1

Annex 1: Context of New Psychoactive Substances (NPS) Summary 1. PURPOSE Summarise the current thinking and latest research into NPS in the UK, to provide background context for Medway NPS Need Audit. This will include: Current policy position in UK on NPS International policy in EU / USA & Australia Key points from recent research conducted in UK with people who use NPS

about their (i) Motivations (ii) Patterns of use (iii) Need for support 2. KEY POINTS

NPS DEATHS RISING AS DRUG DEATHS FALL NPS accounts for 2% of drug related deaths in UK (2012) however NPS deaths rose by 79% from 2011 whilst drug related deaths fell by around 7% over same period1. Deaths involving new psychoactive substances (legal highs) such as mephedrone increased by 79% from 29 in 2011 to 52 in 2012. The total number of drug-related deaths in 2012 was 2,597.

The number of NPS products is rapidly expanding The number of new psychoactive substances reported by Member States to the United Nations Office on Drugs and Crime rose by 51% from 166 at the end of 2009 to 251 by mid-2012. This exceeds the total number of psychoactive substances (234) currently controlled by the international drug conventions. For every new psychoactive substance that is banned, there is another one ready to be launched to take its place From the documentary Legally High: True Stories, Dr Zee

1 ONS table 3 Number of deaths related to drug misuse by sex and underlying cause, England and Wales, deaths registered between 19932012

2

Use is more prevalent outside of major towns & cities

Consumption of new psychoactive substances appears to be more prevalent outside major towns and cities, in areas where it is more difficult to acquire conventional drugs.

Current NPS epidemic is likely to increase The Home Affairs Select Committee (Dec 2013) concluded that there is currently an epidemic of psychoactive substances and it is highly likely that the creation of new psychoactive substances will continue to increase in the future unless immediate action is taken.

Education & Information are crucial to prevent deaths They recommend that Education of young people is crucial in order to prevent further deaths from psychoactive substances. schools and colleges extend the current educational sessions they run on drugs policy with effective evidence-based sessions. The way to protect young people was to emphasise the dangers of new psychoactive substances, rather than banning them, a view shared by the British Medical Association. The Angelus Foundation NHS England should issue guidance to local Clinical Commissioning Groups. Home Affairs Select Committee

The Police are not yet responding to this emerging issue Chief Constables and other law enforcement agencies are failing to understand the impact of psychoactive substances Home Affairs Select Committee The Home Affairs Select Committee (Dec 2013) were deeply concerned that there is not enough data collated by each local police area regarding the usage and effect of these types of substances. We recommend that police forces start a process of data collection immediately in order to have established, within 6 months, the challenges they face locally. This will enable them to develop an effective strategy in tackling the problems presented by psychoactive substances, both in pursuing those who are selling substances which may contain illegal drugs and also producing an appropriate education strategy for potential users.

Introduce a New Legislative Model separate to illicit drugs The Select Committee recommended Home Office should introduce a new legislative model, taking into account the benefits of other systems in use abroad. The new model should shift the evidential responsibility, of proving the safety and

3

the non-narcotic purpose of a substance, onto the seller for all new psychoactive substances. It should also be specifically related to the new psychoactive substances problem and not impinge on current legislation which controls illicit drugs. We take very seriously the global threat posed by new psychoactive substances Government Response to Select Committee (May 2014)

3. New Psychoactive Substances Policy Research

Cannabinoids Misuse of Drugs Act 1971 https://www.gov.uk/government/news/new-drug-description-to-help-ban-family-of-legal-highs 2009 Cannabinoid controls included named compounds and materials related to the drugs in circulation 2013 This list was expanded to include a broader range of emerging materials Nov 2014 Advisory Council of Misuse of Drugs (ACMD) recommended a revised general description to control a third generation of synthetic cannabinoids. Summary: Efforts have been made to illegalise synthetic cannabinoids, but their fast evolution and the development of new materials and combinations means that regular updating of their definition is required. Tryptamines https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/318693/UpdateGenericDefinitionTryptamines.pdf June 2014 Recommendation to class tryptamines as Class A drugs under the Misuse of Drugs Act New Zealand: Has a general control for simple tryptamines where certain substances are banned but others are not USA: Several simple tryptamines are named as Schedule 1 hallucinogens and then related materials are controlled by virtue of USs analogue controls Overall: The main consensus seems to be that the UK wishes to ban NPS but there are problems with keeping definitions up to date as new materials and combinations are continuously being developed to try and evade the law. 2011 Recommendations report https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/119139/acmdnps2011.pdf Provides a general overview and recommendations for government from ACMD, such as encouraging source countries to halt manufacture and placing the burden of proof on the supplier to prove that it is safe for its intended purpose. A good summary of the key points is provided in the executive summary.

