Substance Misuse Treatment Framework (SMTF) Prevention and Education of

Volatile Substance Abuse (VSA)

ISBN 978 0 7504 6217 4

© Crown copyright 2011

WAG10-12331

F8581011

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Contents

Page

Overview

1. Thepurposeofthisdocument 4

2. AboutVolatileSubstanceAbuse 5

3. InterventionswithVolatileSubstancemisusers 6

3.1 Assessment 7 3.2Immediateinterventions 8 3.3Tacklingchronicmisuse 9 3.4Harmminimisation 10 3.5YouthServicesandcommunity-basedactivities 10

4. Prevention 12

4.1 SchoolsandColleges 12 4.2YouthServices 14 4.3.ThePolice 15 4.4Othergroups 15 4.5ParentsandCarers 15 4.6Retailers,TradingStandardsOfficers,andIndustry 15

5. Training 17

6. Actions 18

6.1 Planning,commissioninganddevelopingservices 18 6.2Preventionandearlyintervention 18 6.3Assessmentandinterventions 18 6.4.Stafftraining 19 6.5Controllingsupply 19 6.6Monitoring,researchandevaluation 19

7. Summaryofsomekeyactionsfordifferentstakeholders 20

AnnexASourcesofinformation 22

AnnexBAboutVSA 25

AnnexCPracticeExample-VSAprevention&awarenessactivitiesinYnysMôn 38

AnnexDPracticeExample-RhonddaCynonTaffCBC-TradingStandards 40

AnnexEPracticeExample-CarmarthenshireSubstanceMisuseActionTeam 41

AnnexFAbbreviationsandothertermsusedinthisdocument 42

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TheWorking Together To Reduce Harm Substance Misuse Strategy for Wales2008-2018,whichwaspublishedinOctober2008,includesreferencestoVSA:

• ‘Wewantchildrenandyoungpeopletoacquiretheknowledge,skillsandunderstandingtheyneedtomakeinformedchoiceswhentheyencounterillegaldrugsandlegalsubstancessuchasalcohol,tobacco,medicinesandvolatilesubstances’(page24,paragraph12).

• ‘Volatilesubstanceabuse(VSA)remainsaconcernasitstillcausesmoredeathsamongyoungpeopleaged10-16thanClassAandotherillegaldrugs’(page39,paragraph33).

• ‘RaisingawarenessofthehazardsofvolatilesubstancesiscateredforatbothprimaryandsecondaryschoollevelwithintheAllWalesSchoolLiaisonCoreProgramme(AWSLCP).However,itisrecognisedthatweneedtoaddresstheavailabilityandaccessibilityofvolatilesubstances’(page39,paragraph34).

• ‘Moreneedstobedonetoreducetheavailabilityandaccessibilityofvolatilesubstances.WewillidentifylocalgoodpracticeinengagingcommunitiesinaddressingVSAandenforcementactionbeingtakenwithretailerslinkedtoVSAincidents’(page49,paragraph4).

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Overview

VolatileSubstanceAbuse(VSA)isadangerousbutneglectedformofsubstancemisuse.Volatilesubstancesaredeliberatelymisusedbysomeyoungpeopletoachieveintoxicationand(perhapsincreasingly)byadults.Mostmisuseisshort-term;butsomechronicordependentmisuseoccurs.VSAispotentiallylife-threatening;therehavebeenalmost100deathsinWalessince1971.

ThismoduleoftheSubstanceMisuseTreatmentFrameworkforWales(SMTF),whichunderpinstheWorking Together to Reduce Harm Substance Misuse Strategy for Wales 2008-2018,seekstoimprovetheresponsetoVSAinWalesby:settingoutthefactsaboutVSA;describingtheissuesrelatedtoit;recommendingactionstoaddressit.Somekeyissuesandassociatedactionsarelistedbelow:

• VSA-relateddeathsinWalesareproportionatelyhigherthaninEngland(thoughlowerthaninScotlandandNorthernIreland).SurveyevidenceontheprevalenceofVSAislacking.Improvementsinevidencebaseonprevalenceareurgentlyrequired.AnongoingassessmentofprevalenceofVSAshouldbeestablishedtobenchmarklevelsofuseandenableprogresstobemeasured.

• CurrentandpreviousVSAshouldbeincludedinthecomprehensiveassessmentandrecordedontheclientsfileusingtheWales Integrated In-depth Substance Misuse Assessment Tool (WIISMAT)andsimilarassessmenttools.InterventionsshouldbeprovidedandtheseshouldbemonitoredandevaluatedforVSA-relatedoutcomeswhichwillprovidemoreinformationoneffectiveinterventions.

• ChronicVSAislinkedwithawiderangeofotherproblemsanddifficulties;andresourcesforaddressingtheseissuesarelimited.InterventionsfollowingdisclosureofVSAshouldbeintegratedwithotherinterventionsasappropriate.

• Volatilesubstancesare,formanychildrenandyoungpeople,thefirstmisusedsubstance.Earlyandsustainedpreventionactivities,includingeducationinschool,shouldtakeplace.

• Volatilesubstancesarereadilyavailableanditisessentialthatparentsandcarersareawareoftherisksofthemisuseofeverydayproducts.RetailersshouldbeawareofVSAandmeettheirlegalresponsibilities;TradingStandardOfficerscanhelpretailerstodothis.

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1. Thepurposeofthisdocument

Thisgoodpracticeguidancemodulehasbeendevelopedtoassistplanners,commissionersandserviceproviderstomeetthelocally-assessedneedsofthosemisusingvolatilesubstances(andthoseatriskofdoingso),andothersaffectedbythisissue.Itgivesinformationaboutvolatilesubstancesandadviceondevelopingarangeofserviceprovisionbyawideaudienceofprofessionalsandothers.

Thismoduletakesaccountofotherrelevantpolicyandguidance,suchas:

• Circular17/02,Substance Misuse: Children and Young People.

• NationalTreatmentAgency(NTA)Guidanceonyoungpeople’streatment.

• AdvisoryCouncilontheMisuseofDrugs(ACMD)ReportonVSA.

Italsotakesaccountofevidencefromresearch,evaluationandpractitionerexperience.

Thismoduleincludesreferenceto,andshouldbeconsideredalongside,otherrelevantWelshAssemblyGovernmentdocuments,including:

• WorkingTogethertoReduceHarmtheSubstanceMisuseStrategyforWales2008-2018.

• SubstanceMisuseTreatmentFramework:GuidanceonGoodPracticefortheprovisionofservicesforChildrenandYoungerPeoplewhoUseorMisuseSubstancesinWales.

• SubstanceMisuseTreatmentFramework:CarersandFamiliesofSubstanceMisusers:AFrameworkfortheProvisionofSupportandInvolvement.

• SubstanceMisuseTreatmentFramework:GuidanceforCommunitySafetyPartnershipstoCommissionSubstanceMisuseServices.

ThismodulehasbeenwrittenbyRichardIvesofeducari(richard@educari.com)withthesupportofanExpertStakeholderGroup:

• PaulMee(Chair),ServiceDirector,RhonddaCynonTaffPublicHealthandProtection.

• SueRogers,Director,BritishAerosolManufacturers’Association.

• JohnRamsey,StGeorge’s,UniversityofLondon.

• StephenReam,Director,Re-Solv.

• BrandonCook,TradingStandardsInstitute.

• RussellColley,Retailer,CantonCardiff.

• HelenWynJones,SubstanceMisuseCo-ordinator,IsleofAngleseyCSP.

• PhilGuy,WelshAssemblyGovernment.

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2. AboutVolatileSubstanceAbuse(VSA)

VSAisaneasily-overlookedformofsubstancemisuse.Thesubstancesaremostlycontainedineverydayconsumerproductsandthereforeitisnotillegaltopossessthem.Whileconsumerproductscanbeaccidentallymisusedinavarietyofways,VSAinvolvesdeliberatemisuse.Misuseoftheseproductstoachieveintoxicationismostlynotapublicactivity.

Yet,despitereceivinglittleattention,VSAisaseriousproblem.SomepeopledieasaresultofVSmisuse.ThereisevidencethatearlyonsetofVSAispredictiveofproblemsinlaterlife-includingdrugsproblems.MoredetailsaboutVSAareatAnnexB.

VSAisalsoaneglectedproblem.VSmisuserstendto‘fallthroughthenet’ofservices.Assessmentsofsubstancemisusedonotalwaysincludeanassessmentofvolatilesubstancemisuse.Professionalsmaybelessawareoftheissue,andparentsandcarersmaybeignorantofthepotentialformisuseofproductsthattheyuseeveryday.

VSAneedsaddressingindifferentways:

• Controllingsupply:forexample,retailerswillneedtobeinformedoftheirlegalresponsibilitiesinrelationtosalesofsuchproducts.

• VSAintheworkplace:workplacemanagershaveadutyofcareandneedtobevigilantaboutproductswithmisusepotential.

• Reducing‘demand’forvolatilesubstances:allchildrenandyoungpeoplewillneedinformationaboutthedangersofthesesubstancesifusedinappropriately,andbehelpedtodevelopappropriateattitudesandtheskillstheyneedforlivingsafelyandhealthilyinasocietywhereintoxicatingsubstancesarereadilyavailable.

• VSAawarenessandactionsbyadultdrugsworkersandbydrugsworkerswithyoungpeople.

• VSAawarenessandactionsbyworkerswithvulnerablepeople,suchasthoseinmentalhealthservicesandthoseworkingwithhomelesspeople.

• VSAawarenessandactionsbyworkerswithyoungpeople(particularlythosewhomaybemorevulnerable,suchaslookedafterchildren).

• VSAawarenessandactionsbyparentsandcarers;informationthatwillhelpthemtorecogniseVSAand,ifnecessary,todealwiththeirchild’smisuseandencouragethemtoaddresstheissueproactively.

• SupportforeducatorstoenablethemtoteacheffectivelyaboutVSA.

• Somechildrenandyoungpeoplewhoaremisusingsubstanceswillneedexperthelp.

ThisisnotanexhaustivelistandotheractionswillemergeasnewneedsappearandaspractitionersbecomemoreeffectiveindealingwithVSA.

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3. InterventionswithVolatileSubstanceMisusers

ThreedifferenttypesofyoungVSmisusersrequiredifferentinterventionapproaches:

1. Mostyoungpeoplewhomisusevolatilesubstancesareexperimentalusersanddonotcontinuetheirmisuse;theywillnotrequirespecialistsubstancemisuseinterventions-oranyinterventionsatall;itmaybecounterproductive,becauseitcouldentrenchanactivitythatwastransient.Forthem,interventionmaysimplyconsistofanexplanationoftherisks,perhapsincreasedsupervision,andtheopportunitytoparticipateinmoreconstructiveactivities.Parentsmayneedreassuranceandsupport.

2. Sometimes,agroupofyoungpeoplewillcontinuetomisusevolatilesubstancesbeyondtheexperimentalstage.Together,theymaymisuseinpublicorsemipublicspaces,andcauseconcerntolocalresidents.Thismaybebecauseoftheiruninhibited,orevenbizarre,behaviourwhileintoxicated,orbecauseofpublicdisorderandantisocialbehaviour.Interventionsmightincludecommunitybasedinterventionsinvolvingarangeofagencies,perhapsincludingthepolice.

3. Asmallnumberofyoungmisuserswillcontinuetheirmisuselongaftertheirfriends,whojoinedtheminexperimentationandbeyond,havelongsincestoppedmisusingvolatilesubstances.TheymaybecomepsychologicallydependentordevelopotherseriousproblemswithVSAwhichwillbealliedwithotherdifficultiesintheirlives.Theymaybecomestigmatisedandisolated.Theymayneedspecialisthelp-fromyouthservicesand/orfromdedicatedyoungpeople’sdrugandalcoholservices.

Servicesforyoungpeopleshouldbespecificallydesignedfortheirneedsandbeabletoeffectivelyaddresskeyissuessuchasconfidentialityandconsent.Genericyouthservicesshouldtakethelead,withsupportfromspecialistsubstanceabuseagencies.Mentalhealthserviceswillhaveanimportantrole,forexample,inthetreatmentofpsychiatricco-morbidity.ThoseworkingwithlookedafterchildrenshouldbeawarethatVSAmaybemorelikelyinthisvulnerablegroup.

