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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
19
AR Lingford-Hughes, S Welch, L Petersand DJ Nutt et al: BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP 2012 Journal of Psychopharmacology 26(7)
899–952
1 Strong research evidence (e.g. Cochrane reviews, meta-analyses, high quality
randomised controlled trials)
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
29
Care BundlesCare Bundles
Other toolsOther tools(e.g. Patient information)(e.g. Patient information)
EvaluationEvaluationCentre for Quality Improvement (CCQI).
35
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
41
NEPTUNE II expert groupNEPTUNE II expert groupMembers Observers
Public Health England•Pete Burnkinshaw
Department of Health•John McCracken; •Mark Prunty
Home Office•Melanie Roberts
www.clubdrugclinic.com
@ClubDrugClinic
www.neptune-clinical-guidance.co.uk