Hitting a moving targetManaging NPS harms

Dr Owen Bowden-JonesAddiction 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’

Drug Lifetime use

Ecstasy 89.5

Cocaine 84.6

Ketamine 66.1

Heroin 6.7

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

ALCOHOL BENZOS

piperazines tryptamines

phenethylamines

syntheticcannabinoids

syntheticcathinones

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

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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)

2 Research 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)

4 Expert panel evidence/ consensus

5 Expert by experience evidence (service users/ patients)

6 Lack of evidence (No evidence, for or against)

7 Conflicting evidence

NEPTUNE guidance contentNEPTUNE 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 reduction21

StimulantsStimulants Sedatives/Dissociatives

Sedatives/Dissociatives

HallucinogensHallucinogens Synthetic cannabinoidsSynthetic cannabinoids

CathinonesPiperazines

Phenethylamines (including amphetamines,

methamphetamine, MDMA, 2C series, D series, benzodifurans,

PMMA, PMA)

CathinonesPiperazines

Phenethylamines (including amphetamines,

methamphetamine, MDMA, 2C series, D series, benzodifurans,

PMMA, PMA)

GHB/GBLKetamine

MethoxetamineNitrous Oxide

GHB/GBLKetamine

MethoxetamineNitrous Oxide

TryptaminesDMT, psilocybin, AMT

LSDPhenethylamines

NBOMe, 2CBSalvia divinorum

Amanita mushrooms

TryptaminesDMT, psilocybin, AMT

LSDPhenethylamines

NBOMe, 2CBSalvia 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 Develop clinical guidance

Emergency CareEmergency Care

Drug Services

Drug Services

Sexual Health and Mental Health

Sexual Health and Mental Health

General Practice General Practice

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

shortly

Between 27th March-13th May4,642 visits to website1,538 downloads

But guidance can get left on the shelf………

Novel Psychoactive Treatment: UK NetworkNEPTUNE IINEPTUNE II

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Care BundlesCare Bundles

Other toolsOther tools(e.g. Patient information)(e.g. Patient information)

EvaluationEvaluationCentre for Quality Improvement (CCQI).

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Main evaluation

To evaluate:

1.Impact of initiatives on treatment safety and patient outcomes2.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) • www.neptune-clinical-guidance.co.uk • 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 membershipNEPTUNE I Expert group membership

Dr Owen Bowden-Jones Dr Dima Abdulrahim

Dr James Bell Dr Nigel Borley

Dr Steve Brincksman Ms Emma Crawshaw; Laura Day

Ms Annette Dale-Perera Mr Mark Dunn

Ms Stacey Hemmings Mr Salvo Larosa

Dr Luke Mitcheson Mr. Monty Moncrieff

Mr David MacKintosh Prof David Nutt

Dr John Ramsey Dr John Roche

Prof Fabrizio Schifano Mr David Stuart

Dr Ann Sullivan Dr Tim Williams

Dr Christopher Whiteley Dr Adam Winstock

Dr David Wood Dr Dan Wood

Other contributors: Dr Marta Buffito; Lindsey Hines; Josh Hulbert

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NEPTUNE II expert groupNEPTUNE II expert groupMembers Observers

Public Health England•Pete Burnkinshaw

Department of Health•John McCracken; •Mark Prunty

Home Office•Melanie Roberts

Owen.bowdenjones@nhs.net

Clubdrugclinic.cnwl@nhs.net

www.clubdrugclinic.com

@ClubDrugClinic

www.neptune-clinical-guidance.co.uk