David Stuart, (2019) "Chemsex: origins of the word, a history of the phenomenon and a respect to the culture", Drugs and Alcohol Today, Vol. 19 Issue: 1, pp.3-10, https://doi.org/10.1108/DAT-10-2018-0058
Full text below, originally published in Drugs and Alcohol Today, by Emerald Publishing.
Chemsex; origins of the word,
a history of the phenomenon,
and a respect to the culture.
The collection of articles that appear in this special edition, all focus on the theme of chemsex. Although clearly defined within communities that engage in chemsex, and although very commonly understood within gay communities, “chemsex’ still has no universally agreed-upon academic definition. As one of the guest editors of this special edition of Drugs and Alcohol Today, and as the first person (to my knowledge) that had ever used the term “chemsex”, I will share some of the experience I have gained from working one to one with tens of thousands of gay men over the last decade or so, who engage in chemsex; I will share from the humbling and informative experience of engaging with international gay communities on this topic. I will seek to contextualise the term, the phenomenon, and to provide a history of its’ origins, its’ culture, and a definition that is respectful to that culture.
What is Chemsex?
Chemsex is most commonly understood to be the use of specific drugs, used specifically for sex, by gay and other men who have sex with men. The drugs most commonly associated with chemsex are crystal methamphetamine, cathenones (mephedrone, 3MMC, 4MMC) and GHB/GBL (gammahydroxubutyrate/gammabutyrolactone). These drugs are referred to as “chems”, though other drugs are often involved too, such as Viagra, alcohol, ketamine, cocaine, amyl/akyl nitrates (poppers). These additional drugs are not commonly understood to be “chems”, as they are most often considered casual additions to the “high”, and not individually providing the actual “high” that is sought. It is the specific “highs” associated with crystal methamphetamine, cathenones and GHB/GBL that provide the desired pleasure and disinhibition, and that drive and define the chemsex phenomenon. Chems are also the drugs that are responsible for the greater harms we see within (and in the aftermath of) chemsex environments. Harms resulting from non-chems (including alcohol) in chemsex environments are very rare by comparison.
But it is not only these drugs that define chemsex, and it is not only these drugs used in sexual contexts that define chemsex; people have been using drugs and alcohol for sex for many thousands of years, and the drugs used in chemsex contexts also have histories that pre-date chemsex. Similarly, there are other (non-gay) populations who might use “chems” in sexual contexts, though it would not be defined as chemsex. That’s because it is some of the uniquenesses of gay sex and gay culture that actually define the chemsex phenomenon that has emerged over the last few decades. Those uniquenesses are the cultural factors that impacted the enjoyment of homo-sex; some examples follow;
It is widely discussed within chemsex culture, that when chemsex presents as a problem (which, important to note, is not always the case), it is not the drugs themselves which are the primary problem; in fact in those circumstances, drugs would be the solution to a problem, a tool used to address that problem. Chemsex is not always a problem by any means, but when it is, that problem is most often the ability to feel free and disinhibited during homo-sex, for some of the reasons above. Additional problems can emerge and result from the use of the drugs independently, which can be managed often by harm reduction practices; but the reasons for using the drugs are the pursuit of pleasure, which can often be difficult or challenging for gay men, many of whom struggle to achieve disinhibition from cultural obstacles that can make the enjoyment of gay sex, quite complicated. These are the uniquely gay historical and cultural experiences of gay sex that define chemsex.
Concepts of “problematic” use and “non-problematic” use
There can be an innocent and well-meaning tendency by healthcare providers, to categorise a person’s drug or alcohol use under definitions such as “problematic”, “unproblematic”, “addiction”, “misuse” or “abuse”. Many of these terms are subjective, relying on a person’s opinion, rather than an objective assessment that involves the opinion of the subject themselves. One person who is using ecstasy monthly, might find the comedowns and other consequences to be manageable, and perhaps “worth it for the good time had”; they might define this as “non-problematic”. Another person who uses ecstasy monthly might find the comedowns and other consequences unmanageable, and might define them as problematic. Then again, a work colleague who works beside a person who uses ecstasy monthly, might witness behaviour from their colleague that appears consequential of the drug use; that colleague might be tempted to label their colleague’s drug use as “problematic, even if the person using the drugs, does not.
