1. NPS and Importance of Information Sharing Dr Richard Stevenson A&E Department, Glasgow Royal Infirmary Dr Hazel Torrance Forensic Medicine and Science

2. Brief Recap 2008 – first A&E presentations due to mephedrone 2012 – Drug Trend Monitoring Group (Glasgow) 2012 – Sudden ↑ in A&E presentations (synthetic cannabinoids) 2013 – Deaths due to NPS hit headlines 2014 – Urine screening study of A&E patients (GRI) 2015 – Second A&E study (blood) & Forensic Mental Health (urine)

3. How to Identify of Use? Current dipstick urine screening tests for 6 substances Cocaine, methadone, opiates, benzos, cannabis, amphetamines Most NPS will not be detected (various reasons) Non-specific test  FALSE negatives and FALSE positives Technology exists to test for NPS agents Slow turnaround times –Laboratory based –Expensive instrumentation –Highly skilled operators –Certified standards to confirm identity not always available Not part of routine NHS provision

4. Proof of Harm? Unknown toxicology –Pharmacological effects – dosing, response, duration –Interactions with prescribed drugs –Addiction –Complications of use (warning) –Drug use during pregnancy Often taken in combination with other drugs Urine screens – useful for prevalence Blood – to correlate the effects to blood levels Post mortem toxicology

5. Current Population Concerns Emergency Medicine –Weekly presentations –Mental health, acute poisoning, management Scottish Prison Service –Prisoners obviously under influence of drugs but negative drug screens –Acute behavioural disturbance Forensic Mental Health –Negative drug screens but deteriorating mental health –Conditions for release from hospital

6. Prevalence? Simply don’t know! Self-reporting questionnaires (caution) Country/Region specific Europe – EMCDDA UK Focal Point – UK Scotland? Glasgow/Edinburgh/Aberdeen?

7. Pilot A&E Urine Screening Study Glasgow Royal Infirmary (May - Jul 2014) –80 patients urine screened Prescription Drugs Classical Drugs of Abuse Novel Psychoactive Substances –16 tested positive for at least 1 NPS (note synthetic cannabinoids not tested) –Mostly MDMA mimics or Etizolam –Poor correlation with patient history

8. Larger A&E Blood/Urine Screening Study Started May 2015  October 2015 64 cases so far 52 Males: 12 Females Age Range: 14 – 55Median Age: 24 Years Blood and Urine Tested –Alcohol –Classical Drugs of Abuse –Prescription Drugs –Novel Psychoactive Substances (including some synthetic cannabinoids)

9. A&E Results So Far…

10. MDMA, Cocaine and GHB still very popular Synthetic Cannabinoids present throughout age range Methadone and Heroin use evident with older population Clusters of positive cases –Strong MDMA tablets? –Groups of individuals taking same drug at same event? –Changing availability?

11. Scottish Prison Service Project – Nov 2013 Analysed 904 urine samples from 8 prisons Admission and Liberation samples Abused Prescribed Drugs –Gabapentin, Pregabalin Novel Psychoactive Substances –Benzedrone, MDAI, Etizolam Synthetic Cannabinoids NOT TESTED Further study planned for November 2015 (including Synthetic Cannabinoids)

12. Drug Courts – October 2015 Concern regarding negative drug tests –Clients openly admitting to taking a “legal” high –Under the influence of something but negative test Collect ~70 urine samples from individuals on Drug Court Orders Testing for New Benzodiazepines –Etizolam –Diclazepam –Pyrazolam –Flubromazopam………

13. Forensic Psychiatrists – Greater Glasgow and Clyde Planned for November 2015 Prevalence type study (~150 Urine samples) Testing for –Classic Drugs of Abuse –Novel Psychoactive Substances Include NHS laboratory to assess capability

14. Problems No clear definition of NPS –Misunderstandings between professional fields –Miscommunication with public Not knowing what drug to test Drug tests have limitations –Specific/Non-specific –Testing for knowns and unknowns Not having access to certified reference material Uncontrolled drugs not included in Drug Related Deaths statistics  misleading information

15. Importance of Information Sharing Frontline awareness Drug Trend Monitoring Groups Scotland Specific Prevalence Data –A&E Admissions –Prisons –Mental Health Drug Seizures Deaths TIME SPECIFIC Identify Available Drugs Assess Harm In Population Build Up Understanding

16. Thank You Richard.Stevenson@nhs.net Hazel.Torrance@glasgow.ac.uk