Hitting a moving target Managing NPS harms

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Hitting a moving targetManaging NPS harms

• Dr Owen Bowden-Jones
• Addiction Psychiatrist
• Imperial College London

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• Novel Psychoactive Substances

• 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

• 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

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EMCDDA 2015
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Number of internet sites selling NPS
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Who are using these new substances ?

• Depends where you are,
• and who you are !

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Traditional drug users

• Heroin users moving to mephedrone injecting?
• Some evidence from EMCDDA
• Other anecdotal
• But, evidence of injecting of NPS and club drugs

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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
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LGBT/ MSM

• London, Berlin, New York
• Use in sexual context
• Use of social media

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Young professionals

• Anecdotal evidence of use by professional
• ? Attracted by legality and concerns of workplace
  drug testing

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Perfect drugs for prisons?
Cheap, potent, undetectable
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How should clinical services respond to the
challenge of new trends?
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• 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?

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others
CANNABIS
piperazines
tryptamines
CRACK
HEROIN
synthetic cannabinoids
synthetic cathinones
ALCOHOL
BENZOS
new synthetic opioids
COCAINE
phenethylamines
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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)

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Project NEPTUNE

• Novel Psychoactive Treatment UK Network

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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

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• 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) 899952
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
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NEPTUNE 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 reduction

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Stimulants
Sedatives/ Dissociatives
Hallucinogens
Synthetic cannabinoids
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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 Phenethylamin
es NBOMe, 2CB Salvia divinorum Amanita mushrooms
CB1 and CB2 receptor agonists including JWH and
CP (Classical, non-classical and hybrid)
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Project NEPTUNE
Develop clinical guidance
Emergency Care
Sexual Health and Mental Health
General Practice
Drug Services
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Project NEPTUNEclinical network
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• Guidance published in March 2015
• Additional LGBT guidance to be released shortly

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Between 27th March-13th May 4,642 visits to
website 1,538 downloads
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But guidance can get left on the shelf
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• Novel Psychoactive Treatment UK Network
• NEPTUNE II

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Aims of NEPTUNE 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
  target 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.

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Care Bundles
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Other tools(e.g. Patient information)
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EvaluationCentre for Quality Improvement (CCQI).
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Main evaluation

• To evaluate
• Impact of initiatives on treatment safety and
  patient outcomes
• How the implementation sites achieved their
  objectives (or not) and the factors associated
  with this
• Impact of e-learning programmes on clinical
  knowledge and staff confidence

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Volunteers wanted for testing implementation
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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

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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?

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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

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NEPTUNE I Expert group membership 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 Other contributors Dr Marta Buffito Lindsey Hines Josh Hulbert
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NEPTUNE II expert group

• Members

• Observers

• Owen Bowden-Jones
• Dima Abdulrahim
• Alex Baldacchino
• Seth Bhunnoo
• Steve Brinksman
• Emma Crawshaw
• Paul Dargan
• Jonathan Dewhurst
• Dominic Dougall
• Caroline Frayne
• Mike Flanagan
• Sarah Flowers
• Sanjay Kumar
• Salvo Larosa
• Luke Mitcheson
• Monty Moncrieff
• David Nutt
• John Ramsey
• John Roche

• Public Health England
• Pete Burnkinshaw
• Department of Health
• John McCracken
• Mark Prunty
• Home Office
• Melanie Roberts

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• Owen.bowdenjones_at_nhs.net
• Clubdrugclinic.cnwl_at_nhs.net
• www.clubdrugclinic.com
• _at_ClubDrugClinic
• www.neptune-clinical-guidance.co.uk