4

New Psychoactive Substances in England: a review of the evidence https://www.gov.uk/government/publications/new-psychoactive-substances-in-england-a-review-of-the-evidence Does not provide much information on policy, but gives a good overview of evidence and research into NPS prevalence, motivation for use and health and social effects. Government response to expert panel report on NPS https://www.gov.uk/government/publications/response-to-expert-panel-report-on-the-new-psychoactive-substances-review https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/307865/New_psychoactive_substances_and_prescription_drugsPRINT.pdf Good reading, lays down good background on where the government stand on this issue and the challenges they face in tackling the issue, as well as their attempts to do so. 2014 News story https://www.gov.uk/government/news/so-called-legal-highs-linked-to-deaths-to-be-banned-in-uk Following the publication of an expert review of new psychoactive substances in October, the government is developing proposals for a blanket ban across the whole of the UK. 2014 Written statement to parliament from the Home Office https://www.gov.uk/government/speeches/drugs-policy Proposed range of actions:

- blanket ban instead of substance by substance basis - base legal controls on future cannabinoids on their effects on the brain

instead of their chemical structure - strengthen training of front-line NHS staff to deal with the effects of NPS

use - Publish new guidance by Public Health England for local authorities

May 2014 Status report on NPSs and Club drugs http://www.drugscope.org.uk/Resources/Drugscope/Documents/PDF/Policy/BusinessAsUsual.pdf Lots of information on definitions, effects, current legislation and some information on what other countries are doing:

- UK: Generic Ban a compound along with chemically similar compounds - USA: Analogue Ban a compound along with other compounds that have

a similar effect irrespective of its pharmacy - Ireland & Poland: Blanket ban All head shops closed, all substances

banned

5

- New Zealand: Regulated market The onus is placed on the manufacturer to demonstrate that a product poses minimal risk before it is allowed to be sold.

Evidence review from the Scottish Government http://www.scotland.gov.uk/Resource/0045/00457682.pdf Provides general information and evidence gaps, as well as responses from around the world:

- Japan: Legislation to prohibit advertising, supply and production, but provision for personal use does not constitute an offence

- New Zealand: Legislation to control the manufacture and sale of new restricted substances of which there is not yet enough evidence of potential harm to prohibit them completely. Onus placed on manufacturers to prove their products pose a low risk of harm prior to receiving approval for legal production and sale

- Republic of Korea: Legislation to control several NPS, which has been strengthened by the addition of a new temporary scheduling system that allows the Korean Food and Drug Administration to temporarily schedule NPS for a year

- USA: Legislation controls the manufacture, importation, possession, use and distribution of certain substances. Temporary scheduling of NPS possible. Federal Analogue Act set up to control substances not specifically listed in the Controlled Substances Act, but the term analogue drug has come under criticism

EU Policy http://ec.europa.eu/justice/anti-drugs/files/nps_report_2014_en.pdf Lots of information on various EU-funded programmes, many of which aim to increase knowledge of NPS, improve training of relevant staff members, and other local measures to reduce their use International Drugs Comparison https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/368489/DrugsInternationalComparators.pdf Provides information about what various countries are doing about different drugs. There is a section on NPS:

- UK: Forensic Early Warning System, FRANK, Advisory Council on the Misuse of Drugs all gather intelligence that can then be used to inform legislation and clinical management/treatment

- USA, Republic of Ireland, New Zealand same information as above Australian policy May 2014 http://www.druginfo.adf.org.au/drug-facts/legal-highs Blanket ban on possession and sale of any substances that have a psychoactive effect, other than alcohol/tobacco/food in several regions. Other regions/states in