Attempts to label or categorise another person’s drug or alcohol use usually only end up causing defensive behaviour that can facilitate or exacerbate a person’s denial, creating a further obstacle to them accessing support. It also denies that person’s agency and autonomy to make choices based on their own assessment of the consequences, as it suits them.
Even when the consequences of a person’s drug use do appear alarmingly problematic, such as depression, disengagement from friends and family, or recreational activities; even when the consequences are injuries or infections or something very obvious to an external observer; forced interventions or categorizing a person’s use without the consultation and agreement of the person involved, will only serve to increase defensiveness and denial, and will only serve to estrange the relationship and alienate the person we are attempting to provide care for.
There are many gay men who will define their engagement in chemsex as non-problematic. Research tells us that (Bourne et al, 2015). There are also many for whom chemsex is problematic; there is also research that demonstrates that (Prestage etal, 2018). There is a spectrum of middle-ground of course, where denial, ambivalence, fear and poor awareness can confuse definitions of “problematic use”, can skew and confuse the results research and surveys; what’s important in addressing drug use of any kind, in supporting individuals and communities, is respecting the agency and autonomy of any individual to define their use themselves (should they so wish). Supporting a person to reflect on their own choices, consequences and behaviour should always be limited to just that; supporting the person to reflect, and never labeling or defining another person’s use as “problematic”. Aside from being fundamentally disrespectful of a person’s own agency, the labeling or defining of another person’s drug use as “addictive” or “problematic” serves as the greatest obstacle to providing care for people who use drugs and alcohol. Similarly, healthcare campaigns that deny agency and autonomy to a person to define their own use as addictive or problematic also fail to engage people in healthcare.
Origins of the word chemsex
“Chems” was a commonly used nick-name used for methamphetamine and GHB/GBL by gay men when communicating by phone or text with their drug dealers in the latter part of the last century. Texting and mobile phones were relatively new, and there was a degree of paranoia about how private these conversations were or weren’t. GHB was developing popularity with gay clubbers at the time, and was available for sale in Soho (London) sex shops where pornographic video cassettes and sex toys were sold. Another version of the drug called “blue nitrate” was also common at the time, available from friends or dealers. Methamphetamine was relatively rare and very expensive in London. A small handful of gay men were using it in London (myself included), and we purchased it – not from dealers – but from airline stewards who travelled internationally, and brought it back from San Francisco, New York and Cape Town (mostly), where the drug was more available. Methamphetamine was more common amongst wealthier gay men who travelled to different international “circuit parties”. “Chems” (derived from “chemicals”) was the word we used to refer to these two drugs that were markedly different from the cocaine, ecstasy, poppers, ketamine and speed that had been staples of the gay club scenes for so long.
The other thing that made these drugs different - methamphetamine particularly - was that it shifted our social lives from the clubs to the saunas/bathhouses. We were united less by commonalities or friendship, but more so by our shared preference for chems; many of us had exhausted any sexual frissant that might have existed between us. Despite this we were united by our chem use and preference for sexual environments and networks. Stigma toward methamphetamine from those who did not use it kept us united as a group also. We called ourselves “Chemsex club”, and to my memory, it was the first time I’d heard the words “chems” and “sex” put together in this way. Gaydar (link 1), a sexual networking and dating site for gay men launched in 1999, which provided another forum for chemsex club to network outside of the saunas, and the “club” broke apart (with some relief I remember), and the word “chemsex” began to be used more commonly on Gaydar.
In 2006, mephedrone (a cathenone) became more popular in English cities. Mephedrone was a popular drug beyond gay communities, and was popularly used in many contexts including clubs and general socializing; but it did find a popular home in chemsex contexts too, as the “high” was not dissimilar to methamphetamine in many ways, and one that lent itself to sexual pleasure and disinhibition. It quickly became a chemsex drug.
Some years later, after a difficult time with drugs and the law, I found myself working in an LGBT drug and alcohol service, and my own experience motivated me to develop chemsex specific support services and campaigns, and it was during this time that the word “chemsex” crossed over from the community of people who engaged in chemsex, to a healthcare application.
