The highs and lows of drug tourism: a travel medicine perspective

Tourists have travelled within countries and across international boundaries for the purpose of obtaining or using psychoactive drugs for medicinal or recreational use at least since the 1950s, when the so-called ‘hippie trail’ witnessed alternative tourists making extended overland journeys between Europe and South Asia. The profile of the modern drug tourist is more heterogeneous, and legal restrictions on the purchase and personal use of recreational drugs may limit the extent to which this travel motivation surfaces during the pre-travel health consultation. The unwary drug tourist may not be cognizant of the risks associated with such activity, which include detention and incarceration in a foreign country, often with very strict drug laws for which conviction may be associated with severe penalties; the need for emergency medical evacuation from remote areas; or being subject to the threat of local criminal organizations or corrupt law enforcement officials. Other health risks include the risk of exposure to blood–borne viruses such as HIV and hepatitis C, drug-induced psychosis, risky sexual practices and inadvertently contributing to local crime, poverty and social inequality among host communities. This article will explore the current status of drug tourism, also called narcotourism, with a focus on the profile of modern drug tourists, drug tourism destinations, health risks and prevention strategies. Drug tourism may be defined as ‘…the phenomenon by which persons become attracted to a particular location because of the accessibility of licit or illicit drugs and related services’.1 Problem drug users may seek out destinations to access drug treatment or harm reduction services unavailable in their own countries, or to isolate themselves from their drug-using peers. Table 1 summarizes the tourist destinations most commonly associated with drug tourism. Segev and colleagues reported that 54.3% of mostly Israeli, British, Swedish, German and Australian travellers, with a mean age of 25.3 years, took drugs during travel in Southeast Asia.2 There was significantly greater drug use among male travellers. The drug most commonly consumed was cannabis but ‘harder’ drugs such as lysergic acid diethylamide were also reported. There were much higher rates of drug use in India than in other Asian countries. The Balearic island of Ibiza attracts as many as 250 000 holidaymakers under the age of 30 from the UK each year.3 An airport survey of 1715 UK visitors to Ibiza found that 57.4% used illicit drugs in the UK, with most continuing their use in Ibiza. Binge drug use was the norm, with many individuals reporting drug use on at least 5 nights per week.4 There was an increase over a 4-year period of use of cocaine, ecstasy and the so-called ‘date rape’ drug, gamma hydroxybutyrate.4 Most common drug tourism destinations Consumption of psilocybin mushrooms in towns in the southern state of Oaxaca, despite federal health law prohibitions Ingestion of hallucinogenic peyote cactus in the Wirikuta desert Opiates, ecstasy, mushrooms and marijuana attract drug tourists to the Golden Triangle, connecting Thailand to Myanmar and Laos Full moon parties on Ko Pha-Ngan island, Thailand Consumption of psilocybin mushrooms in towns in the southern state of Oaxaca, despite federal health law prohibitions Ingestion of hallucinogenic peyote cactus in the Wirikuta desert Opiates, ecstasy, mushrooms and marijuana attract drug tourists to the Golden Triangle, connecting Thailand to Myanmar and Laos Full moon parties on Ko Pha-Ngan island, Thailand Most common drug tourism destinations Consumption of psilocybin mushrooms in towns in the southern state of Oaxaca, despite federal health law prohibitions Ingestion of hallucinogenic peyote cactus in the Wirikuta desert Opiates, ecstasy, mushrooms and marijuana attract drug tourists to the Golden Triangle, connecting Thailand to Myanmar and Laos Full moon parties on Ko Pha-Ngan island, Thailand Consumption of psilocybin mushrooms in towns in the southern state of Oaxaca, despite federal health law prohibitions Ingestion of hallucinogenic peyote cactus in the Wirikuta desert Opiates, ecstasy, mushrooms and marijuana attract drug tourists to the Golden Triangle, connecting Thailand to Myanmar and Laos Full moon parties on Ko Pha-Ngan island, Thailand Drug use abroad carries the additional risks associated with unknown sources of supplies, lack of awareness of local health services, and isolation from friends and family support. The escalation of drug-taking behaviours during international leisure travel is linked to unprotected sex, drug driving accidents and mental health problems.5 In a study of 1008 young UK adult backpackers in Australia, 55% of the sample used at least one illicit drug during their backpacking holiday. Risk factors for such use included being male, being a regular club goer, travelling without a partner, travel for more than 4 weeks, and drinking alcohol or smoking for 5 or more days a week.6 A retrospective Swiss study of 3537 travellers surveyed during the pre-travel consultation revealed a decrease in the use of recreational drugs from 9 to 5% during their most recent international travel but this study may have been influenced by recall or social desirability bias.7 The authors postulate that traveller concern about harsh drug enforcement laws in foreign jurisdictions may dissuade them from seeking illicit drugs. A study of 223 younger (18–30 years) Israeli long-term travellers to the tropics reported that 36.7% used illicit drugs during their trip, with higher rates of drug abuse associated with travel to Southeast Asia (43.3%) compared to South America (25.6%).8 Drug use was highest in travellers to India, where so-called ‘full moon’ parties in states such as Goa are popular among drug tourists. Drug use adversely affected adherence to physician-prescribed malaria chemoprophylaxis, which was attributed by many travellers to their fear of the potential of mefloquine to induce vivid dreams, hallucinations and mood disturbance. The phenomenon of tourist participation in Shamanic rituals in the Amazonian region of South America has recently attracted