Transcript Hitting a moving target: Handling emergent topics and lack of

Hitting a moving target
Responding to NPS harms
Dr Owen Bowden-Jones and
Dr Dima Abdulrahim
CNWL Club Drug Clinic
Club Drugs
Novel Psychoactive Substances
• Psychoactive drugs which are
• Club drugs tend to be used
not prohibited by the United
by teenagers and young
Nations Drug Conventions but
adults at bars, nightclubs,
which may pose a public
concerts, and parties
health threat comparable to
LEGAL, that
NOTposed
CLINICAL
DEFINITION
by substances
(NIDA)
• E.g. Cocaine, MDMA,
Ketamine, GHB/GBL,
methamphetamine
listed in these conventions
(UK Home Office)
• E.g. Cathinones, synthetic
cannabinoids, piperazines
Traditional/Classical
Heroin
Crack cocaine
Powder cocaine
Benzodiazepines
Cannabis
Alcohol
EMERGING DRUG TRENDS
Club drugs
Ketamine
GHB/GBL
MDMA
Mephedrone
Methamphetamine
Synthetic Cannabinoids
Novel
Psychoactive
Substances
New drugs
New availability
New users
The new health frontline
New harms
• Harms similar to ‘traditional’ drugs including
dependence, withdrawal, physical and
psychiatric co-morbidity
• New harms
–
–
–
–
–
–
Ketamine bladder
GHB/GBL detoxifications
Psychosis – particularly with synthetic cannabinoids
Hallucinogen Persisting Perception Disorder
Use in sexual context - ‘chemsex’
NPS injecting use
Treatment demand is increasing
How should clinical services respond
to the challenge of new trends?
The CNWL Club Drug Clinic
Dr Owen Bowden-Jones
Consultant Psychiatrist
CNWL Club Drug Clinic
Why did we set up a specialist clinic for club
drug users in 2010?
• Small number of ‘club drug’ users presenting to local services.
Quite different from ‘typical’ users
• Demand from other parts of health frontline
– HIV/Sexual Health
– Accident and emergency
– Mental health acute wards
• Reports of shift in using profiles of younger people away from
heroin towards club drugs and NPS
• Increase in use in MSM – ‘chemsex’
• These ‘new users’ don’t feel traditional heroin and crack
orientated services have the skills to treat them
Who has attended?
‘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
Crime Survey England and Wales
•
Evidence that people who use the
night-time economy, and dance clubs
or nightclubs in particular, are more
likely to use club drugs than the
general population.
•
Levels of drug use increase with
frequency of visits to nightclubs and
pubs.
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
• Levels of club drug use among
LGBT people, and gay and
other men who have sex with
men (MSM) in particular, are
higher than in the general
population.
• In 2011/12 and 2013/14,
CSEW, LGB respondents were
approximately three times
more likely to report taking
illicit substances in the last
year than heterosexual
respondents.
% reporting past year
drug use (CSEW
2013/14)
28.40%
30.00%
20.00%
8.10%
10.00%
0.00%
Lesbian, Gay,
Bisexual
Heterosexual
Young professionals
• Anecdotal evidence of
use by professional
• ? Attracted by legality
and concerns of
workplace drug testing
Psychonauts
Users who consume psychoactive
drugs to explore their psyche – often
with spiritual element
Usually prefer hallucinogens
Hallucinogen Persisting Perception
Disorder (HPPD)
The trip that doesn’t end !
Perfect drugs for prisons?
Cheap, potent, undetectable
What does the Club Drug Clinic do
differently to other drug clinics?
Engagement
•
•
•
•
•
•
Universities
Club venues
Sexual health
Mental health
A&E
Prisons
CNWL and Antidote/London Friend
350
300
60%
Treatment Outcomes
05/2011 - 11/2014
Number of People
250
35%
200
150
100
50
5%
0
Treatment Complete
Incomplete
Outcome
Transferred
The GHB Trial
Improving GHB withdrawal with baclofen
Chief Investigator
Prof Anne Lingford-Hughes
Principal Investigators
Dr Owen Bowden-Jones , Dr David Wood, Dr Paul Dargan
Key partners
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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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 March 2015-September 2015
More than 6,500 visits to website
More than 3,500 downloads
But guidance can get left on the
shelf………
Novel Psychoactive Treatment:
UK Network
NEPTUNE II
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• Novel Psychoactive Treatment: UK Network
NEPTUNE II
To maximise the impact of the NEPTUNE
guidance by disseminating in a manner
convenient for busy clinicians
• e-learning modules for clinical settings
• Develop clinical tools – e.g. care bundles
• Evaluation – does it make a difference?
E-learning: Three staffing groups
Basic introduction for
all clinical staff
e.g. brief intervention
Detailed clinical guidance for
staff working in
Detailed clinical guidance for
staff working in
acute settings
drug services
e.g. management of overdose
e.g. harm reduction/detox
Care Bundles
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
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?
• Hard to maintain funding for specialist service
– really need regional approach to be
sustainable
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
• Club Drug Clinic and NEPTUNE are attempts to
develop and disseminate knowledge
[email protected]
www.clubdrugclinic.com
@ClubDrugClinic
www.neptune-clinicalguidance.co.uk