It’s important that a word exists, a word to uniquely define this phenomenon. In the earlier days of the phenomenon, many gay men who were struggling with chems and sex felt alone and freakish for their behaviour. They had no community of peers to identify with, to de-shame any shame they may have felt about their behaviour. When seeking help or support or to identify with others who shared similar struggles, many found themselves lumped in with other populations or other definitions of drug using behaviours. Many sought support from opiate or alcohol-specific services, where the gay sex elements of their drug use were not addressed with any cultural competency at all. Many others found themselves in meth addiction clinics, where that drug use was addressed but not the gay sex motivations associated with the meth use. A lack of any definition made many gay men seeking support with chemsex feel very alone, misunderstood, wrongly identified, and steered toward support services that failed to competently address the gay cultural roots of the issue. A word was needed to identify this complex syndemic, and to unite a struggling, growing community, and to de-shame what was often a frightening, confusing and lonely experience that didn’t have a name.
Similarly, when gay communities started to respond to the chemsex phenomenon; as discussion groups sprung up, as Facebook groups were created, as chemsex culture was explored in film and theatre, in performance art, photography and Drag culture (link 2) – health services were motivated to respond with culturally competent support services. (links 3, 4, 5, 6) Having a named syndemic, something that set it apart from other forms of drug use, became increasingly important, and increasingly effective. The existence of the word “chemsex” helped government drug policies and service managers develop support programmes to identify a unique kind of public health concern and to respond effectively and with some degree of cultural competency (UK Drug Policy, 2017). Indeed, identifying chemsex as a major risk factor in HIV transmission has helped HIV prevention services to significantly reduce the number of new HIV infections within some cities.
What sets “chems” apart from other drugs?
People use different drugs for different purposes; for instance people who use heroin or crack cocaine do not usually use those two drugs to go out dancing. Some do of course, but the more desirable purpose of those drugs might be to medicate unmanageable emotions associated with memories or thought processes that might be born of historical trauma, or difficult life circumstances. So a person with a particular kind of life experience might be particularly attracted to those drugs. All drugs can be used for this purpose, though some are better than others; alcohol, ketamine, GHB, benzodiazepines can serve this function very well.
Not exclusively of course. Many sedatives might be great at creating a welcome numbness, but they can also be used to instill confidence; alcohol is a depressant that can also make people want to dance or socialize.
Ecstasy, for example, might not be the first choice of drug for a person who seeks to numb unmanageable emotions; ecstasy is a great empathizer, often favored for dancing or connecting with individuals or communities. Ecstasy, MDMA, cocaine, alcohol are excellent socializing and confidence-giving drugs; and historically, they have been the drugs favored by gay men, drugs that have played an important role in facilitating community and connection for gay men internationally during some challenging times in recent history (including the HIV/AIDS epidemic and changing social attitudes, laws and social spaces regarding homosexuality).
Ecstasy, MDMA, cocaine and alcohol (amongst others) are drugs that have also been used in sexual contexts by gay men. These drugs are associated with considerably less harms in sexual contexts than chems are, and have never amounted to an identifiable public health concern in the way that chems have been. Similarly, ecstasy, cocaine, MDMA and alcohol have never mobilized international gay communities in concerned community responses in the way that chemsex has. And the number of deaths associated with sexual/recreational use of ecstasy, cocaine, MDMA or alcohol has never been in the numbers that warrant a public health alert as is the case with chems.
But what mostly sets chems apart from other drugs, is the particular “highs” associated with them. Two people having sex on ecstasy will be very conscious of the empathising effect of the drug, perhaps even resourcing it. The sex might feel very emotionally connected, and disclosures of personal truths and vulnerabilities might be exchanged. They might be very conscious and appreciative of sensual sensations, smells, nuances of facial expressions, each other’s breath. They might be very attuned to the other’s sexual and emotional needs, and responses.
Methamphetamine, by contrast is a very different kind of “high”. It releases considerably higher amounts of dopamine than other drugs will, often profoundly affecting a person’s judgment in ways other drugs do not. And the prevailing effect of the drug is its’ disinhibiting effect; less likely to be its’ empathizing effect. When combined with the neurochemical state of male arousal, and with a particular inhibition a person might have about sex, it creates an overwhelming sexual disinhibition and access to desires and fantasies that might previously have been recessed by religious, cultural or psychological obstacles. Many people describe a Pandora’s Box of sexual fantasies being opened; others describe the drug as removing a filter that helped them to assess the difference between behavior that might be considered “appropriate” and “inappropriate”. Nearly all describe this high as immensely pleasurable and disinhibiting. Some manage this “high” well, other’s struggle with the consequences which can include physical exhaustion, paranoia, depression, and emotional trauma associated with the coming to terms with choices that might have been made while under the influence of the drug. Some struggle to reconcile the sexual fantasies they enjoyed during the “high” with personal, religious, moral or heteronormative concepts of sexuality that pervade when sober.