TherearenotreatmentorinterventionservicesdesignedspecificallyandexclusivelyforvolatilesubstancemisusersinWalesandtheyarenotappropriate,astheissueshouldbedealtwithbyexistingdrugandalcoholservicesandbyservicesforyoungpeople.Currently,VSAreferralstosubstancemisuseserviceswouldreceiveinterventionappropriatetotheircircumstances.

Thereneedstobegreaterawarenessoftheissueamongadultservices(inparticular,mentalhealthservicesandservicesforhomelesspeople)andmechanismsforidentificationandfullerassessmentarerequired.However,littleisknownabouthowbesttohelpadultVSmisusers.Someusersofillegaldrugswillalsomisusevolatilesubstancesinapatternofpoly-druguse.Otherusersofillegaldrugsmayturntovolatilesubstanceswhentheirdrugofchoiceisnotavailable,ortheycannotaffordit.ItisnotclearwhethertheseadultVSmisusersaremainlythosewhomisusedvolatilesubstanceswhentheywereyoungandarereturningtoasubstancewithwhichtheyarefamiliar,orwhethertheyare‘newrecruits’tothe

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practice.Ifthelatter,theremaybegreaterrisksbecauseoftheirinexperiencewiththesubstances.

3.1 AssessmentVSAisnotalwaysidentifiedininitialassessmentsandmaycontinueunrecognisedinpeopleintreatment.ImprovingtheassessmentofVSAisanessentialprerequisitetoimprovingservicesforVSA.Datacollectedwillprovideinformationontheextentandtypesofmisuseandhelptoraisetheprofileoftheissue.

TheNationalTreatmentAgency(NTA)callsfor:‘…betterassessmentofthemostseverelyaffectedyoungpeople,deliveryofmoresystematic,practicalinterventionsandamuchgreatersynergybetweenmentalhealthservicesandthoseworkingcurrentlyinthesubstancemisusefield.’(NTA2005).

WhiletheNTA’sdocumentontheassessmentofyoungpeopledoesnotspecificallymentionVSA,itrecommendsthat:

‘Understandingthedevelopmentofsubstancemisuseisanimportantpartofgainingapictureofhowsubstanceuseispartofayoungperson’slife.Thereisaneedtoappreciate:

• Typesofsubstanceused.

• Ageoffirstuseofsubstances.

• Currentandpastsubstanceuse.

• Frequencyofsubstanceuse.

• Howlongspecificsubstanceshavebeenused.

• Minimum,maximumandusualquantitiestakenatatime.

• Methodofuseorrouteofadministration.

• Substancestakenincombination.

• Patternsofsubstancemisuse.

• Historyofbingeing,memorylossandoverdose.

• Historyofaccidentsandinjuriesrelatedtosubstancemisuse.

• Previousattemptstochangesubstancemisusingbehaviour.

Thisinformationwillgiveaperspectiveonchangesinsubstancemisuseandpossibledifficultiestheyoungpersonmayhaveinchangingsubstancemisusingbehaviour.’(Britton2007,p12)

Foryoungpeoplewhocomeintocontactwithhelpingservicesandwhoundergoanassessment,VSAshouldbepickedup.However,volatilesubstancemisuseisnotalwaysspecificallyincludedinassessmentprotocolsanddocumentation.

Foradultdrugusersincontactwithservices(especiallydrugservices,butalsootherservices,suchasmentalhealthservices),identificationisakeyissue.ToolittleisdoneinassessmentandinongoinginterventionstoidentifyVSmisusersorthosewhomightbelikelytomisusevolatilesubstancesundercertaincircumstances.

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KeyActions

• WalesIntegratedIn-depthSubstanceMisuseAssessmentTool(WIISMAT)ortheequivalentagencytool,shouldincludeanassessmentofpastandcurrentVSA.Thequestioningshouldbesufficientlydetailedtoidentitytherangeofproductsthatmayhavebeenmisused.

• Drugservicesshouldensurethatinitialassessmentsincludeaskingaboutpastandcurrentuseofallsubstances.

• Otherservices(suchasmentalhealthserviceandservicesforhomelesspeople)shouldhavewaysofidentifyingVSA.

• WherecurrentVSAisidentified,itshouldbeconsideredintheriskassessment.

• InitialstafftrainingshouldincludeinformationaboutVSAandtocountertheideathatvolatilesubstancesareonlymisusedbyyoungpeople.

• Ongoingtrainingandsupervisionshouldincludeassistanceinworkingwithvolatilesubstancemisusingclients.

3.2 Immediateinterventions

Actionwhenavolatilesubstancemisuserisintoxicated

Takeacalmandfirmapproach.Exertionorraisedemotionmayincreaseadrenalinetodangerouslevelsfortheirover-sensitizedheart.Keepcalm-andkeepthepersoncalm.Oncetheystopinhalingtheproduct,theywill‘soberup’inafewminutes(unless,ofcourse,alcoholorotherdrugshavealsobeentaken).Sotrytoremovetheproductifpossible;don’tchaseaVSmisuser,orfightwiththem.Understandthatitisn’tpossibletohaveaseriousconversationwithanintoxicatedperson.Medicalhelpmightbeneeded-keepmonitoringthesituation,andifthepersoncollapses,placeintherecoverypositionandcallanambulance.Alatercheck-upmayidentifyparticularhealthproblems.

Williamset al2007suggestthefollowingmedicalinterventions:

‘Mostacutelyintoxicatedinhalantabusersdonotseekmedicalattention,andonlywhenintoxicationislife-threateningorhasledtoseriousinjurywillanabuserpresenttotheemergencydepartment.Acutemedicalmanagementofinhalantabusestartswith…assess[ing]andstabiliz[ing]thepatientandaddress[ing]anyspecificacuteinjuryortoxicity….Myocardialsensitizationbyinhalantsnecessitatesacalmandsupportiveenvironment….Nomedicationsreverseacuteinhalantintoxicationorhavebeenfoundtobehelpfulwithdependenceorwithdrawalsymptoms.’(Williams,et al2007)

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KeyActions

• Allprofessionalsworkingwithyoungpeople,andadultsubstancemisuseserviceprovidersshouldbeawareoftheindicatorsofVSA.

• Allshouldknowhowtocalm,notexcite,anintoxicatedVSmisuser.

• Considerationshouldbegiventotheprovisionofdefibrillators(plustrainingforstaffintheiruse)atlocationswherelargenumberofpotentiallyvulnerableyoungpeoplemeet,aswellasinemergencyservicevehicles.

3.3 TacklingchronicmisuseThepersistentmisuseofvolatilesubstancesiscomplexbehaviourthatisassociatedwithlowself-esteem,familyproblems,isolationandpsychologicaldifficulties.Alargeproportionofthosewhomisusevolatilesubstancesalsomisuseotherdrugs.Supportservicesforyoungmisusersshouldnotbefocusednarrowlyonvolatilesubstances,butshouldbeabletodealwithVSAinthecontextofarangeofproblematicbehaviours.AsproblematicbehavioursareoftenmoreimportantfortheVSmisuserthantheproblemsassociatedwiththeirmisuseofvolatilesubstances,theseproblemsmayneedattentionfirst.Aspartofaninterventionprogramme,sleepandrestfulnessandahealthydietmayaidrecovery.

NodefinedwithdrawalsyndromehasbeenidentifiedwhensomeonestopsVSmisuse(althoughitmaytakeaconsiderabletimefortheresidueofsolventssuchastoluenefromchronicpetrolabusetobeeliminatedfromthebody),sospecialdetoxificationregimesarenotnecessaryformostVSA.Althoughthelipid-solublechemicalscanbedetectedinbodytissuessomeweeksaftermisusehasstopped,theydonothavepsychoactiveeffects.However,somepeoplebecomedependentonGammahydroxybutrate(GBL)andmayexperienceseverewithdrawalsymptomsrequiringmedicationtoameliorate.

Interventionmayneedtocontinueforsometimetoaddressdeep-seatedproblems;aftertheconclusionoftheintervention,follow-upiscrucial.Relapseiscommon,aswithotherdrugs;itshouldberegardednotas‘failure’,butasalearningopportunity.Aftercare,long-termrehabilitation,socialreinsertion,relapsemanagement,andinformalcontactareallimportant.Groupactivitiesandsupportmayhelpex-VSmisuserstostayabstinent.

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KeyActions

• DrugsservicesforyoungpeopleshouldbeabletodealwithVSAinthecontextofarangeofproblematicbehaviours.

• AdultdrugservicesshouldbeawareofthepossibilityofVSAaspartofaconstellationofdrugusebytheirclients.

• AdultdrugservicesthattreatyoungpeopleshouldtackleVSAissuesappropriately.

• YouthservicesshouldbeawareofthepossibilityofchronicVSAaspartofaspectrumofproblematicbehaviour.

• Adultservices,suchasmentalhealthservicesandservicesforhomelesspeople,shouldbeawareofthepossibilityofchronicVSAaspartofaspectrumofproblematicbehaviour.

3.4 HarmminimisationHarmminimisationadviceshouldnotberoutinelygiven;thereisnoapprovedadviceasmostVSAhasunpredictabledangers.However,thefireorexplosionhazard(particularlyforbutaneandpetrolinconfinedspaces)shouldbeexplained.

Somemisusersarenotabletoquitthehabitintheshortterm.Theymaybenefitfromcarefulindividualguidanceonreducingtherisks,includingavoidingcertainparticularlyharmfulproducts(e.g.petrol),awarenessoftherisksoffireandexplosion,notusinglargeplasticbags,andnotsprayinggasesdirectlyintothemouth.Aparticularpieceofadviceregardingpoppersisnottodrinkthem,asthiscanbefatal.

3.5 YouthServicesandcommunity-basedactivitiesTheyouthserviceandcommunity-basedservicesarewell-placedtomakeearlyinterventionstotackleproblemsthat-withoutintervention-maybecomeworseandcostsocietyalotmoretodealwithwhentheyhavetobetackledlater.Buttherearesomedifficulties;firstly,ofidentification-howtopickoutthevulnerable.Secondly,ofstigmatisation:ariskofearlyinterventionisthatayoungpersonwillbeundulystigmatisedbybeingfocusedon.Thirdly,offundingandprioritisation:youthservicesarerequiredtoaddressamultitudeofissuesandproblems;VSAisonlyoneofmany.Moneyisnotavailabletoaddressallthepressingissuesfacingworkerswithyoungpeople.

ThesedifficultiescanbeaddressedbytacklingpotentialVSAissuesaspartofaconstellationofvulnerability.This,anyway,isapreferableapproach.Itimpliesbroadbasedandinclusivepreventionactivitiesthataddressawidespectrumofneed.

Youthandcommunityservicesalsohaveanimportantroleinhelpingyoungpeopletoaccessservices,andinmakingappropriatereferralswhereneeded.

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KeyActions

• Broad-basedandinclusivepreventionactivitiesshouldbeimplementedbyawiderangeofagenciesincontactwithyoungpeople.

• YouthservicesshouldensurethattheyknowwheretoreferyoungpeoplewithchronicVS-relatedproblems.

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4. Prevention

‘Thefundamentalandconsistentmessagewhichweadvocateforallhealthstatementsonthistopicmadetoyoungpeopleasindividualsortowidertargetaudiencesistheunambiguous-“VSAistoodangerous,don’tdoit”.Giventhemortalityriskswhichattachtothisformofdrugmisusethismessageisaccurateanditshouldberepeatedsquarelyandwithoutprovisoorconfusion.Wearenothereadvocatingscaretactics,butthesimple,supportable,repeatedstatementoftheplaintruth.AbusingvolatilesubstancesislikeplayingRussianroulette.’(ACMD1995,p6)

Preventionisanimportantbutdifficulttask.Aswithothersubstances,therearetwosidestoprevention-controllingthesupplyandreducingthedemand;butunlikeillegaldrugs,thesesubstancesarereadilyavailableconsumerproducts.

