. These systems were developed
after a prospective pilot-study in 1996 among 1500 attendees of first aid stations during
raves. It appeared that lots of people attended this service just to ask for a painkiller for
headache or came to get a band-aid. All others asked for help or advice because of
medical complaints, illnesses or injuries.
For the group asking a painkiller for headache a so called headache list was developed.
On this small list only the time and the gender were noted. For the second group, the
users of medical aid, a standard registration questionnaire was developed to gather the
reported health problems. A list of health disturbances was pre-coded. The variables
are shown in table 1.
In every patient the time of arrival and departure at the first aid station, the gender
and the age was added. Additionally, information was obtained whether the problem
already existed before the event, and the number of visits to the medical services on
scene for the same complaint was noted. Furthermore, information was collected on
the type and number of drugs that were used as well as contributory health complaints.
Patients were asked about the fluid intake over the last three days, the food intake over
the last 24 hours, and the sleep and rest pattern during the past week. A fluid intake
less than 2000 ml/day, a food intake of less than three meals per day and less than
6 hours sleep per 24 hours were labelled as self care deficits. Finally, referrals to GP,
dentist or hospital were registered. All cases were finally scored on a two dimension
level. Incidents were categorized as medical, trauma, psychological or miscellaneous
(table 1). Next to these categories each incident was qualified as mild, moderate or
severe (table 2), based on the Severity Index8. The questionnaire is depicted in figure 1.
Patients were examined by qualified nurses and physicians, both with additional
specific training on party-related risks, including effects of recreational drugs. Members
49
Figure 1. Standard questionnaire. Note: on each form five attendees are reported.
Chapter Three
50
of staff of the first aid station were trained in using the questionnaire as well in an
introduction course and a yearly refresher and update course. All staff members were
coached by a colleague, who was especially appointed to support the staff in filling out
the questionnaires. Mistakes and inconsistencies were corrected on scene.
Procedure
After entering the first aid station the patient was received by a front desk officer, who
asked the patient about his complaint, injury or question. Some visitors attended the
first aid station for self treatment; they asked to get a band-aid to avoid blisters or asked
for a painkiller to relieve their headache and were not assessed as a medical problem.
If the patient suffered from headache asking for a painkiller he or she was then scored
according to the headache list. All other patients were transferred to a member of
the medical staff, who assessed the health problems. All data were registered in the
standard questionnaire. The questionnaire was used as guidance.
After discharge from the first aid station or transfer to ambulance personnel for
hospital transport, all data on the questionnaire were checked by a staff member who
was especially assigned to verify the registration. This official also qualified the incident
as mild, moderate or severe and categorized it as medical, trauma, psychological or
miscellaneous. All data were collected in a Statistical Package for the Social Sciences
(SPSS) file.
Data of number of visitors were obtained from the organizers of the events by counting
sold tickets.
Statistics
Group differences were evaluated using Pearson’s chi square test. A probability of <0.05
was considered significant. Descriptive statistics were used where appropriate.
Medical usage was reported as medical usage rate as defined by the National
Association of Emergency Medical Services Physicians7 expressed as patients per
10,000 participants [PPTT]. This is calculated by dividing the number of individuals
seeking medical care by the total attendance for that event multiplied by 10,000.
51
52
22
119.750
2044
170
12
144.500
1566
108
1998
15
216.250
1683
78
1999
14
226.500
1843
81
2000
29
420.500
3629
86
2001
26
466.000
2971
64
2002
18.7
13-41
2.8
1268
62.0%
765
37.4%
AVG age (yr)
range
SD
Male
Female
1997
N=23,581
821
52.4%
727
46.4%
20.0
14-50
4.2
1998
947
56.3%
727
43.2%
21.0
14-61
4.5
1999
976
53.0%
860
46.7%
22.2
14-56
5.1
2000
1824
50.3%
1782
49.1%
21.7
13-63
4.8
2001
1563
52.6%
1404
47.3%
22.0
14-56
5.1
2002
Table 4. Demographics. Note: in some cases gender was not mentioned in the case record form.
N of parties
N of visitors
N of incidents
MUR
1997
Table 3. Review of raves
1728
51.8%
1599
47.9%
22.5
14-54
5.2
2003
35
476.750
3337
70
2003
2037
53.4%
1768
46.3%
23.5
13-59
5.8
2004
33
453.500
3818
84
2004
1349
50.1%
1313
48.8%
23.3
13-54
5.7
2005
33
455.750
2690
59
2005
12.513
53.1%
10.945
46.4%
22.0
13-63
5.2
Total
219
2.979.500
23,581
79
Total
Chapter Three
Results
A summary of all included raves is given in table 3. Data of 219 raves were collected
with approximately 3 million visitors. A total of 23,581 patients attended the first aid
stations. This included 5.9% (1383) returning patients. Medical usage rate (MUR) of the
first aid stations varied from 59-108 patients per 10,000 visitors during 1998 till 2005. In
1997 MUR was 170.
Demographics (Table 4)
The mean age of first aid station attendees gradually increased from 18.7 ± 2.7 to 23.3 ±
5.7 over the years 1996 till 2005 (p<0.05). Over all years more men than women visited
the first aid stations.
First aid (Tables 5 and 6; figure 2)
Figure 2. Health categories. Note: the category Psychological was initiated in 1998; until
that year the category was included in Miscellaneous
Health categories
100
90
80
70
%
60
50
40
30
20
10
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
Year
Medical
Trauma
Psychological
Miscellanious
53
54
22.5
61.5
AVG stay (minutes)
SD
17.1
25.0
1998
20.2
56.2
1999
18.1
61.3
2000
15.8
56.2
2001
17.8
43.0
2002
18.6
37.1
2003
1997
96.8%
2.7%
0.0% (1)
(0)
N=23.851
3 – Mild
2 - Moderate
1 – Severe
Reported deaths
(0)
97.0%
2.4%
0.1% (1)
1998
(0)
98.3%
1.5%
0.1% (2)
1999
(0)
98.6%
1.2%
0.1% (1)
2000
(0)
98.0%
1.1%
0.0% (1)
2001
(0)
96.8%
1.5%
0.1% (4)
2002
(1)
96.0%
2.4%
0.1% (3)
2003
17.2
34.5
2004
(0)
96.4%
2.0%
0.0% (0)
2004
Table 6. Health qualifications and reported deaths. Percentage, and where appropriate numbers (n) are given.
1997
N=23.851
Table 5. Stay at the first aid station
(0)
96.6%
2.2%
0.1% (2)
2005
18.8
40.3
2005
(1)
97.1%
1.9%
0.1% (15)
Total
18.1
46.3
TOTAL
Chapter Three
Patients stayed on an average of 18 ± 46 minutes (range 1 – 390 minutes) at the first
aid station and this remained relatively stable over the years. During the first years of
the observation the category “Medical” scored highest (49.1-59.4%). From 2002 the
amount of the category “Trauma” increased (from 30.2 to 49.8-57.2%) while “Medical”
decreased (from 59.1 to 36.0-43.0%). After 1999 a fall of the category “Psychological”
was observed (from 2.3%-2.6% to 1.2-1.9%). Most health problems were qualified as
mild (97.1%). This was stable throughout the years (96.0-98.6%), whereas moderate
health problems were found in only 1.9% (457) of all cases. Fifteen cases of severe
incidents were observed in nine years (0.1% of all cases). They were qualified nine times
as medical. Hyperthermia, circulatory insufficiency and respiratory insufficiency each
occurred three times. Two trauma incidents were seen (penetrating abdominal trauma;
brain injury). Most frequently found clinical syndrome in these severe incidents was
excited delirium.
The amount of reported deaths was one, with respiratory failure. It was included in the
15 severe incidents.
Of all first aid station attendees 220 persons had no complaints or injuries.
Clinical features (Table 7)
Most reported health problems were minor complaints such as general unwell-being
and fainting (21.2%), nausea (11.6%) and dizziness (8.9%). Vomiting was frequently
observed too (6.0%). Four percent of the cases were states of altered consciousness.
Two to three percent of the cases were abdominal pain, hyperventilation, cramps,
gastric pain, and dyspnoea. In 1-2% palpitations and low body temperature was found.
High body temperature was seen in 0.3% of all cases. Significant differences (p<0.05)
in medical symptoms were found between male and female patients. General unwellbeing and fainting, nausea, dizziness, abdominal ache, dyspnoea and hyperventilation
occurred more frequently in women than in men, while altered consciousness, cramps,
gastric ache, palpitations and high and low body temperature were found more
frequently in men. In the younger group (age<22) all medical variables were found
significantly more frequent, except altered consciousness, and low body temperature.
Contusions and distortions (15.2%), wound/laceration (11.5%) and other skin injuries
(9.4%) were the most frequent trauma. Wound/laceration, fractured bones/dislocations
and foreign body were significantly more found in men than women, whereas skin
55
56
15.7%
10.4%
7.3%
1.4%
1.6%
1.0%
1.1%
0.6%
0.6%
0.5%
0.5%
.000
.212
.000
.000
.458
.108
.000
.005
.089
.001
.000
.778
43.2%
15.5%
5.2%
12.8%
2.2%
1.4%
1.0%
1.3%
0.6%
0.8%
0.4%
0.5%
46.3%
14.9%
17.1%
6.5%
2.1%
1.7%
1.5%
0.9%
0.8%
0.5%
0.8%
0.5%
10,617
15.2% (3579)
11.5% (2711)
9.4% (2224)
2.1% (501)
1.6% (369)
1.3% (298)
1.1% (265)
0.7% (167)
0.6% (152)
0.5% (121)
0.5% (121)
InjuryTotal
Contusion/distortion
Wound/laceration
Blister or other skin injury
Insect stitch or bite
Eye injury
Fractured bone/dislocation
Burn wound
Teeth injury
Nail problem
Foreign body
Local inflammation
24.1%
13.9%
10.5%
6.5%
3.2%
3.5%
3.0%
3.0%
2.8%
2.7%
1.45%
0.7%
0.4%
.000
.004
.000
.000
.180
.000
.000
.000
.000
.002
.000
.000
.000
.008
51.0%
22.1%
13.5%
10.9%
6.3%
3.1%
3.9%
3.5%
1.7%
2.1%
2.7%
1.0%
0.7%
0.2%
48.5%
20.3%
10.0%
7.1%
5.8%
4.7%
1.8%
1.5%
3.1%
2.7%
2.1%
1.5%
1.5%
0.4%
11,196
21.2% (4989)
11.6% (2739)
8.9% (2091)
6.0% (1423)
4.0% (938)
2.8% (653)
2.5% (584)
2.4% (570)
2.4% (564)
2.4% (558)
1.3% (303)
1.1% (265)
0.3% (78)
MedicalTotal
General unwell-being and fainting
Nausea
Dizziness
Vomiting
Altered consciousness (EMV<15)
Abdominal ache
Hyperventilation
Cramps
Gastric ache
Dyspnoea
Palpitations
Low body temperature (< 36.5oC.)
High temperature (> 37.5oC.)
Age <22
55.6%
p
Female
46.4%
Male
53.1%
All
N=23,581
Descriptive variables
More than one complaint is possible
Table 7. Descriptive analysis of clinical features
14.9%
13.2%
12.7%
3.4%
1.6%
1.7%
1.1%
1.6%
0.7%
1.0%
0.6%
16.9%
8.4%
6.6%
5.4%
4.6%
1.8%
1.8%
1.3%
1.9%
2.0%
1.0%
1.7%
0.3%
Age >21
38.3%
.093
.000
.000
.000
.872
.000
.910
.003
.186
.000
.240
.000
.000
.000
.747
.000
.000
.004
.000
.048
.484
.126
.000
.472
p
Chapter Three
1086
220
Combination Medical, Trauma and/or
PsychologicalTotal
No health disturbance
64.1%
61.1%
3.0%
1.3%
1.7%
35.5%
38.6%
2.8%
0.4%
0.4%
.000
.000
.525
.000
.000
3.4%
0.8%
1.0%
144.500
119.750
0.1
Percentage
0.1
100
81
1998
Amount of painkiller asking
persons
Number of rave visitors
1997
0.1
216.250
215
1999
0.2
226.500
445
2000
0.1
420.500
371
2001
0.3
466.000
1361
2002
0.4
476.750
2101
2003
0.4
453.500
1771
2004
2.1%
1.3%
0.6%
Table 8. Headache. Amount of persons attending first aid stations asking for a painkiller as self-treatment to headache.
Total
359
2.9% (683)
1.1% (257)
0.9% (208)
PsychologicalTotal
Anxiety
Disorientation
Delusion
0.3
455.750
1376
2005
.022
.065
.000
57
Chapter Three
injuries, burns and nail problems were more frequent in women. Wounds/lacerations,
skin injuries, insect bites, fractured bones/dislocations, teeth injuries and foreign body
were significantly more frequent in attendees > 21 years.
In the category “psychological” anxiety was the most frequent symptom (2.9%).
Disorientation and delusion were found more frequently in men than in women.
Anxiety and delusion was found significantly more frequent in younger (<22 yr)
attendees. Next to the questionnaire pre-coded variables, eighty cases of seizures were
reported (0.3%), 158 cases of pain (0.7%) and 67 cases of diarrhoea (0.3%).
Headache (Table 8)
Next to the registration on the standard questionnaire, headache was scored separately
on every rave. On top of the 23,581 registered patients, nearly 8.000 rave visitors
attended the first aid station for a painkiller to reduce headache. If added to the data
on the questionnaire, the category Medical would have been increased, as well as MUR
would.
Self-care deficits
Of all patients 6.0% (1416) stated they had a decreased food intake, 3.6% (859) a
decreased fluid intake and 3.6% (855) indicated to suffer from decreased sleep and rest.
Incidents related to recreational drugs
Of all 23,581 registered patients (of approximately three million rave visitors), 37.6%
(8863) of the health problems could be related to recreational drugs. In this context
ecstasy was mostly involved (21.8%) followed by alcohol (16.1%), amphetamine (4.2%),
cannabis (3.0%), GHB (2.6%) and cocaine (1.1%). It is of note that GHB was only used
since 2000.
Existing problems
Medical services had to deal with incidents that started before the party, too. An
average of 14.6% (3440) of the persons asked for help with problems that presented
earlier.
58
Clinical referrals
Of all patients 1.9% (450) was referred to the family doctor, 1.4% (334) to the hospital
emergency room by self transport and 0.9% (210) by ambulance; 0.1% (29) was referred
to a dentist.
Discussion
In this study patients with self referral to first aid stations during rave parties in the
Netherlands are reported. Most of the raves were held indoor. Of approximately 3
million, mainly young, visitors, 23,581 attended the first aid station. In contrast to the
overall assumption, short term health risks are low at rave parties as indicated by the
data. Fifteen cases of severe health problems were observed and one case of death
during these rave parties. Main presented issues were excited delirium, hyperthermia,
circulatory and respiratory insufficiency. These severe incidents were nearly all
related to recreational drug intake, but the number can be considered as very low.
Most complaints, over 97%, consist of complaints of general unwell being, nausea,
dizziness, vomiting and/or minor trauma which were all classified as mild. The data
which are presented are unique. In no other country legal rave parties are organized
on this scale. At all legal raves the authorities request the presence of a first aid station,
staffed by specifically trained nurses, paramedics and physicians. The data also allow a
realistic estimation of the medical usage rate (MUR) during such raves, which are 59108 patients per 10.000 visitors, though it has to be remarked that headache was not
included. In the first year of the study a MUR of 170 was found. This excessive number
can be explained by the fact that raves were a new phenomenon in the Netherlands,
attended by youngsters. Many of them were using recreational drugs like ecstasy and
amphetamines and very inexperienced. Anxiety was found significantly more frequent
among younger people. Harm reduction health education had only been started at
that time.
MUR at raves is comparable to other mass events and surely not excessive. In a
retrospective review of 405 single-day concerts in California USA in 1998, MUR for
Rock-concerts (MUR=137), non-rock concerts (MUR=71) and a punk festival (MUR=71)
were reported9. During three outdoor stadium concerts in the USA in 1999 MUR was
59
Chapter Three
8310. Other mass gathering events were surveyed as well and the following rates were
found: Papal mass in 1995 Denver MUR=411 and in New York 1995 MUR=1912, a crosscountry ski marathon in 1984 MUR=44113, Calgary Winter Olympic 1988 MUR=1914,
College football 1995 MUR=1115 and Los Angeles Summer Olympics 1984 MUR=1616.
However, it is difficult to compare MUR. At first MUR has not been defined clearly. Some
studies for instance include headache, while others don’t register these complaints
at all, because these are considered as self treatment. Next to that, sometimes MUR
is restricted to care executed by physicians. In this research reports from nurses and
paramedics are included too. Cultural differences of people visiting first aid stations on
scene may cause variations on MUR as well, so MUR in different countries can divert.
The self referred patients increased in age over the 8-year period of the study. Slightly
more men than women asked for medical help. The average stay at the first aid station
was less than 20 minutes.
Through the years the category Medical dropped, while Trauma increased. This can
be explained by some factors. It is possible that the amount of outdoor rave parties
have been grown. During outdoor raves more minor trauma incidents, such as blisters
and distortions are presented. Improved education on prevention of health risks
among youth, for instance information about recreational drugs and harm reduction
programs and preventive interventions carried out by rave organizers, such as free
water distribution, crowd management, quality improvement of security personnel
and climate control have probably lead to decreased medical incidents.
The questions of course remain whether the relatively low rate of severe accidents
is related to the open and legal circumstances that exist in the Netherlands. To our
knowledge no data on large rave parties are available form other countries. It’s a guess
that the data on health risks during rave parties compare favourable to data on visitors
of football matches although no prospectively collected data are available and our
guess is based on the lay press. Based on the data no reasons exist to prohibit rave
parties because of direct or potential harm of health. However, other reasons may be
considered more important such as political or principle arguments, or simply legal
prohibition of drugs as used during rave parties. Additionally, the contribution of the
first aid stations and staff in the prevention of health-related problems during rave
parties can not be estimated. Furthermore, long-term effects of rave parties on health
or drug use were not investigated, nor research on possible hearing problems because
60
of loud music was done. Other limitations of the study include that although the
sample is large, it only exists out of self referrers. It is very well possible that a number
of persons who suffered from complaints did not visit the first aid station. Wijngaart
et al17 en Bruin et al18 found some party visitors looked for help with friends, security
personnel or catering staff. Furthermore it cannot be excluded that some ill visitors
went directly to their general practitioner or a (nearby) hospital emergency room,
instead of attending the first aid station at the scene. No data on this were included.