It can be unfairly reductive to summarise in this way, but the sexually disinhibiting “highs” associated with chems lend themselves especially well to the gay sex experience, in a much more intoxicating way than any other drug or alcohol. Combined with poor harm reduction knowledge, it can be particularly dangerous. Combined with a vulnerable psychological health, it can be particularly harmful; and combined with psychosexual issues, or a particular inhibition associated with the enjoyment of gay sex and love, it can be particularly complicated and dependence-forming.
The proliferation of chems via sexual networking Apps
Another factor involved in why certain people use certain drugs, is how different drugs are available to different populations or demographics (Halkitis & Jerome, 2008) Often this is via geographical networks. Other times, it is more demographical than geographical. Historically, certain ethnic populations have been associated with certain drugs, because of particularly racist government drug policies or criminal justice system inequalities. Chemsex is specifically associated with the availability and proliferation of certain drugs (“chems”) via sexual networking applications (hook-up apps) that became popular with the advent of smartphone technologies. This was the simultaneous proliferation and availability of specific drugs to a specific international population of gay men that was unprecedented in the history of substance use epidemiology. Ecstasy, cocaine, MDMA had been popular drugs, but the epidemiology of their use was markedly different, mostly geographical and demographical; incomparable to the international online targeted proliferation of chems unto gay men via online sexual networking apps. It’s important to note too, that this availability and proliferation of chems happened at a specific time in history that might contribute to the vulnerability of a population; a time in history that included the HIV/AIDS epidemic, dramatic shifts in attitudes and legalities associated with homo-sex, as well as a sexual/technological revolution that heralded online sexual networking. These are some of the cultural uniquenesses that define chemsex as a uniquely gay syndemic.
The role of technology in chemsex
The cultural shift that moved gay sex from public parks and cruising grounds, from public toilets and cottages, to online sexual networking was nothing less than seismic. It came with many advantages as well as many disadvantages, but in either case, it was inevitable as technology marched forward. If the experience of gay sex had been complicated for some in regard to HIV fear and stigma, or because of cultural or religious influences, gay men now required a new skill-set of online abbreviations, PR skills to “market” their sexuality and preferences in abbreviated online platforms and profiles. They needed a robustness of character to manage the faster and often troll-like rejections that occur online. A culture of racial rejections, “slut-shaming”, “camp shaming”, toxic masculinity, tribalism, needed to be navigated expertly, lest a person’s self-confidence suffer. For many, the avoidance of isolation and loneliness depend on that skill-set. Hook-up culture was redefined, and it required a skill-set of boundaries and communication skills that many didn’t have. Online hook-up culture asked people to have a basic awareness of their sexual and emotional desires and needs; it then asked them to communicate those desires and needs on broadly public platforms, using a limited number of abbreviated words, some symbols/emoticons and an avatar. People were introduced to new ideas, experiences, fetishes, drugs and more; and though these can be wonderful things, not all people had the emotional robustness, self-awareness, self-care or skill set to manage safely and enjoyably. Many people felt a pressure to live up to the sexual expectations they perceived via online hooking-up apps; and many found that the chems (that were also available online) helped with that pressure and those expectations satisfactorily.
“Trolling” is another product of modern online communication. Trolling can be defined as the passionate or militant typing of opinions and attitudes during online correspondence, but failing to empathise with the human being that one is corresponding with; resulting in an unkind, aggressive diatribe existing under the guise of ‘dialogue’. Trolling in regard to fantasies, sexual preferences, gay tribes, HIV stigma, attitudes toward chems, rejections – in fact just about anything - can be a very complicated part of negotiating sex and dating online. Chems can be an effective way of managing online trolling and hooking-up, by providing a confidence and resilience to the harms trolling can cause.
