Transcript NPS harms - National Treatment Agency for Substance Misuse

Hitting a moving target
Managing NPS harms
Dr Owen Bowden-Jones
Addiction Psychiatrist
Imperial College London
Club Drugs
• Club drugs tend to be used
by teenagers and young
adults at bars, nightclubs,
concerts, and parties
(NIDA)
• E.g. Cocaine, MDMA,
Ketamine, GHB/GBL,
methamphetamine
Novel Psychoactive Substances
• Psychoactive drugs which are
not prohibited by the United
Nations Drug Conventions but
which may pose a public
health threat comparable to
that posed by substances
listed in these conventions
(UK Home Office)
• E.g. Cathinones, synthetic
cannabinoids, piperazines
EMCDDA 2015
Number of internet sites selling NPS
Who are using these new
substances ?
Depends where you are,
and who you are !
‘Traditional’ drug users
• Heroin users moving to
mephedrone injecting?
• Some evidence from
EMCDDA
• Other anecdotal
• But, evidence of
injecting of NPS and
club drugs
Clubbers and students
Drug
Lifetime use
Ecstasy
89.5
Cocaine
84.6
Ketamine
66.1
Heroin
6.7
Drug use by ‘clubbers’ Winstock 2010
Geographical variation
‘Bubble’
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?
piperazines
HEROIN
‘others’
CANNABIS
synthetic
cannabinoids
ALCOHOL
new synthetic opioids
COCAINE
tryptamines
CRACK
synthetic
cathinones
BENZOS
phenethylamines
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 evidencebased 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
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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)
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Lack of evidence (No evidence, for or against)
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Conflicting evidence
NEPTUNE guidance content
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Quality of research evidence
Brief summary of chemistry and pharmacology
Clinical and other uses
Prevalence, user populations and patterns of use
Routes of ingestions and frequency of dosing
Desired subjective effects; unwanted effects
Harms and their management
– Acute harms
– Management of acute harms
– Harms from chronic use
– Management of harms from chronic use
• Public health and safety and harm reduction
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Stimulants
Sedatives/
Dissociatives
Hallucinogens
Synthetic cannabinoids
Cathinones
Piperazines
Phenethylamines
(including amphetamines,
methamphetamine, MDMA, 2C
series, D series, benzodifurans,
PMMA, PMA)
GHB/GBL
Ketamine
Methoxetamine
Nitrous Oxide
Tryptamines
DMT, psilocybin, AMT
LSD
Phenethylamines
NBOMe, 2CB
Salvia divinorum
Amanita mushrooms
CB1 and CB2 receptor agonists
including JWH and CP
(Classical, non-classical and hybrid)
Project NEPTUNE
Develop clinical guidance
Emergency
Care
Drug
Services
General
Practice
Sexual Health
and
Mental Health
• Guidance published in March 2015
• Additional LGBT guidance to be released
shortly
Between 27th March-13th May
4,642 visits to website
1,538 downloads
But guidance can get left on the
shelf………
Novel Psychoactive Treatment:
UK Network
NEPTUNE II
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Aims of
II
To maximise the impact of NEPTUNE by
disseminating the guidance at a national level, in
ways that are convenient to busy clinicians and
easy to use
– Develop e-learning modules for each of the
clinical settings
– Develop care bundles, and other tools,
– Review and support development of national
clinical data collection tools to facilitate recording
of new drugs and improve assessment of needs
among populations at risk of club drug harms
– Evaluate the project using the expertise of
College Centre for Quality Improvement.
Care Bundles
Other tools
(e.g. Patient information)
Evaluation
Centre for Quality Improvement (CCQI).
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Main evaluation
To evaluate:
1. Impact of initiatives on treatment safety and patient
outcomes
2. How the implementation sites achieved their
objectives (or not) and the factors associated with
this
3. Impact of e-learning programmes on clinical
knowledge and staff confidence
Volunteers wanted for testing
implementation
When will NEPTUNE be available?
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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 evidencebased interventions supported by investment in
training and further research
• NEPTUNE an attempt to address this
NEPTUNE 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 group
Members
Observers
Owen Bowden-Jones Sarah Flowers
Tim Williams
Dima Abdulrahim
Sanjay Kumar
Christopher
Alex Baldacchino
Salvo Larosa
Whiteley
Seth Bhunnoo
Luke Mitcheson
Rosie Smith
Steve Brinksman
Monty Moncrieff
Adam Winstock
Emma Crawshaw
David Nutt
David Wood
Paul Dargan
John Ramsey
Dan Wood
Jonathan Dewhurst John Roche
Dominic Dougall
Fabrizio Schifano
Caroline Frayne
Josie Smith
Mike Flanagan
Ann Sullivan
Public Health
England
• Pete
Burnkinshaw
Department of
Health
• John
McCracken;
• Mark Prunty
Home Office
• Melanie
Roberts
[email protected]
[email protected]
www.clubdrugclinic.com
@ClubDrugClinic
www.neptune-clinicalguidance.co.uk