In conclusion evidence is provided that a very low number of health-related problems
occur during legal rave parties in the Netherlands.
Conclusions
During 219 raves with approximately 3 million visitors during a 9-year period, 23,581
patients visited the first aid stations. Medical usage rate (MUR) varied from 59-170
patients per 10,000 rave participants. The mean stay at the first aid station was 18 ±
46 minutes. Most health problems were mild. Fifteen cases of severe incidents were
observed with one death.
61
Chapter Three
Reference List
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in the Netherlands. The meaning and impact on the Dutch economy and society: a survey].
2. Abraham MD, Kaal HL, Cohen PDA. Licit and illicit drug use in the Netherlands. Amsterdam:
Cedro / Mets & Schild, 2002.
3. Engels RC, Ter Bogt T. Outcome expectancies and ecstasy use in visitors of rave parties in the
Netherlands. European Addiction Research 2004;10(4):156-162.
4. Ter Bogt T, Engels RCME. Partying hard: Party Style, motives for and the effects of MDMA use
at rave parties. Substance Use and Misuse; 2005;40(9):1479-502.
5. Van de Wijngaart GF, Braam R, de Bruin D, Fris M, Maalsté NJM, Verbraeck HT. Ecstasy use at
large-scale dance events in the Netherlands. Journal of Drug Issues 1999;29(3):679-702.
6. Pijlman FTA, Krul J, Niesink RJM. Uitgaan en veiligheid: feiten en fictie over alcohol, drugs en
7. Milsten AM, Maguire BJ, Bissel RA, Seaman KG. Mass-gathering medical are: A review of the
literature. Prehosp Disast Med 2002;18:151-162
8. G van de Wijngaart, R Braam, D de Bruin, M Fris, N Maalsté, H Verbraeck, Ecstasy in het
uitgaanscircuit. Utrecht: CVO, 1997.
9. Grange JT, Green SM, Downs W. Concert medicine: Spectrum of medical problems
encountered at 405 major concerts. Acad Emerg Med 1999;6(2):202-207.
10. Jancher T, Samaddar C, Milzman D. The mosh pit experience: Emergency medical care for
concert injuries. Amer J Emerg Med 2000;18(1):62-63.
11. Schult D, Meade DM. The Papal chase. The Pope’s visit: A “mass” gathering. Emerg Med Serv
1993;22(11):46-49,65-75,79.
12. Federman JH, Giordano LM. How to cope with a visit from the Pope. Prehosp Disast Med
1995;10(4):273-275.
13. Gannon DN, Dense AR, Brokema PJ, et al. The emergency care network of a ski marathon. Am
J Sports Med 1985;13(5):316-320.
14. Thompson JM, Savoia G, Powell G, et al. Level of medical care required for mass gatherings:
The XV Winter Olympic Games in Calgary, Canada. Ann Emerg Med 1991;20(4):385-390.
15. Shelton S, Haire S, Gerard B. Medical Care for mass gatherings at collegiate football games.
Southern Med J 1997;90(11):1081-1083.
16. Baker WM, Simone B, Niemann JT, Daly A. Special event medical care: The 1984 Los Angeles
Summer Olympic experience. Ann Emerg Med 1986;15(2):185-190.
17. Boer J. In: FC Bakker, P Patka, D de Jong, HJThM Haarman (ed.). Triage en scoresystemen in
spoedeisende en rampengeneeskunde. Amsterdam: VU Uitgeverij, 2001: pp 179-91.
62
18. D de Bruin, N Maalsté, G van de Wijngaart. Goed fout gaan. Eerste hulp op grote
63
64
Chapter Four
Substance-Related Health Problems
During Rave Parties in the Netherlands
(1997-2008)
Jan Krul, Matthijs Blankers, Armand R J Girbes
This article has been published in PLoSONE, 2011, Volume 6, Issue 12, e29620.
65
Chapter Four
Chapter 4: Substance-Related Health Problems During
Rave Parties in the Netherlands (1997-2008)
Abstract
The objective of this study was to describe a 12-year (1997-2008) observation of
substance-related incidents occurring at rave parties in the Netherlands, including
length of visits to first-aid stations, substances used, and severity of the incidents.
During rave parties, specifically trained medical and paramedical personnel staffed
first aid stations. Visitors were diagnosed and treated, and their data were recorded
using standardized methods. During the 12-year period with 249 rave parties involving
about 3,800,000 visitors, 27,897 people visited a first aid station, of whom 10,100
reported having a substance-related problem. The mean age of these people was 22.3
± 5.4 years; 52.4% of them were male. Most (66.7%) substance-related problems were
associated with ecstasy or alcohol use or both. Among 10,100 substance-related cases,
515 required professional medical care, and 16 of these cases were life threatening.
People with a substance-related problem stayed 20 min at the first aid station, which
was significantly longer than the 5 min that those without a substance-related health
problem stayed. These unique data from the Netherlands identify a variety of acute
health problems related to the use of alcohol, amphetamines, cannabis, cocaine,
ecstasy, and GHB. Although most problems were minor, people using GHB more often
required professional medical care those using the other substances. We recommended
adherence to harm and risk reduction policy, and the use of first aid stations with
specially trained staff for both minor and serious incidents.
66
Substance-Related Health Problems During Rave Parties in the Netherlands (1997-2008)
Introduction
In the early 1990s, a new music culture called dance spread through numerous
countries in the western world. Rave parties or house parties with DJ-directed, fastpaced electronic music and light shows were organized1,2. In The Netherlands, rave
parties attract from 500 to 60,000 visitors. Approximately 650,000 youngsters (15-35
year olds)3 attend these events yearly. Several studies have indicated that the use of
recreational substances during raves is common, and the majority of visitors use one
or more substances1,4-13.
In the Netherlands, rave parties are allowed only if strict regulations are met. One of
these is that a first aid station is required to take care of rave party attendees with
various health-related problems. Here we present an overview of substance-related
visits to first aid stations at rave parties in the Netherlands between 1997 and 2008.
Substance Use in the Netherlands
In 1997, 2001, 2005, and 2009, surveys of substance use in the general population in
the Netherlands were conducted. Each of the substances covered in the present study
were included in these surveys. During this period, lifetime prevalence of cannabis use
generally increased (from 19.1% in 1997 to 25.7% in 2009), as did ecstasy use (from
2.3% to 6.2%) and cocaine use (from 2.6% in 1997, 2.1% in 2001, 3.4% in 2005, to 5.2%
in 2009). For the first time in 2009, lifetime prevalence of γ-Hydroxybutyric acid (GHB)
use was determined to be 1.3%, and the lifetime prevalence of alcohol use was 84%14.
In this study, we describe substance-related health problems that occurred during rave
parties.
Methods
This was a prospective observational study of rave-party attendees who presented
themselves for help at first aid stations at rave parties during the period 1997-2008.
All persons seeking first aid were registered, but only those with substance-related
problems were included in this study. Health-related incidents are described, together
67
Chapter Four
with length of medical care, severity of the incidents, predictability of symptoms, and
short-term risks. Specifically, the following information was collected with regard to rave
party attendees who sought help at first aid stations: (1) Length of stay, (2) substances
used alone or in combination, and (3) nature of the substance-related problems.
In an unpublished 1996 prospective pilot study of rave-party attendees, those seeking
first aid were divided into two groups. The first was a self-care group. These people
visited a first-aid station with only minor health-related problems and were not included
in the study. The second group visited the first aid station seeking help or advice. For
this group, a standard questionnaire was developed to ask about their health-related
problems7. Each person’s age and sex and time of arrival at and departure from the first
aid station were recorded. Additional questions asked about their substance use and
referrals that had been made to a general practitioner, dentist, or hospital. Finally, based
on the Emergency Severity Index 1;2, each health-related incident was categorized as
medical, traumatic, psychological, or miscellaneous, and each incident was designated
as minor, moderate (defined as requiring professional medical care within six hours), or
severe (defined as life-threatening and needing immediate professional medical care).
In the present observational study, data were collected prospectively and anonymously.
According to Dutch regulations, neither medical nor ethical approval was needed to
conduct the study. The study was not supported financially in any way. The data were
obtained from files maintained by Educare, a nonprofit organization that provides firstaid assistance at large-scale events. The Educare Board of Directors consented to our
using the data for scientific purposes.
Procedure
Upon entering the first aid station, the person was seen by a clerical officer, who
determined whether medical assistance was necessary or self-care was sufficient.
If aid was required, the person was referred to a member of the medical staff. This
staff included qualified nurses, paramedics, and physicians, all of whom had received
training in rave-related health risks, including the effects of psychoactive substances.
They had also been trained to use the standardized questionnaire. An experienced
co-worker was appointed to assist the staff in filling out the questionnaires, and this
person coached all of the staff members in using the questionnaires. After the rave-
68
party attendee had been discharged from the first aid station, the co-worker checked
all of the data to verify their integrity.
The number of visitors to each rave party (i.e., the number of tickets sold) was obtained
from the organizers of the event. Serious health-related incidents were defined as
those rated as moderate or severe on the Emergency Severity Index15. Risk of a serious
incident from each substance was defined as the number of serious incidents that
occurred divided by the number of attendees who used that substance. Relative risk
(RR) of a serious incident from each substance was defined as risk of a serious incident
from that substance divided by risk of a serious incident for visitors seeking first aid
who did not report using the substance. For each substance, the likelihood of visiting a
first-aid station was calculated by dividing the number of users of that substance who
sought first aid by the total number of visitor who sought first aid.
Statistics
Descriptive statistics were used to understand the demographic characteristics of the
sample and the nature of their substance-related visits to first-aid stations. To evaluate
the statistical significance of the results, Person’s r and Mann-Whitney U tests were
used for the parametric and nonparametric data, respectively. A p value of < 0.05 was
the cut-off for significance. To explore relationships between health-related incidents
and substance use, an logistic regression analysis was performed. A stepwise forward
regression model was used, with P(in) = 0.05 and P(out) = 0.10; a maximum of 20 iterations
was specified and a cut-off value of 0.5; the predictors of health-related incidents were
added using a stepwise procedure. The models were evaluated for acceptable fit and
proportions of variance explained. From each of the specified models, odds ratios > 2
are presented. All analyses were performed using SPSS version 17.0.
Results
From 1997 to 2008, 3,793,500 visitors attended 249 rave parties. Most (70%) of the raves
occurred at night. Many (N = 27,897; 0.7% of all visitors) of the people visiting a first-aid
station presented with complaints that needed some form of medical attention. The
69
70
2044
1566
1683
1843
3629
2971
3337
3818
2690
1249
1600
1467
27897
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Total
36.2
30.1
27.8
28.1
34.0
30.5
34.0
37.3
37.8
36.4
39.9
41.4
57.6
Substance
use
%
22.3 (5.4)
24.0 (6.3)
24.0 (6.5)
23.4 (5.5)
23.3 (5.7)
23.5 (5.8)
22.5 (5.2)
22.0 (5.1)
21.7 (4.8)
22.2 (5.1)
21.0 (4.5)
20.0 (4.2)
18.7 (2.8)
Mean Age
(SD)
52.4
52.3
48.1
46.1
50.1
53.4
51.8
52.6
50.3
53.0
56.3
52.4
62.0
Sex M %
***
47.0
47.4
51.6
52.8
48.8
46.3
47.9
47.3
49.1
46.7
43.2
46.4
37.4
Sex F %
***
*in minutes.
**p < 0.001, compared to substance-related visits to first aid stations.
*** missing data.
Median
Mean
Nr of
FAA
Year
Table 1. Characteristics of visitors at first aid stations.
10 (554)
10 (554)
10 (241)
10 (364)
10 (312)
10 (323)
10 (269)
10 (294)
5 (272)
7 (359)
10 (361)
10 (389)
12 (294)
General Stay
at FAS* Median
(Range)
20 (389)
30 (274)
28 (212)
25 (293)
23 (312)
20 (241)
20 (269)
15 (294)
13 (272)
15 (264)
20 (197)
18 (389)
15 (294)
Stay at FAS
Substance-related*
Median (Range)
5 (554)**
7 (554)**
8 (241)**
8 (364**
6 (216)**
5 (323)**
6 (163)**
5 (248)**
4 (266)**
5 (359)**
8 (361)**
6 (184)**
7 (137)**
Stay at FAS
Not substance-related*
Median (Range)
Chapter Four
mean age of all people visiting first-aid stations was 22.3 years (SD = 5.4), but the age of
the visitors increased significantly from 18.7 years in 1997 to 24.0 years in 2008 (r = .245,
p < .01). Visitors seeking help at first-aid stations were approximately equally divided
between males (52.4%) and females (47.0%).
Across the 12 years, a total of 10,100 people (36.2% of those seeking first aid),
representing 0.3% of all rave party visitors, experienced a substance-related incident.
The incidents were medical (80%), traumatic (9%), psychological (4%), or miscellaneous
(7%). The median overall length of stay at a first aid station was 10 minutes, but it was 20
minutes for substance-using visitors and 5 minutes for nonsubstance-using visitors—a
difference that is statistically significant (p < .001) (Table 1).
Most (n = 6912, 64.4%) of the substance-using visitors reported using only one
substance, which was usually ecstasy (n = 3308, 32.8%) or alcohol (n = 2296, 22.7%),
but a substantial proportion (n = 2554, 25.3%) reported using two substances
simultaneously. The most commonly reported combined use was ecstasy with alcohol
(n = 1129, 11.2%) (Table 2).
The most common substance-related health problem was a general feeling of being
unwell/fainting, which was associated with the use of all substances. Additional
minor health-related problems were associated with the different substances. Using
amphetamines was associated with having cramps (OR = 6.9); cocaine, with having a
high body temperature (> 37.50 C) (OR = 29.5) or palpitations (OR = 6.5); and GHB, with
altered consciousness (OR = 32.7) (Table 3).
Although ecstasy is a stimulant, the combined use of ecstasy and GHB was associated
with having a subnormal body temperature (OR = 5.6). The combined use of ecstasy
and amphetamines were associated with having psychotic delusions (OR = 9.7), high
body temperature (OR = 5.5), cramps (OR = 4.2), palpitations (OR = 3.4), or a stomach
ache (OR = 2.8). The highest odds ratios were found for the association between altered
consciousness and GHB/ecstasy use (OR = 26.2) and GHB/alcohol use (OR = 25.3) (Table
4).
The number of rave-party visitors who sought first aid fluctuated during the 12 years of
the study. Between 1997 and 2000, 7,136 people (1.0% of the visitors) needed first aid.
71
72
2296
(22.7%)
Single users**
70 (0.7%)
384 (3.8%)
47 (0.5%)
123 (1.2%)
1129 (11.2%)
Amp
Can
Coc
GHB
Ecs
428 (4.2%)
18 (0.2%)
13 (0.1%)
5 (0.0%)
-
70 (0.7%)
331
(3.3%)
Amp
6 (0.1%)
61 (0.6%)
8 (0.1%)
-
5 (0.0%)
384 (3.8%)
190
(1.8%)
Can
66 (0.7%)
6 (0.1%)
-
8 (0.1%)
13 (0.1%)
47 (0.5%)
44 (0.4%)
Coc
190 (1.9%)
-
6 (0.1%)
61 (0.6%)
18 (0.2%)
123 (1.2%)
252
(2.5%)
GHB*
-
190 (1.9%)
66 (0.7%)
6 (0.1%)
428 (4.2%)
1129 (11.2%)
3308
(32.8%)
Ecs
2554
(25.3%)
6912 (68.4%)
Total
Alc = alcohol. Amp = amphetamines. Can = cannabis. Coc = cocaine. Ecs = ecstasy.
*GHB was monitored after the year 2000.
**Magic mushrooms (n = 35). Unidentified products from smartshops such as energizers (n = 229), medication (n = 127), and other unidentified substances
(n = 223) were excluded.
-
Alc
Double users
Alc
N=10,100
Table 2. Number of individual and multiple substance-using first aid visitors.
Chapter Four
15.6
34.8
22.8
Delusions
Dizziness
Generally unwell /
fainting
Nausea
16.8
2.1 (1.7-2.6)
0.4 (0.2-0.8)
1.5 (1.3-1.8)
1.3 (1.0-1.5)
0.3 (0.1-0.8)
0.3 (0.2-0.6)
6.9
6.3
7.5
21.4
40.4
12.3
6.0
19.0
0.3
0.9
3.3
2.6 (1.6-4.4)
3.6 (2.0-6.3)
1.8 (1.3 2.5)
2.1 (1.6-2.7)
5.3 (3.0-9.2)
6.9 (5.0-9.7)
(CI)
OR
15.8
1.6
3.7
31.6
37.4
27.9
0.0
0.5
1.6
0.5
5.3
N=190
Can
1.9 (1.1-3.5)
1.8 (1.1-2.9)
4.1 (2.7-6.3)
(CI)
OR
6.8
4.5
13.6
9.1
34.1
11.4
2.3
4.5
4.5
0.0
0.0
N=44
Coc
29.5 (6.7130.9)
(CI)
OR
6.5 (1.5-28.4)
More than one symptom can occur in combination with each substance.
Reference category for the logistic regression analysis is not reporting use of each of the substances.
95% CI = 95% confidence interval (lower-upper).
ORs are available only for variables included in the forward stepwise model.
Vomiting
3.5
0.3
Cramps
Stomach ache
1.2
Body temperature
> 37.50C
1.2
0.3
Body temperature
< 36.50C
Palpitations
2.6
Altered
consciousness
2.3 (1.2-4.2)
N=331
(CI)
4.7
Amp
OR
Alc
N=2296
17.5
0.8
0.0
14.3
34.5
6.0
0.8
2.0
0.8
22.2
56.0
N=252
GHB
(CI)
OR
3.4 (1.5-7.3)
32.7 (20.751.6)
Table 3. Most common individual substance-related incidents and odds ratio (OR) among first aid station visitors (%)
10.9
3.1
2.5
25.4
52.8
18.0
2.0
5.3
0.8
1.2
3.8
N=3308
Ecs
1.6 (1.2-2.1)
1.5 (1.1-2.1)
2.3 (2.0-2.6)
5.1 (4.6-5.6)
1.7 (1.5-2.0)
2 (1.4-2.9)
1.7 (1.4-2.1)
0.2 (0.1-0.5)
0.75 (0.600.95)
(CI)
OR
73
74
2.2 (1.4-3.7)
9.1
5.8
6.5
2.8 (1.8-4.5)
3.4 (2.1-5.6)
1.6 (1.2-2.0)
5.9 (4.7-7.4)
9.7 (6.314.9)
4.2 (3.1-5.9)
5.5 (2.213.6)
OR (CI)
30.9
2.1
1.3
41.3
48.8
25.7
2.6
0.5
1.0
0.3
3.4
2.6
7.8
Alc +
Can
N=384
3.2 (2.1-4.8)
2.1 (1.4-3.1)
1.5 (1.1-2.1)
2.3 (1.5-3.3)
2.6 (1.6-4.2)
OR (CI)
13.2
0.5
0.5
11.1
43.7
3.7
7.9
0.5
3.7
2.1
21.1
1.6
52.1
GHB +
Ecs
N=190
OR (CI)
0.2 (0.0-0.8)
5.6 (2.7-11.7)
26.2 (16.3-42.2)
More than one symptom can occur in combination with the two combined substances.