6

Australia have banned specific substances with new ones being added to the list and the specific substances vary from region to region. Information on policy in Australia and New Zealand http://www.adf.org.au/policy-advocacy Same as above, more detail

7

4. Understanding NPS Use in UK The drug Benzylpiperazine (BZP) worked as a tipping point from use of other drugs to new psychoactive drugs (NPS). In the late 90s, a heroin drought swept over Australia and New Zealand, and opium in Thailand was removed and Methamphetamine labs took their place. Crystal meth created major problems in regions and BZP was promoted as a safe alternative. From then, orders across the world were made online. The drug landscape has had a paradigm shift, and a lot of it is due to the internet. The internet has discussion forums for information exchange, patent searches, wholesale purchase of chemicals and products and retail sales for drugs online, the latter is a part of the so called Dark Web. NPS identification in 2010-2013: EU reporting

to EMCDDA UK reporting to EMCDDA

2010 41 16 2011 49 13 2012 74 13 2013 81 11 EMCDDA = European Monitoring Centre for Drugs and Drug Addiction Mephedrone is a NPS and came about the drought of MDMA in 2008. Mephedrone replaced MDMA and became popular in the UK as it was both legal and strong. It was banned in 2010 after UK media fire-storm of deaths and governments not doing enough. Other NPSs are: - Synthetic cannabinoids: Clockwork Orange, Black Mamba and Exodus

Damnation. - Stimulant-type drugs: e.g. BZP, mephedrone, MPDV, NRG-1, benzo Fury,

MDAI and ethylphenidate. - Hallucinogenic: e.g. 25i-NBOMe, Bromo-Dragonfly. - Opiate: AH-791

The UK bans compounds along with any chemically similar compounds (Generic ban). Other control responses are the Misuse of Drugs Act, Trading standards, consumer laws, general product safety and Intoxicating Substance Supply Act. Moreover, the NPS review panel recommend a blanket ban on synthetic cannabinoids (?), commission research into prevention and treatment approached, improve data collection and sharing of information and development of the workforce. The health harms of NPS are:

8

- Overdose and temporary psychotic states and unpredictable behaviours. - Hallucination and vomiting, confusion leading to aggression and violence - Intense comedown that can cause users to feel suicidal - Increase in mental health issues including psychosis, paranoia, anxiety,

psychiatric complications - Concerns over mephedrone injecting more frequent, more sharing

Some UK data: - 600,000 aged 16-59 have a lifetime experience of mephedrone of which

about 300,000 are aged 16-24 (BCSEW 2013) - 12,000 15 year olds have tried mephedrone in the last year (Smoking,

drinking, drug use 11-15 - 2013) - Only 30% of 13 year olds had heard of legal highs. Of those who listed

what they thought were legal highs, only 18% got it right the rest were naming illegal drugs. (DfE longitudinal lifestyle study)

NPS deaths (in UK): Mention of

cathinones including mephedrone

Only cathinones including mephedrone

2010 12 4 2011 11 3 2012 30 11 2013 34 6 GBL 63 34 GBL = gamma-Butyrolactone Profile of users: - Clubbers are not interested in NPS - More in areas of poverty and deprivation - There is a range of outlets - Young, vulnerable, youth offenders - Homeless and other vulnerable adults, including adult offenders - Limited knowledge of NPs amongst everyone: users, sellers, workers,

academics, parents, teachers etc. - According to Shapiro, relatively few people buy NPS online. People do not

want to wait, but want drugs immediately.

9

4. New Psychoactive Substances and the individuals who use them: (i) Motivations - Factors influencing use of Mephedrone (NPS): purity, lack of long- or short-

term harms and having good ratings from peers or internet (Freeman, Morgan, Vaughn-Jones, Hussain, Karimi & Curran, 2012).

- Men who have sex with men use NPS to sustain and enhance sexual experiences.

- Initiation to mephedrone (NPS) is based on several consumption decisions e.g. exposure, widespread user availability, curiosity, peer use and competitive pricing (van Hout & Brennan, 2011).

