Hitting a moving target Managing NPS harms Dr Owen Bowden-Jones Addiction Psychiatrist Imperial College London

Club Drugs Club drugs tend to be used by teenagers and young adults at bars, nightclubs, concerts, and parties (NIDA) E.g. Cocaine, MDMA, Ketamine, GHB/GBL, methamphetamine Novel Psychoactive Substances Psychoactive drugs which are not prohibited by the United Nations Drug Conventions but which may pose a public health threat comparable to that posed by substances listed in these conventions (UK Home Office) E.g. Cathinones, synthetic cannabinoids, piperazines

EMCDDA 2015

Number of internet sites selling NPS

Who are using these new substances ? Depends where you are, and who you are !

‘Traditional’ drug users Heroin users moving to mephedrone injecting? Some evidence from EMCDDA Other anecdotal But, evidence of injecting of NPS and club drugs

Clubbers and students Geographical variation ‘Bubble’ DrugLifetime use Ecstasy89.5 Cocaine84.6 Ketamine66.1 Heroin6.7 Drug use by ‘clubbers’ Winstock 2010

LGBT/ MSM London, Berlin, New York Use in sexual context Use of social media

Young professionals Anecdotal evidence of use by professional ? Attracted by legality and concerns of workplace drug testing

Perfect drugs for prisons? Cheap, potent, undetectable

How should clinical services respond to the challenge of new trends?

New drugs – Little/no research into treatment – Harms still poorly understood – Already seeing unpredictable harms with ‘club drugs’ e.g. Ketamine bladder – Rapidly changing profile New populations – Different context of use e.g. methamphetamine and high risk sexual behaviours – Not ‘typical’ drug user. – How to engage?

HEROIN CRACK COCAINE CANNABIS ALCOHOLBENZOS piperazines tryptamines phenethylamines synthetic cannabinoids synthetic cathinones new synthetic opioids ‘others’

Challenge for specialist drug services Clinical staff have poor knowledge of changing patterns of drug use – ‘technical’ knowledge (what are the drugs, how do they work) – ‘cultural’ knowledge (who is using, how are they using) – ‘clinical’ knowledge (how to clinical manage acute/chronic presentation) – ‘service’ knowledge (when and where to refer)

Project NEPTUNE Novel Psychoactive Treatment: UK Network

NEPTUNE I Raise standards in clinical management of ‘club drugs’ including NPS across the health system, by…..undertaking a comprehensive review of treatment research literature for NPS and club drugs, leading to…..development of evidence- based clinical guidance Where evidence lacking, use expert consensus

Guidance addressed Acute club-drug toxicity and management of harms Harms from chronic use of club-drugs: harmful and dependence and their management Reduction of harms, patient safety and public health Guidance aim to improve confidence and competence and increase the skills of clinicians Screening /identification of harms Assessment of harms Management of harms 19

AR Lingford-Hughes, S Welch, L Petersand DJ Nutt et al: BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP 2012 Journal of Psychopharmacology 26(7) 899–952 1 Strong research evidence (e.g. Cochrane reviews, meta-analyses, high quality randomised controlled trials) 2Research evidence (e.g. controlled studies or semi-experimental studies) 3 Emerging research evidence (e.g. descriptive or comparative studies, correlation studies, evaluations or surveys and non-analytic studies for example, case reports, case series) 4Expert panel evidence/ consensus 5Expert by experience evidence (service users/ patients) 6Lack of evidence (No evidence, for or against) 7Conflicting evidence

NEPTUNE guidance content Quality of research evidence Brief summary of chemistry and pharmacology Clinical and other uses Prevalence, user populations and patterns of use Routes of ingestions and frequency of dosing Desired subjective effects; unwanted effects Harms and their management – Acute harms – Management of acute harms – Harms from chronic use – Management of harms from chronic use Public health and safety and harm reduction 21

Stimulants Sedatives/ Dissociatives Sedatives/ Dissociatives Hallucinogens Synthetic cannabinoids