Reference category for the logistic regression analysis is not reporting the use of each combination of the substances.
95% CI = 95% confidence interval (lower-upper).
ORs are available only for variables included in the forward stepwise model.
13.4
2.2
Stomachache
Vomiting
3.5
Nausea
Palpitations
22.9
13.3
0.9
65.2
4.1 (2.7-6.1)
8.9
1.7 (1.3-2.1)
5.4
Disorientation
14.3
3.5 (2.9-4.3)
1.7
Delusions
2.1
24.1
3.0
Cramps
0.2
57.2
1.2
Body temperature >
37.50C
10.3
Generally unwell/fainting
3.1
Body temperature <
36.50C
5.1
Amp
+ Ecs
N=428
16.1
7.1
Anxiety
1.8 (1.3-2.5)
OR (CI)
Dizziness
8.1
Alc +
Ecs
N=1129
Altered consciousness
Table 4. Most common multiple-substance-use problems and odds ratios (ORs) among first-aid station visitors (%).
21.1
2.4
1.6
13.0
35.0
6.5
8.9
0.0
0.0
3.3
20.3
0.8
56.9
Alc +
GHB
N=123
4.3 (1.9-9.3)
25.3 (12.7-50.2)
OR (CI)
Chapter Four
Between 2001 and 2004, the number rose to 13,755 (0.8% of the visitors). From 2005
to 2008, 7,006 visitors sought first aid. Across the 12 years, a total of 515 cases were
considered serious (i.e., professional medical care was required; Category 1 and 2 of the
Severity Index15), and 262 of these were admitted to a hospital emergency room. First
aid stations, however, were mostly often visited by people with no substance-related
health complaint.
Among those who did use substances, the risk of a serious incident was highest among
ecstasy users in the period 1997-2000 (0.21), but this risk decreased to 0.06 in 20052008. For alcohol users, the risk was 0.06 during 1997-2000, but it increased to 0.09 in
2001-2004 and 2005-2008 (Table 5). In 2001-2004, the relative risk of having a cocainerelated incident was 21.0. The largest number of serious incidents occurred with GHB
use (N = 55), with relative risk of 31.9 between 2001-2004 and 48.9 between 2005-2008
(Table 5).
Serious incidents also occurred in these periods with GHB/alcohol use (N = 32; relative
risk = 41.4 and 50.5) and GHB/ecstasy use (N = 47, relative risk = 44.1 and 44.8) (Table 6).
The combined use of alcohol and cannabis was not associated with having a problem.
On the whole, the relative risk of having a serious incident was higher among substanceusing visitors needing first aid compared to those who were not using a substance
(Tables 5-6). Finally, all severe incidents (life-threatening, Category 1 of the Severity
Index15, N = 16) were substance-related; they included four cases of excited delirium,
and three each of circulatory insufficiency, respiratory insufficiency, hyperthermia, and
severe trauma.
Discussion
Approximately one-third of all rave-party visitors who sought first aid reported having
a substance-related problem. Visitors with substance-related problems stayed longer
at first aid stations than those without a substance-use problem. Altogether, 515 of
10,100 substance-related incidents were classified as serious, and 16 of these were lifethreatening. Most substance-related incidents were associated with ecstasy or alcohol
75
Chapter Four
Table 5. Number and risk of first-aid visits and serious incidents associated with using
different substances individually.
Substance
Period
Nr of
FAVs
Risk FAVs
Nr of SI
RR SI (CI)
Risk SI
alcohol
1997-2000
401
0.06
6
1.9 (0.8-4.4)
0.02
2001-2004
1281
0.09
18
2.3 (1.3-3.8)
0.01
2005-2008
616
0.09
8
2.4 (1.1-5.2)
0.01
cannabis
1997-2000
46
0.01
1
2.7 (0.4-19.4)
0.02
2001-2004
110
0.01
0
0 (0.0-0.0)
0
2005-2008
34
0.01
0
0 (0.0-0.0)
0
cocaine
1997-2000
12
0
0
0 (0.0-0.0)
0
2001-2004
23
0
3
21 (7.1-62.2)
0.13
2005-2008
9
0
0
0 (0.0-0.0)
0
ecstasy
1997-2000
1487
0.21
15
1.3 (0.7-2.3)
0.01
2001-2004
1405
0.1
10
1.1 (0.6-2.2)
0.01
2005-2008
418
0.06
6
2.6 (1.1-6.3)
0.01
GHB
1997-2000
12
0
2
20.8 (5.6-77.1)
0.17
2001-2004
136
0.01
27
31.9 (20.8-48.9)
0.2
2005-2008
104
0.02
28
48.9 (29.9-80.0)
0.27
amphetamine
1997-2000
216
0.03
4
2.3 (0.8-6.5)
0.02
2001-2004
84
0.01
5
9.6 (3.9-23.3)
0.06
2005-2008
32
0.01
0
0 (0.0-0.0)
0
no substance
1997-2000
3988
0.56
32
1
0.01
2001-2004
9008
0.66
56
1
0.01
2005-2008
4907
0.7
27
1
0.01
For each substance, the risk of visiting a first aid station was calculated by dividing the number of
first aid visits (FAVs) related to that substance by the number of FAVs for that cohort.
CI = 95% confidence interval. Confidence interval for relative risk (RR) of a serious incident (SI)
was calculated using Morris and Gardner’s 46 formula.
The category no substance is the reference category for the SI risk ratios.
76
Table 6. Number and risk of first aid visits and serious incidents associated with using
different combinations of substances.
Substances
Period
Nr of
FAAs
Risk
FAS
Nr of
SI
RR SI (CI)
Risk
SI
alcohol+cannabis
1997-2000
54
0.01
1
2.3 (0.3-16.6)
0.02
2001-2004
227
0.02
6
4.3 (1.9-9.8)
0.03
2005-2008
99
0.01
4
7.3 (2.6-20.6)
0.04
alcohol+GHB
1997-2000
2
0
0
0 (0.0-0.0)
0
2001-2004
66
0.01
17
41.4 (25.5-67.3)
0.26
2005-2008
54
0.01
15
50.5 (28.5-89.4)
0.28
ecstasy+GHB
1997-2000
10
0
3
37.4 (13.6-102.4)
0.3
2001-2004
113
0.01
31
44.1 (29.7-65.7)
0.27
2005-2008
65
0.01
16
44.7 (25.4-78.9)
0.25
ecstasy+amphetamine
1997-2000
340
0.05
5
1.1 (0.7-4.7)
0.02
2001-2004
63
0.01
1
0.8 (0.4-18.2)
0.02
2005-2008
22
0
1
2 (1.2-58.2)
0.05
no substance
1997-2000
3988
0.56
32
1
0.01
2001-2004
9008
0.66
56
1
0.01
2005-2008
4907
0.7
27
1
0.01
For each combination of substances, the risk of visiting a first aid station was calculated by
dividing the number of first aid visits (FAVs) related to that combination by the number of FAVs
for that cohort.
CI = 95% confidence interval. Confidence interval for relative risk (RR) of a serious incident (SI)
was calculated using Morris and Gardner’s46 formula.
The category no substance use is the reference category for the SI risk ratios.
77
Chapter Four
use or both. It is noteworthy, however, that in the Netherlands alcohol use is relatively
common, but ecstasy use is not. It is possible that the willingness of rave-party visitors
to present themselves at a first aid station with health-related complaints was related to
the drug that they used. For example, ecstasy users’9 need for social contact might have
prompted them to seek assistance with minor health-related problems more readily
than users of other substances. Additionally, readiness to report one’s substance use
might have varied according to the social acceptability of using particular illicit drugs.
Unlike what most other recent studies from various countries have found17-24, the
occurrence of acute substance-related health problems found in this study was
relatively infrequent and the problems were not severe. From their systematic review
of the harmful effects of ecstasy use, Rogers et al. concluded that this drug rarely causes
death25 and Chinet et al. reported that party-goers who use drugs appeared to be
particularly receptive to harm-reduction measures26. It might be concluded, therefore,
that harm and risk reduction as practiced in the Netherlands is effective7,8. It should
also be noted that the Dutch generally use drugs in moderation, and they avoid using
highly risky substances, such as methamphetamine, which are used in many other
countries27-34.
In the current research, no evidence was found for life-threatening, acute effects of
GHB. Nevertheless, professional medical care is often required after GHB use and
the syndrome that can occur (altered consciousness, vomiting, and subnormal body
temperature) can be dangerous. Health education should focus on these secondary
effects in addition to the primary effects.
Questions remain about whether the relatively low rate of severe incidents that
occurred was related to the open nature and legal status of rave parties in the
Netherlands. It would, therefore, be important to replicate this study in other countries.
To our knowledge, there is no other published research on substance-related incidents
that occur during large-scale events. It would be worthwhile for future research to
focus on the causes of these incidents21,35-45. Finally, we recommend that future research
also address the secondary factors related to substance-related incidents and the
mechanisms involved in them, such as GHB-related airway threats and hypothermia,
ecstasy-related hyponatremia, excited delirium, and the serotonin syndrome.
78
Limitations
There were limitations of the current study that should be acknowledged. For example,
long-term effects on substance use or drug addiction were not addressed. Although the
study sample was large, it included only self-referrals, which might not be representative
of all health-related incidents at rave parties. It is possible that many people who
experienced negative effects did not present themselves at a first aid station. In fact,
Wijngaart et al. and de Bruin et al. reported that some rave party visitors sought help
from friends, security personnel, or food-service staff5,11,12. Substance use at rave parties
might be underreported and hence underestimated because stigmatization or a fear of
legal involvement. For reasons such as these, some visitors with health complaints may
have gone directly to their family physician or a hospital emergency room, rather than
visiting an on-the-scene first aid station.
Conclusions
Only a small proportion of rave-party visitors (0.3%) reported substance-related health
problems. The problems that were reported at first aid stations were usually related
to ecstasy or alcohol use. Substance users who sought first aid stayed four times as
long at a first aid station as nonsubstance users. A total of 515 of the substance-related
incidents could be regarded as serious; this amounts to 0.01% of all party visitors, 1.8%
of all visitors who sought first aid, and 5.1% of all substance users who sought first aid.
Sixteen cases were classified as life threatening. Visitors who used GHB, with or without
alcohol or ecstasy, and those who used cocaine were highest on relative risk of having
a serious incident. Finally, it should be notes that although lifetime prevalence of GHB
use is low, this substance causes many problems.
Acknowledgements
The writers would like to thank all staff members of Educare for their dedication,
accuracy, loyalty and contribution to this study. Special thanks to Ludger van Dijk
for the statistic support and Attie van der Meulen, Loes Greiner and Marga Witter for
always being there.
79
Chapter Four
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26. Chinet L, Stephan P, Zobel F, Halfon O. Party drug use in techno nights: a field survey among
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44. Ross DL. Factors associated with excited delirium deaths in police custody. Mod Pathol
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46. Morris JA, Gardner MJ. Calculating confidence intervals for relative risk, odds ratios and
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82
Chapter Five
Gamma-Hydroxybutyrate: Experience
of nine years of GHB-related incidents
during rave parties in the Netherlands
J. Krul, A.R.J. Girbes
This article has been published in Clinical Toxicology, 2011, Vol. 49, No.4.
83
Chapter Five
Chapter 5: Gamma-Hydroxybutyrate: Experience of nine
years of GHB-related incidents during rave parties in the
Netherlands
Abstract
Objective: The objective of this study was to determine the health disturbances and to
assess the severity of the incidents as reported on a nine years experience of GammaHydroxybutyrate-related First Aid Attendees attending First Aid Stations at rave parties.
Design: This was a prospective observational study of self-referred patients from 2000
to 2008. During rave parties, First Aid Stations were staffed with specifically trained
medical and paramedical personnel. Patients were diagnosed, treated and data were
recorded using standardized methods.
Results: During a nine-year period with 202 rave parties, involving approximately
three million visitors, 22,604 First Aid Attendees visited the First Aid Stations, of which
771 reported Gamma-Hydroxybutyrate-related health problems. The mean age of the
Gamma-Hydroxybutyrate-using First Aid Attendees was 25.7 ± 6.1 years, most of them
(66.4%) were male. Approximately one-third (32.7%) used one substance, while 48.1%
combined Gamma-Hydroxybutyrate with ecstasy, alcohol or cannabis. One out of five
(19.2%) combined Gamma-Hydroxybutyrate with other substances or more than one
substance. One case was categorized as severe/life-threatening and 202 (26.2%) cases
as moderate, requiring further medical care. Totally, 43 (5.6%) First Aid Attendees
needed hospital care. Most encountered health disturbance was altered consciousness.
Combinations of altered consciousness, vomiting and/or low body temperature were
found in 186 cases (24.1%) and considered to be potentially dangerous. GammaHydroxybutyrate-related First Aid Attendees required a longer stay at the First Aid Stations
than the total group First Aid Attendees did (median 45 minutes versus 10 minutes).
Conclusion: Unique data from the Netherlands on 22.604 First Aid Attendees during
a nine-year period demonstrate a variety of short-term health disturbances related to
the use of Gamma-Hydroxybutyrate. Although most problems were mild, professional
medical care was required for a quarter of Gamma-Hydroxybutyrate-using First Aid
Attendees.
84
Gamma-Hydroxybutyrate: Experience of nine years of GHB-related incidents during rave parties in the Netherlands
Introduction
In the late nineties of the past century, a new recreational drug appeared in nightlife.
This drug, Gamma-Hydroxybutyric acid or Gamma-Hydroxybutyrate (GHB), was
mentioned in several studies around 1999 as emerging, life-threatening and related to
sexual assault1-10. In the Netherlands, it was introduced in 1999. A risk assessment was
performed by the Dutch government11. It was expected that GHB could be used at socalled rave parties.
In the Netherlands, rave parties are organized for 500 to 60.000 visitors per event.
These events, also known as raves or dance-events, are visited by about 800.000
youngsters every year in the Netherlands12. Parties are held during nighttime or, in
summer, in daytime and last usually 9-12 hours. Several studies have indicated that the
use of recreational drugs during raves is common and the majority of visitors, mostly
youngsters, uses one or more drugs13-20. In the Netherlands, rave parties are allowed
under the condition of preventive measures, including the presence of an effective
medical service system.
The amount of medical care at large scaled events can be expressed in Medical Usage
Rate (MUR)21;22. The number of (first aid) attendees per ten thousand (party) visitors
defines MUR. In a survey in the Netherlands from 1997-2005 an average MUR at house
parties of 79 (59-170) was determined23.
Gamma-Hydroxybutyric acid or Gamma-Hydroxybutyrate (GHB)
Surveys conducted in dance music settings and other targeted surveys report life time
prevalence of GHB use from 3 to 19%24; a survey of 408 pub visitors in Amsterdam
conducted in 2005 reported lifetime prevalence of 10%. However, evidence suggests a
rather niche market for GHB where use is concentrated in very specific subpopulations.
Among respondents sampled in ‘gay’ Amsterdam bars prevalence estimates for GHB
use rose to 17.5% and in the city’s ‘hip’ bars 19% compared to less than 5% among
respondents in the more mainstream or student pubs.
A Dutch survey conducted in 2001 among 72 GHB users reported that three quarters
of the respondents used GHB at least once a month in the past year and 50% of them
85
Chapter Five
had taken it at least once a week. GHB was mostly taken in combination with other
substances25.
In 2008/2009 the use of substances was investigated among parties and festivals. For
GHB, life time prevalence of 14% was found. Three percent of all visitors used GHB, but
great differences were found between parties (range 0-20%)20.
The objective of this study was to determine the health disturbances and to assess
the severity of the incidents as reported during a nine years experience of GammaHydroxybutyrate-related First Aid Attendees attending First Aid Stations at rave parties.
Methods
Design and participants
A prospective observational study of self-referred patients who reported to an available
First Aid Station (First Aid Station) during Dutch rave parties was conducted. All users of
medical care were registered, but only those with GHB-related problems were included
in this publication.
For the registration, a standard registration questionnaire was developed to gather the
reported health problems. Part of the information that was collected were the type
Table 1. Categorized health problems
Category
Definition
Questionnaire items
Medical
General medical complaints or
health disturbances
General unwell-being/fainting, nausea,
vomiting, dizziness, altered consciousness,
palpitations, altered body temperature,
stomach ache, hyperventilation, dyspnoea,
cramps
Trauma
Local injuries
Wound/laceration, burn, blister/skin injury,
contusion, distortion, fracture, tooth injury,
insect bite or stitch, nail problem, foreign
body, local inflammation
Psychological
Psychological and psychiatric
symptoms
Anxiety, disorientation, psychotic delusion,
agitation
Miscellaneous
A combination of medical,
trauma and/or psychological, or
not fitting in other categories
86
and number of substances that were used as well as contributory health complaints.
All cases were scored on a two dimension level. Incidents were categorized as medical,
trauma, psychological or miscellaneous (table 1). Next to these categories each incident
was classified as mild, moderate (defined as professional medical care required) or
severe (defined as life-threatening), based on the Severity Index26.
Qualified nurses, paramedics and physicians, all with additional specific training on
party-related risks, including effects of recreational drugs, examined patients. Members
of staff of the First Aid Station were trained in using the questionnaire as well in an
introduction course and a yearly refresher and update course. A colleague, who was
especially appointed to support the staff in filling out the questionnaires, coached all
staff members. Mistakes and inconsistencies were corrected on scene.
The number of visitors was obtained from the organizers of the events (total number
of sold tickets).
Procedure
After entering the First Aid Station the attendee was received by a front desk officer,
who asked the patient about his complaint, injury or question. Some visitors attended
the first aid station for self-treatment; they asked to get a band-aid to avoid blisters
or asked for a painkiller to relieve their headache and were not assessed as a medical
problem. All other attendees were transferred to a member of the medical staff, who
assessed the health problems. All data were registered in the standard questionnaire.