(ii) Patterns of use - 2010 student survey on use of NPS: 31.4% (of 446 participants) reported

use (Corazza, Simonata, Corkery, Trincas & Schifano, 2014). - National survey in Scotland (2012-2013): mephedrone (NPS) used by 1.6%

of all 16-24 year olds in the last year (Fraser, 2014). - NPS users are typically: clubbers, men who have sex with men, students,

members of the LGBT community. Users are predominantly people who are employed and have established networks.

- NPSs are recreationally used in night clubs, at house parties and music festivals.

- Studies have found that mephedrone (and other NPSs) are added to the existing drug repertoire as a supplement to cocaine and ecstasy (Moore, Dargan, Wood & Measham, 2013; van Hout & Brennan, 2011), rather than replacing other drugs.

- A widespread level of ignorance among users as to exactly what they are using.

- Drugscope on local pattern of use (May 2014): o Folkestone: Trend towards pills and powders. o Canterbury: limited use of NPS, but increase of synthetic

cannabinoids o Maidstone: increase of use over last 12 months (like Canterbury),

focus on stimulant powder and pills. (iii) Need for support

- NPS users reluctant to attend drug services which they believe to be primarily for heroin and cocaine users (Bowden-Jones, 2013).

- Need of raising awareness of the harm of NPSs. Educating the general population, but most importantly children and young adults.

- NPS users present to various health care systems (hospitals, sexual health clinics, mental health services) which complicates the analysis of information across complex systems (Bowden-Jones, 2013). Hence, need of local clinical network and sharing of information.

- Drug staff needs competence, knowledge and credibility, then users will engage (Bowden-Jones, 2013), including cultural competence.

10

- Building resilience: target risk factors e.g. truancy, offending and negative home environments.

- Treatment shall be individualised, and include health and psychological support, rather than just treatment of drug misuse.

- Local authorities should collect data on the usage of NPSs. - Further research into treatment effects, pattern of use, motivation,

pathways of use and setting of use.

5. References Bowden-Jones, O. (2013). Legal highs and other club drugs: why the song and

dance? The Psychiatrist, 37(6), 185-187. doi: 10.1192/pb.bp.113.042713 Corazza, O., Simonato, P., Corkery, J., Trincas, G., Schifano, F. (2014). Legal

highs: Safe and legal heavens? A study on the diffusion, knowledge and risk awareness of novel psychoactive drugs among students in the UK. Rivista di Psichiatria, 49(2), 89-94.

DrugScope. Business as usual? A status report on new psychoactive substances (NPS) and club drugs in the UK. May 2014. http://www.drugscope.org.uk/Resources/Drugscope/Documents/PDF/Policy/BusinessAsUsual.pdf

Faculty if Addictions Psychiatry, Royal College of Psychiatrists: One new drug a week: Why novel psychoactive substance and club drugs need a difference response from UK treatment providers. FR/AP/02. 2014. http://www.rcpsych.ac.uk/pdf/FR%20AP%2002_Sept2014.pdf

Fraser, F. (2014)The Scottish government. New psychoactive substances Evidence Review. Scottish Government Social Research. http://www.scotland.gov.uk/Resource/0045/00457682.pdf

Freeman, T.P., Morgan, C.J.A., Vaughn-Jones, J., Hussain, N., Karimi, K., Curran, H. (2012). Cognitive and subjective effects of mephedrone and factors influencing use of new legal high. Addiction, 107(4), 792-800. doi: 10.1111/j.1360-0443.2011.03719.x

Government. Drugs: New psychoactive substances and prescription drugs. May 2014. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/307865/New_psychoactive_substances_and_prescription_drugsPRINT.pdf

Moore, K., Dargan, P.I., Wood, D.M., & Measham, F. (2013). Do novel psychoactive substances displace established club drugs, supplement them or act as drugs of initiation? The relationship between mephedrone, ecstasy and cocaine. European Addiction Reserach, 19, 276-282. doi: 10.1159/000346678

Public Health England: New psychoactive substances: A toolkit for substance misuse commissioners. Nov 2014. http://www.nta.nhs.uk/uploads/nps-a-toolkit-for-substance-misuse-commissioners.pdf