Cathinones Piperazines Phenethylamines (including amphetamines, methamphetamine, MDMA, 2C series, D series, benzodifurans, PMMA, PMA) Cathinones Piperazines Phenethylamines (including amphetamines, methamphetamine, MDMA, 2C series, D series, benzodifurans, PMMA, PMA) GHB/GBL Ketamine Methoxetamine Nitrous Oxide GHB/GBL Ketamine Methoxetamine Nitrous Oxide Tryptamines DMT, psilocybin, AMT LSD Phenethylamines NBOMe, 2CB Salvia divinorum Amanita mushrooms Tryptamines DMT, psilocybin, AMT LSD Phenethylamines NBOMe, 2CB Salvia divinorum Amanita mushrooms CB1 and CB2 receptor agonists including JWH and CP (Classical, non-classical and hybrid) CB1 and CB2 receptor agonists including JWH and CP (Classical, non-classical and hybrid)

Project NEPTUNE Develop clinical guidance Emergency Care Drug Services Sexual Health and Mental Health Sexual Health and Mental Health General Practice

Guidance published in March 2015 Additional LGBT guidance to be released shortly

Between 27 th March-13 th May 4,642 visits to website 1,538 downloads

But guidance can get left on the shelf………

Novel Psychoactive Treatment: UK Network NEPTUNE II 29

Care Bundles

Other tools (e.g. Patient information)

Evaluation Evaluation Centre for Quality Improvement (CCQI). 35

Main evaluation To evaluate: 1.Impact of initiatives on treatment safety and patient outcomes 2.How the implementation sites achieved their objectives (or not) and the factors associated with this 3.Impact of e-learning programmes on clinical knowledge and staff confidence

Volunteers wanted for testing implementation

When will NEPTUNE be available? Clinical guidance (NEPTUNE I) Associated tools (NEPTUNE II) From end of 2015 Website hosted by Royal College of Psychiatrists, UK Free to all

But problems remain… Any clinical guidance will be out of date almost immediately Lack of toxicology. Who has taken what? Effects of poly-substance use are unpredictable Longer term harms unknown. What to look for? How to engage NPS users in ‘traditional’ drug treatment services?

Conclusions NPS present a challenge for health services and policy makers Limited knowledge on clinical harms, user profiles, engagement strategies and treatment approaches Responses require adaptation of existing evidence- based interventions supported by investment in training and further research NEPTUNE an attempt to address this

NEPTUNE I Expert group membership Dr Owen Bowden-JonesDr Dima Abdulrahim Dr James BellDr Nigel Borley Dr Steve BrincksmanMs Emma Crawshaw; Laura Day Ms Annette Dale-PereraMr Mark Dunn Ms Stacey HemmingsMr Salvo Larosa Dr Luke MitchesonMr. Monty Moncrieff Mr David MacKintoshProf David Nutt Dr John RamseyDr John Roche Prof Fabrizio SchifanoMr David Stuart Dr Ann SullivanDr Tim Williams Dr Christopher WhiteleyDr Adam Winstock Dr David WoodDr Dan Wood Other contributors: Dr Marta Buffito; Lindsey Hines; Josh Hulbert 41

NEPTUNE II expert group Members Owen Bowden-Jones Dima Abdulrahim Alex Baldacchino Seth Bhunnoo Steve Brinksman Emma Crawshaw Paul Dargan Jonathan Dewhurst Dominic Dougall Caroline Frayne Mike Flanagan Sarah Flowers Sanjay Kumar Salvo Larosa Luke Mitcheson Monty Moncrieff David Nutt John Ramsey John Roche Fabrizio Schifano Josie Smith Ann Sullivan Tim Williams Christopher Whiteley Rosie Smith Adam Winstock David Wood Dan Wood Observers Public Health England Pete Burnkinshaw Department of Health John McCracken; Mark Prunty Home Office Melanie Roberts

guidance.co.uk