After discharge from the First Aid Station or transfer to ambulance personnel for hospital
transport, a staff member who was especially assigned to verify the registration checked
all data on the questionnaire. This official also classified the incident as mild, moderate
or severe and categorized it as medical, trauma, psychological or miscellaneous.
Statistics
Descriptive statistics were used. For comparison of nonparametric data, Mann-Whitney
U-test was used, whereas for normally distributed data a student-t test was used. A
p-value of < 0.05 was considered significant. All analyses were performed using SPSS
version 17.0 (SPSS Inc).
87
Chapter Five
Results
Demographics
Table 2. Party characteristics, Medical Usage Rate (MUR: Amount of First Aid Attendees per
ten thousand party visitors) and substance-use among First Aid Attendees
Year
Parties
Party Visitors
First Aid
Attendees
MUR
Substance related health
disturbances* (%)
2000
14
226,500
1843
81
36.4%
2001
29
420,500
3629
86
37.8%
2002
26
466,000
2971
64
37.3%
2003
35
476,750
3337
70
34.0%
2004
33
453,500
3818
84
30.5%
2005
33
455,750
2690
59
34.0%
2006
10
265,000
1249
47
28.1%
2007
13
297,000
1600
54
27.8%
2008
9
252,000
1467
58
30.1%
* Percentage of the First Aid Attendees
A summary of all rave parties included in this study is in Table 2. Data from 202 events
totaling approximately three million visitors and 22,604 First Aid Attendees (First Aid
Attendees) were collected. Mean age was 22.3 ± 5.4 years. The male/female ratio was
about equal. Median stay at the First Aid Station (First Aid Station) was 10 minutes. Of
all First Aid Attendees approximately a third suffered from a substance-related health
disturbance.
Totally 771 attendees visited the First Aid Station after use of GHB. Mean age was 25.7 ±
6.1 years. Approximately two third (66.4%) of them were male. Median stay at the First
Aid Station was 45 minutes and significantly longer than the median stay of the total
group of First Aid Attendees (n=22,604 p<0.001) (Table 3).
88
Table 3. Demographics and Stay at First Aid Station (FAS)
Year
General (N=22,604)
GHB-related (N=771)
Mean Age
(SD-Range)
Male
%
Female Median
%
Stay at FAS
(Range)*
Mean Age (SDRange)
Male
%
Female
%
Median
Stay at FAS
(Range)*
2000
22.2 (5.1-42)
53.0
46.7
7 (359)
27.1 (5.8-23)
69.7
30.3
31 (113)**
2001
21.7 (4.8-50)
50.3
49.1
5 (272)
23.4 (4.3-18)
61.4
38.6
32 (146)**
2002
22.0 (5.1-42)
52.6
47.3
10 (294)
23.9 (4.6-20)
68.7
31.3
35 (294)**
2003
22.5 (5.2-40)
51.8
47.9
10 (269)
25.8 (6.1-27)
66.7
33.3
49.5 (269)**
2004
23.5 (5.8-46)
53.4
46.3
10 (323)
26.6 (7.0-35)
76.4
23.6
45 (239)**
2005
23.3 (5.7-41)
50.1
48.8
10 (312)
25.9 (6.0-27)
62.8
36.5
45.5 (311)**
2006
23.4 (5.5-67)
46.1
52.8
10 (364)
25.6 (5.8-29)
57.7
40.4
57.5 (159)**
2007
24.0 (6.5-70)
48.1
51.6
10 (241)
26.9 (7.1-36)
59.4
40.6
55 (140)**
2008
24.0 (6.3-62)
52.3
47.4
10 (554)
26.0 (6.2-29)
66.0
32.0
55 (107)**
Mean
22.3 (5.4-73)
52.4
47.0
25.7 (6.1-38)
66.4
33.2
Median
10 (554)
45 (312)**
* in minutes
**p<0.001, compared to General Stay at First Aid Station
Off all GHB-using First Aid Attendees 252 (32.7%) attendees used GHB (one substance),
190 (24.6%) combined GHB with ecstasy, 123 (15.6%) with alcohol and 61 (7.9%) with
cannabis. The remaining 145 persons (18.8%) combined GHB with other substances,
like amphetamine (2.3%) or cocaine (0.8%), or more than one other substance. Totally
97 (12.6%) First Aid Attendees used a combination of GHB, ecstasy and alcohol.
89
Chapter Five
Table 4. Severity index and classifications of GHB-related health problems and of problems
with GHB combined with other substances
GHB alone N=252
GHB plus other substances N=519
Severe*
Moderate**
Mild***
Severe*
Moderate**
Mild***
Medical
0.4% (1)
20.2% (51)
64.7% (163)
0
25.2% (131)
60.5% (314)
Trauma
0
0
0.4 %(1)
0
0.2% (1)
0.8% (4)
Psychiatric
0
0.4% (1)
1.2% (3)
0
1.0% (5)
2.1% (11)
Miscellaneous
0
1.2% (3)
11.4% (29)
0
1.9% (10)
5.45 (28)
*=Life-threatening
**=Not life-threatening, but professional medical care required
***=Severe, nor moderate
Table 5. Health related problems* related to GHB-use (N=252)
Health problem
GHB-related
Altered consciousness
56.0% (141)
General unwell-being/fainting
34.5% (87)
Low body temperature < 36.6
22.2% (56)
Vomiting
17.5% (44)
Nausea
14.3% (36)
Disorientation
8,7% (28)
Dizziness
7.1% (18)
Cramps
2,0% (5)
Agitation
2,0% (5)
Anxiety
0,8% (2)
Gastric pain
0,8% (2)
High body temperature > 37.5
0,8% (2)
Psychotic delusion
0,8% (2)
Stomach ache
0,4% (1)
*More than one complaint is possible
90
Clinical features
One of 252 GHB-related cases was categorized as severe/life-threatening (respiratory
failure), while 55 cases (21.8%) scored moderate on the Emergency Severity Index26.
Most GHB-using First Aid Attendees (67.7%) suffered from mild problems. In First
Aid Attendees, who combined use of GHB with other substances (N=519) no lifethreatening cases were found. Totally, 147 First Aid Attendees (28.3%) were classified as
moderate severity (Table 4).
Most occurring health disturbances were altered consciousness, followed by general
unwell-being, low body temperature, vomiting, disorientation and dizziness.
Other reported symptoms were cramps, agitation, anxiety, gastric pain, high body
temperature, psychotic delusion, stomach ache and trauma (Table 5).
Figure 1. GHB-related altered consciousness with Glasgow Coma Scale<15 (N=141,
median=8, range=12)
60 50 40 30 20 10 Frequency 0 Figure 1. GHB-related altered consciousness with Glasgow Coma Scale<15 (N=141, median=8,
range=12)
Of all 87 GHB-related cases of altered consciousness, half of them scored lower than
8 on the Glasgow Coma Scale (GCS) on the range of 3-14 (Figure 1). With 54 cases,
altered consciousness was also found, but the GCS-score remained unknown. In 56
(7%) cases using GHB, low body temperature (<36.60C) was found. No case of severe
hypothermia (<320C.) was seen. One case was classified as moderate and 24 cases as
mild hypothermia.
91
Chapter Five
First Aid Attendees using only GHB presented in 22.3% of the cases different
combinations of altered consciousness, low body temperature and/or vomiting. In
those using GHB in combination with other substances, these symptoms were found
in 25%.
Treatment and clinical referrals
Most First Aid Attendees were treated at the First Aid Station. Three persons (0.4%)
were referred to their family doctor and 43 (5.5%) patients were transported to the
hospital emergency department, because of persevering altered consciousness and
potentially threatened airway.
Discussion
During nine years of experience at rave parties with over three million visitors, 771 First
Aid Attendees who used GHB, were seen at the First Aid Station on scene. Compared to
alcohol-related problems this is indeed a very low number of cases23. In 23.6% of these
First Aid Attendees serious symptoms such as altered consciousness were present.
One severe case of respiratory failure was presented, requiring prolonged hospital
stay with mechanical ventilation. This case included a 43 years old man with a preexisting trachea aberration. Endotracheal intubation was thus impossible on-scene.
The patient was discharged from the hospital after two days. No GHB-related mortality
was observed.
GHB is frequently used in combination with other party drugs. This implies that
in case of patients with suspected GHB related symptoms, the likelihood of other
drugs involved should be taken into account. However, in our series no differences in
severity of symptoms were found in First Aid Attendees using only GHB versus those
who used GHB in combination with other substance(s). But patients with GHB related
problems require a longer stay in the First Aid station than other First Aid Attendees.
Accidental hypothermia is a potentially dangerous condition and can easily be
overlooked. Our observation of the present combination of altered consciousness,
vomiting and hypothermia underscores the importance of systematic examination of
92
First Aid Attendees suspected of GHB related symptoms. Instruction and training of
staff involved in medical assistance during rave parties should therefore focus on these
symptoms, using appropriate protocols. It is of note that this combination of conditions
is underreported in the current literature25;27-37.
Interestingly, the majority of First Aid Attendees with GHB related complaints did not
require hospital care: the supportive care of First Aid Stations with appropriately trained
staff was sufficient to deal with most encountered problems.
Some symptoms, like general unwell-being, nausea and dizziness were likely not GHBspecific. It is conceivable that some of the rave visitors developed these complaints
after a 6-12 hours lasting event, because of tiredness and dehydration.
Questions remain as to whether the relatively low rate of severe incidents is related
to the open and legal circumstances under which rave parties take place in the
Netherlands. It is not unlikely to assume that an open and easy access to medical
facilities during rave parties encourages early recognition of complaints and thereby
more health promoting behavior (disease limiting behavior) in visitors of rave parties.
Data from the Netherlands can therefore not be extrapolated automatically to other
countries, where rave parties with party drugs take place in more or less hidden and
secret conditions. It would therefore be of interest to investigate the incidence of health
related problems during rave parties in other countries. It will however, by definition
be difficult to compare data of different countries with different legislation and medical
infrastructure during rave parties. To our knowledge, no publications on GHB-related
cases during large scaled events at First Aid Station are available at this time.
Limitations of the study
Long-term effects on substance use or drug addiction were not investigated and remain
therefore unknown. Other limitations of this study include that although the sample
is large, it only includes self-referrals and does not necessarily provide a complete
overview of all GHB-related disturbances at rave parties. It is possible that a number
of persons suffered from complaints, but did not visit the First Aid Station. Wijngaart
et al and de Bruin et al found some party visitors sought help with friends, security
personnel or catering staff18;19;38. Furthermore, some visitors with health complaints
93
Chapter Five
may have gone directly to their general practitioner or a hospital emergency room,
instead of attending the on-scene First Aid Station.
In some cases the questionnaire was not filled in accurately. Specifically, of 54 cases
altered consciousness was reported, but no score on the Glasgow Coma Scale was
given.
No biological confirmation of the substance-intake by toxic screening of urine or
blood was done. We have not measured to what the attendees were exposed to,
quantitatively or qualitatively. We only know what they voluntarily reported. Next to
this substance use may have been underestimated related to stigmatization or fear of
law enforcement.
Conclusions
Totally, 771 First Aid Attendees (3.4% of all First Aid Attendees and 0.03% of 22,604
rave party visitors at 202 rave parties) suffered from GHB-related problems. Most of the
health disturbances were mild, 26.2% were moderate, while one was life-threatening.
Most occurring health problem was altered consciousness, frequently seen with a GCS
< 8. Altered consciousness was often combined with (mild) accidental hypothermia
and/or vomiting. Referrals to hospital emergency departments were made in 5.5% of
all GHB-related cases. GHB-using First Aid Attendees stayed significantly longer at the
First Aid Station than general First Aid Attendees did.
At events, where the visitors use GHB, a well-trained and qualified medical team
including nurses and physicians is recommendable.
94
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emergency department review. Emerg Med Australas 2008;20:521-30.
2. Williams H, Taylor R, Roberts M. Gamma-hydroxybutyrate (GHB): a new drug of misuse. Ir
Med J 1998;91:56-7.
3. Hodges B,.Everett J. Acute toxicity from home-brewed gamma hydroxybutyrate. J Am Board
Fam Pract 1998;11:154-7.
4. Ryan JM,.Stell I. Gamma hydroxybutyrate--a coma inducing recreational drug. J Accid Emerg
Med 1997;14:259-61.
7. Graeme KA. New drugs of abuse. Emerg Med Clin North Am 2000;18:625-36.
8. Eckstein M, Henderson S, DelaCruz P, Newton E. Gamma hydroxybutyrate (GHB): report of a
mass intoxication and review of the literature. Prehosp Emerg Care 1999;3:357-61.
9. ElSohly M,.Salamone S. Prevalence of drugs used in cases of alleged sexual assault. J Anal
Toxicol 1999;23:141-6.
10. Kam P,.Yoong F. Gamma-hydroxybutyric acid: an emerging recreational drug. Anaesthesia
1998;53:1195-8.
11. Risicoschattingsrapport betreffende gammahydroxybutyraat (GHB). Den Haag: IGZ, 1999.
12. Gram H, Jongedijk S, Olthof S, et all. Dance in Nederland. De betekenis en impact van dance
op de Nederlandse economie en maatschappij: Een verkenning. Amstelveen: KPMG, 2002.
14. Engels RC, ter Bogt T. Outcome expectancies and ecstasy use in visitors of rave parties in The
Netherlands. European addiction research 2004;10:156-62.
16. ter Bogt TFM, Engels RC. “Partying” hard: party style, motives for and effects of MDMA use at
rave parties. Subst Use Misuse 2005;40:1479-502.
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20. van der Poel A, Doekhie J, Verdurmen J, Wouters M, Korf DJ, van Laar M. Feestmeter 20082009. Uitgaan en middelengebruik onder bezoekers van party’s en clubs. Utrecht: Trimbosinstituut, 2010.
21. Milsten AM, Maguire BJ, Bissel RA, Seaman KG. Mass-Gathering Medical Care: A Review of
the Literature. Prehospital Disast Med 2002;17:151-62.
22. Milsten AM, Seaman KG, Liu P, Bissel RA, Maguire BJ. Variables Influencing Medical Usage
Rates, Injury Patterns, and Levels of Care for Mass Gatherings. Prehospital Disast Med
2003;18:334-46.
23. Krul J, Girbes ARJ. Experience of Health-Related Problems during House Parties in the
Netherlands: Nine years of Experience and Three Million Visitors. Prehospital Disast Med
2009;24:133-9.
24. Nabben T, Benschop A, Korf DJ. Antenne 2005: trends in alcohol, tabak en drugs bij jonge
Amsterdammers. Amsterdam: Rozenberg, 2006.
Rozenberg, 2002.
26. de Boer J. Rampengeneeskunde. Een samenvattend overzicht. Spoedeisende en
rampengeneeskunde, pp 179-91. Amsterdam: VU Uitgeverij, 2001.
27. Bodson Q, Denooz R, Serpe P, Charlier C. Gamma-hydroxybutyric acid (GHB) measurement
by GC-MS in blood, urine and gastric contents, following an acute intoxication in Belgium.
Acta Clin Belg 2008;63:200-8.
28. Degenhardt L, Darke S, Dillon P. GHB use among Australians: characteristics, use patterns
and associated harm. Drug Alcohol Depend. 2002;67:89-94.
29. Eckstein M, Henderson SO, DelaCruz P, Newton E. Gamma hydroxybutyrate (GHB): report of
a mass intoxication and review of the literature. Prehosp Emerg Care 1999;3:357-61.
30. Galicia M, Nogue S, To-Figueras J, Echarte JL, Iglesias ML, Miro O. [Poisoning by liquid ecstasy
2008;130:254-8.
31. Hodges B,.Everett J. Acute toxicity from home-brewed gamma hydroxybutyrate. J Am Board
Fam Pract 1998;11:154-7.
33. Kam PC,.Yoong FF. Gamma-hydroxybutyric acid: an emerging recreational drug. Anaesthesia
1998;53:1195-8.
34. Munir VL, Hutton JE, Harney JP, Buykx P, Weiland TJ, Dent AW. Gamma-hydroxybutyrate: a 30
month emergency department review. Emerg Med Australas 2008;20:521-30.
36. Ryan JM,.Stell I. Gamma hydroxybutyrate--a coma inducing recreational drug. J Accid Emerg
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37. Sporer KA, Chin RL, Dyer JE, Lamb R. Gamma-hydroxyburate serum levels and clinical
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98
Chapter Six
Medical Care at Mass Gatherings:
Emergency Medical Services at LargeScale Rave Events
Jan Krul, Björn Sanou, Eleonora L Swart, Armand R J Girbes
This article has been published in Prehospital and Disaster Medicine 2011, Vol. 26, No.4.
99
Chapter Six
Chapter 6: Medical Care at Mass Gatherings: Emergency
Medical Services at Large-Scale Rave Events
Abstract
Objective: The objective of this study was to develop comprehensive guidelines for
medical care during mass gatherings based on the experience of providing medical
support during rave parties.
Methods: Study design was a prospective, observational study of self-referred patients
who reported to First Aid Stations (FASs) during Dutch rave parties. All users of medical
care were registered on an existing standard questionnaire. Health problems were
categorized as medical, trauma, psychological or miscellaneous. Severity was assessed
based on the Emergency Severity Index. Qualified nurses, paramedics and doctors
conducted the study after training in the use of the study questionnaire. Total number
of visitors was reported by type of event.
Results: During the 2006-2010 study period, 7,089 persons presented to First Aid
Stations for medical aid during rave parties. Most of the problems (91.1%) were
categorized as medical or trauma, and classified as mild. The most common medical
complaints were general unwell-being, nausea, dizziness and vomiting. Contusions,
strains and sprains, wounds, lacerations and blisters were the most common traumas.
A small portion (2.4%) of the emergency aid was classified as moderate (professional
medical care required) or severe, including two cases (0.03%) that were considered life
threatening. Hospital admission occurred in 2.2% of the patients. Fewer than half of all
patients presenting for aid were transported by ambulance. More than a quarter of all
cases (27.4%) were related to recreational drugs.
Conclusions: During a five-year field research period at rave dance parties, most
presentations on-site for medical evaluation were for mild conditions. A medical team
of six healthcare workers for every 10,000 rave party visitors is recommended. On-site
medical staff should consist primarily of first aid providers, along with nurses who have
event-specific training on advanced life support, event-specific injuries and incidents,
health education related to self-care deficits, interventions for psychological distress,
infection control and disaster medicine. Protocols should be available for treating
100
Medical Care at Mass Gatherings: Emergency Medical Services at Large-Scale Rave Events
common injuries and other minor medical problems, and for registration, triage,
environmental surveillance and catastrophe management and response.