11

Van Hout, M.C., & Brennan, R. (2011). Plan food for thought: a qualitative study of mephedrone use in Ireland. Drugs: Education, Prevention and Policy, 18(5), 371-381. doi: 10.3109/09687639.2010.537713

6. Relevant Recommendations from the DrugScope NPS Expert Group

Wider recommendations relating to intervention and treatment, prevention and education and information sharing Recommendation 3.1: Undertake research in key areas 3.1.1 Develop and improve what is currently known about NPS use across the

three strands of the Drug Strategy, including information about patterns and motivations of use, harms, and data collected from enforcement agencies. This should be considered in both health and wider nonhealth settings, relating to the general population; specific settings and subgroups; and (potential) problem users including those in touch with criminal justice and health services.

3.1.2 Commission research into effective prevention and treatment interventions for NPS.

3.1.3 Develop effective preventative campaigns informed by the findings of recommendation 1.1 and including forensic, toxicological and social research data.

Recommendation 3.2: Improve the collection of data and the detection of NPS There is a need to establish prevalence, evidence and harms associated with NPS. This can be achieved through the following actions and in relation to the three tiers of users in the general population; specific subgroups; and (potential) problem users in touch with criminal justice and health services: 3.2.1 Develop detection and data collection tools across criminal justice and health services, and other relevant settings, for example, schools and universities. 3.2.2 Develop understanding of patterns of NPS use in the general population, and in specific subgroups in a range of nonhealth settings. 58 New Psychoactive Substances Review Report of the Expert Panel

Potential Pilot: to pilot a detection tool in areas of high prevalence and with known subpopulations, including a sexual health service, A&E waiting room, criminal justice system and a nighttime economy setting. 3.2.3 Develop internet tools to monitor internet activity around NPS. 3.2.4 Record

12

health and social harms related to NPS by utilising professional networks and other early warning systems. Potential Pilot: to develop and pilot an alert system for clinicians on NPS and drugsoutreach workers on NPS and drugrelated adverse reactions and harms (similar to the MHRA yellow card system for medication adverse reactions). 3.2.5 Understand local markets, including through headshops, retail outlets, prisons and local police assessment. Recommendation 3: Enhance the sharing of information on NPS Sharing information at both local and national levels is essential in helping to achieve a reduction in the demand and supply of drugs and in promoting comprehensive and effective interventions. The sharing of information on NPS can be enhanced through the following actions: 3.3.1 Local areas should already have a network of practitioners in place through which information can be shared, and should establish one if not already in place. Potential Pilot: Promote the development of local intelligence networks using a model such as DrugWatch. . 3.3.2 Develop a national network of professionals to help record health harms

and share information about NPS and other drugs (link to 2.2.3). . 3.3.3 Local and national networks should be used to disseminate effective

practice, for example, project NEPTUNE information. . 3.3.4 FEWS and DEWS should be used to support networks more widely,

where appropriate. . 3.3.5 Ensure FRANK continues to develop as a trusted and sober brand,

through clear cooperation, partnership and joint learning with NGOs, schools, local public health systems, festival promoters, local media and other agencies.

. 3.3.6 Work with internet service providers to avoid internet filters that may be developed to target NPS sales inadvertently blocking sites that provide advice and support aimed at reducing harms.

Recommendation 3.4: Skills and Workforce: developing competence and support In order to tackle NPS and drug use effectively we need a competent and confident workforce supported with appropriate, evidencebased tools for assessment and intervention, including: . 3.4.1 Develop an evaluated programme to ensure that every local area is able

to provide an identification and brief advice approach in line with evidence of effectiveness. This will ensure that all staff that come in contact with people using NPS, for example health, law enforcement and education, have access to some basic skills to help identify problematic use and provide brief advice.

. 3.4.2 Staff working in the drugs field should already have the competence to

13

work with the five main drugeffect types/presentations (i.e. stimulant, hallucinogenic, dissociative, sedative or opioidlike, and cannabislike), and should apply these skills to people using NPS.