The role of HIV in chemsex
Chemsex can be connected to HIV by the transmission risks that might occur in chemsex environments (Sewell et al, 2018), and this evidence has served a function in arguing the case for HIV testing and prevention services to become chemsex proficient, and helping chemsex to be put on public health agendas. But the more important relationship between chemsex and HIV is the role that HIV has played in concepts of pleasure that gay men experience associated with sex. HIV, AIDS and the legacy of the epidemic associated gay sex with risk and danger and trauma. The horrors of the AIDS epidemic of the 80s and early 90s especially, manifested as a shared community trauma; one that continues to exist in the minds and hearts and memories of many gay men, as well as in the bedrooms and bathhouses and cottages. Younger generations have also inherited that trauma to a degree; it can play out as fear of HIV, or as indifference to HIV, or a sense of inevitability about becoming HIV positive. It can be especially obvious in the high numbers of gay men who experience chem-induced psychosis where the perceptions of persecution and paranoia focus on HIV.
These complexities can make gay sex complicated. It’s a very real fact, that chems can make that easier, removing those inhibitions, and providing an arousal that had previously been complicated by fear and anxiety and complexity.
Another complication associated with HIV can be the negotiation of HIV prevention methods online, or the disclosure of sero-status’ (HIV, HCV). Differing preferences and political attitudes, including shaming, can be played out complicatedly online when negotiating condoms, PrEP, undetectable viral loads, or positive/negative disclosures. “Trolling”, the unkind spewing of opinions and attitudes, can be particularly difficult to manage when negotiating these complex safer sex preferences. Many find that simply getting “high” on chems, helps them to blindly forego or bypass these complicated negotiations altogether.
Despite its origins and cultural specificity, it is understandable that the word chemsex be misunderstood and misappropriated to apply to generic forms of alcohol and drug use that might occur within sexual contexts by many other populations and demographics. Mainstream media and popular culture became familiar and fascinated with the word as the gay men’s public health concern of chemsex came to light in (approximately) 2012. There is obviously an important need to remain vigilant to the healthcare needs of all people who use alcohol and drugs in sexual contexts, many of whom need specific care that may not be met in generic drug services or sexual health services. We need to remain vigilant lest any other populations begin to experience similar levels of harms and deaths and sexual health epidemics that gay communities do in regard to chemsex.
Currently, that isn’t the case. There is a cultural upset and trauma associated with chemsex for gay communities around the world. In London, a gay man dies approximately every month in chemsex contexts, Lyon has reported 20 chemsex related deaths in the last year (CoreVIH, 2018). Sadly, a higher number still become known of via social media obituaries and community reports. Gay African American communities in the United States of America have been particularly upset by increases of HIV infections associated with chemsex, and a disproportionate number of deaths resulting from chemsex or “PnP” (“Party and Play”) culture. In London, chemsex related crimes are increasing (Strudwick, 2018). While some of this is academic fact, the greater part is unsubstantiated cultural awareness, which only adds salt to a wound, as if authorities are not listening or prioritizing chemsex as a public health concern; it echoes too, of some of the upset from the earlier years of the AIDS epidemic, when cultural awareness of gay deaths outweighed any research or formal public health outcry.
Whether academic fact, or undocumented community awareness, this all amounts to a communal trauma experienced by international gay communities, struggling to unravel what chemsex means in regard to gay sex, HIV, gay hook-up culture, and the role drugs and sex have come to play in our modern gay lives and communities and scenes. Chemsex is a word that defines this unique set of cultural uniquenesses, and though it is understandable that the word may be misused to apply to other populations, other drugs – it is a hurtful cultural appropriation to apply the term to non-homo-sex contexts.
Like many words or phenomena that catch the zeitgeist of a generation, the word chemsex will fall victim to morph and change, fall prey to misappropriation and cultural appropriation, develop stigmas, win and lose popular favor, do harm and good. It will be used to hurt people, it will be used to help people. It will be used to sell sex, books, ideas, and to promote businesses. It will be hashtagged to increase traffic to its’ many appropriations. It will be referenced in conspiracy theories to deliberately jeopardize gay sex-positivity movements. It will be portrayed variously through art, performance, film and theatre. It will discussed in communities, real and online, and it will be explored in media and academia. For better or worse, all of these things are inevitable, and holistically serve the purpose of raising awareness. As we navigate our emotional and intellectual responses to all these manifestations, it can be helpful to remember the benefits of a named public health and community issue. The word chemsex has a helpful purpose of identifying a unique set of behaviors and circumstances that gay men need culturally specific support with; the word chemsex helps those who might be struggling with chemsex, to know they are not alone, that their community understands (and names) their struggles, so they can identify with others, de-shame the experience for them, and to seek culturally appropriate help if needed. The word chemsex helps gay communities to name and identify a unique syndemic of behaviours and circumstances, so that community responses can be mobilized. The word chemsex helps support services to better understand a culturally unique issue, so that they may develop culturally competent support services that respond sensitively and uniquely, and help to reduce harms and deaths within gay communities.