101
Chapter Six
Introduction
Large public gatherings such as sporting events, concerts and parties are becoming
increasingly common. These events, called mass gatherings, have been defined as
public events attended by a large number of persons1,2. Event attendees typically are
isolated from regular services and medical care.
Rave parties, also known as raves or dance events, with disk jockey-directed, fast-paced
electronic music and light shows, are attended by approximately 800,000 people per
year in the Netherlands3. These parties are held at night during the winter, and in the
daytime in summer. They typically last nine to 12 hours, and attract 3,000 to 60,000
visitors per event. In the Netherlands, rave parties are allowed on the condition that
preventive measures, including the presence of an effective medical service system,
are taken.
The medical care resources required for mass gatherings have been expressed in various
ways. In the United States, the term Medical Usage Rate (MUR) is commonly used, and
is defined as the number of first aid attendees per 10,000 event visitors4,5. In a nine-year
survey at raves in the Netherlands, the average rate of first aid attendees per 10,000
event visitors was 79 (range MUR = 59-170)6. Other countries use Patient Presentation
Rates (PPRs), which are calculated as the number of patients per thousand event visitors
presenting to on-site health care services2. Reported Patient Presentation Rates at First
Aid Stations (FASs) vary from 0.14 to 90, but most reported ranges are between 0.5 and
two per thousand visitors. PPRs have been described as event-specific2.
Mass gatherings can generate many patients for general practitioners, ambulance
services and hospitals. Therefore, health care planning is important for all involved
health service providers, in order to allow for timely treatment on-site and to provide
adequate referral and transport resources. To reduce hospital admittance and
ambulance transport, event medical services are designed to provide: (1) first aid; (2)
advanced life support; (3) health education and prevention; (4) hygiene monitoring
and infection control; and (5) disaster planning.
The purposes of this study are (1) to confirm earlier findings health disturbances at
Mass Gatherings6,7 and (2), mainly, to establish comprehensive guidelines for medical
care during these types of mass gatherings based on previous experience of medical
support during rave parties.
102
Methods
Design and Participants
This was a prospective, observational study of self-referred patients who reported to a
FAS during Dutch rave parties in the period 2006 through 2010. All those presenting
for medical care were registered into the study. An existing standard registration
questionnaire was used to record the reported health problems. All cases were scored
using a two-dimensional framework. First, incidents were categorized as medical,
trauma, psychological or miscellaneous. Second, based on the Emergency Severity
Index, each incident was classified as (1) mild (defined as an absence of professional
medical care needs); (2) moderate (professional medical care required); or (3) severe
(life-threatening)8-10.
Qualified nurses, assisted by paramedics and physicians, all with additional specific
training on party-related risks such as self-care deficits and drug use, examined
patients. Members of staff of the FAS were trained in using the study questionnaire,
and attended an introduction course, along with an annual refresher and update
course. A staff member specifically appointed to provide assistance in filling out the
questionnaires coached all other staff members. Mistakes and inconsistencies in data
collection were corrected on-scene.
Procedure
After entering a FAS, attendees were received by a front desk officer who asked each
patient about his complaint, injury or question. Some visitors attended the First Aid
Station for self-treatment (e.g., they asked for a band-aid to avoid blisters or asked for a
painkiller to relieve headache); these cases were not assessed as medical problem. All
other attendees were transferred to a member of the medical staff who assessed health
problems. All data were registered in a standard questionnaire.
After a patient was discharged from the First Aid Station or transferred to ambulance
personnel for hospital transport, a staff member assigned to verify registration checked
all data on the study form. This person also classified the incident as mild, moderate or
severe and categorized it as medical, trauma, psychological or miscellaneous.
103
Chapter Six
Statistics
Descriptive statistics and analysis were used to process study data. All analyses were
performed using SPSS version 17.0 (SPSS Inc, Chicago, IL, USA).
Results
During the study period, a total of 7,089 patients presented at a FAS with a medical
problem. This included 292 patients (4.1%) with recurrent problems (i.e., they revisited
the FAS for the same health problem) and 1,479 patients (20.9%) with a problem that
existed before the party started.
Demographics
The mean age of FAS attendees was 23.9 years (range, 12-85 years). Slightly more men
(3537 = 49.9%) than women (3523 = 49.7%) visited a FAS. In 29 cases, gender was not
mentioned in the case record form.
Table. Categorized and classified health problems (N = 7,089)*
Mild
Moderate
Severe
Medical
2,484 (35.0%)
110 (1.6%)
1 (0.0%)
Trauma
3,975 (56.1%)
25 (0.4%)
0 (0.0%)
Psychological
83 (1.2%)
10 (0.1%)
0 (0.0%)
Miscellaneous**
291 (4.1%)
26 (0.4%)
1 (0.0%)
*83 persons were neither categorized nor classified; no current health-related incident was found.
**Medical and/or Trauma and/or Psychological
Clinical Features
A total of 6,459 First Aid Station visitors (91.1%) were categorized as medical or trauma
and classified as mild (Table). Most presentations (N=7,089) were mild medical problems
or mild trauma and generally presented for non-specific symptoms of “unwell-being”
104
(21.8%), nausea (9.1%), dizziness (4.6%), vomiting (6.2%) and/or gastric/stomach ache
(5.9%). Mild trauma presentations included contusions/sprains/strains (20.8% of 7,089),
most commonly ankle, lower back and knee), wounds and lacerations (11.3%), blisters
and skin injuries (11.6%, mostly located on the heel) and insect bites or stings (4.6%).
In the mild psychological category, presentations were anxiety (2.2%), disorientation
(1.0%) and agitation (0.8%). Sometimes psychological problems occurred together
with trauma or medical problems. These cases were categorized as Miscellaneous.
A total of 171 cases (2.4%) were classified as moderate and required professional
medical care, while 2 cases (0.03%) were considered life-threatening (Table). Moderate
presentations included altered consciousness (94 of 171, 55%) of which all were
drug-related, both single-used or combinations of more substances, like GammaHydroxybutyrate (GHB) alcohol and/or ecstasy.
The most common moderate trauma cases were fractures (12 of 25, 48%), wounds
(three of 25, 12%), eye injury (three of 25, 12%) and multiple trauma (four of 25, 16%).
Of the ten moderate psychological cases, excited delirium (six of 10, 60%), psychotic
delusions (three of 10, 30%) and severe anxiety (one of 10, 10%) occurred.
Both life-threatening cases were related to recreational drugs. No deaths were reported.
Apart from the First Aid attendees with medical problems, approximately 2,500 visitors
attended for self-treatment. They asked for painkillers, band-aids, sanitary napkins,
tampons or hearing protection.
Clinical Referrals
Hospital referral occurred for 158 (2.2%) First Aid Attendees, of which less than a third
(30%) were transported by ambulance.
Health Disturbance-Related Factors
A number of First Aid attendees receiving medical evaluation reported self-care deficits
as defined in the Handbook of Nursing Diagnosis11. Among all presenting patients,
5.7% were found with altered nutrition (less than recommended body requirements),
3.6% with sleep pattern disturbance, and 2.1% with fluid volume deficit.
More than a quarter of all evaluated cases (27.4%) were recreational drug-related (singleuse or combinations of substances). Most used substances included alcohol (17.8%),
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Chapter Six
ecstasy (11.6%) and/or gamma-hydroxybutyrate (GHB) (3.3%). Use of amphetamines,
cannabis, cocaine and mushrooms was also reported.
A total of 1.5% of the party visitors suffered from asthma or diabetes and accessed the
FAS (primarily for forgotten medication).
Weather and indoor climate conditions influenced the MUR. Health complaints
increased with high temperature and even more with relative humidity > 85%.
Staffing
Two thirds of all patients presented to the FAS from three to eight hours after the start
of the rave. Based on maximum peak load during these five hours, six health care
providers were required for every ten thousand party visitors to eliminate waiting time.
Discussion
During the nine to twelve hour raves included in this study, many party visitors
presented to a FAS. For every 1,000 persons, eight to 12 presented to the medical
facility on-site (self-treatment attendees included). Apart from generally occurring
health complaints, rave party-specific problems can be identified. Most are minor
injuries or minor medical conditions that can be managed with basic first aid skilled
providers. However, including health professionals in addition to first aid providers
and providing specific event-related training are recommended to avoid unnecessary
hospital admittance and to provide more services on-site.
The comprehensive guidelines and recommendations below were developed based
on the experience of providing medical support during raves.
First Aid
Some minor problems, such a superficial wounds and lacerations occur regularly.
Providing wound care, including tetanus prophylaxis, should be considered essential
for such events. In this study, there were many soft tissue-injuries of the ankle and knee.
Therefore, event care providers should therefore be aware of the Ottowa Ankle Rules12
and Ottowa Knee Rules13,14 to determine the need for radiographic referral. During the
106
summer, event visitors are often stung or bitten by insects; therefore, protocols should
provide guidelines for anaphylaxis treatment.
Instructions for coping with lower back pain and blisters should be developed, as well
as how to deal with headache. Most visitors suffering from headache only asked for an
analgesic and were not assessed as patients in our study. FAS staffs should be aware
that for every three First Aid visitors, one additional person will ask for a self-care aid.
On-site medical staff should consider in advance which complaints can be self-treated
safely.
Advanced Life Support
Although life-threatening emergencies are rare, medical staff should be prepared
for unconscious patients and occasional specific severe health emergencies such as
excited delirium. For excited delirium, all severe cases in this study were substancerelated. Most unconscious patient presentations were related to GHB, alcohol or ecstasy
intake15.
Health Education and Prevention
First Aid attendees at raves suffer from various minor problems. However, to avoid
complications, professional health care providers should perform a full assessment for
each attendee. Because some patients suffer from mild psychological distress, first aid
personnel should be trained to perform specific interventions such as anxiety reduction
and reality orientation. Staff should also be prepared to provide health education, and
have knowledge about the most used recreational drugs and drug-related health
disturbances, especially because drug-using attendees may stay significantly longer in
the FAS. Party visitors are young, and some are not aware of basic health requirements
including need for nutrition, water intake and prevention of hyponatremia16-18 and the
balance between rest and activity.
Hygiene Monitoring and Infection Control:
Environmental elements should be monitored such as weather (or climate at an indoor
event) and venue hygienic situation (toilets, hand washing and food). Many First Aid
attendees suffer from gastrointestinal problems. They should be diagnosed carefully,
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Chapter Six
and food-borne illness should be identified immediately to avoid an event-specific
outbreak.
Extreme Emergencies
Typically, Emergency Medical Services, together with other public safety and security
agencies, are required to manage both a relatively predictable patient load as well as
unexpected and catastrophic events at mass gatherings, Disaster planning must be
part of the preparation for mass gatherings. Health care management designs should
incorporate a specific catastrophe response plan in which all possible scenarios are
anticipated.
Environment
Environmental factors contribute to the health challenges for those attending mass
gatherings. Temperature and humidity correlate to the number of Fist Aid attendees at
large-scale events. The relationship with temperature is complex, but with temperatures
of 30ºC or higher, patient presentations increase. The relationship between higher
humidity and an increased number of patients appears to be significant. Other
influences are the availability of alcohol, and the mobility and activity of the crowd1.
Consequences for Staff and Procedures
Sanders et al19 and Arbon1,20 have recommended standards for patient care services
at mass gatherings, and stated that these standards need review. The current study
confirms the staffing need for six health care providers for every 10,000 visitors. However,
this includes operational officers, but excludes management staff. Arbon divided
medical staff as follows: 88.8% first aid providers (of which half had advanced first aid
training), 7.2% nurses, 2.7% ambulance officers and 1.3% medical practitioners1. Based
on the nature of health problems observed at Dutch raves, the authors of this paper
recommend 50% first aid providers and 50% nurses, both with additional training.
In addition, a physician should be added for every 10,000 visitors, and an ambulance
team for every 15,000. First aid providers can treat minor injuries and support First
Aid attendees who are in psychological distress. Nurses are needed for triage, health
assessment, education and coaching, hygiene surveillance, and for intervention for
more severe cases. The medical team should include two Advanced Life Supported108
trained professionals for every 15,000 visitors, as well as one nurse with mental health
care experience.
In addition to the typical first aid and resuscitation equipment, protocols and
materials must be available for registration and triage. Protocols for management
of wound care, ankle and knee injuries, back pain, headache, blister management,
anaphylaxis, environmental issues (weather/climate, and water- and food hygiene) are
recommended as well as a catastrophe response plan.
Limitations
This study was conducted in the Netherlands and may not be valid for other countries.
In addition, the study was limited to data obtained at rave parties. While the study
sample is large, it includes only self-referrals and does not provide a complete overview
of all health disturbances at rave parties. It is possible that a number of persons suffered
from complaints, but did not visit the First Aid Station. Wijngaart et al and de Bruin et
al found some party visitors sought help from friends, security personnel or catering
staff21-23. Further, some visitors with health complaints may have gone directly to their
general practitioners or a hospital emergency room instead of the on-scene FAS.
Conclusion
During a five-year field period, most on-site presentations for medical evaluation at rave
dance parties were for mild conditions. A medical team of six health care workers for
every 10,000 rave party visitors is recommended. On-site medical staff should consist
primarily of first aid providers and nurses with event-specific training in advanced life
support, injuries, health education for self-care deficits, interventions with psychological
distress, infection control and disaster medicine. Protocols should be available for
treating common injuries and minor medical problems, and for registration, triage,
environmental surveillance, and catastrophe management and response.
109
Chapter Six
Reference List
1. Arbon P, Bridgewater FHG, Smith C. Mass gathering medicine: a predictive model for patient
presentation and transport rates. Prehospital Disast Med 2001;16(3):109-116.
2. De Lorenzo RA. Mass gathering medicine: a review. Prehospital Disast Med 1997;12(1):68-72.
Amstelveen: KPMG; 2002.
4. Milsten AM, Maguire BJ, Bissel RA, Seaman KG. Mass-gathering medical care: a review of the
literature. Prehospital Disast Med 2002;17(3):151-162.
5. Milsten AM, Seaman KG, Liu P, Bissel RA, Maguire BJ. Variables influencing medical usage rates,
injury patterns, and levels of care for mass gatherings. Prehospital Disast Med 2003;18(4):334346.
6. Krul J, Girbes ARJ. Experience of health-related problems during house parties in the
Netherlands: nine years of experience and three million visitors. Prehospital Disast Med
2009;24(2):133-139.
7. Krul J, van Litsenburg R. Medische zorg tijdens dance-events. Critical Care 2010;2010:22-26.
8. de Boer J. Rampengeneeskunde. Een samenvattend overzicht. Spoedeisende en rampenge
neeskunde. Amsterdam: VU Uitgeverij; 2001:179-191.
9. Christ M, Grossmann F, Winter D, Bingisser R, Platz E. Modern triage in the emergency
department [in German]. Dtsch Arztebl Int 2010;107(50):892-898.
10. van der Wulp, I, Rullmann HA, Leenen LP, van Stel HF. Associations of the Emergency Severity
Index triage categories with patients’ vital signs at triage: a prospective observational study.
Emerg Med J 2010:28(12):1032-1035.
11. Carpenito LJ. Handbook of Nursing Diagnosis. Philadelphia: J B Lippencott Company; 1991.
12. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to
exclude fractures of the ankle and mid-foot: systematic review. BMJ. 2003;326(7386):417.
13. Jalili M, Gharebaghi H. Validation of the Ottawa Knee Rule in Iran: a prospective study. Emerg
Med J 2010;27(11):849-851.
14. Robb G, Reid D, Arroll B, Jackson RT, Goodyear-Smith F. General practitioner diagnosis and
management of acute knee injuries: summary of an evidence-based guideline. N Z Med J
2007;120(1249):U2419.
15. Krul J, Girbes A. Gamma-hydroxybutyrate: experience of 9 years of gammahydroxybutyrate
(GHB)-related incidents during rave parties in The Netherlands. Clin Toxicol (Phila)
2011;49(4):311-315.
16. Aramendi I, Manzanares W. Hyponatremic encephalopathy and brain death in Ecstasy
(3,4-methylenedioxymethamphetamine) intoxication [in Spanish]. Med Intensiva
2010;34(9):634-635.
110
17. Hsu YJ, Chiu JS, Lu KC, Chau T, Lin SH. Biochemical and etiological characteristics of acute
hyponatremia in the emergency department. J Emerg Med 2005;29(4):369-374.
hyponatremia in California. Ann Emerg Med 2007;49(2):164-171.
19. Sanders AB, Criss E, Steckl P, Meislin HW, Raife J, Allen D. An analysis of medical care at mass
gatherings. Ann Emerg Med 1986;15(5):515-519.
dansevenementen. Utrecht: CVO; 1998.
22. van de Wijngaart GF, Braam R, de Bruin D, et al. Ecstacy in het uitgaanscircuit. Utrecht: CVO;
1997.
large-scale dance events in the Netherlands. Journal of Drug Issues 1999;29(3):679-702.
111
112
Chapter Seven
Medical aspects of raves: a discussion
and directions for the future
113
Chapter Seven
Chapter 7: Medical aspects of raves: a discussion and
directions for the future
At the time the research on raves was started as part of surveillance, little was known in
terms of effects on health disturbance and drug-related incidents during such parties.
Based on some accidents that made it to the lay-press, people considered these events
as dangerous because of drug abuse. Organizers of events asked for reliable data, as
health services and governmental officials did. The development of these raves was
astonishing. In the Netherlands, the number of rave parties increased rapidly and the
number of visitors of these events grew enormously. Next to the developments in the
Netherlands, raves became an important Dutch export product as well. After 15 years
of close observation of the health related aspects during house parties a picture based
on data can be presented from a medical perspective. In this chapter the findings, the
actual situation and future directions of raves as specific events, recreational drugs and
substance-related short-term health disturbances, health education and specific mass
gathering medicine are discussed. And - as far as possible - the findings are transferred
to general mass gathering medicine.
General findings of the research
Overall, investigating hundreds of rave parties with over four million visitors and more
than 30,000 First Aid Attendees, we found at the time of this report that
• An average of a Medical Usage Rate (MUR) of 70, which means that for every 10,000
visitors, 70 people will attend to a First Aid Station (FAS) with a health complaint
that need medical intervention. Next to this 70, about 25 persons on every 10,000
ask for self-treatment (painkiller for headache, hear-protection devices, sanitary
napkins for women, a band-aid for small wounds and blisters, etc.).