Primarypreventionfocusesonchildrenandyoungpeople;themainlocationsarethereforeschools,collegesandyouthservices.Parentsandcarersarealsoanimportanttargetgroup.Emergingevidenceofanoldergroupofmisusersmayindicatetheneedforpreventionactivitiesaimedatadults.

4.1 SchoolsandColleges

‘…Schoolisakeyarenawherethebehaviourofyoungpeoplecanbeinformedandinfluenced.Schoolsalsoprovideastructuredenvironmentwhereindividualsatriskofexclusionbecauseoftheirownorparentalsubstancemisusecanbeidentifiedandhelped.

Studiesshowthateffectiveeducationprogrammesareskills-based,useinteractiveteachingstylestomotivateparticipants,includenormativetechniqueswhichshowthatdruguseamongpeersisnotaswidespreadasyoungpeoplethink,andinvolveothercomponentssuchasworkwithparentsandfamilies,thewidercommunity,healthprofessionalsandthemedia.’Working Together to Reduce Harm: The Substance Misuse Strategy for Wales 2008-2018‘(page25,paragraph12-13)

GuidanceforschoolsonsubstancemisuseeducationisgiveninCircular17/02,Substance Misuse: Children and Young People.

Schoolsandcollegesaresitesforuniversalprevention,addressingthewholepopulation.SubstancemisuseissuesaretackledwithintheschoolcurriculuminScienceandinpersonalandsocialeducation(PSE).Thepersonalandsocialeducationframeworkfor7to19-year-oldsinWalessaysthatchildrenatKeyStage2shouldbegivenopportunitiestounderstand:‘theharmfuleffects,bothtothemselvesandothers,oftobacco,alcoholandotherlegalandillegalsubstances’;atKeyStage3:‘theeffectsofandrisksfromtheuseofarangeoflegalandillegalsubstancesandthelawsgoverningtheiruse,’andatKeyStage4:‘thepersonal,socialandlegalconsequencesoftheuseoflegalandillegalsubstances’.(Personalandsocialeducationframeworkfor7to19-year-oldsinWales2008).

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‘Substanceuseandmisuse’isaddressedasoneoftheseventopicsintheWelshNetworkofHealthySchoolSchemes(WNHSS).Thedocument,Indicators for the Welsh Network of Healthy School Schemes National Quality Award(WNHSS,2010)statesthatschemesofworkshould:‘identifyarangeofaspectsofsubstancesandreflectpolicy.Thisincludestobacco,alcohol,solventsandotherlegalandillegalsubstances,medicinesandhouseholdproducts’.

Whensubstancemisuseisaddressed,volatilesubstancesshouldalsobeincluded,butnotover-emphasised-thereisalwaystheriskofraisinginterestwherenoneexisted.Apriorneedsassessmentthattakesaccountofthelevelsofunderstandingofthepupilsaswellastheirsubstancemisuseexperiencewillhelpwithschoolprogrammeplanning.SinceVSAis,alongwithtobaccoandalcohol,oneofthefirstsubstancestriedbyyoungpeople,educationaboutVSAneedstostartearlycertainlyinprimaryschools.However,itshouldnotbeaddressedinisolationfromothersubstancesorotherriskybehaviours.

Schools’substancemisusepoliciesshouldincludepolicyonteachingaboutVSAandhavereferencetoVSAinconnectionwithhandlingsubstance-relatedincidents-includinginformationaboutthedangersofover-exertionwhenintoxicatedwithsomevolatilesubstances.

‘GoodPracticeInSubstanceMisuseEducation

1. EffectiveSubstanceMisuseEducationshouldstartearlyandbeageappropriate.

2. Useshouldbemadeofbroadlifeskillapproachesaspartofaplannedpersonalandsocialeducationprogramme.

3. Substancemisuseeducationaimstoempowerchildrenandyoungpeopletomakeresponsible,wellinformeddecisionsaboutsubstances.

4. LearningoutcomesforsubstancemisuseeducationshouldincludethekeycomponentsofthePSEFramework.Theseareskilldevelopment,knowledgeandunderstandingandattitudesandvalues.

5. Substancemisuseeducationshouldbenon-judgmental,withoutstereotypingorstigmatisation.

6. Childrenandyoungpeopleneedtodeveloptherelevantskillswithinasafesupportivelearningenvironment.

7. Substancemisuseeducationhasbeenshowntobemoreeffectivewhenitispartofawholeorganisationapproach.

8. Teachersandyouthworkersarebestplacedtoleadandcoordinatethedeliveryofeffectiveeducationalprogrammesthatcanbeenhancedbytheuseofandsupportfromexternalagencies.

(Circular17/02SubstanceMisuse:ChildrenandYoungPeople).

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EducationaboutVSAshouldincludeinformation,aswellaswarnings,abouttherisksofthisuniquelydangerousformofsubstancemisuse.Butevidenceontheeffectivenessofsubstancemisuseeducationdemonstratesthatinformationisnotenoughandthatyoungpeopleneedtodevelopskillsforlivinginacomplexsocietywhereintoxicatingsubstancesarereadilyavailable.Theyalsoneedtobehelpedtoexploretheirattitudestosubstancesandformulateapersonalstance.Researchalsopointstotheimportanceofso-called‘normativeeducation’-counteringthemyththat‘everyoneisdoingit’.

TeachersandotherschoolstaffwillneedtrainingtoenablethemtoeffectivelyaddressVSAwiththeirpupils.AstheSubstance Misuse Treatment Framework Guidance on Good Practice for the provision of services for Children and Younger People who Use or Misuse Substances in Walespointsout:

‘Trainingshouldbeavailableforallrelevantprofessionals,andadvancedtrainingisrequiredbydesignatedstaffwhohaveresponsibilityforeducatingyoungpeoplewhoattendtheirinstitutions/organisationsaboutsubstancesandsubstancemisuse’(page12).

InnovativeandcreativeapproachestoeducatingchildrenandyoungpeopleaboutVSAshouldbeencouraged.Theseincludepeer-ledmethodsandcarefuluseofexternalvisitors(inthecontextofaplannedsubstancemisusecurriculum)whohaveexpertiseinthisarea.

CommunitySafetyPartnerships(CSPs)aretoconsiderVSApreventionandawarenesswithintheiroverallsubstancemisuseprogrammes.Inschools,thesewouldbeinadditionto,andsupplement,theworkoftheAllWalesSchoolLiaisonCoreProgramme(AWSLCP).TheyshouldalsoconsideraddressinghowparentsareinformedaboutVSA,andhelpthemtoaddresstheseissueswiththeirchildren.Considerationshouldalsobegiventoimprovingretailers’awarenessof,andcompliancewith,thelawonsalesofvolatilesubstances.

Aspartoftheirsubstancemisuseprovision,CSPsshouldconsiderjointplanningandcommissioninginco-operationwithotherCSPs.Thiswillenablescaled-upservicesacrossawidegeographicalareawhichwilldevelopmoreexperienceintacklingVSA,andhavecapacitytorespondtoanyepisodicVSA.

4.2 YouthServicesYouthservicesreachyoungpeopleintheirownenvironment,ontheirownterms.Theservicesengagewithsomeoftheyoungpeoplethatschoolsfindhardtoreach,becauseofdisaffectionortruanting.TheyaremorelikelytobeincontactwithyoungpeopleNotinEmployment,EducationorTraining(NEETs).Suchindividualsarelikelytobemoreatriskofsubstancemisuse,soyouthserviceshaveanimportantroleinpreventionworkwiththem.

Thecontributionofyouthserviceswillbelessstructuredthansubstancemisuseeducationintheschoolcontext.Itwillbuildontheexistingknowledgeandinterestsofyoungpeopleanditwillembedsubstancemisuseeducation(includingVSA)withintherealitiesofyoungpeople’slives.

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YouthservicestaffwillneedtrainingtoraisetheirawarenessaboutVSAalongwithsupportandresourcestohelpthemtoaddressthetopicwithchildrenandyoungpeople.

4.3 ThePoliceThereisextensiveschoolpoliceliaisonthroughtheAllWalesSchoolLiaisonCoreProgrammewhichisundertakenbySchoolCommunityPoliceOfficers,workingwithPSEteachersinprimaryandsecondaryschoolsinalmostallschoolsinWales.TheProgrammeconsistsof3mainstrands,withfivelessonsineachstrand;thestrandsare:‘SubstanceEducation’;‘SocialBehaviourandCommunity’;and‘PersonalSafety’.VSAisincludedinthefirststrandinthesupplementarymenu:schoolscanchoosetheVSAlessoniftheywish.OfficersinvolvedintheselessonshavebeentrainedaboutVSA.SchoolCommunityPoliceOfficers(SCPO)alsoundertakesupportiveschoolpolicing.

InJuly2005anAllWalesPolicecampaigntoaddressVSAamongyoungpeoplewaslaunched.Followingthelaunch,thenetworkofSchoolCommunityPoliceOfficerswasusedtorapidlycirculatecampaignmaterialspriortothesummerholidays.

4.4 OthergroupsManyotherprofessionalgroups-socialworkers,thoseworkingwithlookedafterchildren,probationstaff,andothersinthecriminaljusticesystem,forexample-needtohavegreaterawarenessofVSA.

Employershaveadutyofcaretotheiremployeestoensureasafeandhealthyworkplace.Thisincludesreducingtheriskofvolatilesubstancesbeingdeliberatelymisusedtoachieveintoxication.GBLisusedinarangeofcommercialapplicationsandhealthandsafetyofficersshouldbeawareoftheproductsinvolvedtoensureanymisusecanbeswiftlyaddressed.Forexample,somecoffeebarsusenitrousoxideinwhippedcreamdispensers.Anaestheticagentsareaccessibleinsomemedicalandveterinaryworkplacesandtheiruserequirescarefulcontrol.

4.5 ParentsandCarersParentsandcarers(includingfostercarers)arecrucialpartnersinprevention.TohelpthemfulfiltheirparentalresponsibilitiesinrelationtoVSAtheyneeddispassionateandnon-alarmistinformationaboutthesubject,aswellasencouragementandadviceonhowtospeakwiththeirchildrenaboutit.Parentsshouldbeparticularlyvigilantiftheynoticetheirchildrenusingunusualamountsofproductssuchasaerosoldeodorantsorbutanecigarettelighterrefills.Schoolshaveacrucialrolethroughtheirregularcontactwithparentsandcarers.

4.6 Retailers,TradingStandardsOfficers,andindustry

‘…itisrecognisedthatweneedtoaddresstheavailabilityandaccessibilityofvolatilesubstances.’(Working Together to Reduce Harm: The Substance Misuse Strategy for Wales 2008-2018p39)

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OneuniquefeatureofVSAistheneedtoworkwithretailerstocontrolthesupplyoftheseproductstomisusers.Unlikealcohol,theseproducts(withtheexceptionofbutanecigarettelighterrefills)canlegallybesoldtounder-18-year-olds,exceptwheretheretailerhascausetobelievethattheywillbeusedtoachieveintoxication.Thisplacesquiteaburdenontheretailer,whogenerallyhasnoexperienceoftheissue,orofworkingwithyoungpeople.Nevertheless,mostretailerswanttosupportthelawandarewillingtobeeducatedaboutthetopic.ManyproductsintheUKwhichcanbedeliberatelymisusedtoachieveintoxicationcarrythe‘SACKI’warning:‘SolventAbuseCanKillInstantly’.Majorretailersroutinelyincludeprintedwarningsatthecheckoutthattheyreservetherightnottosellintoxicatingproductstounder-18s,andsmallerretailersaregenerallywillingtodisplaysuchwarnings.Controllingsalesinmoreinformalortemporarysettings,suchasmarkets,ismoredifficult,andthegrowthofself-servicetillsinsupermarketsisanincreasingconcern.