The word chemsex has a definition and a purpose. Chemsex is the use of any combination of drugs that includes crystal methamphetamine, mephedrone (and other cathenones) and/or GHB/GBL -specifically for the purposes of gay sex. It is syndemically associated with some recent and dramatic changes that affected the experience of gay sex and pleasure;
As the person who (to my best knowledge) first coined the term “chemsex”, I can also testify to its’ purpose.
I engaged in an extremely enjoyable, disinhibiting (and for me) eventually problematic use of drugs, that was different to all other historical and global drug use epidemics I’d known of. I felt alone and freakish as I sought to comprehend my choices, the consequences. I had been trying very hard to enjoy sex as a gay man, despite many obstacles and challenges, many of them quite traumatic, though subtly so. I was seeking pleasure in sex and love and connection, and finding it problematic. My search for support with this problem – in literature, online, cultural discourse, support services, all invited me to label my kind of problem as a drug problem. I was sent to addiction services. I was called an “addict”. Drugs were defined as my problem, though I’d only ever experienced drugs to be a kind of solution to my problem; not THE problem.
I found a brotherhood amongst other gay men who identified with the struggles I had; people I was doing drugs and having sex with. That brotherhood grew. We called what we were doing “chemsex”. It better described what we were doing, it saved us from being defined under umbrella terms that didn’t feel right, that didn’t apply, that in fact disrespected our cultural differences. We called it chemsex, and that brought us comfort and less loneliness. It helped us to define something that was quite unique and complex, even confusing for us. The brotherhood continued to grow, and as I very accidentally became involved in gay men’s healthcare, the word chemsex came with me. It’s a word that has a purpose; that purpose is identity and inclusiveness, for those who feel it includes them, helps them, recognizes their unique pursuits and needs. It’s a word that helps ensure the gay sex element of any problems that might develop are not ignored, as gay men are lazily directed toward addiction services that ignore a crucial element of their drug use and behavior. It’s a word that had the purpose of naming an upsetting and widespread issue within our communities, one that is associated with an awful disproportionate number of harms and deaths. It’s a word that serves the purpose of supporting government drug policies and support services to incorporate the cultural integrity and competency into the care they provide; for without it, the issue cannot be competently or sensitively addressed.
Mostly though; the specifically defined word chemsex had the purpose of supporting my own community of gay men who use specific drugs as they pursue the pleasure, the connection, the joy and the love they deserve from gay sex, despite some overwhelming obstacles that make that difficult.
The ultimate purpose of the word was kindness. Something I see communicated every time I see another gay man identify with the term.
(Bourne et al) International Journal of Drug Policy, Volume 26, Issue 12, December 2015, Pages 1171-1176
(Halkitis & Jerome 2008) Addictive Behaviors Volume 33, Issue 1, January 2008, Pages 83-93
(Link 1) https://www.gaydar.net
(Link 2) https://www.youtube.com/watch?v=vrpuW3LaMpw&list=PLsi7TLi2MKjbPhXSKN26OcZXKFzQQm-oP&index=6
(Link 3) https://www.menrus.co.uk/drugs-content/chemsex-support-outside-london/
(Link 4) https://mainline.nl/posts/show/8475/inloopavonden-chems-en-seks-verdubbeld
(Link 5) https://www.scribd.com/document/328039214/The-Exploration-of-Chem-Fun-in-the-Hong-Kong-Gay-Community
(Link 6) http://kemseks.si
(Link 7) Definition, Cultural appropriation https://dictionary.cambridge.org/dictionary/english/cultural-appropriation
(Prestage et al) International Journal of Drug Policy, Volume 55, May 2018, Pages 169-179
(Sewell et al, 2018)
Sexually Transmitted Infections Volume 2018 Issue 94 Pages 494-501
(UK Drug Strategy, 2017) https://www.gov.uk/government/publications/drug-strategy-2017 Reference page 15