• Median stay at the FAS is 10 minutes. If the medical problem is substancerelated, the stay is prolonged to a mean of 20 minutes. And if the stay is GammaHydroxybutyrate (GHB)-related it is 45 minutes.
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Medical aspects of raves: a discussion and directions for the future
• Approximately 2% of all First Aid Attendees suffer from a health disturbance, which
needs professional medical care (doctor (MD), nurse (RN) or physiotherapist). This is
0.01% of all party visitors. Half of them are transferred to a hospital. A total of 0.05%
of all First Aid Attendees are in a life-threatening situation, which means one lifethreatening case on approximately every 200,000 rave visitors.
• Of all registered First Aid Attendees 36% have a substance-related problem. In
64% of these cases drugs are single used and in 25% a combination of two drugs
(of which one of them usually is alcohol) is present; the rest of the cases is a
combination of more than two substances. In case of health-disturbance related
to substances single-used ecstasy (33% and decreasing through the years), alcohol
(23% and increasing), 3% amphetamine, 3% GHB, 2% cannabis and less than 1%
cocaine, are involved.
When these facts are transferred to an event like Sensation, a yearly recurrent danceevent at the Amsterdam Arena with approximately 35,000 visitors, medical services
can expect 250 First Aid Attendees (FAAs) and 80 self-treatment patients. About five
of these FAAs need professional medical care. At this scale a life-threatening incident
is uncommon, but can happen incidentally. Approximately 90 FAAs suffer from a drugrelated problem.
Developments of recreational drug-use
In the beginning of the research, around 1997, the focus was mainly on ecstasy and
amphetamine, which were thought to be most dangerous and even life threatening at
that time. And indeed, a significant number of incidents occurred with those substances.
Substance-using youngsters were not acquainted with the right dose and the advised
use to accomplish the specific (non-toxic) effects and they could therefore not avoid
problems. Organizers of parties were at that time not aware of the need to control
the climate and to offer free drinking water in order to prevent from dehydration and
hyperthermia. And the Dutch drug market was unknown and hardly monitored. This
situation changed rapidly in the following years. Lifetime prevalence (LTP) of ecstasy
changed from 2.3% in 1997 to 6.2% in 2009. Market-offered pills in the Netherlands
contained usually 60-80 mg methylenedioxy-methamphetamine (MDMA), which is a
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Chapter Seven
dose for youngsters with an average bodyweight to experience the desired energy
and entactogenic effects. Party organizers developed health en safety policies to
avoid unwanted health incidents. The Dutch government started to support DIMS, the
Drugs Information and Monitoring System of the Trimbos-institute, which monitored
the drug market. Municipal health organizations, health education agencies, mental
health and drug-addiction institutes offered education programs and materials, like
websites, peer education onsite, leaflets and brochures to encourage harm reduction.
Dutch policy was based on promoting health and reduction of incidents rather than on
suppression of drug use.
After 2009 the ecstasy market changed. Probably because of a lack of raw material of
which ecstasy is made, in 2010 the ecstasy market collapsed. Different derivates were
sold instead of MDMA as ecstasy. And after this year the MDMA market recovered.
But there was a difference. The offered pills contained a higher dose of MDMA than in
earlier days, and increased to an average of 110-120 mg and higher.
LTP of amphetamine changed from 2.2 to 3.1% during 1997-2009, so not only more
people used amphetamine but also at higher doses. And while the use of alcohol in
the mid nineties of the last century was not fashionable, the use of alcohol increased
heavily at parties during the research period. Meanwhile, GHB was introduced in
nightlife and party scenes in the Netherlands. In 2009 a LTP of 1.3% was found. From the
year 2000 a significant part of professional medical care-needed incidents were related
to GHB. Approximately 25% of all GHB-related FAAs needed professional care, almost
in all cases because of altered consciousness. To compare: 1-2% of all alcohol-related or
ecstasy-related FAAs needed interventions of professional medical practitioners.
Developments of substance-related incidents
Most found drug-related incidents can be categorized as mild and no professional
medical care is needed. Headache, general unwell-being, fainting, dizziness, nausea
and vomiting are frequently reported complaints. However, it is not proven that
these problems can be attributed to drug-use. Health status of the persons involved
or the environmental conditions of the event can also be (part of ) the cause of these
inconveniences.
116
Serious single-use substance-related incidents that need professional medical care
are rare. Risks of serious incidents (with substance use compared to without use) differ
from 1-2 more risky for cannabis, ecstasy or alcohol, to 2-6 for amphetamine, to 1-13 for
cocaine, to 17-27 for GHB.
Combinations of substances have higher risk scores. This applies especially to alcohol
and GHB. This combination is 26-28 more risky than the risk when no substance is used.
Using ecstasy as well as GHB is 25-30 more risky compared to no use. It appears that
GHB is most dangerous.
Specific serious drug-related problems were unconsciousness, airway at risk (by
vomiting) and respiratory insufficiency with depressants (alcohol and GHB) and
threatened airway (by trismus), seizure, excited delirium, hyperthermia and circulatory
insufficiency with stimulants (ecstasy, amphetamine and cocaine).
Although the research period officially ended in 2011, monitoring drug-related
incidents in the Netherlands continued. And a strange or new phenomenon seemed to
occur. Serious ecstasy-related incidents increased largely. From 1997-2008 a total of 31
patients needed professional medical care in a population of 3.800.000 party visitors.
These figures remained constant in 2009 and 2010. In 2011 however, 26 cases were
reported in one single year1. This is alarming. Surprisingly, during a global congress
December 2011 in Prague on nightlife and health, “Club Health”, medical professionals
from the United Kingdom confirmed these findings in their country. Possibly the
change of dose can be the cause of the problem. Other explanations can be changes of
behavior or knowledge with ecstasy users. Further research is therefore needed.
Developments of event medical care
At the start of the research period few rules and regulations existed for medical care at
mass gatherings. At that time no consistent or standardized guidelines were available.
The only, more or less constant requirement was to assure one (volunteer) first aid
provider on every 750 party visitors.
During the following years medical care at events became more professional and nurses
were employed next to or instead of first aid providers. Additionally, physicians were
added to medical teams onsite and the level of care was upgraded from basic first aid
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Chapter Seven
and life support to specialized care and advanced life support. Medical care providers
were trained on event-specific risks, such as substance-related incidents and health
education. Mass gathering medicine guidelines were developed for events in general
and dance parties in particular. Event health care was more integrated in overall safety
plans and non-medical service members, such as security personnel, were trained in
recognizing serious health threads and communication with medical teams.
Specific educational programs for substance-related first aid and professional care
were developed for nightlife workers, security personnel, police officers, first aid
providers and emergency care professionals, like ambulance attendants, medical
dispatchers, emergency room personnel and general practitioners. Courses on
knowledge of substances, personal and environmental risk factors with drug-using,
specific health disturbances, focused on serotonin syndrome with trismus, excited
delirium, hyperthermia and seizure, hyponatremia, infarcts and strokes and first aid/
medical care are recommended.
Event organizers identified environmental health and harm risks and developed
interventions accordingly. During the years of the research a formula was found to
calculate the quantitative number of operational medical personal needed to staff First
Aid Stations at raves. The following variables appeared to be essential:
-
Number of party visitors,
-
Medical Usage Rate,
-
Staying time of First Aid Attendees at the First Aid Stations,
-
Number of aid attributions on location (outside the First Aid station),
-
The number of First Aid Stations at the event,
-
Weather or climate conditions.
Next to these factors the number of personnel and qualitative composition of the
medical team is fundamental. Therefore it is proposed that each team needs to meet
the following conditions:
-
The professional level needs to be 50% RN’s and 50% first aid providers.
-
If the volume of the events exceeds 10,000 visitors one MD should be included
-
If the volume of the events exceeds 15,000 visitors an Advanced Life Support (ALS)
educated team should be added, as well as an ambulance.
-
All team members must have an event-specific training on specific health risks,
medical incidents, registration and organization.
118
-
A medical team needs to be prepared to offer event-specific care, health education,
hygiene surveillance and must be able to manage the first phase of major incident
case in case of extreme emergencies and catastrophes.
Although these criteria are considered to be most important and both evidence-based
and best practice-based at rave parties and other public events2-17, they can be used to
improve quality standards of mass gathering medicine of other public events and mass
gatherings.
Future directions
As far as it gets to substance-related short term incidents, both educational programs
and medical care on site needs to focus on
-
The dangers of GHB. Unconsciousness, threatened airway because of vomiting and
lower body temperature are not enough known by users of this drug.
-
Use of ecstasy may lead to serotonin syndrome. Probably the dose of the substance
is of importance, but the personal vulnerability certainly is. Users do not realize
that unconsciousness, trismus, hyperthermia, seizure and excited delirium are
neurological emergencies. And, sadly, medical crew onsite, in ambulances and
in emergency rooms does neither. Recognizing excited delirium, in public often
confused with aggression and violence, needs to be educated to police and
security.
The professionalization of event medical care needs to be continued and expanded.
With rave events as an example and sometimes even a termination value, of all other
public events the MUR, staying time at the First Aid Station and specific risks should be
identified and matching and event-specific medical supplies should be applied.
It’s time to evaluate the main goals of substance-related education and harm reduction
policy. Educational programs are developed for youngsters during the late nineties.
Perhaps the new generation needs new information and new methods and media.
Governmental experts need to use evidence-based data to develop policies on harm
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Chapter Seven
reduction, rather than on repression mainly, which appears to be the contemporary
strategy.
It is advisable to be prepared for changes in the supply of recreational drugs,
modifications in the number of incidents, alterations of use among event visitors and
developments of events and event health care management in order to avoid or tackle
(serious) problems. The drug-market, substance-users behavior, event- and substancerelated incidents and public event medical care should (remain) being monitored.
Use of recreational drug is not reserved to Dutch youngsters, of course. It’s used
globally. It would be interesting to compare Dutch research on short-term substancerelated health disturbances with data of other countries. The project eSBIRTes, which is
to identify and develop effective tools for Screening, Brief Interventions and Referral to
Treatment for young adults presenting at the Emergency Department with problems
related to drug use in corporation with The Netherlands, Belgium, Spain, the United
Kingdom and Hungary, can be an example.
120
Reference List
1. Krul J, Girbes AR, Sanou BT. Increase in serious ecstasy-related incidents in the Netherlands.
Lancet 2012;380:1385.
2. Grange JT, Green SM, Downs W. Concert Medicine: Spectrum of medical problems
encountered at 450 major concerts. Acad Emerg Med 1999;6:202-7.
3. Thompson JM, Savoia G, Powell G, et al. Level of medical care required for mass gatherings:
The XV Winter Olympic Games in Calgary, Canada. Ann Emerg Med 1991;20:385-90.
4. Bellis MA, Hughes K, and Lowey H. Healthy nightclubs and recreational substance use. From
a harm minimisation to a healthy settings approach. Addictive Behaviors 27, 1025-1035.
2002.
5. Weir E. Raves: a review of the culture, the drugs and the prevention of harm. CMAJ
2000;162:1843-8.
6. Meites E, Brown JF. Ambulance need at mass gatherings. Prehosp Disaster Med 2010;25:5114.
8. Michael JA, Barbera JA. Mass gathering medical care: a twenty-five year review. Prehosp
Disaster Med 1997;12:305-12.
9. De Lorenzo RA. Mass gathering medicine: a review. Prehosp Disaster Med 1997;12:68-72.
10. Martin-Gill C, Brady WJ, Barlotta K, Yoder A, Williamson A, Sojka B et al. Hospital-based
healthcare provider (nurse and physician) integration into an emergency medical servicesmanaged mass-gathering event. Am J Emerg Med 2007;25:15-22.
11. Chan SB, Quinn JE. Outcomes in EMS-transported attendees from events at a large indoor
arena. Prehosp Emerg Care 2003;7:332-5.
12. Grange JT. Planning for large events. Curr Sports Med Rep 2002;1:156-61.
13. Krul J, van Litsenburg R. Medische zorg tijdens dance-events. Critical Care 2010;2010:22-6.
14. Sanders AB, Criss E, Steckl P, Meislin HW, Raife J, Allen D. An analysis of medical care at mass
gatherings. Ann Emerg Med 1986;15:515-9.
15. Al Tawfiq JA, Memish ZA. Mass gathering medicine: a leisure or necessity? Int J Clin Pract
2012;66(2):530-32.
16. Krul J, Sanou B, Swart EL, Girbes AR. Medical Care at Mass Gatherings: Emergency Medical
Services at Large-Scale Rave Events. Prehospital Disast Med 2012;27(1)71-4.
17. GHOR Nederland. Landelijke handreiking geneeskundige advisering publieksevenementen.
2012. Bunnik, Libertas.
121
122
Chapter Eight
Increase in serious ecstasy-related
incidents in the Netherlands
Jan Krul, Armand RJ Girbes, Björn T Sanou
This corresponding letter has been published in The Lancet; 2012 Oct 20;380(9851):1385.
123
Chapter Eight
Chapter 8: Increase in serious ecstasy-related incidents in
the Netherlands
We have noticed a sudden increase in ecstasy-related incidents in the Netherlands. In
this country, rave parties are legal and medical surveillanceisprovidedbyspecifically
trained health-care workers. Medical events are categorised as life- threatening
(category 1), not life- threatening but requiring medical assistance (category 2), and
other non-serious events (category 3).
Between 1997 and 2010, 31 cases fulfilling category 1 and 2 criteria related to ecstasy
use were recorded out of more than 5 million rave attendees.1,2 However, in 2011
alone, 26 category 1 or 2 cases were recorded, indicating a striking increase. Although
no scientific data exist to indicate the cause of this increase, as workers in the field
we suggest that market-related factors such as higher doses of pills and non-uniform
doses per pill might be the main cause.
We therefore warn of more ecstasy-related harm in the population, indicating the need
for preventive measures by responsible authorities, more awareness in the population,
and better research.
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Increase in serious ecstasy-related incidents in the Netherlands
Reference List
1. Krul J, Sanou B, Swart EL, Girbes AR. Medical care at mass gatherings: emergency medical
services at large-scale rave events. Prehosp Disaster Med 2012; 27:71-75.
2. Krul J, Blankers M, Girbes AR. Substance related health problems during rave parties in the
Netherlands (1997-2008). PLoS.One 2011;6:e29620.
125
126
Chapter Nine
127
Chapter Nine
Chapter 9: Summary of the main findings
In this dissertation, findings were focused on two themes - prospective studies on
health disturbances during rave parties in the Netherlands in general and recreational
drug-related incidents specifically. Next to these, rave parties were researched to map
medical care at large-scaled public events. The general aim of these studies were
fourfold:
-
How many visitors attend the first aid station on scene at raves, what is the average
-
What is the prevalence of visitors of first aid stations at raves with substance-related
-
-
number of first aid attendees per 10,000 party visitors, how long do patients stay
on a first aid station and what types of incidents can be identified?
health problems? And what kind of drugs are involved?
Which substance-related incidents are reported, what is the frequency and
severity?
What are the requirements for medical support at raves?
In this chapter, the main results are summarized. Finally, the limitations of the studies
are reviewed.
The first aforementioned research questions are addressed in Chapter 1. In the general
introduction the setting of the research was defined. All findings of the study were
found at rave parties, also known as house – or dance parties. “Dance” is a collective
name for all types of electronic dance music (EDM). The main feature is that the music
is performed with electronic instruments and is DJ-directed. “house” in the Netherlands
was a collective name for dance music. This led to confusion, since “house” is also the
name of a subgenre. Therefore, “dance” (or EDM) is now the most common over-all
term. In other countries, “techno” and “progressive” are used as collective names. Large
dance events are worldly wide known as “raves” with a range of 1000-60,000 visitors.
These events are also known as “Mass Gatherings”, and defined as “Any gathering of a
large number of people attending an event that is focused at specific sites for a finite
time with a potential for a delayed response to emergencies”.
In The Netherlands, rave parties attract up to 60,000 visitors. Approximately 650,000
youngsters (15-35 year old) attend these events yearly. Since the nineties of the last
128
century, the number of raves and the diversity of these events are booming. Different
studies confirmed, after extensive research, that youngsters are using alcohol and/or
drugs during nightlife. Ecstasy, because of its energizing and euphoric effects, is very
popular, next to alcohol, cannabis, amphetamine and cocaine. At the late 90’s GammaHydroxybutyrate (GHB) was introduced. Nowadays, specific nightlife segments have
specific substance profiles:
-
Alcohol: the highest among mainstream (mixture of different music styles) and
dance,
-
Cannabis: the highest in the alternative scenes,
-
Cocaine, amphetamine and GHB: higher in dance than in all other scenes,
-
Ecstasy: much higher in dance than in other scenes.
These substances are reviewed in the next chapter.
Chapter 2 focuses on most-used recreational drugs. National prevalence surveys on
drug use were carried out in the Netherlands since 1997 among the general 15-64 years
old population. In 2009, from a representative sample (N=5,769), 92% of all respondents
reported a lifetime prevalence of alcohol. This was 25.7% for cannabis, 6.2% for ecstasy,
5.2% for cocaine, 3.1% for amphetamine and 1.3% for GHB.
Main reason for drinking alcohol is to feel pleasure and relaxation, and become
talkative and socially outgoing and to fulfill social expectations. People like to increase
their self-confidence and get some degree of intoxication, as well. People take MDMA
pills, because it induces euphoria and it enhances a sense of intimacy with others. Next
to that it is used because of it energetic effects and to enhance activities, like listening
to music. Amphetamine is snuffed or taken as pills mainly to keep going and to stay
awake, while cannabis is smoked to relax and get “stoned”. Cocaine is snored to get
a fast kick, to keep going and stay awake. Finally, people use GHB to relax and to get
“high” and because it enhances a sense of sexuality.
Of all six most-used recreational drugs, name, social aspects, physiological effects,
chemistry, epidemiology and pharmacokinetics are reviewed.
Chapter 3 reported on a 9-years experience of medical support during house parties
(raves) in the Netherlands. In a prospective observational study of self-referred patients
from 1997 till 2005 in a setting of first aid stations with specifically trained medical
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Chapter Nine
and paramedical staff during raves, self referred patients were diagnosed, helped and
recorded in a standardised way.
During 219 raves with approximately 3 million visitors during a 9-year period, 23,581
patients visited the first aid stations. Medical usage rate (MUR) varied from 59-170
patients per 10,000 rave participants. The mean age increased from 1997 till 2005 from
18.7 ± 2.7 to 23.3 ± 5.7 years. The mean stay at the first aid station was 18 ± 46 minutes.