SomeTradingStandardsDepartmentsandindividualTradingStandardsOfficers(TSO)havetakenonthetaskofinformingretailersabouttheirresponsibilitiesunderthelawandtheirobligationstotheircommunities.Someareashavealsoundertakentestpurchasingtocheckcompliancewiththelaw.Whiletherehavebeenfewprosecutions,‘mysteryshopper’actionsandsubsequentwarningstooffendingretailershavehelpedtoimprovecompliance.AnnexDprovidesanexampleofgoodpracticethathasbeenimplementedbyatradingstandardsdepartment.

PoppersandGBLaresometimesavailableforsalefromindividualsattendingclubs,pubsandmusicevents.Poppersareavailablefromso-called‘headshops’(shopssellingdrugsparaphernalia)wheretheyareoftensoldas‘roomodorisers’togetaroundtherestrictionsonsellingsubstancesforhumanconsumption.PoppersandGBLcanalsobepurchasedontheinternet.Partyshopownersshouldbeawarethatdisposablecylinderscontainingheliumsoldtofillballoonsmaybepurchasedasameansofcommittingsuicide.

Manufacturersandotherpartsoftheindustryproducingordistributingproductscapableofmisusetoachieveintoxicationhavearoletoplay.Thevoluntary‘SACKI’warningappearsonmostaerosols,includingimportedproducts.Useofthewarningislesscommononotherproducts.Someproducts(suchasacertaintypeoffireextinguisher)havebeenphasedout,andsomeproductshavehadthemisusableingredientremoved(sometimesbecauseofregulationssuchasthe1987MontrealProtocolonSubstancesthatDepletetheOzoneLayer).Unpalatableadditiveshavenotdemonstratedeffectiveness.Otherproductmodificationswhichhavebeeninvestigatedhavetechnicalorconsumerusabilitydrawbacks.

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5. Training

‘Thesubstancemisuseworkforceisverybroad-itincludesthoseworkingwithadults,childrenandyoungpeopleandthoseinspecialisedandmainstreamservicesineducation,treatmentandthejusticesystem.Volunteersalsoplayanimportantroleinthedeliveryofservices.Ensuringthatthisworkforceisadequatelyskilledandresourcedisessentialtoprovidingappropriate,safeandeffectivesubstancemisuseinterventions.’

(Working Together to Reduce Harm: The Substance Misuse Strategy for Wales 2008-2018p57)

Thebroadsubstancemisuseworkforce,aswellasschoolandyouthservicestaff,needstodeveloptheirskillsindealingwithVSA.Thekeyskillbeinggreaterawarenessoftheissue,astheAdvisoryCouncilontheMisuseofDrugspointedout:

‘Staffinservicessuchasprobation,…thepolice,socialworkinfieldworkanddaycaresettings,communitynursing,accidentandemergencyunits,generalpractitionersandpharmacistswillcomeacrossvolatilesubstancemisusersinavarietyofsettings.Theirbasictrainingshouldhaveequippedthemtodealwiththespecificprofessionalissueswhichledthemtoencounteramisuser.Despitethisbasictraining,thereisaneedforallthesedisciplinestounderstandthenatureandcomplexityofVSAtogetherwithitsassociatedhazards.Thesedisciplineswillneedtomastermanyofthespecificissuestogetherwithanunderstandingofhowtheserelatetotheirownparticularworkcontexts.’(ACMD)

Thus,theentirerelevantworkforceneedstobeawareofVSA(includingbeingabletorecognisesignsandsymptomsofmisuse),tounderstandtheissuesspecifictothisformofsubstancemisuse,andbeabletocontextualisetheirlearningtothedemandsoftheirworkcontext.Staffworkingwithlooked-afterchildrenandwiththoseleavingcareshouldbeawarethatsuchchildrenmaybeathigherriskofVSmisuse.Sinceadults,aswellasyoungpeople,misusevolatilesubstances,itisimportantthatadultservicesincontactwithvulnerablepeople(particularlymentalhealthservicesandthoseworkingwithhomelesspeople)areawareofVSA.

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6. Actions

6.1 Planning,commissioninganddevelopingservicesTheSubstance Misuse Treatment Framework Guidance for Community Safety Partnerships to Commission Substance Misuse Servicesrecommends:takingastrategicandsystematicapproachtocommissioningservices;promotingajointapproachbetweenagencieswithinCommunitySafetyPartnerships;andjointcommissioningplanningacrossCSPboundaries.

TheSubstance Misuse Treatment Framework ‘Guidance on Good Practice for the provision of services for children and, younger people who use or misuse substances in Walessuggestsincreaseduseofjointplanningtoprovideservicesforchildrenandyoungpeople.Itincludesahelpfuldiagramofthe‘planningpathway’,andpointstothevalueofpooledfundinginprovidingservicesforchildrenwithcomplexneeds.LocalSubstanceMisuseActionPlanshavetobedevelopedandimplemented,co-ordinatedbylocalauthorities,whoworkinpartnershipwithothermembersoftheCommunitySafetyPartnerships.

Inordertocommissionservicesmoreeffectively,moreneedstobeknownaboutthepatternsofVSAacrossWales.Thereisalsoaneedtocreateknowledgeabouttheimpactandeffectivenessofdifferentapproachestopreventionandinterventions.

CSPscontributetothesettingofsharedprioritiesandincommissioningsubstancemisuseservicesdrawonevidenceoflocalneeds,includingneedsidentifiedthroughtheChildrenandYoungPeople’sPartnership(CYPP)andotherlocalpartnerships.Indoingso,theCSPandCYPPshouldensurethattheirplansareinformedbytheneedsofyoungpeopleinrelationtoVSA.

CSPsshouldensurethatlocalauthorities(LAs)includeVSAintheirSinglePlans,andthatVSAbeconsideredinthedeliveryprogrammeswithinallschoolsintheirarea.

6.2 PreventionandearlyinterventionCSPsshouldencouragethatschool-basedsubstancemisuseeducationandpreventionincludesVSA,andthatyoungpeopleespeciallyatriskofVSmisusereceiveadditionalsupportandguidance.Schools,PupilReferralUnits(PRUs),youthservices,andother‘universal’provisioncanalsocontributetoearlyinterventionthrough‘lowlevel’actions.CSPsshouldmonitorlocalcircumstancestoidentifyareaswhichattimesmightrequireadditionalinputonVSA-forexample,someparksinthesummer.Parentsandcarersmustbeinvolvedandengagedinpreventionactivitiesandgiveninformationandsupporttoenablethemtohelptheirchildren.

6.3 AssessmentandinterventionsJoinedupservicesofferingappropriatereferralsandseamlesssupportarerequired.InparticularitisimportanttomanagetransitionsfromChildren’sServicestoAdultServices,andbetweendifferentareasofWales.

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TheWales Integrated In-depth Substance Misuse Assessment Tool (WIISMAT),ortheequivalentagencytool,shouldincludeanassessmentofpastandcurrentVSAmisuse.Thequestioningshouldbesufficientlydetailedtoidentitytherangeofproductsthatmayhavebeenmisused.Drugservicesshouldensurethatinitialassessmentsincludeaskingaboutpastandcurrentuseofallsubstances;wherecurrentVSAisidentified,itshouldbeconsideredintheriskassessment.TherearenosimpleurinescreeningtestsforVSAasthereareformostothermisuseddrugs(e.g.cannabis,amphetamine,cocaine,opiates).

Inanemergencyappropriatetreatmentmaybelife-saving.Itissensibletoencourageallyoungpeopletoacquireatleastabasicknowledgeoffirstaid.

6.4 StafftrainingInitialstafftrainingshouldincludeinformationaboutVSAandtocountertheideathatvolatilesubstancesareonlymisusedbyyoungpeople.Ongoingtrainingandsupervisionshouldincludeassistanceinworkingwithvolatilesubstancemisusingclients.TrainingistobemappedacrosstorelevantNationalOccupationalStandards(NOS).

6.5 ControllingsupplyItisnecessarytoworkwithretailersandtradebodiestocontrolthesupplyofpotentialsubstanceswhichcouldbemisused,whereappropriate.Particularconcernsareself-servicesupermarkettillsandlessformaltradinglocations,suchasmarkets.

6.6 Monitoring,researchandevaluationActionsonVSAshouldbeevidence-informed,collaborativeandachievable.Theyshouldbemonitored.Sourcesofdatainclude:

• theWalesNationalDatabaseforSubstanceMisuseincludescodesforalimitedrangeofvolatilesubstancesincluding‘solventsunspecified’,‘toluene(glue)’and‘butane’.Itisessentialthatdataontheprimaryuseofthesesubstancesiscorrectlyrecordedtoensureplannersareinformedoflocalneedswhenplanningserviceprovision.

• theHealthBehaviourofSchool-agedChildren(HBSC)Survey,agenerichealthstudywhichisconductedeveryfouryearsandcapturesVSAprevalencedata.

Websites

UKCharityfocusedwithVSA: www.re-solv.org

UKCharityfocusedonVSA: www.solveitonline.co.uk

DAN24/7solventslink: www.dan247.org.uk

USANationalInhalantsPreventionCoalition: www.inhalants.org

NIDA(USANationalInstituteonDrugAbuse): www.inhalants.drugabuse.gov

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7. Summaryofsomekeyactionsfordifferentstakeholders

Group Basic Actions Essential Actions Additional Actions

Community Safety Partnerships

take account of VSA:

1. encourage that it is in school programmes

2. address parents and carers about VSA in the context of other issues

use evidence of VSA:

1. to plan appropriate services

2. support TSOs and retailers in controlling supply

help to improve the evidence base

Service Commissioners

include VSA in commissioned work

use evidence of successful approaches to tackling VSA to commission services

help to improve the evidence base

Service Providers 1. be aware of VSA among clients

2. include VSA in staff training

identify VSA in assessments and use evidence informed interventions to address it

help to improve the evidence base through monitoring and evaluation

Schools 1. include VSA in drug education

2. include VSA in substance misuse incident management policy

1. include knowledge, skills and attitudes in education about VSA

2. inform parents and carers about VSA (in appropriate contexts)

1. train staff to teach about VSA and recognise possible signs and symptoms

2. operate effective whole-school well-being policies

Youth/Community Services

implement broad based and inclusive activities that address VSA in context

refer appropriately those with chronic VS-related problems

liaise with other local agencies to monitor trends and developments

Trading Standards Officers

include VSA in staff training

provide information to retailers about VSA

undertake test purchases, including less formal retail settings such as markets

Police include VSA in staff training

be aware of VSA in the community, and address issues appropriately

liaise with TSOs and retailers to address VSA-related sales issues

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Group Basic Actions Essential Actions Additional Actions

Health Services include VSA in staff training (particularly in mental health services)

staff understand the dangers of adrenaline treatment and the appropriate use of the defibrillator in VSA emergencies

support the provision of defibrillators in appropriate non health care settings and train staff in their use

Retailers 1. display warning notices on shelving and at point of sale

2. include VSA in staff training

co-operate with TSOs and the police in regulating VSA sales

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AnnexA

Sourcesofinformation

ReferencesandkeydocumentsAdvisoryCouncilontheMisuseofDrugs,1995Volatile Substance MisuseHomeOffice.

BrittonJ2007Assessing young people for substance misuseNTA.

DepartmentforChildren,Education,LifelongLearningandSkills2008Personal and social education framework for 7 to 19-year-olds in WalesWelshAssemblyGovernment.

DepartmentofHealth2005‘Out of Sight? ... not out of mind’ - Children, Young People and Volatile Substance Abuse (VSA)http://www.library.nhs.uk/ChildHealth/ViewResource.aspx?resID=98726(accessed1610-09).

EuropeanMonitoringCentreforDrugsandDrugAddictions(EMCDDA),2008GHB and its precursor GBL: an emerging trend case studyEMCDDA(www.emcdda.europa.eu/publications/thematic-papers/ghb)(accessed16-10-09).

Esmail,A.,Meyer,L.,Pottier,A.,andWright,S.1993‘Deathsfromvolatilesubstanceabuseinthoseunder18years:resultsfromanationalepidemiologicalstudy’Archives of Disease in Childhood,69,356-60.