attention in the online and print media. The psychoactive alkaloids present in the so-called San Pedro cactus (Echinopsis pachanoi) account for its use by visitors to the Andes mountain range for healing and religious divination purposes. High profile deaths in young tourists attributed to ingestion of the purgative hallucinogenic decoction, ayahuasca, have raised concern about this activity in travellers. A 26-year-old British man was stabbed to death near the Peruvian city of Iquitos in apparent self-defence by a Canadian man, also taking part in a shamanic ceremony involving the hallucinogenic drink ayahuasca.9 Ayahuasca acts as a monoamine oxidase inhibitor by inhibiting the metabolism of the psychedelic compound dimethyltryptamine in the gut. It induces a state of altered consciousness lasting for up to 8 h, accompanied by colourful visual hallucinations, heightened perception, diminished auditory sensation and mental alertness. The accompanying emesis (‘the purge’) is considered spiritually significant by users. Local healers (curanderos) conduct nocturnal rituals during which oral consumption of a traditional ayahuasca brew is believed to facilitate greater insight for the participant drug-taker. Kavenská characterizes ayahuasca tourists as individuals motivated by curiosity, a desire for ‘self-realization and growth’, and who use the substance as a vehicle for ameliorating emotional, addiction or chronic illness-related issues.10 Their qualitative study of ayahuasca ritual participants cited lack of trust in a shaman as the principal negative element of the experience. Winkelman points to instances of sexual predation perpetrated by native ayahuasca providers disguised as traditional healers.11 Voluntary sexual risk-taking among illicit drug-taking tourists has been studied extensively. Kelly and co-workers found high levels of drug use (85.3%) in a sample of 171 British seasonal casual workers on the island of Ibiza in Spain.12 Half of the casual workers surveyed had unprotected sex, often while under the influence of alcohol, with the majority (85.7%) failing to seek a sexual health check-up in Ibiza. High rates of ecstasy use have previously been reported in this cohort of occupational travellers.13 The authors hypothesize that new arrivals to the island are quickly integrated into the local drug scene by existing workers who are familiar with how to obtain recreational drugs for personal use. They warn that casual sexual activity during seasonal work-related travel may be sustained when these young people return to the UK, as unsafe sexual practices become normalized. Guilamo-Ramos et al. have studied sex tourism in the Dominican Republic and suggested that local tourist demands cause drug routes to migrate to tourism hotspots where drug tourism facilitates HIV risk behaviours.14 Use of illicit drugs, especially cocaine and amphetamines, places drug tourists at risk of unintentional injury and interpersonal violence. In an airport survey of 6502 young British and German holidaymakers visiting Mediterranean nightlife destinations, Hughes et al. reported the highest levels of drug use by German visitors to Portugal.15 There was a positive association between unintentional injury, domestic drug use and use of drugs other than cannabis during travel. The use of drugs during their Mediterranean holiday, frequent alcohol intoxication and travel to Majorca or Crete were factors in the incidence of violence involving other individuals. In a study of Consular notifications of Canadian arrests overseas, drugs were implicated in 420 out of 6514 cases.16 There was a disproportionate over-representation of women in relation to drug offences, but it is unknown whether these were for drug possession, consumption or trafficking. The health problems associated with incarceration, including transmissible infectious diseases, violence, and suicide were highlighted by the authors, who advocate risk reduction strategies to educate travellers about the legislation and harsh penalties related to the possession and use of narcotics in unfamiliar jurisdictions. The illegal importation of packets of drugs, usually cocaine but occasionally of ecstasy,17 across international borders, is mostly observed in male travellers.18 The drug pellets appear as uniformly isodense or slightly hyperdense opacities on a plain radiograph of the abdomen. This phenomenon of ‘body packing’ carries a risk of acute intoxication causes by leakage or rupture of the swallowed packets in the gut. Cocaine intoxication in this scenario may be recognized by airline personnel and medical volunteers by the presence of mydriasis, seizures, agitation, tachycardia, hypertensive crisis, hyperthermia, arrhythmias or myocardial infarction. There may be associated episodes of air rage and efforts to physically restrain these victims may potentiate the cardiac effects of the drug and precipitate death. The travel medicine community must be aware of the potential for drug tourism during pre-travel consultations and sensitively highlight the risks of such activities. Greater efforts to promote prevention in popular drug travel destinations are also indicated. The use of peer educators may be appropriate in attempting to discourage younger travellers from experimenting with drugs in nightlife resorts. The music festival industry may have a useful role to play in harm reduction. Promotion of responsible behaviour among resort employees is also of paramount importance. Changes in drug legislation across national jurisdictions can be confusing for young tourists to navigate. Tourists should be made aware of local drug law enforcement policies as well as measures to take in the event of a drug-related medical emergency. Further research will illuminate the current patterns of illicit drug use during travel and help to inform preventive educational strategies. Moreover, high-quality research into the therapeutic effects of various psychoactive drugs should continue since it will help to establish safe dosages and reduce harm to travellers seeking to use them, either for recreational, therapeutic or spiritual purposes. None received. Conflict of interest: None declared.

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