3.4.3 Given the diversity of the populations using NPS, all staff should be culturally competent in working with specific groups, with additional training provided as appropriate for local populations. Potential Pilot: Identify the training necessary to ensure that all appropriate healthcare staff (not just drugs workers) are able to identify NPS and drugs issues in their patients. Recommendation 3.5: Expanding the toolkit Practitioners and public health staff require appropriate, evidencebased information and tools for prevention, education, assessment and intervention. The current toolkit can be expanded through the following actions: . 3.5.1 It is essential that NPS are addressed as part of a curriculum that helps to

build young peoples resilience, whilst noting the limited evidence base on effective programmes. This would be best achieved by Personal, Social, Health and Economic education becoming a statutory subject, which would secure appropriate curriculum time, generate evidence based tools, raise awareness and drive quality.

. 3.5.2 Schools and other educational settings should continue to be provided with advice and support on evidencebased practice.

. 3.5.3 Schools should be supported with information on the resources that are available to ensure that their drugs policies are in line with best practice and reflect the NPS landscape.

. 3.5.4 Guidance and/or toolkits should continue to be developed to support local responses and the commissioning of evidencebased prevention across the life course.

. 3.5.5 Support should also be given to local authorities and other commissioners i.e. Police and Crime Commissioners, to assist planning and commissioning using multiagency assessments, evidencebased prevention tools and resources such as the Joint Strategic Needs Assessment support pack, to ensure NPS are considered and addressed in local needs assessments and that pathways are always available.

. 3.5.6 Develop and share evidencebased tools with clinicians for the assessment and management of NPS harms.

Potential Pilot: This could be achieved by piloting particular tools in areas of high prevalence, for example the nighttime economy setting. 3.5.7 NPS users should be involved in developing targeted publicity campaigns. Potential Pilot: Targeted, segmented social marketing campaigns, focused on reducing harms in highrisk groups and settings, within the context of the wider health and social care agenda. 3.5.8 A mechanism should be developed to allow users to easily assess harms posed by drugs including NPS.

14

Potential Pilot: Develop and pilot an online selfassessment tool to allow users to assess harms. This should be short, confidential and signpost relevant pathways.

7. LOCAL INSIGHTS

Three areas of Kent were chosen to demonstrate the fragmentary nature of NPS distribution and use: Folkestone There are two head shops; one is an old school hippy-style shop selling posters, t-shirts, paraphernalia and so on. They dont sell to under 18s and are in dialogue with KCA and are willing to share information. The second is less discerning and does serve young people in consequence of which it is monitored by police and trading standards. The current trend is now towards pills and powders as opposed to synthetic cannabinoids, but there is also increased use by young people of drugs more associated with adult use specifically, Blues (valium and phenazepam), Gaba (gabapentin) and Trixies (trihexyphenidil). Canterbury Here there are two head shops: as in Folkestone, one is old school and does demonstrate a degree of responsibility towards its customers, the other one is Skunkworks. NPS use has been limited, although with the last year, there has been an increase in synthetic cannabinoids, but also AMT (legal DMT) and NBOMe (formerly legal LSD). The user reports gathered in this area concerning smoking blends of various types are generally negative: chest pain, shortness of breath, loss of consciousness, co-ordination problems, unpleasant visuals, intense anxiety, fear of dying but theyre viewed as cheaper and legal. Some local drug workers believe that media reports about synthetic cannabinoids being stronger than cannabis could be tending to promote use. Maidstone The workers reported that this town has a proliferation of head shops; three established (including Skunkworks) plus pop up shops, all in close proximity of each other within the town centre. Like Canterbury, local workers report a steady increase in reported use over the past 12 months. Initially this focused around stimulant pills and powders such as Charley Sheen (a cocaine-like drug), but recently smoking mixtures are dominating the conversations in sessions with some groups of young people. PROFILES Three main user groups of NPS were identified: teenagers (13-18), students and clubbers, and gay men (particularly gay clubbers). In addition to these there are smaller user groups which include: older age groups (30 years plus), heroin users

15

and so-called psychonauts (people who experiment with mind-altering chemicals and keep records of their experience). The Insight Project also found that NPS are usually sourced from: head shops (including online); friends; dealers; and in pubs and clubs. For some gay men they are also sourced at chem-sex parties, through niche websites and male escorts. Often these drugs are consumed with peers at social events/ situations (for example, clubs and festivals) and tend to be mixed with other illegal drugs.