Most health problems were mild. Fifteen cases of severe incidents were observed with
one death. These unique data from the Netherlands demonstrate a very low number
of serious health related short-term problems during raves. Specific substance-related
health disturbances are inventoried in the next chapter.
Chapter 4 describes a 12-year (1997-2008) observation of substance-related incidents
occurring at rave parties in the Netherlands, including length of visits to first-aid
stations, substances used, and severity of the incidents. During rave parties, specifically
trained medical and paramedical personnel staffed first aid stations. Visitors were
diagnosed and treated, and their data were recorded using standardized methods.
During the 12-year period with 249 rave parties involving about 3,800,000 visitors,
27,897 people visited a first aid station, of whom 10,100 reported having a substancerelated problem. The mean age of these people was 22.3 ± 5.4 years; 52.4% of them
were male. Most (66.7%) substance-related problems were associated with ecstasy or
alcohol use or both. Among 10,100 substance-related cases, 515 required professional
medical care, and 16 of these cases were life threatening. People with a substancerelated problem stayed 20 min at the first aid station, which was significantly longer
than the 5 min that those without a substance-related health problem stayed. These
data from the Netherlands identify a variety of acute health problems related to the
use of alcohol, amphetamines, cannabis, cocaine, ecstasy, and GHB. Although most
problems were minor, people using GHB more often required professional medical
care those using the other substances. In the next chapter GHB-related incidents are
researched specifically.
Adherence to harm and risk reduction policy, and the use of first aid stations with
specially trained staff for both minor and serious incidents is recommended.
Chapter 5 was to determine the health disturbances and to assess the severity of the
incidents as reported on a nine years experience of GHB-related First Aid Attendees
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attending First Aid Stations at rave parties. This prospective observational study
concerned self-referred patients at First Aid Stations during rave parties from 2000 to
2008. Patients were diagnosed, treated by specifically trained medical and paramedical
personnel and data were recorded using standardized methods.
During the nine-year period with 202 rave parties, involving approximately three
million visitors, 22,604 First Aid Attendees visited the First Aid Stations, of which 771
reported GHB-related health problems. The mean age of the GHB-using First Aid
Attendees was 25.7 ± 6.1 years, most of them (66.4%) were male. Approximately onethird (32.7%) used one substance, while 48.1% combined GHB with ecstasy, alcohol or
cannabis. One out of five (19.2%) combined GHB with other substances or more than
one substance. One case was categorized as severe/life-threatening and 202 (26.2%)
cases as moderate, requiring further medical care. Totally, 43 (5.6%) First Aid Attendees
needed hospital care. Most encountered health disturbance was altered consciousness.
Combinations of altered consciousness, vomiting and/or low body temperature were
found in 186 cases (24.1%) and considered to be potentially dangerous. GHB-related
First Aid Attendees required a longer stay at the First Aid Stations than the total group
First Aid Attendees did (median 45 minutes versus 10 minutes).
First Aid Attendees demonstrate a variety of short-term health disturbances related
to the use of GHB. Although most problems were mild, professional medical care was
required for a quarter of GHB-using First Aid Attendees.
Chapter 6 describes the research to develop comprehensive guidelines for medical
care during mass gatherings based on the experience of providing medical support
during rave parties.
It was a prospective, observational study of self-referred patients who reported to First
Aid Stations (FASs) during Dutch rave parties. All users of medical care were registered
on an existing standard questionnaire. Health problems were categorized as medical,
trauma, psychological or miscellaneous. Severity was assessed based on the Emergency
Severity Index. Qualified nurses, paramedics and doctors conducted the study after
training in the use of the study questionnaire. Total number of visitors was reported by
the organisor of the event.
During the 2006-2010-study period, 7,089 persons presented to First Aid Stations for
medical aid during rave parties. Most of the problems (91.1%) were categorized as
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Chapter Nine
medical or trauma, and classified as mild. The most common medical complaints were
general unwell-being, nausea, dizziness and vomiting. Contusions, strains and sprains,
wounds, lacerations and blisters were the most common traumas. A small portion (2.4%)
of the emergency aid was classified as moderate (professional medical care required)
or severe, including two cases (0.03%) that were considered life threatening. Hospital
admission occurred in 2.2% of the patients. Fewer than half of all patients presenting
for aid were transported by ambulance. More than a quarter of all cases (27.4%) were
related to recreational drugs.
During the five-year field research period at rave dance parties, most presentations onsite for medical evaluation were for mild conditions. A medical team of six healthcare
workers for every 10,000 rave party visitors is recommended. On-site medical staff
should consist primarily of first aid providers, along with nurses who have eventspecific training on advanced life support, event-specific injuries and incidents, health
education related to self-care deficits, interventions for psychological distress, infection
control and disaster medicine. Protocols should be available for treating common
injuries and other minor medical problems, and for registration, triage, environmental
surveillance and catastrophe management and response.
In Chapter 7, medical aspects of raves are discussed and directions for the future are
given. As general findings the following facts were found:
Overall, investigating hundreds of rave parties with over four million visitors and more
than 30,000 First Aid Attendees, we found at the time of this report that
• An average of a Medical Usage Rate (MUR) of 70, which means that for every 10,000
visitors, 70 people will attend to a First Aid Station (FAS) with a health complaint
that need medical intervention. Next to this 70, about 25 persons on every 10,000
ask for self-treatment (painkiller for headache, hear-protection devices, sanitary
napkins for women, a band-aid for small wounds and blisters, etc.).
• Median stay at the FAS is 10 minutes. If the medical problem is substance-related,
the stay is prolonged to a mean of 20 minutes. And if the stay is GHB-related it is 45
minutes.
• Approximately 2% of all First Aid Attendees suffer from a health disturbance, which
needs professional medical care (doctor (MD), nurse (RN) or physiotherapist). This is
0.01% of all party visitors. Half of them are transferred to a hospital. A total of 0.05%
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of all First Aid Attendees are in a life-threatening situation, which means one lifethreatening case on approximately every 200,000 rave visitors.
• Of all registered First Aid Attendees 36% have a substance-related problem. In
64% of these cases drugs are single used and in 25% a combination of two drugs
(of which one of them usually is alcohol) is present; the rest of the cases is a
combination of more than two substances. In case of health-disturbance related
to substances single-used ecstasy (33% and decreasing through the years), alcohol
(23% and increasing), 3% amphetamine, 3% GHB, 2% cannabis and less than 1%
cocaine, are involved.
During the research period recreational drug-use changed. Monitoring of the Dutch
drug market started; lifetime prevalence (LTP) of ecstasy and amphetamine increased.
And while the use of alcohol in the mid nineties of the last century was not fashionable,
the use of alcohol increased heavily at parties during the research period. Meanwhile,
GHB was introduced in nightlife.
Youngsters who used substances got acquainted with the effects and were educated
how to avoid problems. Organizers of events became aware of taking preventive
measurements, like climate control and offering free drinking water. Dutch policy was
based on promoting health and reduction of incidents rather than on suppression of
drug use.
Serious single-use substance-related incidents that need professional medical care
are rare during the research period. Risks of serious incidents (with substance use
compared to without use) differ from 1-2 more risky for cannabis, ecstasy or alcohol, to
2-6 for amphetamine, to 1-13 for cocaine, to 17-27 for GHB.
Combinations of substances have higher risk scores. This applies especially to alcohol
and GHB. This combination is 26-28 more risky than the risk when no substance is used.
Using ecstasy as well as GHB is 25-30 more risky compared to no use. It appears that
GHB is most dangerous.
Specific serious drug-related problems were unconsciousness, airway at risk (by
vomiting) and respiratory insufficiency with depressants (alcohol and GHB) and
threatened airway (by trismus), seizure, excited delirium, hyperthermia and circulatory
insufficiency with stimulants (ecstasy, amphetamine and cocaine).
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Chapter Nine
From 1997-2008 a total of 31 patients with substance-related problems needed
professional medical care in a population of 3.800.000 party visitors. These figures
remained constant in 2009 and 2010. In 2011, 26 cases were reported in one single
year. This is reported in Chapter 8.
From the period the research started medical care at events became more professional
and nurses were employed next to or instead of first aid providers, added by physicians.
The level of care was upgraded from basic first aid to specialized care and advanced life
support. Medical care providers were trained on event-specific risks. Mass gathering
medicine guidelines were developed for events. Event health care was more integrated
in overall safety plans and non-medical service members, such as security personnel,
were trained in recognizing serious health threads and communication with medical
teams.
Specific educational programs for substance-related first aid and professional care were
developed for nightlife workers, security personnel, police officers, first aid providers
and emergency care professionals.
Limitations of the research
There were limitations of the current study that should be acknowledged. For example,
long-term effects on substance use or drug addiction were not addressed. This study
was conducted in the Netherlands and may not be valid for other countries. In addition,
the study was limited to data obtained at rave parties. Although the study sample was
large, it included only self-referrals, which might not be representative of all healthrelated incidents at rave parties. It is possible that many people who experienced
negative effects did not present themselves at a first aid station.
No biological confirmation of the substance-intake by toxic screening of urine or blood
was done. It is not measured to what the attendees were exposed to, quantitatively
or qualitatively. It’s only known what they voluntarily reported. Substance use at rave
parties might be underreported and hence underestimated because stigmatization
or a fear of legal involvement. For reasons such as these, some visitors with health
complaints may have gone directly to their family physician or a hospital emergency
room, rather than visiting an on-the-scene first aid station.
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Chapter Ten
Summary in Dutch
(Nederlandse samenvatting)
135
Chapter Ten
Chapter 10: Summary in Dutch (Nederlandse
samenvatting)
Medische evenementenzorg tijdens dance-events:
gezondheidsverstoringen en middelengerelateerde
incidenten.
De bevindingen van dit proefschrift zijn op twee thema’s gericht: gezondheidsversto
ringen tijdens rave party’s in Nederland in het algemeen en druggerelateerde
incidenten in het bijzonder. Daarnaast is medische zorg in kaart gebracht tijdens deze
grootschalige publieksevenementen.
Het algemene doel van deze studies was vierledig en beantwoordde de volgende
onderzoeksvragen:
- Hoeveel bezoekers melden zich op de eerstehulppost (EHP) tidens raves, wat is
het gemiddelde aantal eerstehulp-patiënten per 10.000 evenementbezoekers, hoe
lang verblijven patiënten op de EHP en welke typen incidenten kunnen worden
geïdentificeerd?
- Wat is de prevalentie van bezoekers van eerstehulpposten op raves met
middelengerelateerde gezondheidsproblemen? En wat voor soort drugs zijn
betrokken?
- Welke middelengerelateerde incidenten worden gemeld, wat is de frequentie en
de ernst?
- Wat zijn de vereisten voor medische zorg op raves?
In dit hoofdstuk worden de belangrijkste resultaten samengevat. Tenslotte worden de
beperkingen van de studies beschreven.
De eerste hiervoor genoemde onderzoeksvragen worden behandeld in hoofdstuk
1. Alle bevindingen van de studie werden verzameld op raves, ook wel bekend als
house- of dance-events. “Dance” is een verzamelnaam voor alle soorten elektronische
dansmuziek (EDM). Het belangrijkste kenmerk is dat de muziek wordt uitgevoerd
met elektronische instrumenten en is DJ-gericht. “House” was in Nederland een
verzamelnaam voor dansmuziek. Dit leidde tot verwarring, omdat “house” is ook
136
de naam van een subgenre. Daarom is “dance” (of EDM) nu de meest gangbare
term. In andere landen worden “techno” en “progressive” gebruikt als generieke
benamingen voor deze muziekstijl. Grote dance events zijn mondiaal breed
bekender als “raves”. Deze evenementen trekken doorgaans 1000-60.000 bezoekers.
Het zijn “massabijeenkomsten”, welke (in enkelvoud) omschreven worden als “Een
verzamelplaats van een groot aantal mensen die een evenement bijwonen op een
specifieke plaats voor een beperkte tijd met een potentieel voor een vertraagde reactie
op noodsituaties”.
In Nederland hebben dance party’s een volume tot ± 60.000 bezoekers. Ongeveer
650.000 jongeren (15-35 jaar) wonen deze gebeurtenissen jaarlijks bij. Sinds de
jaren negentig van de vorige eeuw is het aantal raves en de diversiteit van deze
gebeurtenissen toegenomen.
Na uitgebreid onderzoek bevestigen verschillende studies dat jongeren alcohol en/
of drugs gebruiken tijdens het uitgaan. XTC, vanwege zijn energieke en euforische
effecten, is erg populair, naast alcohol, cannabis, amfetamine en cocaïne. Eind jaren
90 werd gamma-hydroxyboterzuur (GHB) geïntroduceerd in het uitgaanscircuit. Bij
specifieke uitgaanssettingen blijken specifieke middelen gebruikt te worden:
- Alcohol: meest voorkomend in mainstream settingen (mix van verschillende
muziekstijlen) en dance,
- Cannabis: de hoogste in de alternatieve settingen,
- Cocaïne, amfetamine en GHB: meer bij dance dan in alle andere settingen,
- XTC: veel hoger bij dance dan elders.
Bovengenoemde uitgaansdrugs worden besproken in het volgende hoofdstuk.
Hoofdstuk 2 richt zich op de meest gebruikte recreatieve drugs. Nationaal onderzoek
naar de prevalentie van drugsgebruik wordt in Nederland sinds 1997 regulier
uitgevoerd onder de algemene bevolking in de leeftijdscategorie 15-64 jaar. Uit een
representatieve steekproef in 2009 (N = 5769) bleek een ooit-gebruikt prevalentie van
92% van alcohol. Dit was 25,7% voor cannabis, 6,2% voor XTC, 5,2% voor cocaïne, 3,1%
voor amfetamine en 1,3% voor GHB.
Voornaamste reden voor het drinken van alcohol is om plezier en ontspanning te
voelen, en om spraakzamer, meer zelfverzekerd en socialer in de omgang te worden.
Een zekere mate van intoxicatie is gewenst. XTC (MDMA) wordt gebruikt, omdat het
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Chapter Ten
leidt tot euforie en het een gevoel van intimiteit met anderen bevordert. Daarnaast
wordt het gebruikt om de energetische effecten en om de beleving van activiteiten
te verbeteren, zoals het luisteren naar muziek. Amfetamine wordt gesnoven, of geslikt
als pillen, vooral om door te kunnen gaan en om wakker te blijven, terwijl cannabis
wordt gerookt om te ontspannen en “stoned” te worden. Cocaïne wordt gesnoven om
een snelle

kick te krijgen, om door te kunnen gaan en wakker te blijven. GHB wordt
gedronken om te ontspannen, om ‘high’ te worden en omdat het het gevoel van
seksualiteit vergroot.
Van alle zes meest gebruikte recreatieve drugs worden de naam, sociale aspecten,
fysiologische effecten, chemie, epidemiologie en farmacokinetiek beschreven.
Hoofdstuk 3 rapporteert over een negen jaren durend onderzoek van medische
hulpverlening tijdens dance party’s in Nederland. In een prospectieve observationele
studie, waar zelfverwijzers door specifiek opgeleid medisch en paramedisch personeel
werden gediagnosticeerd, behandeld en geregistreerd op gestandaardiseerde wijze,
wordt verslag gedaan van de gerapporteerde gezondheidsverstoringen.
Tijdens 219 party’s met ongeveer 3 miljoen bezoekers gedurende een periode van 9
jaar bezochten 23.581 patiënten een eerstehulppost. De Medical Usage Rate (MUR)
varieerde van 59 tot 170 patiënten per 10.000 evenementbezoekers. De gemiddelde
leeftijd steeg van 1997 tot 2005 van 18,7 ± 2,7 tot 23,3 ± 5,7 jaar. Het gemiddelde verblijf in
de eerste hulppost duurde 18 ± 46 minuten. De meeste gezondheidsproblemen waren
mild. Vijftien ernstige incidenten zijn waargenomen, waarvan één met lethale afloop.
Deze unieke gegevens uit Nederland tonen een zeer laag aantal ernstige korte termijn
gezondheidsproblemen aan tijdens dance party’s. Specifieke middelengerelateerde
gezondheidsproblemen zijn nader geïnventariseerd in het volgende hoofdstuk.
Hoofdstuk 4 beschrijft een twaalfjarige (1997-2008) observatie van middelengerela
teerde incidenten die zich voordoen op dance party’s in Nederland, met inbegrip van
de duur van de bezoeken aan eerstehulpposten, de gebruikte stoffen en de ernst van
de incidenten.
Tijdens deze evenementen bemanden specifiek opgeleid medisch en paramedisch
personeel de hulpposten. Bezoekers werden gediagnosticeerd en behandeld, en
hun gegevens werden geregistreerd met behulp van gestandaardiseerde methoden.
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Tijdens de periode van 12 jaar met 249 dance party’s met een totaal van ongeveer
3.800.000 bezoekers, bezochten 27.897 mensen de eerstehulppost, van wie er 10.100
een middelengerelateerd gezondheidsprobleem hadden. De gemiddelde leeftijd van
deze mensen was 22,3 ± 5,4 jaar; 52,4% van hen waren man. De meeste (66,7%) met een
drug gerelateerde problemen werden in verband gebracht met XTC of het gebruik van
alcohol of beide. Onder 10.100 middelengerelateerde cases hadden 515 professionele
medische zorg nodig en waren 16 van deze gevallen levensbedreigend. Mensen met
een middelengerelateerd probleem verbleven 20 minuten bij de EHBO-post. Dit was
significant langer dan de 5 minuten die EHBO-bezoekers verbleven bij problemen die
niet te maken hadden met middelengebruik. Een aantal acute gezondheidsproblemen,
gerelateerd aan het gebruik van alcohol, amfetaminen, cannabis, cocaïne, XTC en/
of GHB werd geïdentificeerd. Hoewel de meeste problemen mild en beperkt waren,
bleek dat mensen die GHB hadden gebruikt vaker professionele medische zorg nodig
hadden dan zij die andere stoffen hadden gebruikt. In het volgende hoofdstuk wordt
over specifieke GHB-gerelateerde incidenten gerapporteerd.
Verdere ontwikkeling en naleving “harm-reduction” beleid en het inzetten en
standaardiseren van eerstehulpposten op dance events met speciaal opgeleid
personeel voor zowel kleine en ernstige incidenten wordt aanbevolen.
Hoofdstuk 5 beschrijft het prospectieve observationele onderzoek naar specifieke GHBincidenten, die eerstehulpposten bezochten tijdens dance events van 2000 tot 2008.