Field-Smith,M.E.,Butland,B.K.,Ramsey,J.D.,andAnderson,H.R.2009Trends in deaths associated with abuse of volatile substances1971-2005.StGeorge’s,UniversityofLondon.(www.vsareport.org)(accessed17-10-09).

Flanagan,R.J.,Streete,P.J.,andRamsey,J.D.(1997).Volatile substance abuse: practical guidelines for the analytical investigation of suspected cases and interpretation of resultsUnitedNationsDrugControlProgramme,Vienna.

FullerE2008(Ed)Drug use, smoking and drinking among young people in England in 2007TheHealthandSocialCareInformationCentre.

GhodseHAhmedKCorkeryJNaidooVSchifanoF2010Trends in UK deaths associated with abuse of volatile substances, 1971-2008(Report23)StGeorge’s,UniversityofLondon.(www.vsareport.org)(accessed13-10-10).

HoareJ2009Drug Misuse Declared: Findings from the 2008/09 British Crime Survey England and Wales (Home Office Statistical Bulletin).

NationalAssemblyforWalesSubstance Misuse: Children and Young People(Circular17/02).

NationalChildren’sBureau(NCB)2005Dangerous Highs: Children and young people calling ChildLine about volatile substance abuseNCB.

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NationalTreatmentAgency2005Young People’s Substance Misuse Treatment Services - Essential ElementsNTA(http://www.nta.nhs.uk/areas/young_people/young_peoples_guidance.aspx)(accessed29-09-09).

Ron,M1986‘Volatilesubstanceabuse:areviewofpossiblelong-termneurological,intellectualandpsychiatricsequelae’British Journal of Psychiatry,148,235-46.

Substance Misuse Treatment Framework Guidance on Good Practice for the provision of services for Children and Younger People who Use or Misuse Substances in WalesWelshAssemblyGovernment.

Substance Misuse Treatment Framework for Wales: Service User Involvement FrameworkWelshAssemblyGovernment.

Substance Misuse Treatment Framework: Carers and Families of Substance Misusers: A Framework for the Provision of Support and InvolvementWelshAssemblyGovernment.

WelshNetworkofHealthySchoolSchemes(WNHSS)2010Indicators for the Welsh Network of Healthy School Schemes National Quality AwardWelshAssemblyGovernment.

Williams,J.,Storck,M.,theCommitteeonSubstanceAbuse,andtheCommitteeonNativeAmericanChildHealth,2007“InhalantAbuse”PediatricsVol.119No.5May2007,pp.1009-1017.

FurtherreadingAdvisoryCouncilontheMisuseofDrugs1995Volatile substance abuse.HMSO.

AdvisoryCouncilontheMisuseofDrugs2003Hidden Harm - responding to the needs of children of problem drug usersHMSO.

AssociationofChiefPoliceOfficersofEngland,WalesandNorthernIreland2006Joining Forces Drugs: Guidance for Police Working with Schools and Colleges.

SkellingtonOrrKandShewanD2006Review of Evidence Relating to Volatile Substance Abuse in ScotlandEdinburgh:ScottishExecutiveSubstanceMisuseResearchProgramme(http://www.scotland.gov.uk/Resource/Doc/147377/0038818.pdf)(accessed30-09-09)Thisdocumenthasaverycomprehensivereferencelist.

TheUKGovernment’s2005strategyfortacklingvolatilesubstance(Out of sight - Not out of mind. Children, Young People and Volatile Substance Abuse (VSA) A Framework for VSA)canbedownloadedfromhttp://www.dh.gov.uk/assetRoot/04/11/56/05/04115605.pdf.)(accessed30-09-09).

FlanaganRStreetePandRamseyJ1997Volatile substance abuse: practical guidelines for the analytical investigation of suspected cases and interpretation of results.UnitedNationsDrugControlProgramme,Vienna.

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Field-SmithMButlandBRamseyJandAndersonH2009Trends in deaths associated with abuse of volatile substances 1971-2007.StGeorge’s,UniversityofLondon(downloadablefromwww.vsareport.org).

RonM1986Volatilesubstanceabuse:areviewofpossiblelong-termneurological,intellectualandpsychiatricsequelae.British Journal of Psychiatry,148,235-46.

MORI 2005 Volatile Substance Abuse Today: A Qualitative StudyresearchfortheDepartmentofHealth)(www.dh.gov.uk/en/Publichealth/Healthimprovement/Drugmisuse/Substancemisusegeneralinformation/DH_4136708)(accessed10-10-10).

WilliamsJStorckMtheCommitteeonSubstanceAbuseandtheCommitteeonNativeAmericanChildHealth2007“InhalantAbuse”PediatricsVol.119No.5May2007,pp.1009-1017(downloadablefrom:http://pediatrics.aappublications.org/cgi/content/full/119/5/1009(accessed30-09-09)).

MaterialsforschoolsandtheyouthserviceRe-Solv,thenationalcharityforVSA,hasanumberofteachingresourceswhichcanbepurchasedfromtheirwebsite,www.re-solv.org,includingthe‘Toxic Agents’ Activities Pack; ‘Hazard Crew’ Information Pack, A Loaded Gun(DVDandTeachersManual),theYouth Workers Activity Pack and Aqua cards(www.re-solv.org).

TheAllWalesSchoolLiaisonCoreProgramme(AWSLCP)canbedownloadedfromwww.schoolbeat.org.

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AnnexB

AboutVSA

WhatitisVSA-VolatileSubstanceAbuse-isthedeliberateinhalationofvolatilecompoundstoachieveintoxication.Itisalsocalled‘solventabuse’or‘inhalantabuse’(or‘misuse’).Theterm‘glue-sniffing’wasusedtodescribethemisuseofadhesives,buttheyareinhaledratherthan‘sniffed’andareprobablylesscommonlymisusedthansomeotherproducts,suchasbutanegaslighterrefillsandaerosols,aswellasarangeofotherproducts,suchaspropanegas,chloroform,anaestheticagents(includingnitrousoxide(‘laughinggas’))andpetrol.Therequirementforaproducttobemisusedtoachieveintoxicationisthatitcontainsavolatile,intoxicatingcompoundthatcanbereleasedinacontrolledwayfromtheproductcontainingit.Intoxicationmaybeshort-livedandrecoveryrapid.1Thereissomeevidencethatmisuseamongyoungpeoplemaybeepisodic,with‘epidemics’ofmisuseinparticularareasoratparticulartimesofyear.2Inthisdocument,theterm,‘VSA’,isused,althoughitisnotstrictlyaccurateforsome(non-volatile)substances.

ClassificationofVSA

ClassificationofVSAisproblematic.AnarticleintheJournal,Addiction,pointsout:

‘Mostotherclassesofdrugsofabusearebasedongroupingtogetherthosechemicalsthatsharepharmacologicaleffectsthatarerelatedtotheirabuse.Thus,theabilitytoproduceasimilarintoxication,cross-toleranceandcross-dependenceanddistinctivepatternsofabstinencesymptomsservesastheprimarybasisfortheclassificationofdrugsofabuse.Itisalsowellestablishedthatsuchapharmacologicalclassificationoftenpredictsepidemiologicalpatternsofabuse.Forexample,hallucinogenandopiateabuseoccurstypicallyinquitedifferentpopulations.Unfortunately,therehasnotbeensufficientresearchtoclearlyidentifypharmacologicalgroupingsofinhalants,withthemajorexceptionofnitrites.Generally,manyinhalantsproducepharmacologicaleffectssimilartothoseofalcoholandcentralnervoussystemdepressantdrugs.Volatilegeneralanaestheticsalsoproduceeffectssimilartomanyabusedinhalantsandtodepressantdrugs[8],andthesechemicals,too,havebeensubjecttoabuse.Inaddition,differentinhalantshavebeenshowntobeassociatedwithdifferentpatternsoftoxicitybasedontheircellularsitesofaction[13]…Moreresearchisneededonpharmacologicalandtoxicologicaldifferencesamonginhalantsifprogressistobemadeoninhalantclassificationbasedonpharmacologyandsharedeffects.’(Balster,Randothers2009‘Classificationofabusedinhalants’Addiction104,6,(June2009),pp.878882)

1Recoveryisrapidforbutane,butmuchslowerfortolueneand(probably)forpetrol.2Forexample,theschoolsummerholidays.Althoughthismaybeatleastpartlyduetothegreater

visibilityofyoungpeopleinthesummermonths,therearemoreVSA-relateddeathsinthesummer.

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IthasbeenconventionaltoexcludesomeproductsfromthedefinitionofVSA.Somesubstanceswereexcludedbecausetheywerethoughttohavebeenusedbydifferentsub-culturestothoseusingmostothervolatilesubstances;somewereexcludedbecausetheywerenotknownaboutormisuseduntilrelativelyrecently.Inthisdocument,thefollowingsubstancesareincluded:

• Alkylnitrites(‘poppers’).Recently,thereappearstobeincreasinguseofpoppersonthe‘dancescene’.TheUK-widestudyofVSAdeathsincludesalkylnitrite-relateddeaths.Somevolatilenitritesaresuspectedtocausecancer.

• Heliumgas.Thereissomeevidenceofincreasinguseofthisproductinrecreationalsettingssuchasmusicfestivals.Heliumislegaltopurchaseandhaslegitimateindustrialuses,aswellasbeingusedtofillpartyballoons.Therearearoundsevenoreighthelium-associatedsuicidesintheUKeachyear.

ThesesubstancesareneithercontrolledbytheMisuseofDrugsAct1971norbytheMedicinesAct;theyarenotcaughtintheregulatorynetandthereforecanbeneglected.

Alsoincludedisgammabutyrolactone(GBL),anon-volatilesolventmisusedbyoralconsumptiontoachieveintoxicationwhichisconvertedinthebodyintogammahydroxybutyrate(GHB).GHBeffectsaresimilartothoseofalcohol,witheuphoria,relaxation,reducedinhibitionandsedationdependingonthedose(forareviewseeEMCDDA,2008).GHBhasbeenaClassCdrugundertheMisuseofDrugsActsince2003,andGBL(ontherecommendationoftheACMD)hasbeencontrolledsincetheendof2009.

Additionalinformationaboutthesesubstancesisgiveninthefollowingboxes.Aconsumerprotectionapproachmaybeappropriateinhelpingtoreducetheharmsassociatedwiththem.Theyareincludedherepartlytoassistinraisingawarenessoftheirpotentialformisuse.Theeffectsofthesesubstancesareratherdifferenttoothersusuallyincludedunderthe‘VSA’heading;thereforesomeoftheeffectsofVSAmentionedinthisdocumentdonotapplytothesesubstances.

Drugsthatdonotvaporiseeasilyatroomtemperature(forexample:cocaine,heroin,nicotine,andtobacco,)canalsobemisusedbyinhalation(insufflationorsmoking),buttheirpharmacologicalpropertiesandfamiliaritydistinguishthemfromthesubstancesdiscussedhere.

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GBL

Chemicalname:Gamma-Butyrolactone(γ-butyrolactone)

Appearance:Hygroscopiccolourlessoilyliquidwithaweak,butcharacteristic,odour.Solubleinwater.

Uses:Solventandreagent,usedasastainremover(e.g.asalloywheelcleaner),asuperglueremover,paintstripper,andasolventinsomewetaluminiumelectrolyticcapacitors.

Mechanismofintoxication:ItisconvertedintoGHBbyenzymesinthebody.Somepeoplebecomedependentonthedrugandmayexperienceseverewithdrawalsymptomsrequiringmedicationtoameliorate.

Legalstatus:GBLandGHBarecontrolledasaClassCdrugundertheMisuseofDrugsAct1971.

Alkylnitrites(‘poppers’)

Chemicalname:Amyl,butyl,isobutylnitrite,andisopropylnitritecollectivelyknownasalkylnitritesor‘poppers’.

Appearance:Clear,yellowliquidsIntheUK,nitritesareusuallysoldasagold-colouredliquidinsmallbottlesundermanydifferentbrandnames,suchas‘TNT’and‘LiquidGold’.Theseareoftendescribedas‘roomodorisers’,althoughtheirsmellisunpleasantwhenstale.

Uses:Amylnitritewasusedtoeaseangina.Ithasbeenreplacedbyothermedicines:itsonlyremainingmedicaluseisasanantidoteforcyanidepoisoning.

Mechanismofintoxication:Theliquidisinhaledeitherstraightfromthebottleorfromacloth.Alkylnitritesarenotstrictly‘intoxicating’.Theydilatebloodvessels,givinga‘rush’asheartbeatquickensandbloodrushestothehead.Commonly-reportedeffectsareheadaches,dizziness,nausea,asenseofslowingtime,flushedfaceandneckandlight-headedness.Somepeopleusenitritesforaprolongedsensationoforgasm,topreventprematureejaculationandtorelaxtheanalmuscles,makinganalintercourseeasier.Theyaresuspectedtobecarcinogenic.Mistakenlyswallowingtheliquidcanbefatal.

Legalstatus:‘Mostnitritesarenotillegaltomanufacture,supplyorbeinpossessionofandtheyarenotcontrolledundertheMisuseofDrugsAct.ThosesellingpoppershavealsoescapedprosecutionundertheMedicinesActonthebasisthatnitriteswerebeingsoldas‘roomodorisers’andnotmedicines.’(DrugScopewebsite).

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Heliumgas

Chemicalname:Helium(chemicalsymbol,He)isthesecondlightestelementandthesecondmostabundantelementintheobservableuniverse.

Appearance:Colourless,odourless,tasteless,gasthatislighterthanair.

Uses:Manyindustrialusesandusedforgivingairshipslift.Inhalingasmallvolumeofthegastemporarilychangesthequalityandthetimbreofthevoice.

Mechanismofintoxication:Thepressurisedgasincylindersisusedtoinflateballoonsfromwhichthegasisinhaled.Heliumisaninertgasthatdoesnotreactwithothersubstances,butitdisplacesairinthelungs,whichmaygiveaneffectduetoreducedoxygensupply.Thereisariskofasphyxiation.Inhalingheliumdirectlyfromapressurisedcylinderisverydangerousandcanresultincerebralgasembolism.Heliumwashescarbondioxidefromthebloodandconsequentlydiminishestherespiratorydrivethatforcesustobreathe.

Legalstatus:Legal.

TheLawonVSAVolatilesubstancesarelegalandaccessible.However,theirsaletounder-18-year-oldsiscontrolledbytheIntoxicatingSubstancesSupplyAct1985,whichmakesitillegalforapersontosupplyproductscapableofbeingmisusedtoayoungperson(under18years)if‘heknowsorhasreasonablecausetobelievethatthesubstanceoritsfumesarelikelytobeinhaled…forthepurposesofachievingintoxication’.Thelawdoesnotgivealistofsubstancesandtheretailermustdecidewhetheraparticularyoungcustomerisgoingtomisuseaproduct.Additionally,undertheConsumerProtectionAct(TheCigaretteLighterRefill(Safety)Regulations1999),itisillegaltosupplygaslighterrefillstoanyoneunder18yearsold.Thesaleof“poppers”containingiso-butylnitriteisoutlawedbyTheDangerousSubstancesandPreparations(Safety)Regulations2006whichprohibitsthesupplyofisobutylnitritetothepublicbecauseitisasuspectedhumancarcinogen.

Controllingsupply

Controllingthesupplyofreadilyavailableandsociallyusefulsubstancesisdifficult.Theproductsaremany,withanumberofdifferentchemicalsinvolved;misuserscansubstituteproducts.Informationabouttheharmsofvariousproductsislimited.Thefollowing‘supplyside’approachesarepossible,butallhavelimitations:

• Eliminatingtheproduct-someproductsareespeciallydangerous,andtherearesatisfactorysubstitutes.IntheUK,therehavebeencallsforbutanelighterrefillcanstobebannedbecausesmokerscaninsteadusedisposablecigarettelighters.

• Reformulatingtheproducttoremovetheintoxicatingsubstance-thesubstitutionofpetrolwithun-misusableOpal,anunleadedfuelwithlowlevelsofaromatics,hashadsomesuccessinAustralianindigenouscommunities.Reformulationofcorrectionfluids(suchasTipp-Ex)andsometypesoffireextinguishersresultedintheeliminationofmortalityassociatedwiththeirdeliberatemisuse.

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• Modifyingtheproduct-Forexample,addingachemicaltomaketheproductunpalatable.(However,experimentswiththebitteringagent,Bitrex,havebeeninconclusive).

• Modifyingthecontainer-Tomakemisusedifficult.Forexample,theintroductionofthe‘vapourphasetap’inmanyaerosolsmayhavemadeitalittlemoredifficultformisuserstoaccessthegaspropellant.

• Warninglabelsontheproductcontainer-AlthoughVSmisuserswillknowwhichproductsaremisusable,labelscanbehelpfultoalertothers(egParents)tosuchproducts.IntheUK,manyproductscapableofbeingmisusedcarrythe‘SACKI’warning:‘SolventAbuseCanKillInstantly’.(However,inGermany,suchwarninglabelsarebannedbecauseoffearsthatlabellingmaydrawattentiontothepotentialformisuse).

• Suppliereducation-Retailersneedinformationandadviceaboutproducts’potentialformisuse.Thisisdifficult,becauseofthewiderangeofproductsandthemanyretailoutlets.

• Legalcontrolsonthesaleandsupplyofproductscapableofbeingmisused-theseexistinmanycountries,butaredifficulttoenforce.UKcontrolsonsalestounder-18sobviouslydonotimpactonadultVSmisusers.

• MakingVSmisuseillegal-VSAisanoffenceinJapan,Singapore,andtheRepublicofKorea.However,inmostcountriesthecriminalizationofmisusersofvolatilesubstancesisconsideredcounterproductive.

PrevalenceofVSAThereisalonghistoryoftheinhalationofvolatilesubstancessuchasdiethylether(ether)andnitrousoxide(‘laughinggas’)forpleasure.ButitwasintheUSAduringthe1950sand1960sthatpublicityaboutgluesniffinghelpedtopublicizethepossibilitiesofglueasanintoxicant.IntheUK,publicanxietyaboutVSAreachedapeakin1983whenthereweremorepresscuttingsonthesubjectthanonallotherdrugs.Althoughpublicconcernhaswaned,theproblemhasnotgoneaway.

SurveyevidenceshowsthatexperimentationwithVSAisquitecommonamongchildrenandyoungpeople.Forexample,alargeschool-basedsurveyof11to15-year-oldsinEnglandfoundthatsixpercenthadtriedVSmisuseinthepreviousyear(comingafteralcohol,tobaccoandcannabisinprevalencelevel),andfivepercenthadtriedpoppers(Fuller2008).ComparabledataforWalesisnotavailable.Volatilesubstanceabusecanbeepisodic,andbecometemporarilyapparentamonggroupsofyoungpeople(forexampleinchildren’shomes).

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AskingquestionsaboutVSA

Becauseoftherangeofdifferentproductsthatcanbeinhaledtoachieveintoxication,andbecausetheproductshavelegitimateuses,askingquestionsaboutwhetherpeoplehavemisusedthem,istricky.AnarticleinAddictionexploredthesedifficulties,theauthorsfindingthat,intheirUSAsample,almosthalf(49%)oftheyoungpeoplewho(atGrade7)saidthattheyhadmisusedasubstance,ayearlater(atGrade8)didnotreportit.Aroundtwo-thirdsofthe‘recanters’werelife-timeinhalantuserswhohadadmittedmisuseinGrade7andthendenieditinGrade8;whiletheremainingthirdwerethosewhoincorrectlyreporteduseatGrade7andnotatGrade8.Theauthorsconclude:

‘Inhalantuserecantingisasignificantproblemthat,ifnothandledcarefully,islikelytohaveaconsiderableimpactonourunderstandingoftheetiologyofinhalantuseandeffortstopreventit.’(MartinoSetal2009‘Recantingoflife-timeinhalantuse:howbigaproblemandwhattomakeofit’Addiction,104,8(p1373-1381))

ThisfindingmustreduceconfidenceinestimatesofVSAprevalence,andreinforcetheimportanceofcarefulquestionwording.

LittleisknownaboutadultVSA,buttheBritishCrimeSurvey,alarge-scaleannualhouseholdsurveycoveringEnglandandWales(Hoare2009),foundthat2.4percentof16to59-year-oldshadtried‘glues’(definedas‘includingglues,solvents,gasoraerosols’(Hoare2009,p3)),aproportionthathasremainedveryconstantoverseveralyearsoftheSurvey.3Reporteduseofthesesubstancesinthepreviousmonthwasvirtuallynil(however,ahouseholdsurveyislikelytounderestimateuse).‘Amyl’nitrite4hadbeentriedby9.9percent,andusedinthepreviousmonthby0.5percent.YoungerpeopleinthesurveyweremorelikelytoreportVSA:among16to24yearolds,theBritishCrimeSurveyfoundthat3.2percenthadtried‘glues’,butonly0.3percenthadusedtheminthepreviousmonth.‘Amyl’nitritehadbeentriedby14.3percent,andhadbeenusedby1.2percentinthepreviousmonth.Thesurveyfoundthatlastyearuseof‘amyl’nitriteintheiryoungsample(age16to24years)wasthreetimesashighamongthosegoingtonightclubsfourormoretimesinthepreviousmonthcomparedtothosegoingonetothreetimes(asimilarpatternwasseenwithotherdrugs).‘Amyl’nitriteusewasmuchmorecommonamongcity-dwellersthanothers.Levelsof‘amyl’nitriteuseinWaleswerearoundtheaverageforthewholesample.5GBLandheliumusehasnotbeensurveyedinnationalsamples.

Volatilesubstancesquicklyintoxicate,andsmalldosesswiftlyleadto‘drunken’behaviour,similartotheeffectsofalcohol,althoughVSmisusersmayexperiencedelusionsandhallucinations(bothauditoryandvisual).Volatilesubstancesareeasytoacquireand,therefore,withalcoholandtobacco,arethefirstintoxicatingsubstancesthatchildrentry.

3DataisnotdisaggregatedforWalesalone.4‘Amylnitrite’isusedinaccuratelytodescribe‘poppers’thatactuallycontainisopropylnitrite

(previouslyisobutylnitrite).5At1.4percentlastyearuse;figuresarenotgivenforothertimeperiods.Among16to24-year-olds

itwasslightlylowerinWales(3.4%)comparedtothesampleaverage(4.4%).

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Whilemostexperimenterswithvolatilesubstancesdonotcontinue,andVSAdoesnotleadtotheuseofotherpsychoactivesubstances,someamongthesmallproportionthatcontinuetomisusevolatilesubstancescandevelopseriousproblems.Someheavymisusersinhalelargequantities;onereportwasofaweeklyintakeofsixlitresofadhesive.Thesepeoplehaveotherdifficultiesintheirlives,andaVSAhabitisjustoneofamultitudeofproblems.

Althoughyoungpeoplefromallsocio-economicgroupsexperimentwithvolatilesubstances,forsomeofthosewhoarepoorordispossessed,VSAisthe‘drugofchoice’.ChronicVSAisassociatedwithpoorsocio-economicconditions,withdelinquencyandwithillegaldruguse,disruptedfamilies,andothersocialandpsychologicalproblems.Somechildrenlookedafterbythelocalauthoritymaybemorelikelytomisusevolatilesubstances.TheNationalChildren’sBureau(NCB)analysed356VSArelatedcallstoChildLineandreportedthatmanyvulnerableyoungpeopleweremisusingvolatilesubstancesasaresponsetotheirverydifficultcircumstances(NCB2005).Homelesspeopleandpeopleinprisonsandremandcentresmaybemorelikelytomisusevolatilesubstances.

VSAproblemsSomeregularmisusersmaydeveloptoleranceandneedlargerquantitiestoachieveintoxication.Whiletheredoesnotseemtobeadependencesyndrome,somepeoplearecompulsiveandhabitualmisusers:‘Thereare…pharmacologicalreasonsforsuspectingthatpersistentexposuretovolatilesubstancesmightbeabletoinduceadependenceoftheso-calleddepressanttype’(AdvisoryCouncilontheMisuseofDrugs1995,para3.11).