De patiënten werden gediagnosticeerd, behandeld door specifiek opgeleid medisch
en paramedisch personeel en de gegevens zijn opgenomen met gestandaardiseerde
methoden.
Tijdens de periode van negen jaar met 202 dance party’s met ongeveer drie miljoen
bezoekers, werden 22.604 patiënten geregistreerd op de eerstehulpposten. Hiervan
hadden 771 personen GHB-gerelateerde gezondheidsproblemen. De gemiddelde
leeftijd van de GHB-gebruikende hulppostbezoekers was 25,7 ± 6,1 jaar, de meesten
van hen (66,4%) waren mannen. Ongeveer een derde (32,7%) gebruikte uitsluitend
GHB, terwijl 48,1% een combinatie van GHB met XTC, alcohol of cannabis tot zich
namen. Een op de vijf (19,2%) combineerde GHB met meerdere andere stoffen. Eén
casus werd gecategoriseerd als ernstig/levensbedreigend en 202 (26,2%) gevallen
als middelernstig; zij behoefden professionele medische zorg. In totaal werden
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Chapter Ten
43 patiënten (5,6%) doorverwezen naar een ziekenhuis. De meest aangetroffen
gezondheidsverstoring was verminderd bewustzijn. Combinaties van verminderd
bewustzijn, braken en/of lage lichaamstemperatuur werden gevonden in 186 gevallen
(24,1%). GHB-gerelateerde eerstehulp bezoekers verbleven significant langer dan de
totale patiëntenpopulatie (mediaan 45 minuten versus 10 minuten).
Patiënten vertonen een verscheidenheid aan korte termijn-gezondheidseffecten
bij gebruik van GHB. Hoewel de meeste problemen mild waren, bleek professionele
medische zorg geïndiceerd voor een kwart van GHB-gebruikende patiënten.
Hoofdstuk 6 geeft het prospectieve, observationele onderzoek weer naar de
ontwikkeling van richtlijnen voor medische zorg tijdens massabijeenkomsten
gebaseerd op de ervaring van medische dienstverlening tijdens dance events, op basis
van de gestandaardiseerde registratie van bezoekers, die zich voor zorg meldden bij de
eerstehulppost.
Gezondheidsproblemen werden gecategoriseerd als (a) medisch, (b) trauma, (c)
psychisch of (d) diversen. De ernst werd beoordeeld op basis van de Emergency Severity
Index in de kwalificaties (1) levensbedreigend, (2) midden ernstig; professionele
medische zorg noodzakelijk en (3) mild. Gekwalificeerde verpleegkundigen, paramedici
en artsen werden getraind in het gebruik van de gestandaardiseerde vragenlijst. Het
totaal aantal bezoekers werd gemeld door de evenementorganisator.
Tijdens de onderzoeksperiode 2006-2010 werden 7.089 personen geregistreerd bij
de eerstehulpposten tijdens dance party’s. De meeste problemen (91,1%) werden
gecategoriseerd als medisch of trauma, en geclassificeerd als mild. De meest
voorkomende medische klachten waren algehele malaise, misselijkheid, duizeligheid
en braken. Kneuzingen, verrekkingen en verstuikingen, wonden, snijwonden en
blaren waren de meest voorkomende trauma’s. Een klein deel (2,4%) van de cases
werd gekwalificeerd als midden ernstig of ernstig, waaronder twee gevallen (0,03%)
die werden beschouwd als levensbedreigend. Ziekenhuisopname was geïndiceerd bij
2,2% van de patiënten. Meer dan een kwart van de gevallen (27,4%) was uitgaansdrugs
gerelateerd.
Tijdens het vijf jaar durende veldonderzoek bestond het overgrote deel van de zorg
uit ondersteuning bij milde gezondheidsproblemen. Een medisch team van zes
gezondheidswerkers voor elke 10.000 dance party bezoekers wordt aanbevolen.
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Ter plaatse van het evenement dient de medische staf voornamelijk

te bestaan uit
eerstehulpverleners en verpleegkundigen, die specifiek zijn opgeleid op het gebied van
advanced life support, event-specifieke letsels en incidenten, gezondheidseducatie met
betrekking tot zelfzorgtekorten, interventies bij psychische nood, infectiesurveillance
en rampgeneeskunde. Protocollen moeten beschikbaar zijn voor de behandeling
van voorkomende verwondingen en andere kleine medische problemen en voor
registratie, triage, hygiënemonitoring en catastrofezorg.
In hoofdstuk 7 worden de medische aspecten van dance events besproken en worden
aanwijzingen voor de toekomst gegeven. De algemene bevindingen waren:
Na onderzoek tijdens honderden dance party’s met meer dan vier miljoen bezoekers
en meer dan 30.000 eerstehulp patiënten, werd vastgesteld, dat
• Een gemiddelde MUR van 70, wat betekent dat voor elke 10.000 eventbezoekers,
70 mensen een beroep doen op een EHBO-post en daar worden behandeld en
geregistreerd. Naast dit zeventigtal doen ongeveer 25 personen een beroep op
de eerstehulppost voor zelfzorg (pijnstiller tegen hoofdpijn, gehoorbescherming,
maandverband, pleisters voor kleine wonden en blaren, enz.).
• Het mediane verblijf in een eerstehulppost is 10 minuten. Als de patiënt een
middelengerelateerd probleem heeft is de mediaan 20 minuten. En als het verblijf
specifiek GHB-gerelateerd is, is het 45 minuten.
•
Ongeveer 2% van alle geregistreerde eerstehulppostbezoekers heeft professionele
medische zorg nodig van een arts, verpleegkundige of fysiotherapeut. Dit is 0,01%
van alle evenementbezoekers. De helft van hen is verwezen naar een ziekenhuis.
Totaal 0,05% van alle patiënten bevonden zich in een levensbedreigende situatie.
Er is dus 1 levensbedreigende casus per 200.000 dance evenement bezoekers.
• Van alle geregistreerde patiënten heeft 36% een middelengerelateerd gezond
heidsprobleem. In 64% van deze gevallen werd een middel enkelvoudig
gebruikt en in 25% van de gevallen was er sprake van een combinatie van twee
middelen (waarvan één daarvan meestal alcohol betrof ), de rest van de gevallen
waren combinaties van meer dan twee middelen. In geval van enkelvoudig
middelengerelateerde gezondheidsverstoringen betrof het in 33% van de gevallen
XTC (waarbij een vermindering in de loop der jaren te zien was), 23% alcohol
(vermeerdering door de jaren heen), 3% amfetamine, 3% GHB, 2% cannabis en
minder dan 1% cocaïne.
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Chapter Ten
Gedurende de onderzoeksperiode deden zich veranderingen voor rond recreatief
drugsgebruik. Monitoring van de Nederlandse drugsmarkt werd gestart via DIMS, het
Drugs Informatie en Monitoring System van het Trimbos-instituut, en drugsgerelateerde
incidenten door de MDI (Monitor DrugsIncidenten), eveneens van het Trimbos, beiden
gesubsidieerd door de Nederlandse overheid. De lifetime prevalentie (LTP) van XTC
en amfetamine namen toe. En terwijl het gebruik van alcohol op danceparty’s in
het midden van de jaren negentig van de vorige eeuw nauwelijks voorkwam, nam
dit in grote mate toe gedurende de onderzoeksperiode. Ondertussen werd GHB
geïntroduceerd in het uitgaansleven.
DIMS noteerde rond 2009/2010 een verandering in de XTC-markt. In die periode nam
de zuiverheid (het MDMA-gehalte) in de pillen af. Vanaf 2011 nam de zuiverheid weer
toe, maar ook de dosering. Bestonden de XTC-pillen in de jaren voor 2009 uit gemiddeld
70-90mg MDMA, in 2011 was de gemiddelde dosis twee keer zo hoog.
In de loop der jaren leerden jongeren wat de effecten van uitgaansdrugs waren of
konden zijn en werden zij voorgelicht op welke wijze zij problemen zo veel mogelijk
konden voorkomen. Organisatoren van evenementen werden zich bewust werd van
het nemen van preventieve maatregelen, zoals klimaatbeheersing en het aanbieden
van gratis drinkwater, en voerden deze activiteiten door in hun werkprocessen. En
tenslotte kenmerkte het Nederlandse drugsbeleid zich door repressie van productie
en handel enerzijds en “harm-reduction” en gezondheidsbevordering bij gebruikers
anderzijds.
Ernstige uitgaansdrugs-gerelateerde incidenten, die professionele medische zorg nodig
hebben, komen zelden voor gedurende de onderzoeksperiode. Risico’s op ernstige
incidenten bij gebruik van een middel ten opzichte van geen-gebruik verschillen per
drug. Zo is er 1-2 keer meer risico bij cannabis, XTC of alcohol, 2-6 keer meer risico bij
amfetamine, 1-13 keer meer risico bij cocaïne en 17-27 keer meer risico bij GHB.
Combinatiegebruik van middelen kennen hogere risico scores. Dit geldt vooral voor
alcohol en GHB. Deze combinatie is 26-28 keer riskanter dan het risico wanneer er geen
middel wordt gebruikt en de combinatie XTC en GHB is 25-30 keer meer risicovol. Uit
het onderzoek naar korte termijn risico’s blijkt dat GHB relatief de meest gevaarlijke
uitgaansdrug is.
142
Specifieke aangetoonde ernstige drugsgerelateerde problemen waren bewuste
loosheid, bedreigde luchtweg (door braken) en respiratoire insufficiëntie bij met
dempende middelen (alcohol en GHB), en bedreigde luchtwegen (door trismus), insult,
opwindingsdelier, hyperthermie en circulatoire insufficiëntie bij stimulantia (XTC,
amfetamine en cocaïne).
Heel recent werd een opvallend cijfer vastgesteld. Tussen 1997-2008 werden in
een populatie van 3.800.000 partybezoekers 31 incidenten vastgesteld waarbij
professionele medische zorg nodig was. Dit gemiddelde van 2-3 incidenten per jaar
werd ook in de daarop volgende twee jaren vastgesteld. Echter, in 2011 werden 26
cases gemeld, terwijl er geen grote veranderingen konden worden vastgesteld in het
volume van de populatie of de prevalentie van middelengebruik. Nader onderzoek
moet uitwijzen of deze getallen mogelijk het gevolg zijn van de veranderde XTC-markt
in 2011. In Hoofdstuk 8 wordt hierover gerapporteerd.
Tijdens de onderzoeksperiode veranderde ook de professionele zorg bij dance events.
Eerder werden uitsluitend eerstehulpverleners ingezet, nu deden professionals (vooral
verpleegkundigen, maar ook artsen) hun intrede in de evenementenzorg. Het niveau
van de zorg werd opgewaardeerd van “leken”-EHBO tot gespecialiseerde zorg en
Advanced Life Support. Medische hulpverleners werden getraind om event-specifieke
risico’s te herkennen, te voorkomen en te behandelen. Er werden specifieke richtlijnen
en protocollen ontwikkeld in de evenementenhulpverlening. Gezondheidszorg en
veiligheid werden meer geïntegreerd en andere evenementen-dienstverleners zoals
beveiligingspersoneel en facilitaire medewerkers werden getraind in het herkennen
van ernstige gezondheidsproblemen en communicatie met medische teams.
Specifieke educatieve programma’s voor middelengerelateerde eerste hulp en
professionele zorg zijn ontwikkeld voor werkers in het uitgaanscircuit, zoals
beveiligingspersoneel, politie, EHBO’ers en zorgprofessionals.
Beperkingen van het onderzoek
Enkele beperkingen van het onderzoek moeten worden erkend. Zo kwamen de lange
termijn effecten op middelengebruik of drugsverslaving niet aan de orde. Voorts werd
143
Chapter Ten
deze studie uitgevoerd tijdens dance events in Nederland en kan het niet zonder meer
toegepast worden op andere evenementen of in het buitenland. Hoewel de steekproef
groot was, bestonden de participanten uitsluitend zelfverwijzers, die mogelijk niet
alle gezondheid gerelateerde incidenten op dance party’s representeren. Het is
mogelijk dat een aantal bezoekers met gezondheidsklachten zich niet meldde op een
eerstehulppost.
Toxische screening van urine of bloed werd niet gedaan, waardoor er geen feitelijke
biologische bevestiging van de middelinname was. Het is niet gemeten waar de
deelnemers aan werden blootgesteld, kwantitatief noch kwalitatief. Het onderzoek is
gebaseerd op anamnestische informatie. Daarbij kan het zijn dat het bekennen van
middelengebruik ondergerapporteerd en onderschat kan zijn vanwege angst voor
stigmatisering of juridische consequenties. Ook om redenen als deze, kunnen sommige
bezoekers met gezondheidsklachten direct naar hun huisarts of een spoedeisende
hulp (van een ziekenhuis) zijn gegaan, in plaats van een bezoek te brengen aan een
eerstehulppost op een evenement.
144
About the author
145
About the author
About the author
Jan Krul was born on June 13, 1960, in Groningen, the Netherlands. In 1981, he was
certified as a registered nurse, followed by a bachelor of art degree in Nursing in 1992.
In 1998 he obtained his Master of Science Degree in Nursing (Main study subject:
Education) from the University of Cardiff (UK). During his studies he initially specialized
in Mental Health and Accident & Emergency Nursing, as well as teaching and education.
In the early nineties of the 20th century he got involved in Mass Gathering Medicine,
while providing and developing professional standards of Medical Care at large-scaled
public events. Meanwhile, he was confronted with substance-related emergencies.
In 1995, Jan Krul started his own consultation practice, focusing on mental health, event
health care and recreational drug related short-term health disturbances. He ended his
hospital career in The University Medical Center of Groningen in 2009, after practicing
approximately 25 years, first as a nurse and finally as a crisis management consultant.
Next to his hospital activities, he acted as a teacher, advisor and researcher at different
places in Dutch health care and worldwide projects. In corporation with the Trimbosinstitute, the Dutch expertise center for Mental Health and Addiction, he started the
national project First Aid at Recreational Drugs-related incidents, which resulted in
different curricula and standards of educational skills.
Currently, Jan Krul is an independent scientific health protection consultant and
educator in the Netherlands. In the future, he hopes to attribute valuable contributions
to research and development of mass gathering medicine, recreational-drug incidents,
emergency care, and (mental health) consultation methodology.
146
Acknowledgements
Epilogue in Dutch
147
Acknowledgements
Acknowledgements
Epilogue in Dutch
Dankwoord
Ik ben veel dank verschuldigd aan
mijn promotor prof. dr. Armand Girbes voor de aanhoudende inspiratie tijdens de
promotie-route, ook tijdens roerige periodes. Jij gaf mij alle vrijheid en rust om te
schrijven en bekrachtigde mijn academische kennis en kunde, ook op momenten dat
mijn zelfverzekerdheid het volledig liet afweten;
mijn copromotor dr. Noortje Swart voor het kritisch lezen, becommentariëren en
aanvullen van concepten van (delen van) het proefschrift;
de leden van de leescommissie prof. dr. Jan Bakker, prof. dr. Paul Calle, prof. dr. Dirk Korf,
prof. dr. Stephan Loer en dr. Jan ter Maaten, voor het lezen en beoordelen van mijn
manuscript, en voor de bereidheid tijdens de aanstaande verdediging te opponeren;
de dierbare collega’s van Educare. Het was een genoegen en een voorrecht om in een
mix van vriendschap en professionaliteit met jullie te werken. Veel erkentelijkheid
ook voor de zorgvuldige registratie, die de onmisbare fundament legde voor mijn
onderzoek;
de zorgvragers tijdens evenementen. Bijna dertigduizend keer bezochten zij de
eerstehulpposten op evenementen. Zij lieten mij de minder prettige kanten van
uitgaan zien. Van hen heb ik veel “achter de cijfers” geleerd;
de trainers EHBDu en medewerkers van het Trimbos-instituut (met name UAD en
DIA en in het bijzonder Aukje Sannen), die door het uitdragen van hun kennis van
drank- en drugsgebruik, middelenincidenten en eerste hulpverlening uniformiteit en
professionaliteit versterken, en inspiratie vormen voor het onderzoeken van nieuwe
vraagstukken;
de collega’s van de Centrale Spoedopvang van het UMCG; jullie hebben mij de mooiste
jaren van mijn loopbaan als verpleegkundige gegeven;
Attie van der Meulen en Björn Sanou, mijn twee paranimfen, die mij hopelijk met
alle energie zullen steunen tijdens de verdediging. Attie, heel lang geleden begon
148
Acknowledgements
onze vriendschap tijdens de beroepsvoorbereidende periode van de opleiding tot
psychiatrisch verpleegkundige. Wat hebben we ondertussen veel samen beleefd.
En Björn, wij leerden elkaar op een party kennen als zorgverlener en begeleider
van een zieke vriend. Wie had kunnen vermoeden, dat deze ontmoeting zou leiden
tot de professionele en vriendschappelijke relatie die we nu hebben. Ik vind het
indrukwekkend getuige geweest te zijn van je ontwikkeling van student geneeskunde
tot anesthesioloog-intensivist.
Tenslotte, wil ik hen bedanken, die altijd in mij geloofd hebben en van wie ik geniet hun
zoon, broer, zwager, oom en/of kameraad te zijn: alle vrienden en familie, maar vooral
mijn moeder Reina, mijn stiefvader Tiemen, mijn broers Tiddo en Harrie, schoonzussen
Sineke en Sandra en mijn neefjes Franco en Jeffrey: wat hou ik toch van jullie allemaal,
en Attie, Loes en Marga (de eeuwige jurygeluidswagen en hartsvriendinnen voor altijd).
Als laatste wil ik mijn vader dank zeggen voor de basis van mijn bestaan. Hij is helaas
overleden voordat hij ook maar iets van mijn beroepscarrière en mijn levensgeluk heeft
kunnen meemaken. Hij was vast en zeker trots op me geweest.
149
Mass Gathering Medicine at raves: Incidents and substance-related emergencies
Uitnodiging
Openbare verdediging van het proefschrift
Mass Gathering Medicine at raves: Incidents and substance-related
emergencies Vrijdag 29 november 2013, 11:45 uur in de Aula van
de Vrije Universiteit Amsterdam
De Boelelaan 1105 te Amsterdam
Receptie na afloop ter plaatse
Glamour & Glitter Blingbling Discofeest vanaf 21:30 uur in Huize Maas
Vismarkt 52 te Groningen
Jan Krul
[email protected]
Paranimfen
Björn Sanou Jan Krul
Jan Krul
[email protected]
Attie van der Meulen [email protected]