ForeveryVSmisuser,deathisalwaysapossibility.Itmayfollowconvulsionsandcoma,inhalationofvomit,respiratorydepression,ordirectcardiacorcentralnervoussystemtoxicity.VSA-relateddeathsmaybemorecommonthanthestatisticsshow,aspost-mortemexaminationdoesnotalwaysrevealthatmisuseofvolatilesubstanceshasoccurred,only,insomecases,acutelungcongestionandperhapscold-inducedburnstothemouthandthroat(Flanagan,Street,andRamsey1997).

IntheUK,anongoingannualsurveyhasidentified99VSA-relateddeathsinWalesbetween1971and2008;in2008thereweretwodeaths(Ghodse,et al,2010).UK-wide,thedeathratepeakedin1990with152deaths,decliningsince,with36deathsbeingrecordedin2008(seeTable,p33).TheproportionofdeathsinWalesisslightlyhigherthaninEngland,butmuchlowerthaninScotlandorNorthernIreland(calculatedusingstandardisedmortalityratios).

Mostofthosewhodiearemale,buttheproportionoffemaledeathshasincreasedinrecentyears.Whyfemaledeathsarelowerisnotfullyunderstood;prevalencestudiesindicatethatroughlyequalproportionsofmalesandfemalestryvolatilesubstances.Itmaybeacombinationoffactorssuchasyoungwomenmisusinglessfrequently,insmallerquantities,insafercircumstances,andutilisingdifferent(lessdangerous)methodsofadministration.

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AlthoughdeathsoccuracrossthesocialclassesintheUK,‘…indeathsofthoseunder16,therewasamarkeddifferenceinmortalitybetweensocialclassesI(thehighest)andV(thelowest),withnearlyfourtimesasmanydeathsoccurringinsocialclassV…comparedwithsocialclassI’(Esmail,Meyer,Pottier,andWright,1993,p358).

Table:VSA-relateddeathsintheUKandinWalesbyyear

Year ‘71-’98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07 ‘08 total

UK (N) 1,780 75 66 63 65 54 48 46 51 59 36 2,343

Wales (N) 70 7 1 1 5 1 4 1 5 2 2 99

TakenfromTable4inGhodse,et al,2010

Otherdangersarisefromintoxication:intoxicatedpeoplemayberecklessanddobizarrethingsiftheyexperiencehallucinations.Becomingunconscious,theymaychokeontheirvomit.Volatilesubstancesareoftenmisusedtogetherwithotherdrugs;especiallyalcoholandtobacco.Toolittleisknownabouttheeffectsofcombiningvolatilesubstanceswithothersubstances,butpoly-drugusecanpotentiatedrugseffectsandincreaserisksunpredictably.Smokingisparticularlydangerousbecauseoftheriskoffireorexplosion.

TheextentofmorbidityfromVSAisunknownbecausereportsofchronictoxicityarenearlyallsinglecasestudies.Mostproductsarechemicalmixtures;formulasmaychangeandastheproductsarenotintendedforingestion,manufacturersdonotlisttheconstituents.NegativehealtheffectsdirectlyrelatedtoVSmisusearerelativelyrareintheUK.Theseinclude:

• Manyproductsareinflammablesothereisariskoffireorexplosion-especiallywhenVSmisuseiscombinedwithsmoking.

• SomeVSmisusersuselargeplasticbags;suffocationisthereforearisk.

• Sprayingsubstancessuchasbutanegasdirectlyintothemouthmaycausecoldburnsandmayleadtopulmonaryoedemaandsuffocation.

• Sensitizationoftheheart-cardiacarrhythmiasmayoccurifexertionorfrightfollowsVSmisuse.

Specificriskscomefromparticularsubstances,althoughmanyofthemoretoxiconeshavebeenremovedfromproductsbyconsumerprotectionlegislation.However,some,inevitably,stillcontainhazardoussubstances,suchaspetrol.Damagetothelungs,bonemarrow,andnervoussystemisuncommonandgenerallyreversible.Somepeoplearemorevulnerable(perhapsgenetically)tosomeharmfuleffects.

Althoughtherehavebeenreportsofbraindamage,areviewdidnotfindconclusiveevidence(Ron,1986).Sometypesofvolatilesubstancemisuseduringpregnancymayleadtoincreasedmaternalandfetalmorbidity;althoughitisdifficulttoidentifyspecificcausesoffetaldamage.Paternalexposuretovolatilesubstancesmayalsohaveintergenerationeffects.

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Keycomponents

‘Thisframeworkaddressesthekeycomponentsofacomprehensiveresponsetothethreatsposedtochildrenandyoungerpeoplebyavarietyofsubstances.Thesecomponentsare:

• UniversalEarlyEducationProgrammes-theseconveyaccurateandbalancedinformationaboutsubstancesandtheiruseandmisusetochildrenandyoungpeople.

• TargetedProgrammes-thatenablechildrenandyoungpeopletotakepartindiscussionsamongthemselvesandwithwell-informedadultsaimedatimprovingtheirunderstandingofhowtheycanrespondtotheendemicpresenceofsubstancesinourcommunities.

• InterventionsToImprovePotential-theseexisttopreventchildren,youngpeopleandyoungadultsmovingfromusetomisuseofsubstancesbyanticipatingtheimpactsofrisk/protectivefactorsandincreasingindividuals’resilience.

• IndicatedProgrammes(generallyreferredtoastreatment)-theseareprovidedasindividualisedandplannedprogrammesofassessment,interventionandcareforcertainidentifiedchildrenoryoungpeoplewhoaremisusingsubstances.’

SubstanceMisuseTreatmentFrameworkGuidanceonGoodPracticefortheprovisionofservicesforChildrenandYoungerPeoplewhoUseorMisuseSubstancesinWales(fromsection2.13,p19).

TreatmentGuidancefromtheNationalTreatmentAgency

‘Evidenceofinhalant[volatilesubstances]physicaldependenceislimited,withcasereportssuggestingawithdrawalsyndromesimilartoalcoholwithdrawal.Physicalsymptomsareusuallyshort-lived,thoughagitationandcravingmaycontinueforweeks.Itisrecommendedthatinhalantusersareroutinelyassessed,andifintoxicatedtheyoungpersonmayneedunrestrictedobservationforsometime.

‘Thereisnospecificpharmacologicaltreatmentrecommendedbutsupportandsymptomatictreatmentmayberequiredintheshorttermforagitation.Clearly,acomprehensiveassessmentofallneedsshouldbeconducted,accompaniedbythedevelopmentofacareplan.’

(DepartmentofHealth2009Guidance for the pharmacological management of substance misuse among young people).

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Thefour-tierstrategicframework

…thefour-tierstrategicplanningconcept…isbasedonthefunctionsrequiredofservicesinrelationtothelevelorcomplexityofyoungerpeople’sneeds,theiropinionsandthelevelsofspecialisationoftheservicesthattheyrequire.Thetiersare:

• Tier1:Universalprimary-levelservices.

• Tier2:Youth-orientedservices.

• Tier3:Servicesprovidedbyteamsthatspecialiseintreatingyoungpeoplewhomisusesubstances.

• Tier4:Veryspecialisedservicesforyoungpeoplewhomisusesubstances.

Thetieredconcept…emphasisesactivitiesandfunctionsratherthanthedisciplinesofprofessionalsortheidentitiesofsectorsandagenciesandpromotesintegrationbetweensectors,agenciesanddisciplines.…manyprovideragenciescanlegitimatelydeliverservicesofmorethanonetypeandwhichfallintomorethanonetier.’

Substance Misuse Treatment Framework Guidance on Good Practice for the provision of services for Children and Younger People who Use or Misuse Substances in Wales(fromsection5,p23).

VSATreatmentAsummaryofissuesinVSAtreatment(fromaNorthAmericanperspective)isgivenbyWilliamset al:

‘Littleresearchexistsconcerningtreatmentneedsandsuccessfultreatmentmodalitiesspecifictoinhalantusers,socliniciansrelyonapplyingmethodsthatareusedtotreatotheraddictivedisorders,suchascognitive-behavioraltherapy,multi-systemandfamilytherapy,12-stepfacilitation,andmotivationalenhancementtechniques.…..Treatmentchallengesareposedbythediversityofabusedinhalantsanduserpopulations,co-morbidpsychopathology,psychosocialproblems,polydruguse,andthephysiologicandneurologiceffectsofinhalantabuse.Treatmentoflonger-terminhalantusersishinderedbythefactthattherearefewprogramsdesignedspecificallyforinhalantabusetreatment,accesstocaremaybelimited,providersgenerallyhaveapessimisticviewaboutusers’neurologicdamageandchanceforrecovery,andprovidersoftenlacksufficientknowledgeandtrainingaboutinhalantabuse,inhalantusers,andtheirtreatmentneeds.Althoughtheprinciplesofeffectivesubstanceabusetreatmentingeneralapplytoinhalantabusetreatment,anytreatmentregimenmustaddressthemanyclinical,emotional,social,academic,pharmacologic,neurocognitive,cultural,anddemographicfactorsthatmakethistypeofsubstanceabuseunique.’(Williams,et al2007)

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ThebroadercontextVSAisnotsimplyaproblemofindividualpathology,butoccurspartlybecauseoffailuresofsocialstructures.Thus,inthebroadestsense,interventionsinvolvehealingthefamilyandthecommunity;andmakingchangesinsociety.Interventionsmayalsoincludedevelopingprideinone’sculture;asWilliamset alpointout:

‘Increasingpersonalandethnicself-identitythroughrole-modellinghasbeensuggestedashelpfulintreatingsomegroupsofinhalantabusers,andpositiveculturalidentificationhasbeenshowntobeimportantinAmericanIndian/AlaskaNativepopulations’(Williams,et al2007).

ServiceuserinvolvementItisimportantthatsubstancemisuseservicesareinformedbyanddevelopedwithconsiderationgiventotheviewsofserviceusers.TheWelshAssemblyhasproducedgoodpracticeguidanceonserviceuserinvolvementwhichhasbeenpublishedasamoduleoftheSubstanceMisuseTreatmentFramework(WelshAssemblyGovernment2008).Childrenandyoungpeopleshouldbeinvolvedindecisionsbeingmadeaboutthem,asshould,asfaraspossibleandappropriate,theirparentsandcarers.

Involvingparentsandcarersinservicesforyoungersubstanceusersandsecuringtheirsupportisessential….Therefore,servicesshouldworkinpartnershipwithyoungerpeopleand,ifappropriateaccordingtoageandcircumstances,withtheirparents,carersandotherclosefamilymemberstoaddresssubstance-relatedproblems….Mostparentsandcarerswishtobeinvolvedindecisionsmadeaboutinterventionsandtreatmentsthattheirchildrenreceive.Thisframeworkrecognisesthevaluablerolesthatparents/carerscanplayinassistingyoungerpeoplewhohaveproblemsarisingfromsubstancemisuse.Servicesshouldactivelyencourageparentalinvolvementwithintheboundariesofpolicyandexistingstatuteandcaselawonconsentandconfidentiality.Theremayalsobecircumstancesinwhichparentalconsentismandatory.

Whileprofessionalsshouldseek,ingeneral,todiscussanyconcernswiththefamilyand,wherepossible,seektheiragreementtomakingreferralstolocalauthoritychildren’ssocialservicesthisshouldonlybedonewheresuchdiscussionandagreement-seekingwillnotplaceachildatincreasedriskofsignificantharm.Substance Misuse Treatment Framework: Guidance on Good Practice for the provision of services for Children and Younger People who Use or Misuse Substances in Wales(page36)

InvolvingparentsandcarersininterventionswithyoungVSmisusers,whilegenerallydesirable,canbedifficultinpractice.Servicesarenotalwaysconfiguredtoenablepractitionerstoinvolveparents;youngpeoplearenotalwayskeentohavetheirfamiliesinvolved;andfamiliesthemselvesmaywantto‘leaveittotheprofessionals’.

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Nevertheless,improvedinterventionoutcomesarelikelywhenfamiliesareappropriatelyinvolved.Thisispartlybecausechronicvolatilesubstancemisuseisoftenpartofadysfunctionalfamilydynamic;therefore,workingtochangethefamily’sinteractions,aswellasattemptingtochangethebehaviouroftheindividualmisuser,maypaydividends.

TheACMD’s‘HiddenHarm’Reportdemonstratedthatlargenumbersofchildrenarelivinginfamilieswereadultfamilymembersmisusecontrolleddrugs(ACMD2003).Therewillbesomefamilieswhereadultsmisusevolatilesubstances,althoughthereisnodataontheextentofthis.

‘Theorganisationalprocessesthatarenecessaryinordertodeliverqualityservices:

1. Familymembersaffectedbydruguseareactivelyinvolvedintheorganisation.

2. Theserviceworksinpartnershipwithotherrelevantlocalorganisationsandservices.

3. Theserviceisclearaboutitsprinciples,aimsandfocusandhowthesewillbeachievedandmonitored.

4. Theservicehasinplacepolicies,proceduresandprotocolscoveringconfidentialityanditslegalresponsibilities.

5. Allservicestaffareappropriatelytrainedandsupported.’

(‘QualityStandards:FiveEssentialRequirements’:p15-16inSubstance Misuse Treatment Framework: Carers and Families of Substance Misusers: A Framework for the Provision of Support and Involvement).

Actions

Hopingtoachieve:

‘AprogressivedeclineinthenumberofdeathsfromVSAbychildren,youngpeopleandadults.

Areductionintheincidenceofharmfromaccidentsandtraumaasaresultofabusingvolatilesubstances.

AnincreaseinpublicawarenessofVSAanditsrisks.

Increasedidentificationofchildrenandyoungpeopleabusingoratriskofabusingvolatilesubstances.

Areductioninillegalunder-agesalesofvolatilesubstancestochildrenandyoungpeople’.

(DepartmentofHealth,2005).

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‘CommunitySafetyPartnerships(CSPs)shouldensurethattheirplansreflectandinformthelocalCYPP.ThroughtheparticipationoftheirmembersinthelocalChildrenandYoungPeople’sPartnership,CSPswillcontributetothesettingofsharedprioritiesandbeabletoensurethattheirworktocommissionsubstancemisuseservicesisbasedonthem.Itisessentialthatbothpartnershipsco-operateintheplanningofsubstancemisuseservicesforchildrenandyoungpeople.Substance Misuse Treatment Framework: Guidance on Good Practice for the provision of services for Children and Younger People who Use or Misuse Substances in Wales(page40).

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AnnexC

PracticeExample-VSApreventionandawarenessactivitiesinYnysMôn

WhentheRedCrossannualreporthighlightedVSAasoneofthetopthreesubjectsthatyoungpeopleregularlyenquiredaboutontheRedCrossYouthOutreachBus,theneedtoprovideup-to-dateinformationonvolatilesubstancesandtheassociateddangerswashighlighted.TheYnysMônSubstanceMisuseActionTeam(SMAT)decidedtoaddressVSApreventionthroughawareness-raisingforprofessionals,parentsandyoungpeople.

VSAtrainingforprofessionalsFollowingdiscussionswithserviceprovidersandprofessionals,itwasevidentthattherewaslimitedknowledgeaboutVSA,andthatmoreneededtobedonetosupportyoungpeoplewithVSA-relatedproblems.

TheSMATdecidedtotenderitsVSAtrainingandawarenessrequirements,andthesuccessfulbidderinvitedallprofessionalsworkingwithyoungpeople(includingvoluntaryagencies)toattendfivetrainingeventsoveroneweek,invariouslocationsacrossYnysMôn.Thesesessionsincluded:

• HistoryofVSA.

• Typesofvolatilesubstancesthatcanbemisused.

• Currenttrendsandmethodsofmisuse.

• MainrisksofVSA.

• Confrontingmisconceptions.

• Tacklingyoungpeople’sperceptionsofVSA.

• MethodsofdeliveringVSAtrainingtoyoungpeople.

Allthetrainingwasprovidedfree,andeveryattendeereceivedacomprehensiveSolvent Abuse Packforfuturereference.Informalfeedbackfollowingthetrainingconfirmedthatalltheattendeesagreedthetrainingwas‘aboveaverage’to‘verygood’,andextremelyrelevanttotheirworkwithyoungpeople.

VSAawarenessforyoungpeopleAtwhatageshouldVSAissuesbeaddressed?FollowingdiscussionswithSchoolCommunityPoliceOfficers(SCPOs)itwasdecidedtocontinuetoinformprimaryschoolchildrenaboutVSAthroughtheAllWalesSchoolLiaisonCoreProgramme(AWSLCP).However,toraisetheawarenessofsecondaryschoolchildren,‘aquacards’(suppliedbythecontractors,thesewerecolourfulcredit-cardsizecardscontainingvitalfactsandcontactdetails)werehandedoutduringeducationalinformationdaysandpubliceventswhichinvolvedschoolchildrenaged13to16years.Thecardswereextremelypopularwithyoungpeople.

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YnysMônSMAThasaverycloseworkingrelationshipwiththeYouthServicesDepartment,whichhasaproactiveapproachtosubstancemisuse.Thecontractor’sVSAinformationpacksforyouthworkershasbeencondensedandpartlytranslated,andhasbeendistributedtoyouthclubleaders;relatedtrainingwillbeprovidedduringthe2011/12financialyear.

VSAinformationandawarenessforparentsandcarersAnInformationPackforparentsofYear6pupilsmovingtosecondaryschoolhasbeendevelopedbytheSMATlocalalcoholgroup.ThePackincludesadviceforparentsondrugs,alcohol,peerpressureandbullying.Itwillalsoincludethe‘cupboardleaflet’whichwasdesignedbyparentsandcoversthetypesofproductsfoundinthekitchencupboard;aswellasinformationonhowparentscouldaddressVSAwiththeirchildren.

AlsoenclosedintheInformationPackisaschoolyearcalendarthemedonalcoholawareness,andtheartworkwasdevelopedthroughlocalcolleges.ThePackswerepresentedtopupilsontheir‘movingup’dayin2010,andithasbeenagreedbytheSMATtocontinuein2011andthereafter.

Todate,therehavebeennoVSA-relateddeathsonYnysMôn.TreatedincidentsofyoungpeopleinvolvingVSAiscurrentlylow,andtherearenoneintheadultservice.ThelocalYoungPeoplesSubstanceMisuseServices(YPSMS)ServiceManagerwelcomedthesuggestionforadditionalstafftraining;thiswillbedevelopedfurtherduringthe2011/12financialyear.

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AnnexD

PracticeExample

RhonddaCynonTaffCountyBoroughCouncil-TradingStandardsInRhonddaCynonTaff,TradingStandardsprovidesinformationandguidanceleafletstoretailers,whichhavebeensupported,whererelevant,byspecificadviceduringroutinevisits.

Aswithissuesrelatingtootherage-restrictedproducts,TradingStandardswillrespondtoanycomplaintsorintelligencereceivedabouttheillegalsaleofvolatilesubstances.However,relativelyfewcomplaintsarereceivedregardingthisissue.

TradingStandardshashowevercarriedouttestpurchasingoperationsinconnectionwithvolatilesubstances.In2007,12attemptedpurchasesweremadeforunderagesalesofbutanegaslighterrefills.Oneachoccasionthesalewasrefused.In2009,nineattemptedtestpurchasesweremadeofbutanegascigarettelighterrefillswiththeassistanceofvolunteerchildrenagedbetween13and15years.Theseresultedinonesaletoa13-year-oldgirl.Theretailerwasissuedwithasimplecautioninconnectionwiththeoffence.Furthertestpurchaseoperationsareundertakeneachyear.

Anytestpurchaseresultinginasaleofacigarettelighterrefillcanistertoanunderagevolunteerisstraightforwardtoinvestigate,astheoffenceiscommittedwhenthesaleismade.

Howeverifasaleweretobemadeofanyothervolatilesubstancetoanunderagevolunteeritwouldbedifficulttotakeacasetocourt,asmostretailerswillclaim(withsomejustification)thattheydidnotrealisethatintoxicationwasthepurposeforwhichtheyoungsterpurchasedthesubstance.

Ineffect,the1985legislationisalmostunenforceableasitisverydifficulttoprovethatthesellerhadreasonablecausetobelieveboththatthepurchaserwasunder18andthatthepurchaserwaslikelytoinhalethesubstance.Thusthislegislationisoflittleenforcementvalue,anddoesnotencourageTradingStandardsservicestocarryoutanygreatlevelofenforcement.

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AnnexE

PracticeExample

CarmarthenshireSubstanceMisuseActionTeamInresponsetoconcernsaboutyoungpeopleinYear7increasinglymisusingvolatilesubstances,thePreventionEducationandTrainingsub-groupofCarmarthenshireSubstanceMisuseActionTeamestablishedaSolventAbuseSteeringGroup.MembersofthisgroupincludedNationalPublicHealthSerivce(NPHS),DyfedPowysPolice,HealthySchools,theAssociateSchoolImprovementOfficerforPSE,SchoolNursingTeam,TradingStandardsandalocaltheatrecompany.

FollowingthedevelopmentofadetailedActionPlan,someoftheactivitiesthattookplaceincluded:

• training(conductedbyRe-Solv)forTier1and2workers,includingtheyouthservice,thepolice,socialservices,schoolhealthnursingandthevoluntarysector;

• thetradingstandardsdepartmentledaretailawarenesscampaignwhichdeliveredover350informationpackstoretailers,raisingawarenessofthewidevarietyofproductsthatcanbemisused,andexplainingtheirlegalresponsibilities;

• schoolnursesinallsecondaryschoolsinthecountyreceivedaposterwithadviceandhelplinenumbers;

• theHealthySchoolsSchemeandtheAssociateSchoolImprovementOfficerforPSEproducedasecondaryschoolresourcehelpingteacherstoincludevolatilesubstancesaspartofthePSEcurriculumonsubstancemisuse;

• apilotprojectrunbyalocaltheatrecompany,aimedatraisingawarenessoftheharmsassociatedwithvolatilesubstancemisusethroughapeereducationapproach;

• DyfedPowysPolicedistributed,county-wide,solventmisusepreventionleafletstoallYear7pupilsandtheirparents;

• DyfedPowysPolice,togetherwithpartneragencies,undertookawarenesssessionsaspartofschools’parents’evenings.

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AnnexF

Abbreviationsandothertermsusedinthisdocument

ACMD AdvisoryCouncilontheMisuseofDrugs

AWSLCP AllWalesSchoolLiaisonCoreProgramme

CBC CountyBoroughCouncil

CSP CommunitySafetyPartnership

CYPP ChildrenandYoungPeople’sPartnership

EMCDDA EuropeanMonitoringCentreonDrugsandDrugAddiction

GBL Gammabutyrolactone

GHB Gammahydroxybutyrate

HBSC HealthBehaviourofSchoolChildrenSurvey

LA LocalAuthorities

NCB NationalChildren’sBureau

NOS NationalOccupationalStandards

NEETs YoungPeopleNotinEmployment,EducationorTraining

NPHS NationalPublicHealthService

NTA NationalTreatmentAgency

PRU PupilReferralUnit

PSE PersonalandSocialEducation

Re-Solv Nationalcharityforthepreventionofsolventandvolatilesubstanceabuse

SACKI Warninglabelonsomeproductscapableofmisuse:itstandsfor:‘SolventAbuseCanKillInstantly’

SCPO SchoolCommunityPoliceOfficers

SMTF SubstanceMisuseTreatmentFrameworkforWales

SMAT SubstanceMisuseActionTeam

TSO TradingStandardsOfficer

VS VolatileSubstances

VSA VolatileSubstanceAbuse

WIISMAT WalesIntegratedIn-depthSubstanceMisuseAssessmentTool

WNHSS WelshNetworkofHealthySchoolSchemes

YPSMS YoungPeople’sSubstanceMisuseServices